Pharmaceutical Benefits Under State Medical Assistance Programs, 2000

Pharmaceutical Benefitsunder State Medical AssistancePrograms

2000

Published by theNational Pharmaceutical Council, Inc.1894 Preston White DriveReston, VA 20191-5433

©2000 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, togetherwith detailed information on the pharmaceutical benefits provided. The datacollection effort covers all states with Medicaid programs and the District ofColumbia.

Information for this compilation was acquired from multiple sources, including asurvey of Medicaid prescription drug programs, administered for the NationalPharmaceutical Council by The Lewin Group, Falls Church, Virginia. While wehave checked all secondary data in the book for consistency relative to theoriginal source, we have not validated the original data reported by the HealthCare Financing Administration (HCFA) and other organizations.

The data were compiled and the book prepared for publication by CatherineHarrington, Dawn Bartoszewicz, Corinna Sorenson, Haejin Chung and SheelaRaju of The Lewin Group; and Kimberly Dietrich of the NationalPharmaceutical Council.

Pharmaceutical Benefits 2000

National Pharmaceutical Council iii

INTRODUCTION

The year 2000 edition of Pharmaceutical Benefits under State MedicalAssistance Programs marks the 35th year that the National PharmaceuticalCouncil (NPC) has published this unique source of information on pharmacyprograms within the State Medical Assistance Programs (Title XIX). Over theyears, this “Medicaid Compilation” of statistics has become a standard referencein government offices, research libraries, consultancies, and numerouscorporations.

The “Medicaid Compilation” incorporates information on each State pharmacyprogram from an annual NPC survey of State Medicaid program administratorsand pharmacy consultants and statistics from the Health Care FinancingAdministration (HCFA). A main data source of the compilation, the HCFA-2082, is an annual report providing State-reported data on Medicaid populationcharacteristics and utilization during a Federal fiscal year.

Historically, states summarized and reported data processed through theirMedicaid claims processing and payment operations unless they opted toparticipate in the Medicaid Statistical Information System (MSIS) project. Priorto Federal fiscal year 1999, MSIS was a voluntary program where statesparticipating in the MSIS project provided data tapes from their claimsprocessing systems to HCFA in lieu of the 2082 tables. In accordance with theBalanced Budget Act of 1997, all claims processed on or after January 1, 1999,had to be submitted electronically in the MSIS format. This new requirementhas caused some states to have difficulty providing data to HCFA within thenormal timeframe, which has resulted in a delay in the release of the HCFA-2082 report for fiscal year 1999.

Because of this delay, the NPC is presenting this preliminary draft of the“Medicaid Compilation, 2000” in Adobe Portable Document Format (PDF).This preliminary draft contains the latest information provided by StateMedicaid program administrators and pharmacy consultants for Federal fiscalyear 1999, however, it still contains Medicaid population characteristics andutilization based on the 1998 HCFA-2082 report. Once the HCFA-2082 reportfor fiscal year 1999 is released by HCFA, the NPC and The Lewin Group willupdate the information and make the full printed edition of the book available.

In order to give a better understanding of the content of the “MedicaidCompilation,” the information contained in this version of the book issummarized below by section:

• Section 1: Reports on the trends in of Medicaid expenditures over the lastdecade (through 1999, the last year data are available) and highlightsdifferences between Medicaid and national spending.

• Section 2: Contains details about Medicaid Managed Care enrollment as ofJune 30, 1999, including a breakdown by plan type and enrollment by plantype.


iv National Pharmaceutical Council

• Section 3: Consists of sociodemographic statistics, by age, race, insurance,income, and employment, for the fifty states and the District of Columbia forthe calendar year 1999. Additionally, a description of the Medicaid certifiedfacilities in each state, including the number of hospitals, skilled nursingfacilities, and ICF-MR facilities, home health agencies, and rural healthclinics are presented.

• Section 4: Provides Medicaid pharmacy program characteristics, drawnlargely from the 2000 NPC annual survey of State pharmacy programadministrators. In addition, this section provides Medicaid statistics fromthe Health Care Financing Administration for fiscal year 1998 (the last yeardata are available). Medicaid pharmacy programs are characterized byestimates of total payments and recipients, drug payments and recipients,drug benefit design, and pharmacy payment and patient cost sharing.

• Section 5: Profiles the 20 states that are providing pharmaceutical coveragefor the elderly, as of December 31, 2000.

• Section 6: Contains detailed profiles of the States’ Medicaid pharmacyprograms. This section contains a description of medical assistance benefitsand eligibles, drug payments and recipients, benefit design, pharmacypayment and patient cost sharing, use of managed care, and state contacts.

The book also contains a series of appendixes. Appendix A features a list ofState contacts, HCFA regional offices and Medicaid bureau personnel.Appendix B provides HCFA statistics on Medicaid eligibles, recipients, andpayments (FY 1998 HCFA-2082 data). Appendix C provides the currentMedicaid drug rebate law. Appendix D contains the list of HCFA upper limitson multiple source products. Appendix E is a glossary and list of acronyms andAppendix F lists an index for keywords.

NPC gratefully acknowledges the cooperation and assistance of the many stateand federal program officials and their staffs, and The Lewin Group foradministering the survey and analyzing the data.

We hope you continue to find the information contained in this compilationuseful and, as always, we welcome your suggestions and comments.

Gary PersingerVice President, Health Care SystemsNational Pharmaceutical Council


National Pharmaceutical Council i

TABLE OF CONTENTS

INTRODUCTION.................................................................................................................................... iii

SECTION 1: EXPENDITURE TRENDS IN MEDICAID.................................................................1-1

SECTION 2: MEDICAID MANAGED CARE ...................................................................................2-1

Medicaid Managed Care Enrollment .......................................................................................2-3

Medicaid Managed Care Waivers ..........................................................................................2-11

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

Sociodemographics− Age Demographics .....................................................................................................3-3− Race Demographics....................................................................................................3-4− Insurance Status..........................................................................................................3-5− Income and Employment............................................................................................3-6

Health Care Delivery System− Medicaid/Medicare Certified Facilities......................................................................3-7− Licensed Pharmacies ..................................................................................................3-8− Physicians.................................................................................................................3-10− Other Providers ........................................................................................................3-11

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

The Medicaid Program ..............................................................................................................4-3

− Total U.S. Medical Assistance Recipients ...............................................................4-10− Total U.S. Medical Assistance Payments.................................................................4-11− Federal Medical Assistance Percentages..................................................................4-12− Medicaid Payments and Recipients..........................................................................4-13

Medicaid Drug Program..........................................................................................................4-15

− Drug Payments and Recipients.................................................................................4-27− Drug Payment Trends...............................................................................................4-28− Drug Payment – Percent Change from 1997 to 1998...............................................4-19− Ranking Based on Drug Payments ...........................................................................4-20− Drugs as a Percentage of Total Vendor Payments ...................................................4-21− Drugs as a Percentage of Total Vendor Payments, Trends ......................................4-22− Share of Drug Payments, Top 5 Therapeutic Categories .........................................4-23− Total Drug Recipients ..............................................................................................4-24− Drug Payments Per Recipient...................................................................................4-25


ii National Pharmaceutical Council

− Medicaid Drug Reimbursement Report ...................................................................4-26

Medicaid Drug Rebates ...........................................................................................................4-27

− Medicaid Drug Rebates ............................................................................................4-28− Medicaid Drug Rebate Trends .................................................................................4-29

Medicaid Drug Coverage.........................................................................................................4-31

− Pharmacy Advisory Committees..............................................................................4-33− Pharmacy Benefit Design – Coverage......................................................................4-34− Coverage of Injectables ............................................................................................4-37− Coverage of Vaccines and Unit Dose.......................................................................4-38− Coverage of Over-the-Counter Medications ............................................................4-39− Prior Authorization Process and Procedures ............................................................4-41− Prior Authorization...................................................................................................4-44− Drug Utilization Review ..........................................................................................4-47− Prescribing and Dispensing Limits...........................................................................4-48

Pharmacy Payment and Patient Cost Sharing ......................................................................4-49

− Pharmacy Payment and Patient Cost Sharing ..........................................................4-51− Maximum Allowable Cost Programs.......................................................................4-52− Mandatory Substitution ............................................................................................4-53− Counseling Requirements and Payment for Cognitive Services..............................4-54− Prescription Price Updating .....................................................................................4-55

SECTION 5: EXPANDED DRUG COVERAGE FOR THE ELDERLY ........................................5-1

SECTION 6: STATE PROFILES ........................................................................................................6-1

APPENDIXES

Appendix A: State and Federal Medicaid Contacts ....................................................................A-1Appendix B: Medicaid Program Statistics – HCFA-2082 Report .............................................. B-1Appendix C: Medicaid Rebate Law ............................................................................................ C-1Appendix D: HCFA Upper Limits for Multiple Source Products...............................................D-1Appendix E: Glossary ................................................................................................................. E-1


National Pharmaceutical Council 1-1

Section 1:Expenditure Trendsin Medicaid


1-2 National Pharmaceutical Council



EXPENDITURE TRENDS IN MEDICAID

Medicaid programs account for a significant portion of all health care expenditures in the United States.In 1999, Medicaid expenditures totaled $187.0 billion, which is 15.4% of national health careexpenditures.1 Managing a Medicaid budget requires an understanding of the forces that influencetrends in spending including changes in policy at both the state and federal levels. Changes in policyimpact important factors that drive total expense including population size and demographic mix, prices,managed care penetration, and supply of services (i.e., number of providers). This section focuses onunderstanding the trends in of Medicaid expenditures over the last decade (through 1999, the last yeardata are available) and highlighting differences between Medicaid and national spending.

SPENDING TRENDS

Overall, Medicaid expenditures have more than doubled in the last decade, from $93.2 million in 1991to $187.0 million in 1999; however, the spending growth rate has been affected by program changesover the last decade.1 As seen in Figure 1-1, the rate of growth dropped throughout most of the decadebut then started to rise in 1997. During the early to mid 90’s, welfare reform, moderate growth of theaged and disabled population, and an improved economy lead to a reduction in spending growth; indeed,all these led to changes in population size and mix effects.2 Also, increased use of managed careaffected utilization incentives and the supply of providers. More recently, in the late 90’s, eligibilityexpansion due to the passage of State Children’s Health Insurance Plans (also known as Title XXI aspart of the Balanced Budget Act of 1997) has lead to an increase in the spending growth rate.1

Figure 1-1: Medicaid Expenditures and Growth Rates1

$93.2$108.2

$121.6$133.7

$144.1 $152.2 $159.8$171.7

$187.0

8.9%7.5%

5.6%7.7%

12.4%

26.6%

5.0%

10.0%

16.0%

$0

$50

$100

$150

$200

$250

1991 1992 1993 1994 1995 1996 1997 1998 19990

5

10

15

20

25



Figure 1-2 shows that the majority of payments in Medicaid is for long-term care services which includeskilled nursing, mental retardation, home health care, and mental health institutions. The spending rateincrease in long-term care is primarily due to rising expenditures for home health services. In 1998,home health expenses were split into three categories, traditional home health, home and community-based care, and personal care. Together, spending in the home care categories increased spending 44%over home health care spending in 1997. Spending for skilled nursing facility services in Medicaid hasbeen fairly flat with a 4.6% increase from 1997 to 1998). Spending for prescription drugs is also rising(12.5% increase, 1997-1998), however, the total share of dollars is still relatively small. Spending forhospital inpatient services and physician services has decreased.3

Figure 1-2: Distribution of Medicaid Spending* by Type of Service3

51

2621

10

52

25

55

23 20

12

2218

1411

21

62^

$0

$10

$20

$30

$40

$50

$60

$70

LTC± Hospital -Inpatient‡

Physician† Prescription Drugs

1995199619971998

* Excludes managed care payments± LTC (long-term care) = nursing facilities, mental health, home health, and mental retardation facilities‡ Direct payments for services† Physician, lab, clinic, EPSDT, outpatient hospital^ Due to a category change, the 1998 LTC figure also includes payments for home and community based services andpersonal care support services

POPULATION SIZE, DEMOGRAPHICS, AND GROWTH RATE

Medicaid is the largest financier of health care in the United States in terms of number of beneficiaries.In 1998, there were 40.6 million Medicaid beneficiaries.4 This number represents an increase of about12 million Medicaid recipients since 1991, although recent changes to welfare laws and an improvedeconomy resulted in a decline in the number of eligible people (from 41.6 million in 1997 to 41.4 in1998).4 In the past, it was automatically assumed that a person who was on welfare would qualify forthe Medicaid program. Recently, welfare reform has resulted in a break in the link between publicassistance and Medicaid. This change was originally intended to allow people who did not receive



public assistance to still qualify for medical coverage. However, due to complex eligibilityrequirements, applying for Medicaid is a confusing and difficult process for many people, resulting infewer enrollees. Besides the working poor and those on assistance, Medicaid coverage can be extendedto low income people who are elderly, blind, or disabled. In 1998, the majority of Medicaid funds, 71%of expenditures, were spent on aged, blind, and disabled beneficiaries (who constitute only 26% ofpersons served).5 In contrast, in 1998, children made up 53% of the total beneficiaries, yet only 14% ofall Medicaid expenditures went toward children.5 Figure 1-3 below examines the breakdown ofMedicaid expenditures by eligibility type.

Figure 1-3: Medicaid Expenditures & Enrollment by Group, 19985

$14.8$20.5

$101.0

18.3 M

7.9 M 10.6 M

$0

$20

$40

$60

$80

$100

Adults Children Aged, Blind, & Disabled

Notes: Figures do not include spending for administration ($6.4 B) or disproportionate share hospitals ($15.9 B). Enrollmentfigures are in millions.

MANAGED CARE TRENDS

The percentage of beneficiaries enrolled in Medicaid managed care increased from 9.5% in 1991 to55.6% in 1999.6 The majority of those enrolled in managed care are non-disabled adults and childrenwhere enrollment is mandatory. Over half of all Medicaid managed care enrollees are in a HealthMaintenance Organization (HMO) or Health Insuring Organization (HIO), organizations that contract ona prepaid capitated risk basis to provide a comprehensive set of services. Room for further growth inMedicaid managed care exists in the medically needy population of older and disabled persons.However, the outlook for Medicaid managed care is cloudy right now because of the withdrawal ofmany managed care firms from both the Medicare and Medicaid markets.7



PROVIDER PARTICIPATION IN MEDICAID

Physician participation in the fee-for-service Medicaid program is low. In many geographic areas patientaccess to primary care services is limited. Physicians hesitate to take on Medicaid patients becauseMedicaid reimburses at a much lower rate than does private insurance. By law, Medicaid cannot paymore than Medicare. Medicare reimburses physicians using a fee schedule, the Resource Based RelativeValue Scale. A comparison of the 1993 Medicare Fee Schedule to average Medicaid payments in 1994shows that Medicaid paid out an amount equal to an average of 77% of the Medicare Fee Schedule.8 Incontrast, typical physician payments by private insurers run from 115% to 120% of the Medicare FeeSchedule.9 In addition, states have continued to limit physician payment rates; average fees forphysician services rose just 4.6% overall from 1993 to 1998.2

MEDICARE AND MEDICAID COMPARISON

In some ways it is useful to consider Medicare and Medicaid as a combined entity since changes in oneprogram often dramatically impact the other. Both programs are federally financed (partially forMedicaid) and are managed by the Health Care Financing Administration (HCFA). They also bothcover elderly and disabled persons, but differ in the range of services offered. Both programs enrollabout the same number of persons (41.4 million in Medicaid and 38.8 million in Medicare in 1998).10

However, Medicare does not offer much in the way of either prescription drug or nursing homecoverage. Therefore, dually eligible people tend to receive hospital and physician services fromMedicare and prescription drug and nursing home services from Medicaid. Figure 1-4 illustrates thespending pattern differences between Medicaid and Medicare.

Figure 1-4: Medicare versus Medicaid Spending, 19991

MedicareMedicaid

Drugs

Nursing Homes

Physicians and Clinical ServicesHospitals

$0

$20

$40

$60

$80

$100

$120

$140



MEDICAID COMPARED TO NATIONAL HEALTH SPENDING

Average annual growth in National Health Expenditures versus Medicaid growth rates are shown belowin Figure 1-5.

Figure 1-5: National versus Medicaid Average Growth Rates1

5.4% 5.2%4.8%

5.6%

7.7%

5.6%

7.5%

5.4%

8.9%

5.0%

0%

2%

4%

6%

8%

10%

1995 1996 1997 1998 1999

Gro

wth

NationalMedicaid

Over the last decade, both national and Medicaid expenditures for nursing home services have risensteadily. However, the rate of growth for both national and Medicaid nursing home spending hasdeclined from 1996 to 1999 (except for a significant increase in Medicaid spending from 1998 to 1999).1See Figures 1-6a and 1-6b below. Most of this decline in the national growth rate was due torestructuring of the Medicare Prospective Payment System (PPS) for skilled nursing home payments.



Figure 1-6a: National and Medicaid Nursing Home Expenditures1

$74.6$79.9

$85.1 $88.0

$35.4 $37.8 $39.8 $40.7 $42.4

$90.0

$0

$20

$40

$60

$80

$100

1995 1996 1997 1998 1999

Billi

ons

NationalMedicaid

Figure 1-6b: National versus Medicaid Nursing Home Expenditures, Growth Rates1

7.1%6.5%

3.5%

4.0%

6.6%

5.3%

2.3%

9.1%

2.3%

4.1%

0%

2%

4%

6%

8%

10%

1995 1996 1997 1998 1999

NationalMedicaid



National hospital spending rose somewhat in the latter half of the 1990’s, while Medicaid hospitalspending grew significantly from 1998 to 1999, approximately 9.4%.1 See Figures 1-7a and 1-7b.

Figure 1-7a: National and Medicaid Hospital Expenditures1

$343.6 $355.9 $367.7 $377.1 $390.9

$54.3 $56.8 $58.0 $60.8 $66.5

$0

$50

$100

$150

$200

$250

$300

$350

$400

$450

1995 1996 1997 1998 1999

Billi

ons National

Medicaid

Figure 1-7b: National versus Medicaid* Hospital Expenditures, Growth Rates1

3.4% 3.6%2.6%

3.7%

4.3% 4.5% 4.8%

3.3%

9.4%

2.2%

0%

2%

4%

6%

8%

10%

1995 1996 1997 1998 1999

Billi

ons

NationalMedicaid



National home health spending rose consistently in the early 1990’s and then dropped after Medicarechanged reimbursement procedures and payment levels in 1997. See Figures 1-8a and 1-8b below.Spending for home health in the Medicaid program is increasing and is expected to continue to increasewith the implementation of the Olmstead law. The Olmstead ruling requires states to providecommunity-based health services to disabled persons, when feasible.

Figure 1-8a: National versus Medicaid Home Health Care Expenditures1

$30.5$33.6 $34.5 $33.5 $33.1

$4.2 $4.5 $4.9 $5.4 $5.6

$0

$10

$20

$30

$40

1995 1996 1997 1998 1999

Bill

ions

National

Medicaid

Figure 1-8b: National versus Medicaid Home Health Care Expenditures, Growth Rate1

10.1%

2.8%

11.7%

6.2%

10.3%

17.1%

-3.0% -1.4%

4.1%

8.9%

-5%

0%

5%

10%

15%

20%

1995 1996 1997 1998 1999

NationalMedicaid



The national rate of spending growth for prescription drugs rose rapidly in the 1990’s. The Medicaidspending rate for prescription drugs also rose rapidly in the 1990’s, even more rapidly than the nationaltrend. See Figures 1-9a and 1-9b below. As the mix of enrollees increasingly changes from adults andchildren towards the aged and disabled, spending for prescription drugs is likely to continue to rise(since the latter group has greater need for medication).

Figure 1-9a: National versus Medicaid Prescription Drug Expenditures1

$60.8$67.2

$75.1$85.2

$99.6

$9.7 $10.9 $12.3 $14.4 $17.1

$0

$20

$40

$60

$80

$100

$120

1995 1996 1997 1998 1999

Billi

ons National

Medicaid

Figure 1-9b: National versus Medicaid Prescription Drug Expenditures, Growth Rate1

11.2% 10.5%11.9%

13.4%

16.9%12.4% 12.0%13.7%

16.7%18.7%

0%

5%

10%

15%

20%

25%

1995 1996 1997 1998 1999

Rat

e

National RateMedicaid Rate



SUMMARY

Medicaid expenditure trends for the latter half of the 1990’s were:

• The rate of growth in Medicaid spending was generally higher than the overall national growthrate. Compared to a national growth rate between 4.8% and 5.6% throughout the latter half ofthe 1990’s, the rate of growth in Medicaid was between 5.0% and 8.9%. The Medicaid growthrate rose significantly from 1997 to 1999 due to program expansions.

• Most Medicaid spending is for long-term care services. Home health and personal care serviceexpenditures are growing most rapidly in this sector.

• Spending continues to be driven primarily by the aged, blind, and disabled population.

• Spending growth rates for hospital services remained fairly flat in the Medicaid program,paralleling national rates, until 1999, when Medicaid experienced a major spending increase.

• Pharmacy spending is increasing rapidly in Medicaid and nationally; however, pharmacy costsstill remain a relatively small proportion of total spending.



REFERENCES

1 National Health Expenditures by Type of Service and Source of Funds: Calendar Years 1960-99.Health Care Financing Administration, Office of the Actuary, National Health Statistics Group.www.hcfa.gov/stats/nhe-oact/tables/nhe99.csv. Figures for Medicaid do not include MedicaidSCHIP Expansion or Part B premium payments made by Medicaid.

2 Bruen B and Holahan J. Medicaid and the Uninsured. Slow Growth in Medicaid SpendingContinues in 1997. Issue Paper. The Henry J. Kaiser Foundation, November 1999.

3 Medicaid Statistics, Table 5. Medicaid Vendor Payments by Type of Service.www.hcfa.gov/medicaid/msis/2082-5.htm. HCFA, CMSO, HCFA-2082 Report.

4 Medicaid Statistics, Table 1. Medicaid Beneficiaries, Vendor, Medical Assistance andAdministrative Payments. www.hcfa.gov/medicaid/msis/2082-1.htm. HCFA, CMSO, HCFA-2082Report.

5 Medicaid Statistics, Table 3. Medicaid Beneficiaries, and Vendor Payments by Basis of Eligibility,www.hcfa.gov/medicaid/msis/2082-3.htm. HCFA, CMSO, HCFA-2082 Report.

6 National Summary of Medicaid Managed Care Programs and Enrollment. June 30, 1999. ManagedCare Trends. www.hcfa.gov/medicaid/trends99.htm.

7 Iglehart JK. The American Health Care System. New England Journal of Medicine1999;340(5):403-8.

8 Norton SA. 1994. The Declining Gap between Medicaid and Medicare Physician Fees. InWinterbottom C, Liska DW, and Obermaier KM. State-Level Databook on Health Care Access andFinancing, Health Tracking, 2nd ed., Robert Wood Johnson Foundation, 1995, pg. 138.

9 Over 100 private insurers interviewed by The Lewin Group, 2000-2001.

10 1999 HCFA Statistics. Health Care Financing Administration. U.S. Department of Health andHuman Services.





Section 2:Medicaid Managed Care





MEDICAID MANAGED CARE ENROLLMENT

Since 1981, when Congress authorized states to implement Section 1915b and Section 1115 Medicaid waivers toincrease access to managed care and test innovative health care financing and delivery options, enrollment inMedicaid managed care has grown considerably. Over the past five years, managed care enrollment as apercentage of total Medicaid enrollment has increased by 140 percent (i.e., from 23.2% to 55.6%). In 1999, morethan half of all Medicaid beneficiaries were enrolled in some type of managed care program. As of June 30,1999, all but two states (Alaska and Wyoming) were enrolling Medicaid beneficiaries in some type of managedcare plan.

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

23.2% 29.4%14.4%0%

20%

40%

60%

80%

100%

1993 1994 1995* 1996 1997 1998 1999

% o

f Enr

ollm

ent

Managed Care Fee-for-Service

40.1% 47.8% 53.6% 55.6%

44.4%46.4%52.2%59.9%70.6%76.8%85.6%

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care.*Approximated numbers for 1995. Total Medicaid population was provided by the Office of the Actuary, which used HCFA 2082 data tocalculate average Medicaid enrollees over 1995. The managed care population differs from the 11,619,929 reported in the 1995 report asthe 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 andcontracts on a prepaid capitated risk basis to provide a comprehensive set of services.

• Comprehensive Managed Care Organization (Comp-MCO): a health maintenance organization with acontract under §1876 or a Medicare-Choice organization, a provider sponsored organization or any private orpublic organization which meets the requirements of §1902 (w). They provide comprehensive services tocommercial and/or Medicare, as well as Medicaid enrollees.

• Medicaid-only Managed Care Organization (Mcaid-MCO): a Medicaid-only MCO that providescomprehensive services to Medicaid beneficiaries, but not commercial or Medicare enrollees.



• Prepaid Health Plan (PHP): an entity that provides less than comprehensive services on an at-risk basis orone that provides any benefit package on a non-risk basis.

• Primary Care Case Management (PCCM): a provider (usually a physician, physician group practice, or anentity employing or having other arrangements with such physicians, but sometimes also including nursepractitioners, nurse midwives, or physician assistants) who contracts to locate, coordinate, and monitorcovered primary care (and sometimes additional services). This category includes any PCCMs and thosePHPs that act as PCCMs.

• “Other” Managed Care Arrangement: arrangements used if the plan is not considered a PCCM, PHP,Comprehensive MCO, Medicaid-only MCO, or HIO.

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

Table 2-1: Medicaid Managed Care Plans

Plan TypeNumber of

PlansNumber ofEnrollees

Health Insuring Organization 6 365,738Comprehensive Managed Care Organization 237 8,488,107Comprehensive Medicaid-only Managed Care Organization 136 3,524,049Primary Care Case Management 60 4,274,456Prepaid Health Plan 129 8,104,413Other 13 20,192Total 581 24,776,955*

* Total number of enrollees includes 7,020,352 individuals enrolled in more than one managed care plan type.Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care.

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



Medicaid Managed Care Enrollment, As of June 30, 1999

StateMedicaid

EnrollmentMedicaid Managed

Care EnrollmentPercent in

Managed Care

Rank Based onPercent in

Managed CareNational Total 31,940,188 17,756,603 55.59% -Alabama 513,863 377,952 73.55% 17Alaska 70,764 0 0.00% 51Arizona 401,066 363,662 90.67% 6Arkansas 388,048 232,123 59.82% 30California 4,972,673 2,540,902 51.10% 36Colorado 234,753 216,357 92.16% 5Connecticut 322,181 230,217 71.46% 19Delaware 88,186 68,869 78.10% 12District of Columbia 122,918 75,499 61.42% 26Florida 1,512,216 912,045 60.31% 28Georgia 848,618 638,082 75.19% 15Hawaii 152,757 120,246 78.72% 11Idaho 87,203 31,184 35.76% 42Illinois 1,312,599 158,888 12.10% 47Indiana 500,671 331,363 66.18% 22Iowa 206,822 176,487 85.33% 8Kansas 180,523 95,868 53.11% 34Kentucky 539,810 324,447 60.10% 29Louisiana 771,092 44,741 5.80% 49Maine 168,092 23,720 14.11% 46Maryland 501,000 347,937 69.45% 21Massachusetts 891,428 575,186 64.52% 23Michigan 1,130,608 1,130,608 100.00% 1Minnesota 438,133 268,360 61.25% 27Mississippi 485,716 200,347 41.25% 39Missouri 714,392 276,628 38.72% 41Montana 69,738 69,738 100.00% 2Nebraska 171,723 122,006 71.05% 20Nevada 92,996 36,945 39.73% 40New Hampshire 71,407 5,812 8.14% 48New Jersey 611,589 356,956 58.37% 31New Mexico 284,705 208,528 73.24% 18New York 2,255,694 659,569 29.24% 43North Carolina 831,708 689,104 82.85% 9North Dakota 43,389 23,886 55.05% 33Ohio 975,415 244,888 25.11% 44Oklahoma 372,501 193,902 52.05% 35Oregon 378,894 308,798 81.50% 10Pennsylvania 1,304,427 1,004,601 77.01% 13Puerto Rico 997,474 764,068 76.60% 14Rhode Island 134,018 85,900 64.10% 24South Carolina 498,147 23,149 4.65% 50South Dakota 68,195 50,220 73.64% 16Tennessee 1,312,969 1,312,969 100.00% 3Texas 1,788,569 352,062 19.68% 45Utah 132,566 118,601 89.47% 7Vermont 113,925 65,692 57.66% 32Virgin Islands 19,359 0 0.00% 51Virginia 460,373 292,214 63.47% 25Washington 707,245 706,202 99.85% 4West Virginia 256,869 111,532 43.42% 38Wisconsin 395,336 187,543 47.44% 37Wyoming 34,825 0 0.00% 51State Medicaid enrollment includes individuals enrolled in State health care reform programs that expand eligibility beyond traditionalMedicaid eligibility standards. This table provides unduplicated figures for Medicaid Enrollment and Managed Care Enrollment by State.Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care.



Pharmaceutical Benefits Under Managed Care Plans

State

MedicaidManaged Care

Enrollment

Where do managed care recipientsreceive pharmacy benefits?

(State, Managed Care Plan, Both)

Special requirementsfor pharmacy benefits

in managed care?Alabama 377,952 N/A N/AAlaska 0 - -Arizona* 363,662 - -Arkansas 232,123 State NoneCalifornia 2,540,902 Both Guidelines, contractualColorado 216,357 Managed Care Plan N/AConnecticut 230,217 Managed Care Plan ContractualDelaware 68,869 State N/ADistrict of Columbia 75,499 Both NoneFlorida 912,045 Managed Care Plan ContractualGeorgia 638,082 N/A N/AHawaii 120,246 Both Guidelines, contractualIdaho 31,184 State N/AIllinois 158,888 Managed Care Plan ContractualIndiana 331,363 Managed Care Plan Statutes, contractualIowa 176,487 State NoneKansas 95,868 Managed Care Plan ContractualKentucky 324,447 Both ContractualLouisiana 44,741 State N/AMaine 23,720 State NoneMaryland 347,937 Both RegulationsMassachusetts 575,186 Managed Care Plan ContractualMichigan 1,130,608 Both ContractualMinnesota 268,360 Managed Care Plan ContractualMississippi 200,347 Both ContractualMissouri 276,628 Managed Care Plan Guidelines, contractualMontana 69,738 State NoneNebraska 122,006 State Statutes, regulations, guidelines, contractualNevada 36,945 Both ContractualNew Hampshire 5,812 State NoneNew Jersey 356,956 Managed Care Plan GuidelinesNew Mexico 208,528 Managed Care Plan N/ANew York 659,569 State Statutes, FFS programNorth Carolina 689,104 State NoneNorth Dakota 23,886 State NoneOhio 244,888 Managed Care Plan StatutesOklahoma 193,902 Managed Care Plan ContractualOregon 308,798 Both Guidelines, contractualPennsylvania 1,004,601 Managed Care Plan ContractualRhode Island 85,900 Managed Care Plan N/ASouth Carolina 23,149 Managed Care Plan ContractualSouth Dakota 50,220 N/A N/ATennessee* 1,312,969 Managed Care -Texas 352,062 State N/AUtah 118,601 State (Carve-out) N/AVermont 65,692 State NoneVirginia 292,214 Managed Care Plan ContractualWashington 706,202 Both ContractualWest Virginia 111,532 State N/AWisconsin 187,543 Managed Care Plan Statutes, regulations, contractualWyoming 0 - -*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drugdecisions.Sources: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care. Asreported by state drug program administrators in the 2000 NPC Survey.



Medicaid Managed Care Enrollment Trends, 1997-1999

State 1997 1998 1999National Total 15,345,502 16,573,996 17,756,603Alabama 407,643 362,272 377,952Alaska 0 0 0Arizona 349,142 368,344 363,662Arkansas 159,458 186,215 232,123California 1,854,294 2,246,406 2,540,902Colorado 184,000 215,936 216,357Connecticut 231,966 220,803 230,217Delaware 65,061 62,010 68,869District of Columbia 80,721 51,022 75,499Florida 896,559 915,554 912,045Georgia 560,771 673,528 638,082Hawaii 135,200 131,761 120,246Idaho 32,428 30,866 31,184Illinois 187,048 175,649 158,888Indiana 220,000 233,065 331,363Iowa 88,282 190,692 176,487Kansas 94,430 84,437 95,868Kentucky 268,205 325,233 324,447Louisiana 40,469 40,729 44,741Maine 12,511 16,295 23,720Maryland 347,640 306,474 347,937Massachusetts 461,989 532,971 575,186Michigan 865,434 752,568 1,130,608Minnesota 169,329 225,498 268,360Mississippi 81,255 153,562 200,347Missouri 264,496 252,097 276,628Montana 62,004 66,331 69,738Nebraska 93,085 110,606 122,006Nevada 26,376 35,089 36,945New Hampshire 9,102 7,368 5,812New Jersey 384,644 376,839 356,956New Mexico 139,337 193,818 208,528New York 660,725 634,233 659,569North Carolina 351,043 559,035 689,104North Dakota 24,295 22,045 23,886Ohio 352,833 292,819 244,888Oklahoma 222,818 154,270 193,902Oregon 312,345 299,826 308,798Pennsylvania 870,365 904,701 1,004,601Puerto Rico 702,250 813,791 764,068Rhode Island 70,944 74,446 85,900South Carolina 14,311 15,823 23,149South Dakota 41,542 43,834 50,220Tennessee 1,188,570 1,268,769 1,312,969Texas 275,951 437,898 352,062Utah 93,785 112,803 118,601Vermont 22,946 52,153 65,692Virgin Islands 0 0 0Virginia 306,804 299,266 292,214Washington 730,052 718,023 706,202West Virginia 125,521 131,349 111,532Wisconsin 205,523 194,874 187,543Wyoming 0 0 0State Medicaid enrollment includes individuals enrolled in State health care reform programs that expand eligibility beyond traditionalMedicaid eligibility standards.Sources: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1997; 1998; 1999. DHHS, HCFA, Office ofManaged Care.



Medicaid Managed Care Plan Type, As of June 30, 1999

State HIOComprehensive

MCO

ComprehensiveMedicaid-only

MCO PCCM PHP OtherNational Total 6 237 136 60 129 13Alabama 0 1 0 24 9 0Alaska - - - - - -Arizona 0 2 30 0 1 0Arkansas 0 0 0 1 1 0California 5 18 13 2 9 5Colorado 1 4 1 1 1 0Connecticut 0 4 1 0 0 0Delaware 0 3 0 0 0 0District of Columbia 0 7 1 0 0 0Florida 0 16 0 3 1 0Georgia 0 0 0 1 2 0Hawaii 0 8 2 0 0 0Idaho 0 0 0 1 0 0Illinois 0 7 3 4 0 0Indiana 0 1 2 1 0 0Iowa 0 5 0 1 1 0Kansas 0 0 1 1 0 0Kentucky 0 0 2 1 1 0Louisiana 0 0 0 1 0 0Maine 0 1 0 1 0 0Maryland 0 3 5 0 0 0Massachusetts 0 3 2 1 1 0Michigan 0 15 13 1 49 2Minnesota 0 8 1 0 0 1Mississippi 0 3 0 1 0 0Missouri 0 6 4 0 0 0Montana 0 2 0 1 1 0Nebraska 0 2 0 1 1 0Nevada 0 4 0 0 0 0New Hampshire 0 2 0 0 0 0New Jersey 0 4 2 0 0 0New Mexico 0 3 0 0 0 0New York 0 16 16 1 8 2North Carolina 0 5 0 2 1 0North Dakota 0 1 0 1 0 0Ohio 0 8 3 0 0 0Oklahoma 0 4 0 1 0 0Oregon 0 8 3 0 0 0Pennsylvania 0 5 8 2 15 0Puerto Rico 0 4 0 0 0 0Rhode Island 0 4 0 0 0 0South Carolina 0 0 1 0 0 2South Dakota 0 0 0 1 0 0Tennessee 0 0 9 0 2 0Texas 0 6 6 1 0 0Utah 0 5 0 0 8 0Vermont 0 2 0 0 0 0Virginia 0 7 0 1 0 0Washington 0 9 2 1 15 0West Virginia 0 3 0 1 0 0Wisconsin 0 18 5 0 2 1Wyoming - - - - - -HIO=Health Insuring Organization; Comprehensive MCO=Comprehensive Managed Care Organization; Comprehensive Medicaid-onlyMCO=Comprehensive Medicaid-only Managed Care Organization; PCCM=Primary Care Case Management; PHP=Prepaid Health Plan.Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care.



Medicaid Managed Care Enrollment by Plan Type,As of June 30, 1999

State HIOComprehensive

MCOComprehensive

Medicaid-only MCO PCCM PHP OtherNational Total 365,738 8,488,107 3,524,049 4,274,456 8,104,413 20,192Alabama - 39,597 - 310,584 637,654 -Alaska - - - - - -Arizona - 22,889 361,273 - 24,431 -Arkansas - - - 194,753 232,122 -California 365,498 938,125 1,208,314 26,617 333,160 2,279Colorado 240 37,880 43,029 50,214 216,357 -Connecticut - 193,432 36,785 - - -Delaware - 68,869 - - - -District of Columbia - 73,640 1,859 - - -Florida - 446,538 - 465,507 41,660 -Georgia - - - 613,560 24,522 -Hawaii - 191,086 52,356 - - -Idaho - - - 31,184 - -Illinois - 98,956 41,505 - 18,427 -Indiana - 69,194 42,848 219,321 - -Iowa - 47,048 - 45,570 176,487 -Kansas - - 22,402 73,466 - -Kentucky - - 158,628 165,819 - -Louisiana - - - 44,741 - -Maine - 5,569 - 18,151 - -Maryland - 238,240 109,697 - - -Massachusetts - 117,715 23,808 433,663 627,894 -Michigan - 521,790 228,830 - 1,130,608 1,124Minnesota - 264,231 3,885 - - 244Mississippi - 10,216 - 190,131 - -Missouri - 186,109 90,519 - - -Montana - 1,965 - 39,847 69,738 -Nebraska - 28,052 - 24,345 122,006 -Nevada - 36,945 - - - -New Hampshire - 5,812 - - - -New Jersey - 261,804 95,152 - - -New Mexico - 2,420,860 - - - -New York - 359,379 235,065 4,768 59,531 826North Carolina - 38,881 - 517,511 132,712 -North Dakota - 718 - 23,168 - -Ohio - 142,235 102,653 - - -Oklahoma - 98,140 - 95,762 - -Oregon - 206,651 23,940 134,279 698,307 -Pennsylvania - 414,698 428,682 154,468 713,145 -Puerto Rico - 764,068 - - - -Rhode Island - 85,900 - - - -South Carolina - - 7,454 - - 15,695South Dakota - - - 50,220 - -Tennessee - 1,312,969 - - 1,312,969 Texas - 107,932 107,929 136,201 - -Utah - 73,921 - - 118,601 -Vermont - 65,692 - - - -Virginia - 150,067 - 142,147 - -Washington - 323,079 93,221 3,805 1,413,447 -West Virginia - 46,878 - 64,654 - -Wisconsin - 182,669 4,215 - 635 24Wyoming - - - - - -*The total number of enrollees includes 7,020,352 individuals who were enrolled in more than one managed care plan. It also includesindividuals 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, 1999. DHHS, HCFA, Office of Managed Care.



Medicaid Managed Care Enrollment by Payment Arrangement,As of June 30, 1999

State Fee-For-Service (FFS) Fully Capitated (FUL) Partially Capitated (PAR)National Total 4,892,041 17,844,439 2,040,475Alabama 310,584 677,251 -Alaska - - -Arizona - 408,593 -Arkansas 194,753 232,122 -California 26,617 2,847,376 -Colorado 50,214 297,506 -Connecticut - 230,217 -Delaware - 68,869 -District of Columbia - 75,499 -Florida 465,489 488,216 -Georgia 613,560 2,408 22,114Hawaii - 243,442 -Idaho 31,184 - -Illinois - 150,554 8,334Indiana 219,321 112,042 -Iowa 45,570 223,535 -Kansas 73,466 22,402 -Kentucky 165,819 158,628 -Louisiana 44,741 - -Maine 18,151 5,569 -Maryland - 347,937 -Massachusetts 433,663 141,523 627,894Michigan - 751,744 1,130,608Minnesota 244 268,116 -Mississippi 190,131 10,216 -Missouri - 276,628 -Montana 39,847 71,703 -Nebraska 24,345 28,052 122,006Nevada - 36,945 -New Hampshire - 5,812 -New Jersey - 356,956 -New Mexico - 208,528 -New York 4,768 630,887 23,914North Carolina 517,511 171,593 -North Dakota 23,168 718 -Ohio - 244,888 -Oklahoma - 98,140 95,762Oregon 134,279 928,898 -Pennsylvania 154,468 1,556,525 -Puerto Rico - 764,068 -Rhode Island - 85,900 -South Carolina 5,852 7,454 9,843South Dakota 50,220 - -Tennessee - 2,625,938 -Texas 136,201 215,861 -Utah - 192,522 -Vermont - 65,692 -Virginia 142,147 150,067 -Washington 711,050 1,122,502 -West Virginia 64,654 46,878 -Wisconsin 24 187,519 -Wyoming - - -Individual state totals will not sum to total managed care enrollment (page 2-5) because state totals include individuals enrolled in morethan one plan type including dental, mental, and long-term care.Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care.



MEDICAID MANAGED CARE WAIVERS

In 1981, Congress authorized states to implement Section 1915b and Section 1115 Medicaid waivers to increaseaccess to managed care and test innovative health care financing and delivery options. The U.S. Department ofHealth and Human Services granted these waivers to allow states to “waive” requirements in Sections 1902 and1903 of the Social Security Act and “mandate” enrollment of Medicaid eligibles in managed care programs.

SECTION 1915B “FREEDOM OF CHOICE” WAIVERS

Section 1915b waivers are granted to give states the authority to conduct Medicaid programs outside of the scopeof the Medicaid statute, allowing them to waive freedom of choice, statewide access to care, and comparabilityrequirements under Section 1902 of the Social Security Act. With a 1915b waiver, a state can require mandatoryenrollment of Medicaid recipients in managed care plans. 1915b waivers cannot negatively impact beneficiaryaccess, quality of care of services, and must be cost-effective (cost must be less than the Medicaid programwould cost without the waiver). Section 1915b waivers are typically limited to a targeted geographical area orpopulation, are approved for an initial period of two years, and can be renewed in two-year increments if the statereapplies.

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

• Subsection 1 - Case Management: States are allowed to implement case management systems which can beas simple as requiring each beneficiary to choose a primary care provider or as comprehensive as mandatingenrollment in a prepaid health plan.

• Subsection 2 - Central Broker: States are allowed to act as a central broker in assisting medical assistanceeligibles in selecting among competing health care plans, if such a restriction does not substantially impairaccess to medically necessary services of adequate quality.

• Subsection 3 - Shared Cost Saving: States are allowed to share (through provision of additional services) costsavings (resulting from use by the recipient of more cost-effective medical care) with recipients of medicalassistance under the State plan.

• Subsection 4 - Restrict Providers: States can limit the number of providers of certain services. These waiversare sometimes referred to as selective contracting waivers and were gaining in popularity. Recently approved1915b(4) waivers included programs to restrict the number of providers of transportation services, organtransplants, and inpatient obstetrical care.

Refer to the table on page 2-13 for a listing of 1915b waivers.

Although Section 1915b waivers allow states to increase access to managed care plans, states are still limitedunder Federal regulation and cannot use them to serve beneficiaries beyond Medicaid State Plan Eligibility orchange their benefits package. In order to expand their Medicaid programs even further than under 1915bwaivers, states apply for Section 1115 research and demonstration waivers.

SECTION 1115 RESEARCH AND DEMONSTRATION WAIVERS

Section 1115 research and demonstration waivers released states from standard Medicaid requirements, allowingthem the flexibility to test substantially new ideas of policy merit. Along with 1915b waivers, 1115 waiversallowed states to waive freedom of choice, statewide access to care, and comparability requirements. However,an 1115 waiver also allowed states to provide new and additional services, test new payment methods, offerbenefits to new and expanded populations, and contract with managed care organizations that did not meet thenecessary criteria of Section 1903 of the Social Security Act.



To receive approval of a Section 1115 waiver, states submit a proposal to HCFA for discussion and review.Once operational, states allow formal evaluations of the research and public policy value of the programs and todemonstrate that their programs do not exceed costs which would have otherwise occurred under traditionalMedicaid programs (i.e., states must demonstrate budget neutrality). Section 1115 waivers are usually grantedfor a five-year period and each state must request for continuation. For example, Arizona operated its programunder an 1115 waiver for 17 years.

Currently, there are 20 Medicaid programs with 1115 waiver approvals. Arizona, Arkansas, California, Delaware,District of Columbia, Hawaii, Kentucky, Maryland, Massachusetts, Minnesota, Missouri, Montana, New York,Ohio, Oklahoma, Oregon, Rhode Island, Tennessee, Vermont and Wisconsin have actually implemented their1115 waivers. Refer to the table on page 2-16 for a listing of implemented 1115 waivers.



1915(b) Waivers, As of June 30, 1999

State Program(s) Approved1915b

Statutes Utilized ExpirationMaternity Waiver Program 1 9/30/99Partnership Hospital Program 1, 4 3/29/01AlabamaPatient 1st 1, 3, 4 6/29/01

Alaska None -- --Arizona None -- --

Arkansas Non-Emergency Transportation 1 2/29/00CALOPTIMA 1, 2, 4 5/06/00Health Plan of San Mateo 1, 2, 3, 4 7/4/00Hudman 4 7/21/00Managed Care Network 1, 3, 4 11/25/99Medi-Cal Mental Health Care Field Test 4 6/25/00Medi-Cal Specialty Mental Health Services Consolidation 4 10/4/99Partnership Health Plan of California 1, 2, 4 2/16/00Primary Care Case Management Program 1, 2, 3, 4 8/09/01Sacramento Geographic Managed Care – Medical 1, 2, 4 11/16/99San Diego Geographic Managed Care 1, 2, 4 10/16/00Santa Barbara Health Initiative 1, 2, 4 1/17/00Santa Cruz County Health Option (SCCHO) 1, 2, 4 11/19/00Selective Provider Contracting Program 4 12/12/01

California

Two-Plan Model Program 1, 2, 3, 4 12/16/00Mental Health Capitation Program 1, 3, 4 3/8/00

ColoradoManaged Care Program 1, 2 2/28/00

Connecticut HUSKY A 1, 4 12/20/99Delaware None -- --District of Columbia DC Managed Care Program 1, 2, 4 3/31/00

MediPass 1 6/30/99Prepaid Mental Health Plan 1, 4 6/30/01FloridaSub-Acute Inpatient Psychiatric Program 3, 4 3/22/00Georgia Better Health Care 1 7/01/00

GeorgiaMental Health/Mental Retardation Services 1, 4 2/19/00

Hawaii None -- --Idaho Healthy Connections 1, 2 11/15/99Illinois None -- --Indiana Hoosier Healthwise 1 1/26/00

Iowa Plan for Behavioral Health 1, 3, 4 12/31/00Iowa

Iowa Medicaid Managed Health Care 1, 2 5/9/01KMMC: Prime Care Kansas 1, 2, 4 6/26/00

KansasKMMC: Health Connect 1, 2, 4 6/26/00Human Services Transportation 4 10/30/00Kentucky Patient Access and Care System (KENPAC) 1 4/13/00KentuckyKentucky Access 1, 3, 4 11/24/99




Statutes Utilized ExpirationLouisiana Community Care Program 1 6/28/00Maine None -- --Maryland None -- --Massachusetts None -- --

Comprehensive Health Care Program 1, 2, 4 12/27/99Michigan

Specialty Community Mental Health Services 1, 4 9/30/00Minnesota Consolidated Chemical Dependency Treatment Fund 1, 4 3/24/01Mississippi None -- --Missouri Managed Care Plus (MC+) 1, 2, 4 3/14/00

Mental Health Access Plan 1 6/30/99Montana

Passport to Health 1 10/25/99Medicaid Health Connection – MH/SA 1 6/30/99

NebraskaNebraska Health Connection – Med/Surg 1, 2 6/30/99

Nevada None -- --New Hampshire None -- --New Jersey None -- --New Mexico SALUD! 1,4 7/1/99

Non-Emergency Transportation 4 1/13/00Southwest Brooklyn Managed Care Demonstration Project 1, 4 8/16/00New YorkThe Westchester County Managed Care Program 1, 4 3/31/00ACCESS II 1 11/29/99Carolina Access 1 11/29/99Carolina Alternatives 1, 4 6/30/99Health Care Connection 1 11/29/99

North Carolina

Health Maintenance Organization (HMO) 1 11/29/99North Dakota North Dakota Access and Care Program 1 5/5/01Ohio None -- --Oklahoma None -- --Oregon Tri-County Metro. Transportation District 4 1/25/01

Family Care Network 1 7/26/01HealthChoices SE - Behavioral 1, 2, 3, 4 1/26/00HealthChoices SE – Physical Health 1, 2, 3, 4 1/26/00HealthChoices SW - Behavioral 1, 2, 3, 4 12/31/99HealthChoices SW – Physical Health 1, 2, 3, 4 12/31/99

Pennsylvania

Lancaster Community Health Plan 1 7/21/00Rhode Island None -- --South Carolina High Risk Channeling Project (HRCP) 1, 3, 4 2/11/01South Dakota Prime 1, 3 7/1/00Tennessee None -- --

Lonestar Select I 4 9/3/00Lonestar Select II 4 8/19/99HMO - STAR 1, 2, 3, 4 8/31/010HMO - STAR Plus (+) 1, 2, 3, 4 1/31/00

Texas

PCCM - STAR Plus (+) 1, 2, 3, 4 1/31/00




Statutes Utilized ExpirationChoice of Health Care Delivery 1, 2, 4 2/16/01

UtahPrepaid Mental Health Program 4 10/28/99

Vermont None -- --Medallion 1 9/24/99

VirginiaMedallion II 1, 4 9/27/00Mental Health Services 1, 4 11/7/99Healthy Options 1, 4 2/24/01WashingtonHospital Selective Contracting 4 12/31/00Mountain Health Care Trust 1, 4 8/26/99

West VirginiaPhysician Assured Access System (PAAS) 1 9/5/99

Wisconsin None -- --Wyoming Hospital Inpatient Selective Contracting 4 3/15/01

Source: 1999 National Summary of State Medicaid Managed Care Programs. Program Descriptions as of June 30, 1999. U.S. Departmentof Health and Human Services, Health Care Financing Administration, Office of Managed Care.



Section 1115 Research and Demonstration Waivers

State Program Implemented Expiration

Alabama Bay Health Plan 5/1/97 10/1/99

Arizona Arizona Health Care Cost Containment System(AHCCCS) 10/1/82 9/30/99

On Lock Senior Health Services 11/1/83 9/30/00

Senior Care Action Network 1/1/85 4/30/00

Sutter Senior Care 5/1/94 9/30/00California

Centers For Elders Independence 4/1/95 9/30/00

Delaware Diamond State Health Plan 1/1/96 12/31/03

District of Columbia Health Services for Children w/Spec. Needs 2/1/96 12/1/99

Hawaii Hawaii QUEST 8/1/94 3/31/02

Kentucky Kentucky Partnerships 11/1/97 10/31/02

Maryland Health Choice 7/1/97 6/1/02

Massachusetts Mass Health 7/1/97 4/30/01

Minnesota Senior Health Options Program (MSHO) 3/1/97 2/28/02

MinnesotaCare Program for Families and Children 7/1/95 6/30/02Minnesota

Prepaid Medical Assistance Program Plus (PMAP+) 7/1/85 6/30/02

Missouri Managed Care Plus (MC+) 9/1/95 3/14/00

Montana HMO 2/1/96 1/31/04

New York New York State Managed Care Program 10/1/97 7/14/02

Ohio Ohio 1115 (TANF & TANF-related) 7/1/96 6/30/01

SoonerCare Choice PCCM Model 1/1/96 12/31/00Oklahoma

SoonerCare Plus MCO Model 1/1/96 12/31/00

Oregon Oregon Health Plan 2/1/94 1/31/02

Rhode Island Rite Care 8/1/94 7/31/02

Tennessee TennCare 1/1/94 12/31/01

Vermont Vermont Health Access 1/1/96 12/31/01

Wisconsin WI Partnership Program 1/1/96 N/A

Source: 1999 National Summary of State Medicaid Managed Care Programs. Program Descriptions as of June 30, 1999. U.S. Departmentof Health and Human Services, Health Care Financing Administration, Office of Managed Care; Comprehensive Health Care ReformDemonstrations (12/8/00). Available at http://www.hcfa.gov/medicaid/ord-demo.htm. Accessed December 2000.



Section 3:State Characteristics





Age Demographics, 1999

StateTotal StatePopulation

Percent Ages20 and under

PercentAges 21-44

PercentAges 45-64

PercentAges 65+

National Total 271,742,826 30.8% 35.9% 21.4% 11.9%Alabama 4,200,926 27.7% 35.5% 24.0% 12.8%Alaska 646,842 38.0% 38.7% 18.4% 4.9%Arizona 4,905,332 33.2% 36.1% 19.7% 11.0%Arkansas 2,562,587 30.1% 35.0% 19.9% 15.0%California 33,375,150 32.2% 37.9% 19.6% 10.3%Colorado 3,970,806 28.8% 42.1% 20.2% 8.9%Connecticut 3,283,332 29.2% 32.8% 24.8% 13.1%Delaware 783,012 31.2% 35.5% 19.2% 14.0%District of Columbia 511,711 23.2% 41.8% 20.1% 14.8%Florida 14,677,912 26.4% 34.1% 21.2% 18.3%Georgia 7,666,432 31.1% 36.5% 22.8% 9.7%Hawaii 1,200,863 30.2% 35.7% 20.4% 13.6%Idaho 1,274,230 34.7% 33.7% 21.2% 10.4%Illinois 12,294,861 33.1% 36.4% 19.6% 10.8%Indiana 5,839,738 30.8% 35.2% 22.6% 11.4%Iowa 2,837,156 30.7% 33.8% 21.1% 14.4%Kansas 2,616,318 31.4% 33.6% 19.7% 15.3%Kentucky 3,864,679 29.0% 33.9% 24.9% 12.1%Louisiana 4,310,285 31.7% 35.1% 21.5% 11.6%Maine 1,266,498 27.8% 33.9% 25.5% 12.9%Maryland 5,046,171 27.2% 37.7% 21.8% 13.2%Massachusetts 6,116,806 29.3% 36.5% 21.5% 12.7%Michigan 10,040,679 33.3% 35.2% 19.9% 11.6%Minnesota 4,833,278 34.1% 35.8% 19.4% 10.7%Mississippi 2,761,422 32.6% 35.8% 19.0% 12.6%Missouri 5,405,443 29.5% 36.9% 20.8% 12.7%Montana 924,582 33.7% 34.3% 21.3% 10.7%Nebraska 1,716,417 33.5% 35.2% 19.2% 12.0%Nevada 1,862,276 33.2% 36.4% 19.9% 10.5%New Hampshire 1,224,200 32.9% 33.7% 23.5% 9.9%New Jersey 8,092,295 29.7% 36.1% 23.3% 10.9%New Mexico 1,829,164 35.7% 31.6% 20.2% 12.4%New York 18,420,007 30.5% 35.5% 21.1% 13.0%North Carolina 7,426,910 28.2% 36.1% 23.2% 12.5%North Dakota 646,079 33.7% 32.3% 20.2% 13.9%Ohio 11,224,522 30.0% 35.3% 22.6% 12.1%Oklahoma 3,268,838 29.2% 33.4% 23.7% 13.7%Oregon 3,355,739 30.2% 35.2% 23.8% 10.7%Pennsylvania 11,912,109 28.6% 34.4% 23.4% 13.6%Rhode Island 968,057 27.9% 34.9% 21.8% 15.4%South Carolina 3,851,167 29.6% 35.0% 22.8% 12.6%South Dakota 711,326 32.9% 33.1% 21.2% 12.9%Tennessee 5,572,470 31.5% 34.1% 23.9% 10.5%Texas 19,944,736 33.5% 36.7% 20.2% 9.5%Utah 2,105,665 37.7% 37.3% 17.4% 7.6%Vermont 593,161 29.4% 37.1% 23.0% 10.5%Virginia 6,687,894 29.5% 36.4% 22.2% 12.0%Washington 5,747,382 30.5% 37.5% 22.4% 9.6%West Virginia 1,750,073 24.8% 33.0% 24.7% 17.5%Wisconsin 5,128,974 28.4% 36.7% 23.1% 11.8%Wyoming 486,314 31.3% 34.4% 23.4% 10.9%

Source: The Lewin Group analysis of the Current Population Survey, March 2000 Supplement.



Race Demographics, 1999


PercentWhite

PercentBlack

PercentHispanic

PercentOther

National Total 271,742,826 71.1% 12.5% 11.7% 4.7%Alabama 4,200,926 71.1% 27.1% 0.8% 0.9%Alaska 646,842 73.0% 4.1% 1.8% 21.0%Arizona 4,905,332 65.5% 2.7% 28.7% 3.0%Arkansas 2,562,587 79.4% 17.5% 1.4% 1.7%California 33,375,150 50.3% 6.5% 30.3% 12.9%Colorado 3,970,806 79.8% 3.0% 14.4% 2.8%Connecticut 3,283,332 76.3% 11.9% 9.9% 1.9%Delaware 783,012 69.6% 25.4% 3.5% 1.5%District of Columbia 511,711 25.9% 64.6% 6.3% 3.2%Florida 14,677,912 65.4% 15.1% 17.6% 1.9%Georgia 7,666,432 62.0% 32.9% 3.3% 1.8%Hawaii 1,200,863 21.7% 2.9% 4.3% 71.1%Idaho 1,274,230 86.6% 0.3% 10.9% 2.3%Illinois 12,294,861 71.0% 16.0% 10.1% 2.9%Indiana 5,839,738 90.9% 5.9% 2.5% 0.8%Iowa 2,837,156 92.5% 1.9% 3.4% 2.2%Kansas 2,616,318 84.6% 8.8% 4.1% 2.4%Kentucky 3,864,679 89.0% 8.9% 1.4% 0.7%Louisiana 4,310,285 61.5% 35.2% 1.6% 1.8%Maine 1,266,498 97.9% 0.1% 0.6% 1.4%Maryland 5,046,171 63.7% 27.0% 3.3% 5.9%Massachusetts 6,116,806 84.1% 5.8% 6.1% 3.9%Michigan 10,040,679 80.5% 14.2% 2.8% 2.5%Minnesota 4,833,278 89.4% 2.5% 2.8% 5.3%Mississippi 2,761,422 61.9% 37.0% 0.8% 0.4%Missouri 5,405,443 85.8% 11.0% 1.2% 2.0%Montana 924,582 88.5% 0.2% 1.8% 9.5%Nebraska 1,716,417 88.7% 4.5% 4.3% 2.5%Nevada 1,862,276 70.3% 5.0% 18.5% 6.3%New Hampshire 1,224,200 96.6% 1.0% 1.0% 1.4%New Jersey 8,092,295 69.5% 14.3% 12.1% 4.2%New Mexico 1,829,164 47.6% 1.2% 40.4% 10.9%New York 18,420,007 64.1% 15.2% 15.2% 5.5%North Carolina 7,426,910 69.5% 24.1% 3.0% 3.4%North Dakota 646,079 91.6% 0.2% 0.6% 7.6%Ohio 11,224,522 86.4% 11.3% 1.4% 0.9%Oklahoma 3,268,838 79.6% 7.5% 2.6% 10.3%Oregon 3,355,739 85.9% 2.2% 6.3% 5.6%Pennsylvania 11,912,109 84.3% 10.5% 3.0% 2.2%Rhode Island 968,057 84.8% 5.3% 5.9% 4.1%South Carolina 3,851,167 71.2% 26.8% 0.8% 1.2%South Dakota 711,326 92.0% 1.6% 0.5% 5.8%Tennessee 5,572,470 82.2% 15.8% 0.8% 1.1%Texas 19,944,736 51.1% 12.5% 32.9% 3.4%Utah 2,105,665 88.7% 1.3% 5.8% 4.2%Vermont 593,161 97.7% 0.3% 0.4% 1.6%Virginia 6,687,894 73.0% 19.3% 2.5% 5.2%Washington 5,747,382 88.8% 1.8% 4.0% 5.4%West Virginia 1,750,073 94.2% 4.3% 0.4% 1.1%Wisconsin 5,128,974 88.5% 6.7% 1.9% 3.0%Wyoming 486,314 92.6% 1.6% 4.4% 1.4%




Insurance Status, 1999


MedicaidPopulation

Percent Coveredby Medicaid

MedicarePopulation

Percent Coveredby Medicare

National Total 271,742,826 28,485,614 10.5% 35,886,603 13.2%Alabama 4,200,926 399,999 9.5% 634,905 15.1%Alaska 646,842 117,183 18.1% 33,271 5.1%Arizona 4,905,332 438,939 8.9% 598,907 12.2%Arkansas 2,562,587 264,677 10.3% 429,046 16.7%California 33,375,150 4,277,170 12.8% 3,782,175 11.3%Colorado 3,970,806 172,031 4.3% 402,074 10.1%Connecticut 3,283,332 232,809 7.1% 495,807 15.1%Delaware 783,012 72,312 9.2% 115,330 14.7%District of Columbia 511,711 107,897 21.1% 80,852 15.8%Florida 14,677,912 1,243,033 8.5% 2,901,579 19.8%Georgia 7,666,432 960,075 12.5% 863,436 11.3%Hawaii 1,200,863 124,588 10.4% 161,514 13.4%Idaho 1,274,230 117,487 9.2% 147,135 11.5%Illinois 12,294,861 1,068,655 8.7% 1,451,317 11.8%Indiana 5,839,738 321,825 5.5% 758,451 13.0%Iowa 2,837,156 204,886 7.2% 426,795 15.0%Kansas 2,616,318 205,572 7.9% 426,411 16.3%Kentucky 3,864,679 408,724 10.6% 549,788 14.2%Louisiana 4,310,285 584,223 13.6% 592,659 13.7%Maine 1,266,498 126,610 10.0% 194,020 15.3%Maryland 5,046,171 222,431 4.4% 695,125 13.8%Massachusetts 6,116,806 795,817 13.0% 849,412 13.9%Michigan 10,040,679 1,138,541 11.3% 1,271,138 12.7%Minnesota 4,833,278 441,987 9.1% 535,510 11.1%Mississippi 2,761,422 309,529 11.2% 419,869 15.2%Missouri 5,405,443 506,629 9.4% 768,233 14.2%Montana 924,582 130,020 14.1% 113,110 12.2%Nebraska 1,716,417 168,997 9.8% 220,248 12.8%Nevada 1,862,276 93,607 5.0% 213,939 11.5%New Hampshire 1,224,200 103,841 8.5% 128,917 10.5%New Jersey 8,092,295 499,489 6.2% 932,604 11.5%New Mexico 1,829,164 326,668 17.9% 262,578 14.4%New York 18,420,007 2,792,226 15.2% 2,596,260 14.1%North Carolina 7,426,910 730,203 9.8% 1,073,054 14.4%North Dakota 646,079 67,742 10.5% 95,936 14.8%Ohio 11,224,522 1,068,729 9.5% 1,564,115 13.9%Oklahoma 3,268,838 384,492 11.8% 530,082 16.2%Oregon 3,355,739 480,716 14.3% 411,036 12.2%Pennsylvania 11,912,109 1,227,356 10.3% 1,761,765 14.8%Rhode Island 968,057 89,947 9.3% 160,201 16.5%South Carolina 3,851,167 355,727 9.2% 582,075 15.1%South Dakota 711,326 75,786 10.7% 99,149 13.9%Tennessee 5,572,470 1,083,307 19.4% 644,347 11.6%Texas 19,944,736 1,895,039 9.5% 2,070,144 10.4%Utah 2,105,665 151,444 7.2% 179,783 8.5%Vermont 593,161 93,991 15.8% 69,493 11.7%Virginia 6,687,894 355,615 5.3% 928,879 13.9%Washington 5,747,382 684,140 11.9% 593,766 10.3%West Virginia 1,750,073 273,880 15.6% 349,774 20.0%Wisconsin 5,128,974 457,212 8.9% 657,393 12.8%Wyoming 486,314 31,811 6.5% 63,196 13.0%




Income and Employment, 1999


Percent Below 100% PovertyLevel

PercentUnemployed

National Total 271,742,826 13.1% 2.0%Alabama 4,200,926 15.1% 1.9%Alaska 646,842 10.4% 3.7%Arizona 4,905,332 16.8% 1.8%Arkansas 2,562,587 15.0% 1.7%California 33,375,150 15.6% 2.7%Colorado 3,970,806 9.3% 1.1%Connecticut 3,283,332 10.1% 1.5%Delaware 783,012 10.9% 1.4%District of Columbia 511,711 23.0% 3.9%Florida 14,677,912 13.6% 1.5%Georgia 7,666,432 14.7% 2.3%Hawaii 1,200,863 10.9% 2.6%Idaho 1,274,230 13.2% 2.4%Illinois 12,294,861 11.0% 1.5%Indiana 5,839,738 9.8% 1.0%Iowa 2,837,156 8.5% 1.4%Kansas 2,616,318 9.9% 1.2%Kentucky 3,864,679 14.6% 2.3%Louisiana 4,310,285 20.1% 2.0%Maine 1,266,498 10.8% 2.2%Maryland 5,046,171 7.7% 1.6%Massachusetts 6,116,806 9.2% 1.7%Michigan 10,040,679 11.4% 2.0%Minnesota 4,833,278 10.7% 1.3%Mississippi 2,761,422 17.4% 2.4%Missouri 5,405,443 10.1% 1.8%Montana 924,582 17.3% 2.9%Nebraska 1,716,417 13.2% 1.0%Nevada 1,862,276 11.2% 2.4%New Hampshire 1,224,200 10.0% 1.6%New Jersey 8,092,295 9.1% 2.6%New Mexico 1,829,164 20.4% 2.2%New York 18,420,007 17.0% 2.4%North Carolina 7,426,910 14.8% 1.4%North Dakota 646,079 15.2% 2.4%Ohio 11,224,522 11.4% 1.7%Oklahoma 3,268,838 14.8% 1.7%Oregon 3,355,739 15.1% 3.0%Pennsylvania 11,912,109 11.6% 2.3%Rhode Island 968,057 11.7% 1.6%South Carolina 3,851,167 13.0% 1.5%South Dakota 711,326 10.7% 1.3%Tennessee 5,572,470 12.8% 2.2%Texas 19,944,736 15.3% 1.8%Utah 2,105,665 9.4% 1.7%Vermont 593,161 10.0% 2.5%Virginia 6,687,894 8.9% 1.0%Washington 5,747,382 9.0% 1.8%West Virginia 1,750,073 18.0% 2.9%Wisconsin 5,128,974 8.9% 1.9%Wyoming 486,314 11.7% 2.3%




Medicaid/Medicare Certified Facilities

State HospitalsSkilled Nursing

FacilitiesICF-MRFacilities

Home HealthAgencies

Rural HealthClinics

National Total* 6,052 14,831 6,731 7,160 3,352Alabama 123 221 8 143 60Alaska 24 15 0 16 11Arizona 85 149 11 68 8Arkansas 96 193 40 182 82California 468 1,269 1,041 579 225Colorado 83 202 3 131 43Connecticut 47 250 122 82 0Delaware 11 38 2 16 0District of Columbia 16 19 131 16 0Florida 239 724 108 318 135Georgia 182 326 13 99 125Hawaii 27 41 22 19 1Idaho 48 82 67 54 35Illinois 219 658 318 288 198Indiana 151 496 574 180 52Iowa 120 300 127 180 134Kansas 149 264 42 149 156Kentucky 118 307 12 111 72Louisiana 175 225 473 255 49Maine 41 126 28 36 50Maryland 67 244 5 53 0Massachusetts 119 505 7 133 0Michigan 174 389 2 193 153Minnesota 151 412 272 250 60Mississippi 104 132 13 62 133Missouri 141 455 18 171 163Montana 62 101 2 51 32Nebraska 96 172 4 70 76Nevada 42 49 20 36 2New Hampshire 30 67 1 35 21New Jersey 107 306 9 54 0New Mexico 51 69 43 67 14New York 268 665 750 211 10North Carolina 135 407 333 165 125North Dakota 51 88 66 35 80Ohio 205 893 461 348 17Oklahoma 151 242 54 188 61Oregon 63 124 1 60 30Pennsylvania 252 752 206 328 53Rhode Island 17 99 5 25 1South Carolina 76 178 158 78 96South Dakota 63 89 4 46 55Tennessee 148 276 83 153 34Texas 479 1,014 915 860 391Utah 50 81 14 43 15Vermont 16 42 2 13 23Virginia 118 229 19 161 58Washington 97 266 17 62 61West Virginia 66 114 62 68 69Wisconsin 142 369 41 131 65Wyoming 27 34 2 39 18

*National total does not include certified facilities in US territories.Source: Oscar Report 10. Facility Counts: Active Providers. Health Care Financing Administration, Center for Medicaid and StateOperations. December 2000.



Licensed Pharmacies (As of June 30, 2000)*

StateTotal

Pharmacies

Hospital/InstitutionalPharmacies

IndependentPharmacies

Non-IndependentCommunityPharmacies

(Four or More)

Out-of-State orNon-Resident

PharmaciesNational Total 73,781 8,502 25,273 15,046 7,714Alabama 1,779 178 816 548 237Alaska 111 (g) 12 (h) - - 122Arizona 845 110 158 577 0Arkansas 739 173 230 509 117California 6,271 647 5,456 (a) - 168Colorado 817 - - - 205Connecticut 685 58 207 420 175Delaware 154 13 19 128 216District of Columbia 150 15 60 75 0Florida 6,176 1,965 3,581 (a) (a) 272Georgia 2,358 216 (p) (p) -Hawaii 407 - - - 167Idaho 486 57 250 (a, e) - 159Illinois 2,788 358 2,429 (a) (a) 198Indiana 1,353 197 - - 145Iowa 1,188 131 (f) 825 (a, f) (a) 216Kansas 787 178 609 (a) - 230Kentucky 1,438 125 466 671 176Louisiana 1,663 171 585 520 223Maine 290 42 - - 187Maryland 1,243 (i) 61 274 600 175Massachusetts 1,189 (j) 158 345 669 0Michigan 2,329 - - 31 -Minnesota 1,338 181 516 461 200Mississippi 962 130 - - 220Missouri 1,550 (k) 135 - - 254Montana 318 24 - - 111Nebraska 464 95 - - 181 (l)Nevada 575 43 187 345 172New Hampshire 263 34 47 169 0New Jersey 2,308 - - - -New Mexico 541 56 128 (a) 152 (a) 182New York 4,456 499 2,042 1,902 N/ANorth Carolina 2,032 (f) 154 554 967 189North Dakota 421 48 162 20 191Ohio 2,833 (n) 228 574 1,574 234Oklahoma 1,275 90 (d) 913 (a) (a) 257Oregon 1,003 118 280 427 172Pennsylvania 3,198 303 - - -Rhode Island 206 22 48 138 210South Carolina 1,079 136 285 566 215South Dakota 421 41 146 75 159Tennessee 1,710 370 493 727 120Texas (a) 5,488 (b) 594 1,664 2,153 188Utah 689 103 375 (a) (a) 157Vermont 154 17 137 - 0Virginia 1,513 - - - 307Washington 1,440 216 (c) 412 628 184West Virginia 797 - - - 217Wisconsin 1,125 - - 0 0Wyoming 348 - - - 206

*Figures reported reflect number of pharmacies licensed by state boards of pharmacy.Individual columns will not sum to total. Blanks (-) indicate that information was not available.Source: 2000-2001 National Association of Boards of Pharmacy, Survey of Pharmacy Law.



LEGEND

a – Chains included in independent community pharmacies figure.b – Also licenses 889 nuclear, public health, clinic, ambulatory surgical center, and HMO pharmacy.c – Includes 107 hospital, 17 nursing home, 25 home infusion, six nuclear, 42 HMO, and 19 other pharmacies.d – Approximately.e – Plus 19 limited service and 53 parenteral admixture pharmacies.f – In-state.g – Includes eight wholesalers drug distributors.h – Drug rooms.i – Total includes other areas not listed: clinic, correctional, HMO, nursing home, IV nuclear, research, and other.j – Total also includes 12 home IV pharmacies, 11LTCF pharmacies, and one mail order pharmacy.k – Includes 1,296 class A community/ambulatory pharmacies (no breakdown available between independent and chains[4 or more]). Plus six long-term care, 26 home health, three nuclear, and one renal dialysis.l – Nebraska “registers” out-of-state pharmacies.m – Plus 336 who are practicing, but place is unknown.n – Includes 223 nuclear, clinic, fluid therapy, mail order, specialty, and pharmacies serving nursing homes only.o – As of January 7, 2000.p – 2,142 (2,098 independent and chain pharmacies, 10 nuclear pharmacies, 28 prison pharmacies, four pharmacy clinics, andtwo pharmacy school).



Physicians, 1998

State PhysiciansPhysiciansPer 1,000

Office BasedPhysicians

PercentOffice Based

Primary CarePhysicians

PercentPrimary Care

National Total 696,600 2.6% 462,719 66.4% 249,291 35.8%Alabama 8,816 2.1% 6,316 71.6% 3,335 37.8%Alaska 1,185 1.8% 850 71.7% 439 37.0%Arizona 9,821 2.0% 6,991 71.2% 3,393 34.5%Arkansas 4,966 1.9% 3,615 72.8% 1,957 39.4%California 82,640 2.5% 58,077 70.3% 29,432 35.6%Colorado 9,734 2.5% 6,988 71.8% 3,523 36.2%Connecticut 11,746 3.6% 7,387 62.9% 3,979 33.9%Delaware 1,787 2.3% 1,216 68.0% 594 33.2%District of Columbia 4,180 8.2% 1,990 47.6% 1,225 29.3%Florida 36,573 2.5% 27,359 74.8% 12,327 33.7%Georgia 16,821 2.2% 11,700 69.6% 6,122 36.4%Hawaii 3,372 2.8% 2,385 70.7% 1,283 38.0%Idaho 1,959 1.5% 1,619 82.6% 775 39.6%Illinois 31,902 2.6% 20,107 63.0% 12,478 39.1%Indiana 11,630 2.0% 8,429 72.5% 4,442 38.2%Iowa 5,051 1.8% 3,499 69.3% 1,963 38.9%Kansas 5,517 2.1% 3,817 69.2% 2,161 39.2%Kentucky 8,381 2.2% 6,078 72.5% 3,137 37.4%Louisiana 10,972 2.5% 7,295 66.5% 3,795 34.6%Maine 2,831 2.2% 2,071 73.2% 1,097 38.7%Maryland 20,925 4.1% 11,807 56.4% 6,400 30.6%Massachusetts 25,729 4.2% 14,659 57.0% 7,956 30.9%Michigan 22,229 2.2% 14,040 63.2% 8,296 37.3%Minnesota 12,019 2.5% 8,058 67.0% 4,769 39.7%Mississippi 4,710 1.7% 3,380 71.8% 1,744 37.0%Missouri 12,801 2.4% 8,229 64.3% 4,303 33.6%Montana 1,723 1.9% 1,442 83.7% 630 36.6%Nebraska 3,692 2.2% 2,512 68.0% 1,501 40.7%Nevada 3,115 1.7% 2,466 79.2% 1,141 36.6%New Hampshire 2,860 2.3% 2,045 71.5% 1,058 37.0%New Jersey 24,200 3.0% 15,954 65.9% 8,856 36.6%New Mexico 3,911 2.1% 2,585 66.1% 1,435 36.7%New York 71,186 3.9% 39,872 56.0% 24,934 35.0%North Carolina 17,991 2.4% 12,157 67.6% 6,438 35.8%North Dakota 1,456 2.3% 1,075 73.8% 603 41.4%Ohio 26,822 2.4% 17,653 65.8% 10,017 37.3%Oklahoma 5,841 1.8% 4,165 71.3% 2,158 36.9%Oregon 7,585 2.3% 5,644 74.4% 2,832 37.3%Pennsylvania 35,394 3.0% 22,502 63.6% 12,170 34.4%Rhode Island 3,397 3.5% 2,050 60.3% 1,260 37.1%South Carolina 8,196 2.1% 5,725 69.9% 3,086 37.7%South Dakota 1,434 2.0% 1,105 77.1% 591 41.2%Tennessee 13,728 2.5% 9,589 69.8% 4,946 36.0%Texas 41,512 2.1% 28,526 68.7% 14,505 34.9%Utah 4,297 2.0% 3,003 69.9% 1,535 35.7%Vermont 1,837 3.1% 1,154 62.8% 746 40.6%Virginia 17,298 2.6% 11,571 66.9% 6,253 36.1%Washington 13,901 2.4% 9,923 71.4% 5,117 36.8%West Virginia 4,029 2.3% 2,659 66.0% 1,551 38.5%Wisconsin 12,037 2.3% 8,723 72.5% 4,622 38.4%Wyoming 861 1.8% 657 76.3% 381 44.3%

Source: Area Resource File. Office of Research and Planning, Bureau of Health Professions. February 2000.



Other Providers

State Registered Nurses*Registered Nurses*

per 1,000Pharmacists**

(Licensed by State)Pharmacists**

per 1,000National Total 2,161,700 8.1 334,851 1.2Alabama 32,800 7.6 6,541 1.6Alaska 6,300 10.3 518 0.8Arizona 33,200 7.3 5,548 1.1Arkansas 17,900 7.1 3,374 1.3California 179,700 5.6 27,152 0.8Colorado 30,900 7.9 5,254 1.3Connecticut 33,400 10.2 4,265 1.3Delaware 7,700 10.5 1,209 1.5District of Columbia 8,900 16.8 1,350 2.6Florida 119,300 8.1 19,425 1.3Georgia 53,600 7.2 9,551 1.2Hawaii 8,900 7.5 1,372 1.1Idaho 7,100 5.9 1,447 1.1Illinois 104,700 8.8 12,278 1.0Indiana 46,900 8.0 8,038 1.4Iowa 29,100 10.2 4,878 1.7Kansas 21,600 8.3 3,540 1.4Kentucky 30,400 7.8 4,746 1.2Louisiana 32,400 7.4 5,774 1.3Maine 13,300 10.7 1,267 1.0Maryland 43,000 8.4 6,700 1.3Massachusetts 73,300 12.0 9,283 1.5Michigan 79,600 8.1 10,693 1.1Minnesota 46,200 9.9 5,628 1.2Mississippi 19,900 7.3 3,440 1.2Missouri 51,200 9.5 6,317 1.2Montana 7,100 8.1 1,262 1.4Nebraska 15,200 9.2 2,445 1.4Nevada 9,900 5.9 7,427 4.0New Hampshire 11,200 9.6 1,824 1.5New Jersey 67,100 8.3 15,542 1.9New Mexico 11,700 6.8 2,258 1.2New York 167,600 9.2 18,780 1.0North Carolina 62,000 8.4 8,977 1.2North Dakota 6,400 10.2 2,039 3.2Ohio 101,200 9.1 13,797 1.2Oklahoma 19,600 5.9 4,560 1.4Oregon 26,500 8.2 3,952 1.2Pennsylvania 126,300 10.5 16,894 1.4Rhode Island 11,400 11.6 1,723 1.8South Carolina 27,400 7.3 5,116 1.3South Dakota 7,700 10.4 1,391 2.0Tennessee 46,400 8.0 7,358 1.3Texas 124,200 6.4 19,825 1.0Utah 13,000 6.3 2,140 1.0Vermont 5,300 9.0 793 1.3Virginia 54,400 8.1 7,471 1.1Washington 43,500 7.8 6,279 1.1West Virginia 15,000 8.3 2,948 1.7Wisconsin 45,600 8.8 5,837 1.1Wyoming 4,200 8.8 1,001 2.1

*As of December 1996. ** As of June 30, 2000.Source: U.S. Department of Health and Human Services, Health Resources and Services Administration, Division of Nursing, 1996.2000-2001 National Association of Boards of Pharmacy, Survey of Pharmacy Law.





Section 4:Pharmacy ProgramCharacteristics





THE MEDICAID PROGRAM

Medicaid (Title XIX of the Federal Social Security Act) is a Federal-State funded program of national healthassistance that provides health care coverage to certain individuals and families with low-incomes and resources.The 50 States, the District of Columbia, and the U.S. territories of Puerto Rico, Guam, Virgin Islands, AmericanSamoa, and Northern Mariana Islands each operate medical assistance programs according to state or territorialrules and criteria that vary within a broad framework of federal guidelines.

MEDICAID RECIPIENTS

Every state, in order to receive federal funding under Title XIX, must provide Medicaid benefits to certain“categorically needy” persons. Categorically needy individuals include those who meet the requirements for theblock grant Temporary Assistance for Needy Families (TANF) program (replaced the Aid to Families withDependent Children (AFDC) program); and, with a few exceptions, the aged, blind, and disabled who receiveSupplemental Security Income (SSI). Other groups that are categorically needy and thus automatically eligiblefor Medicaid include:

• Children under age six whose family income is at or below 133% of the Federal poverty level (FPL),

• All children (under age 19) born after September 30, 1983 in families with incomes at or below the FPL,

• Pregnant women whose family income is below 133% of the FPL,

• Certain Medicare beneficiaries, and

• Recipients of adoption assistance and foster care under Title IV-E of the Social Security Act.

States may also provide Medicaid coverage to optional groups, or other “categorically needy” groups. Optionalcoverage may be extended to certain aged, blind, or disabled persons who do not normally qualify for mandatorycoverage due to higher incomes, but who are below the FPL. Coverage may also be extended to pregnant womenand infants up to age one who are not covered under mandatory coverage, but whose income is also below thefederal poverty level.

In addition to the “categorically needy” that must be covered by Medicaid programs, there are other groups whoare “medically needy” who may be included in Medicaid at the option of each state. States may elect to provideservices to persons whose income levels are above the level to qualify for Medicaid but have medical expenses soexcessive as to offset their incomes.

Along with designating groups of people who must be covered by a state’s Medicaid plan and defining othergroups that may be covered at the discretion of the state, the federal government specifies certain generalrequirements that must be met for Medicaid eligibility. A state can provide coverage for persons who do not meetthese requirements (i.e., the uninsured), but state and/or local funds must be used to support the medical expensesof these individuals. A Medicaid agency that chooses to cover other optional groups must provide Medicaid to alleligible individuals in that group.

MEDICAID SERVICES

The original Title XIX legislation listed several types of medical care as eligible for federal funding. Federalregulations pertaining to Medicaid mandate that in order to receive federal matching funds, certain basic servicesmust be offered to all “categorically needy” individuals. 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 areotherwise covered under the State plan;

• Nurse-midwife services (to the extent authorized under State law);

• Pediatric and family nurse practitioners services; and

• Federally-qualified health center services and any other ambulatory services offered by a federally-qualified health center that are otherwise covered under the State plan.

If a State chooses to include the “medically needy” population, the State plan must provide, as a minimum, thefollowing 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 facilitiesfor the mentally retarded (ICF/MRs), it must offer medically needy groups certain services provided tothe categorically needy.

States may also receive Federal funding if they elect to provide other optional services. The most commonlycovered optional services under the Medicaid program include:

• Clinic services;

• Intermediate care facilities for the mentally retarded (ICFs/MR);

• Nursing facility services (children under 21 years old);

• Prescribed drugs;

• Optometrist services and eyeglasses;

• TB-related services for TB infected persons;

• Prosthetic devices; and

• Dental services.

States may provide home and community-based care waiver services to certain individuals who are eligible forMedicaid. 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, rehabilitation, and other servicesrequested by the State and approved by HCFA.



CHARACTERISTICS OF BENEFITS PROVIDED

Inpatient Hospital Services

Inpatient hospital services are those ordinarily furnished in a hospital for the care and treatment of inpatients. Thefacility is one maintained primarily for the care and treatment of patients with disorders other than mentaldiseases. There are several general federal limitations on inpatient hospital services that apply to all states withMedicaid programs (42 CFR 440.10):

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

• The facility must meet the requirements for participation in Medicare;

• The care and treatment of inpatients must be under the direction of a physician or dentist; and

• The facility must have in effect an approved utilization review plan, applicable to all Medicaid patients,unless a waiver has been granted by the Secretary of Health and Human Services.

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 servicesprovided to an outpatient. Three federal limitations are imposed on these services; though states are free tospecify 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 forstate standard setting; and

• The facility must meet the requirements for participation in Medicare.

Rural Health Clinic Services

Rural health clinic (RHC) services became mandatory for the categorically needy in July 1978. Each RHC isrequired to have a nurse practitioner (NP) or physician’s assistant (PA) on its staff. Therefore, a clinic can becertified only if the state permits the delivery of primary care by an NP or PA. Services in certified clinics mustbe provided and furnished by a physician or by a PA, NP, nurse-midwife, or other specialized nurse practitioner.Services and supplies are furnished as an incident to professional services. Part-time or intermittent visiting nursecare and related medical supplies are provided if the clinic is located in a Health Manpower Shortage Area, theservices are furnished by nurses employed by the clinic, and the services are furnished to a homebound recipientunder 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. Asspecified in 42 CFR 440.30 (a-c), federal requirements for Medicaid mandate that these services be:

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

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

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



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

Skilled Nursing Facility Services

Skilled nursing facility (SNF) services are provided to individuals age 21 or older. They do not include servicesprovided in institutions for mental diseases (42 CFR 440.40(a)). These services must be required on a daily basisand 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 forparticipation. These requirements include provider agreements, facility certification, and facilitystandards; and

• Ordered by and under the direction of a physician.

The services include those provided by any facility located on an Indian reservation and certified by the Secretaryof Health and Human Services. Further, the requirements concerning control of the utilization of Medicaidservices affect skilled nursing facility services in areas such as certification and re-certification of need forinpatient care, individual written plan of care, etc.

Early and Periodic Screening, Diagnosis and Treatment

Early and periodic screening, diagnosis and treatment (EPSDT) refers to screening and diagnostic services todetermine physical or mental defects in recipients under age 21, as well as health care, treatment and othermeasures to correct or ameliorate any defects and chronic conditions discovered (42 CFR 440.40(b)). Certainbasic screening and treatment services must be provided by each state as a minimum (42 CFR 441.56). Theseservices include:

• Health and developmental history screening;

• Unclothed physical examination;

• Developmental assessment;

• Immunizations appropriate for age and health history;

• Assessment of nutritional status;

• Vision testing;

• Hearing testing;

• Laboratory procedures appropriate for age and population group;

• Dental services furnished by direct referral to a dentist for diagnosis and treatment for children three yearsof age and over;

• Treatment of defects in vision and hearing, including eyeglasses and hearing aids; and

• Dental care needed for relief of pain and infections, restoration of teeth and maintenance of dental health.

The state Medicaid agency may provide for any other medical or remedial care specified as a Medicaid serviceeven if the agency does not otherwise provide for these services to other recipients or provides for them in a lesseramount, duration, or scope.

Family Planning Services

Family planning services and supplies are allowable for women of childbearing age as a means of enablingindividuals to freely determine the number and spacing of their children. Although there are no federalregulations defining what family planning services a state can provide, provisional regulations define familyplanning services as consultation (including counseling and patient education), examination, and treatment,



furnished by or under the supervision of a physician or prescribed by a physician; laboratory examination;medically approved methods, procedures, pharmaceutical supplies and devices to prevent conception; naturalfamily planning methods, diagnosis and treatment for infertility; and voluntary sterilization. In addition, statesmay provide any medically approved means other than abortion, for family planning purposes, if furnished by orunder supervision of a physician or if prescribed by a physician. Abortions are specifically excluded from familyplanning services and states are prohibited from considering any abortion as a family planning service.

Voluntary sterilization must be included among the range of family planning services offered by a state. Federalregulations require that the individual to be sterilized voluntarily give informed written consent and that theindividual must be mentally competent and at least 21 years of age at the time consent is obtained.

Physicians’ Services

Physicians’ services are covered, whether provided in the office, the patient’s home, a hospital, a skilled nursingfacility, or elsewhere. Such services must be within the physicians’ scope of practice of medicine or osteopathyas defined by state law, and by or under the personal supervision of an individual licensed under state law topractice 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 licensedpractitioner of the healing arts within the scope of their professional practice, as defined and limited by Federaland State law (42 CFR 440.120). The drugs must be dispensed by licensed authorized practitioners on a writtenprescription that is recorded and maintained in the pharmacist’s or 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,skilled nursing facility, or intermediate care facility (ICF), except for home health services in an ICF that are notrequired to be provided by the facility. Services provided must be on physicians’ orders as part of a written planof care that is reviewed by the physician every 62 days. Home health services include three mandatory services(part-time nursing, home health aide, medical supplies and equipment) and four optional service (physicaltherapy, occupational therapy, speech pathology, and audiology services) (42 CFR 440.70). These services aredefined 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 iscurrently licensed to practice in the state, receives written orders from the patient’s physician, documentsthe care and services provided, and has had orientation to acceptable clinical and administrative recordkeeping 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 inthe 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 toprovide medical rehabilitation.

• Home health services are provided to categorically needy recipients age 21 and over and to those under21 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, andnurse midwife, nurse practitioner, and private duty nursing. Details of these services are provided below:

• Personal Care Services: Services provided to an individual who is not an inpatient or resident of ahospital, nursing facility, immediate care facility for the mentally retarded, or institution for mentaldisease. Services are authorized by a physician in accordance with treatment or service plan authorizedby the state, provided by a qualified individual who is not a member of the recipients family, andfurnished in a home or other location.

• Rehabilitative Services: These services include any medical or remedial service recommended by aphysician or other licensed practitioner of the healing arts within the scope of state law. Services are forthe maximum reduction of physical or mental disability and restoration of a recipient to their best possiblefunctional level.

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

• Nurse Midwife: Services that encompass the management and care of mothers and newborns. Care isprovided throughout the maternity cycle and is furnished within the scope of practice authorized by thestate.

Nurse-Midwife Services

Nurse-midwife services are those concerned with management of the care of mothers and newborns throughoutthe maternity cycle. The Omnibus Budget Reconciliation Act of 1980 required that payment be made providingfor nurse-midwife services to categorically needy recipients (42 CFR 440.165). These provisions require states toprovide coverage for nurse-midwife services to the extent that the nurse-midwife is authorized to practice understate law or regulation. The statute also requires that states offer direct reimbursement to nurse-midwives as oneof the payment options. Nurse-midwives must be registered nurses who are either certified by an organizationrecognized by the Secretary of HHS or who have completed a program of study and clinical experience that hasbeen 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 servicesfurnished by a certified pediatric nurse practitioner (CPNP) or a certified family nurse practitioner (CFNP) toMedicaid recipients. These provisions require that services be covered to the extent that the CPNPs or CFNPs areauthorized to practice under state law or regulation, regardless of whether they are supervised by or associatedwith a physician or other health care provider. States are required to offer direct payment to CPNPs and CFNPsas 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 nursepractitioners, and be currently certified by the American Nurses’ Association as a pediatric nurse practitioner or afamily nurse practitioner.

Federally Qualified Health Center and other Ambulatory Services

Medicaid programs must offer Federally Qualified Health Center (FQHC) services and other ambulatory servicesoffered 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 includephysician services, services provided by physician assistants, nurse practitioners, clinical psychologists, clinicalsocial workers, and services and supplies incident to services normally covered if furnished by a physician or ifincident 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 thefollowing conditions:

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

• The Health Resources and Services Administration recommends, and the HHS Secretary determines, thatthe facility meets the requirements of the grant; or

• The Secretary determines that a facility may qualify through waivers of the requirements. Such a waivercannot exceed two years.

AMOUNT AND DURATION OF SERVICES

Within broad Federal guidelines and certain limitations, states may determine the amount and duration of servicesoffered under their Medicaid programs. Federal regulations require that the amount and/or duration of each typeof 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 ofservice to all “categorically needy” and categorically-related eligible person.

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

MEDICAID PAYMENT FOR SERVICES

In 1998, the Medicaid program provided health care services to 40.6 million people, at a cost of $142 billion. TheMedicaid program operates on the basis of a division of responsibilities between the federal government and thestates with the federal government paying states for a portion of state medical expenditures and administrativecosts. Funding for the program is shared between the two bodies, with the federal government matching statehealth care provider reimbursements at an authorized rate of between 50% and 83%, depending on the state’s percapita income (see the Federal Medical Assistance Percentage (FMAP) table, page 4-12).

The FMAP is based upon the state’s per capita income; if a state’s per capita income is equal to or greater than thenational average, the federal share is 50%. If a state’s per capita income is below the national average, the federalshare is increased up to a maximum of 83%.

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



Total U.S. Medical Assistance Recipients*by Type of Service

Service FY 1998Percent

Using Service FY 1997Percent

Using ServicePercentChange

Pharmaceuticals 19,337,543 47.6% 20,954,163 62.4% -7.7%

Physicians 18,554,746 45.6% 21,170,194 63.0% -12.4%

Hospital Outpatient 12,157,729 29.9% 13,632,035 40.6% -10.8%

Lab/X-ray 9,380,689 23.1% 11,074,000 33.0% -15.3%

EPSDT 6,174,628 15.2% 6,449,748 19.2% -4.3%

Clinic 5,285,415 13.0% 4,713,424 14.0% +12.1%

Dental 4,965,202 12.2% 5,935,344 17.7% -16.3%

Hospital Inpatient 4,408,162 10.8% 4,834,677 14.4% -8.8%

Other Practitioners 4,341,915 10.7% 5,141,685 15.3% -15.6%

Personal Support Services* 3,108,432 7.6% -- -- --

Family Planning 2,011,124 4.9% 2,091,116 6.2% -3.8%

Nursing Facility/Services 1,645,728 4.0% 1,603,018 4.8% +2.7%

Home Health Care 1,224,714 3.0% 1,861,124 5.5% -34.2%

ICF-Mentally Retarded 126,490 0.3% 136,025 0.4% -7.0%

Total Recipients 40,649,482‡ 33,579,168‡ +21.1%

*Many services originally recognized as Home Health Care, Physicians, Other Practitioners and other services are now reported asPersonal Support Services, please refer to page 4-8 for an explanation of these services.‡Figures will not add to totals due to recipients’ use of multiple services.

Source: HCFA, CMSO, HCFA-2082 Report, FY98.



Total U.S. Medical Assistance Payments*by Type of Service

Service FY 1998Percentof Total FY 1997

Percentof Total

PercentChange

Nursing Facility/Services $31,892,064,551 22.4% $30,503,842,614 24.7% +4.6%

Hospital Inpatient $24,299,261,217 17.1% $25,152,622,821 20.4% -3.4%

Pharmaceuticals $13,521,707,689 9.5% $11,972,331,192 9.7% +12.9%

ICF-Mentally Retarded $9,481,723,907 6.7% $9,798,302,785 7.9% -3.2%

Personal Support Services* $8,221,956,899 5.8% -- -- --

Physicians $6,070,022,680 4.3% $7,041,038,648 5.7% -13.8%

Hospital Outpatient $5,758,982,745 4.0% $6,168,996,402 5.0% -6.6%

Clinic $3,921,167,731 2.8% $4,252,480,130 3.4% -7.8%

Home Health Care $2,701,512,000 1.9% $12,236,599,938 9.9% -77.9%

EPSDT $1,334,828,107 0.9% $1,616,718,462 1.3% -17.4%

Lab/X-ray $938,700,266 0.7% $1,032,714,257 0.8% -9.1%

Dental $901,385,043 0.6% $979,220,296 0.8% -7.9%

Other Practitioners $587,137,593 0.4% $1,035,781,863 0.8% -43.3%

Family Planning $449,136,397 0.3% $418,365,295 0.3% +7.4%

Total Payments $142,317,903,795‡ $123,552,098,563‡ +15.2%

*Many services originally recognized as Home Health Care, Physicians, Other Practitioners and other services are now reported asPersonal Support Services, please refer to page 4-8 for an explanation of these services.‡Figures may not add to totals due to rounding.

Source: HCFA, CMSO, HCFA-2082 Report, FY98.



Federal Medical Assistance Percentage (FMAP), FY1999 and FY2000

State 1999 FMAP 2000 FMAP 2000 Enhanced FMAP*Alabama 69.27% 69.57% 78.70%Alaska** 59.80% 59.80% 71.86%Arizona 65.50% 65.92% 76.14%Arkansas 72.96% 72.85% 80.99%California 51.55% 51.67% 66.17%Colorado 50.59% 50.00% 65.00%Connecticut 50.00% 50.00% 65.00%Delaware 50.00% 50.00% 65.00%District of Columbia** 70.00% 70.00% 79.00%Florida 55.82% 56.52% 69.57%Georgia 60.47% 59.88% 71.91%Hawaii 50.00% 51.01% 65.71%Idaho 69.85% 70.15% 79.11%Illinois 50.00% 50.00% 65.00%Indiana 61.01% 61.74% 73.22%Iowa 63.32% 63.06% 74.14%Kansas 60.05% 60.03% 72.02%Kentucky 70.53% 70.55% 79.38%Louisiana 70.37% 70.32% 79.22%Maine 66.40% 66.22% 76.36%Maryland 50.00% 50.00% 65.00%Massachusetts 50.00% 50.00% 65.00%Michigan 52.72% 55.11% 68.58%Minnesota 51.50% 51.48% 66.04%Mississippi 76.78% 76.80% 83.76%Missouri 60.24% 60.51% 72.36%Montana 71.73% 72.30% 80.61%Nebraska 61.46% 60.88% 72.62%Nevada 50.00% 50.00% 65.00%New Hampshire 50.00% 50.00% 65.00%New Jersey 50.00% 50.00% 65.00%New Mexico 72.98% 73.32% 81.32%New York 50.00% 50.00% 65.00%North Carolina 63.07% 62.49% 73.74%North Dakota 69.94% 70.42% 79.29%Ohio 58.26% 58.67% 71.07%Oklahoma 70.84% 71.09% 79.76%Oregon 60.55% 59.96% 71.97%Pennsylvania 53.77% 53.82% 67.67%Rhode Island 54.05% 53.77% 67.64%South Carolina 69.85% 69.95% 78.96%South Dakota 68.16% 68.72% 78.11%Tennessee 63.09% 63.10% 74.17%Texas 62.45% 61.36% 72.95%Utah 71.78% 71.55% 80.08%Vermont 61.97% 62.24% 73.57%Virginia 51.60% 51.67% 66.17%Washington 52.50% 51.83% 66.28%West Virginia 74.47% 74.78% 82.35%Wisconsin 58.85% 58.78% 71.15%Wyoming 64.08% 64.04% 74.83%

* The "Enhanced Federal Medical Assistance Percentages" are for use in the new Children's Health Insurance Program under TitleXXI, and for some or all of children's medical assistance under the new Medicaid sections 1905(u)(2) and 1905(u)(3).

** For 1999 and 2000, the values in the table were set for state plans under Titles XIX and XXI and for capitation payments and DSHallotments under those titles. For other purposes, including programs remaining in Title IV of the Act, the percentage for Alaska is54.13% and for the District of Columbia is 50.00%.

Source: Federal Register, January 12, 1999, Vol. 64, No. 7, pages 1805-1808.



Medicaid Payments and Recipients, 1998

StateTotal

Vendor PaymentsTotal

RecipientsPayments

Per RecipientNational Total $142,317,903,795 40,649,482 $3,501Alabama $1,902,300,047 527,078 $3,609Alaska $330,378,398 74,508 $4,434Arizona $1,643,966,305 507,668 $3,238Arkansas $1,375,797,421 424,727 $3,239California $14,236,592,915 7,082,175 $2,010Colorado $1,439,366,499 344,916 $4,173Connecticut $2,420,791,474 381,208 $6,350Delaware $419,732,143 101,436 $4,138District of Columbia $731,292,552 166,146 $4,402Florida $5,686,844,862 1,904,591 $2,986Georgia $3,012,346,312 1,221,978 $2,465Hawaii $507,433,146 184,614 $2,749Idaho $424,512,387 123,176 $3,446Illinois $6,172,865,261 1,363,856 $4,526Indiana $2,564,005,047 607,293 $4,222Iowa $1,288,770,390 314,936 $4,092Kansas $916,323,608 241,933 $3,788Kentucky $2,425,288,141 644,482 $3,763Louisiana $2,383,508,985 720,615 $3,308Maine $747,027,618 170,456 $4,383Maryland $2,489,280,148 561,085 $4,437Massachusetts $4,609,360,933 908,238 $5,075Michigan $4,345,007,824 1,362,890 $3,188Minnesota $2,924,447,719 538,413 $5,432Mississippi $1,442,373,276 485,767 $2,969Missouri $2,569,646,129 734,015 $3,501Montana $361,238,668 100,760 $3,585Nebraska $753,162,904 211,188 $3,566Nevada $462,087,777 128,144 $3,606New Hampshire $606,004,232 93,970 $6,449New Jersey $4,218,822,993 813,251 $5,188New Mexico $862,144,872 329,418 $2,617New York $24,298,610,635 3,073,241 $7,907North Carolina $4,013,996,742 1,167,988 $3,437North Dakota $341,015,420 62,280 $5,476Ohio $6,120,967,557 1,290,776 $4,742Oklahoma $1,177,853,941 342,475 $3,439Oregon $1,377,514,740 511,171 $2,695Pennsylvania $6,080,191,710 1,523,120 $3,992Puerto Rico $250,000,000 964,015 $259Rhode Island $919,353,410 153,130 $6,004South Carolina $2,018,620,428 594,962 $3,393South Dakota $355,833,902 89,537 $3,974Tennessee $3,167,188,993 1,843,661 $1,718Texas $7,139,928,843 2,324,810 $3,071Utah $618,675,433 215,801 $2,867Vermont $351,341,290 123,992 $2,834Virgin Islands $10,097,973 19,764 $511Virginia $2,118,202,866 653,236 $3,243Washington $2,044,234,831 1,413,208 $1,447West Virginia $1,243,150,526 342,668 $3,628Wisconsin $2,206,398,750 518,595 $4,255Wyoming $192,004,819 46,121 $4,163Source: HCFA, CMSO, HCFA-2082 Report, FY98.





MEDICAID DRUG PROGRAM

The Medicaid program defines prescribed drugs as simple or compound substances or mixtures of substancesprescribed for the cure, mitigation, or prevention of disease, or for health maintenance, which are prescribed by aphysician or other licensed practitioner of the healing arts within the scope of their professional practice (42 CFR440.120). The drugs must be dispensed by licensed authorized practitioners on a written prescription that isrecorded and maintained in the pharmacist’s or practitioner’s records.

MEDICAID PRESCRIPTION DRUG REIMBURSEMENT

On July 31, 1987, the Health Care Financing Administration (HCFA) published a notice of the final rule for limitson payments for drugs in the Medicaid program. The regulations adopted in the rule became effective October29, 1987 (52 FR 28648). In this final rule, HCFA attempted to (1) respond to public comments on the NPRM (51FR 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 ofsavings in the marketplace for multiple-source drugs.

To accomplish this, HCFA adopted a federal upper limit standard for certain multiple-source drugs, based onapplication of a specific formula. The upper limit for other drugs is similar, in that it retains the estimatedacquisition cost (EAC) as the upper limit standard that state agencies must meet. However, this standard isapplied on an aggregate basis rather than on a prescription-specific basis. State agencies are therefore encouragedto 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 drugmarketed or sold by the same manufacturer or labeler under two or more different proprietary names or under aproprietary 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 beenevaluated as therapeutically equivalent in the current edition of the publication, Approved Drug Productswith Therapeutically Equivalent Evaluations, and

• At least three suppliers list the drug (which is classified by the FDA as Category A in its publication) inthe 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 aphysician certifies in his or her own handwriting that a specific brand is “medically necessary” for a particularrecipient.

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

The formula to be used in calculating the aggregate upper limit of payment for certain multiple-source drugs willbe 150% of the least costly therapeutic equivalent that can be purchased by pharmacists in quantities of 100tablets or capsules (or if the drug is not commonly available in quantities of 100, the package size commonlylisted), 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 drugsmust 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 aggregateexpenditures 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 ruledoes not prescribe a preferred payment method, as long as the state’s aggregate spending in each category is equalto or below the upper limit requirements. States are also required to submit assurances to HCFA that therequirements are met.

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

State programs vary, depending upon whether or not state maximum allowable cost programs cover the samedrugs listed by HCFA. States with established MAC programs may be unaffected if their MAC rates are alreadylow, or they may have to make certain adjustments in their MAC levels to meet the federal aggregate expenditurelimits. States without MAC programs may develop a new payment method to increase the use of lower costgeneric drug products in order to stay within the upper payment limits, or may simply adopt HCFA’s formula forlisted 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.



Drug Payments and Recipients, 1998

StateTotal

Drug PaymentsTotal

Drug Recipients‡Drug Payments

Per RecipientNational Total* $13,521,707,689 19,337,543 $699Alabama $236,674,147 395,290 $599Alaska $32,887,828 43,734 $752Arizona $1,442,917 56,796 $25Arkansas $150,891,615 262,907 $574California $1,553,598,462 2,644,430 $587Colorado $110,159,725 147,033 $749Connecticut $186,593,992 108,331 $1,722Delaware $41,350,537 69,027 $599District of Columbia $41,254,973 57,733 $715Florida $933,782,041 1,014,372 $921Georgia $370,562,935 805,923 $460Hawaii $39,623,380 32,222 $1,230Idaho $54,971,097 86,775 $633Illinois $583,239,675 959,472 $608Indiana $325,712,348 323,811 $1,006Iowa $147,115,884 215,173 $684Kansas $118,825,316 155,875 $762Kentucky $319,983,951 429,102 $746Louisiana $352,784,785 552,481 $639Maine $121,771,298 137,816 $884Maryland $148,532,940 176,403 $842Massachusetts $497,146,531 613,186 $811Michigan $374,145,567 589,818 $634Minnesota $173,602,492 203,220 $854Mississippi $231,735,360 368,609 $629Missouri $382,512,566 353,902 $1,081Montana $42,368,399 58,641 $723Nebraska $92,558,539 145,408 $637Nevada $34,518,901 50,903 $678New Hampshire $55,374,478 70,339 $787New Jersey $426,075,488 309,849 $1,375New Mexico $41,507,229 96,637 $430New York $1,368,451,273 1,803,428 $759North Carolina $466,528,812 764,886 $610North Dakota $27,619,684 37,675 $733Ohio $645,118,962 702,143 $919Oklahoma - - -Oregon $87,805,350 148,258 $592Pennsylvania $525,261,211 580,749 $904Rhode Island $61,401,958 44,852 $1,369South Carolina $224,962,203 401,611 $560South Dakota $31,106,511 46,588 $668Tennessee $36 1 $36Texas $817,591,112 1,894,447 $432Utah $68,827,853 126,953 $542Vermont $43,445,887 58,037 $749Virginia $284,578,558 383,880 $741Washington $244,478,658 274,463 $891West Virginia $148,962,081 267,398 $557Wisconsin $232,326,359 221,508 $1,049Wyoming $17,138,952 32,510 $527*National figures include Puerto Rico and the Virgin Islands.**Oklahoma did not submit detailed drug information for 1998.‡Recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs.Source: HCFA, CMSO, HCFA-2082 Report, FY98.



Drug Payment Trends

State 1994 1995 1996 1997 1998National Total* $8,873,950,031 $9,790,651,449 $10,697,438,066 $11,972,331,192 $13,521,707,689Alabama $163,021,321 $178,667,753 $203,811,076 $226,105,163 $236,674,147Alaska $16,744,047 $18,469,364 $21,661,213 $28,376,842 $32,887,828Arizona $1,165,786 $2,027,734 $2,460,613 $1,855,672 $1,442,917Arkansas $88,069,017 $102,114,998 $115,070,827 $135,757,334 $150,891,615California $1,122,754,027 $1,145,514,700 $1,223,444,736 $1,335,065,753 $1,553,598,462Colorado $70,483,595 $78,833,103 $82,543,502 $96,964,178 $110,159,725Connecticut $120,470,177 $145,366,245 $146,856,083 $166,667,301 $186,593,992Delaware $18,351,293 $21,458,681 $27,743,076 $34,713,581 $41,350,537District of Columbia $25,227,269 $26,231,966 $32,765,197 $37,512,355 $41,254,973Florida $484,052,934 $556,864,923 $658,291,958 $772,780,639 $933,782,041Georgia $260,307,087 $288,511,672 $319,230,386 $339,257,021 $370,562,935Hawaii** $34,461,968 $24,802,573 $26,854,246 - $39,623,380Idaho $29,378,146 $33,153,237 $41,028,033 $45,042,165 $54,971,097Illinois $330,697,673 $440,883,001 $446,214,047 $523,561,885 $583,239,675Indiana $232,645,959 $187,674,037 $269,001,714 $293,318,000 $325,712,348Iowa $91,202,410 $97,382,501 $111,346,007 $123,861,339 $147,115,884Kansas $71,285,408 $81,455,408 $90,754,656 $104,628,978 $118,825,316Kentucky $217,044,606 $251,745,610 $272,539,525 $316,464,180 $319,983,951Louisiana $269,035,462 $292,293,619 $297,433,210 $315,444,016 $352,784,785Maine $64,043,624 $63,906,058 $83,822,289 $102,537,196 $121,771,298Maryland $125,216,705 $139,205,331 $154,908,882 $172,701,280 $148,532,940Massachusetts $251,184,700 $308,411,398 $302,911,947 $398,076,057 $497,146,531Michigan $290,264,217 $312,003,749 $352,620,438 $365,282,227 $374,145,567Minnesota $113,841,194 $148,450,414 $150,350,355 $155,830,086 $173,602,492Mississippi $140,045,378 $162,743,883 $176,758,960 $208,577,199 $231,735,360Missouri $228,660,484 $259,657,651 $281,700,005 $320,660,206 $382,512,566Montana $26,211,646 $28,335,142 $32,742,122 $35,470,912 $42,368,399Nebraska $55,495,790 $61,738,837 $71,482,836 $79,727,194 $92,558,539Nevada $17,653,922 $21,320,507 $24,384,747 $26,652,299 $34,518,901New Hampshire $28,419,726 $34,099,265 $42,310,704 $45,361,780 $55,374,478New Jersey $308,046,437 $344,176,481 $374,015,636 $369,839,049 $426,075,488New Mexico $47,770,092 $50,545,800 $61,171,361 $63,345,896 $41,507,229New York $727,303,151 $819,359,316 $907,083,895 $1,090,917,486 $1,368,451,273North Carolina $215,197,252 $277,430,790 $344,950,165 $403,811,339 $466,528,812North Dakota $17,639,044 $19,711,865 $20,904,298 $25,226,544 $27,619,684Ohio $415,250,727 $480,233,424 $518,641,009 $580,572,988 $645,118,962Oklahoma** $89,253,227 $100,909,395 $98,292,786 $110,880,182 -Oregon $85,902,712 $82,647,757 $67,013,699 $73,216,753 $87,805,350Pennsylvania $489,131,313 $543,774,387 $536,797,657 $552,268,949 $525,261,211Rhode Island $39,752,373 $47,808,612 $45,679,642 $52,165,739 $61,401,958South Carolina $110,845,482 $124,500,348 $143,804,519 $159,606,414 $224,962,203South Dakota $19,017,682 $21,567,935 $24,147,295 $27,591,466 $31,106,511Tennessee $76,314,794 $190,467 $15,337 $1,118 $36Texas $511,841,929 $578,661,512 $667,743,192 $750,056,208 $817,591,112Utah $39,728,466 $44,397,971 $48,149,414 $50,825,675 $68,827,853Vermont $28,384,265 $33,658,620 $36,539,101 $44,291,004 $43,445,887Virginia $195,777,613 $213,182,924 $221,421,619 $249,620,903 $284,578,558Washington $168,193,537 $161,555,588 $172,652,369 $204,980,369 $244,478,658West Virginia $106,852,366 $130,451,359 $124,984,023 $133,044,683 $148,962,081Wisconsin $183,836,535 $190,678,825 $205,429,565 $205,503,614 $232,326,359Wyoming $10,475,463 $11,884,713 $13,635,463 $14,864,016 $17,138,952

*National figures include Puerto Rico and the Virgin Islands.**Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively.Source: HCFA, CMSO, HCFA-2082 Report, FY98.



Drug Payment - Percent Change from 1997 to 1998

State 1997 1998 Percent ChangeNational Total* $11,972,331,192 $13,521,707,689 13%Alabama $226,105,163 $236,674,147 5%Alaska $28,376,842 $32,887,828 16%Arizona $1,855,672 $1,442,917 -22%Arkansas $135,757,334 $150,891,615 11%California $1,335,065,753 $1,553,598,462 16%Colorado $96,964,178 $110,159,725 14%Connecticut $166,667,301 $186,593,992 12%Delaware $34,713,581 $41,350,537 19%District of Columbia $37,512,355 $41,254,973 10%Florida $772,780,639 $933,782,041 21%Georgia $339,257,021 $370,562,935 9%Hawaii** - $39,623,380 -Idaho $45,042,165 $54,971,097 22%Illinois $523,561,885 $583,239,675 11%Indiana $293,318,000 $325,712,348 11%Iowa $123,861,339 $147,115,884 19%Kansas $104,628,978 $118,825,316 14%Kentucky $316,464,180 $319,983,951 1%Louisiana $315,444,016 $352,784,785 12%Maine $102,537,196 $121,771,298 19%Maryland $172,701,280 $148,532,940 -14%Massachusetts $398,076,057 $497,146,531 25%Michigan $365,282,227 $374,145,567 2%Minnesota $155,830,086 $173,602,492 11%Mississippi $208,577,199 $231,735,360 11%Missouri $320,660,206 $382,512,566 19%Montana $35,470,912 $42,368,399 19%Nebraska $79,727,194 $92,558,539 16%Nevada $26,652,299 $34,518,901 30%New Hampshire $45,361,780 $55,374,478 22%New Jersey $369,839,049 $426,075,488 15%New Mexico $63,345,896 $41,507,229 -34%New York $1,090,917,486 $1,368,451,273 25%North Carolina $403,811,339 $466,528,812 16%North Dakota $25,226,544 $27,619,684 9%Ohio $580,572,988 $645,118,962 11%Oklahoma** $110,880,182 - -Oregon $73,216,753 $87,805,350 20%Pennsylvania $552,268,949 $525,261,211 -5%Rhode Island $52,165,739 $61,401,958 18%South Carolina $159,606,414 $224,962,203 41%South Dakota $27,591,466 $31,106,511 13%Tennessee $1,118 $36 -97%Texas $750,056,208 $817,591,112 9%Utah $50,825,675 $68,827,853 35%Vermont $44,291,004 $43,445,887 -2%Virginia $249,620,903 $284,578,558 14%Washington $204,980,369 $244,478,658 19%West Virginia $133,044,683 $148,962,081 12%Wisconsin $205,503,614 $232,326,359 13%Wyoming $14,864,016 $17,138,952 15%

*National figures include Puerto Rico and the Virgin Islands.**Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively.Source: HCFA, CMSO, HCFA-2082 Report, FY97, FY98.



Ranking Based on Drug Payments

State1998

Payments1998

Ranking

% of 1998 TotalMedicaid Drug

Payments1997

Payments1997

RankingCalifornia $1,553,598,462 1 11.49% $1,335,065,753 1New York $1,368,451,273 2 10.12% $1,090,917,486 2Florida $933,782,041 3 6.91% $772,780,639 3Texas $817,591,112 4 6.05% $750,056,208 4Ohio $645,118,962 5 4.77% $580,572,988 5Illinois $583,239,675 6 4.31% $523,561,885 7Pennsylvania $525,261,211 7 3.88% $552,268,949 6Massachusetts $497,146,531 8 3.68% $398,076,057 9North Carolina $466,528,812 9 3.45% $403,811,339 8New Jersey $426,075,488 10 3.15% $369,839,049 10Missouri $382,512,566 11 2.83% $320,660,206 13Michigan $374,145,567 12 2.77% $365,282,227 11Georgia $370,562,935 13 2.74% $339,257,021 12Louisiana $352,784,785 14 2.61% $315,444,016 15Indiana $325,712,348 15 2.41% $293,318,000 16Kentucky $319,983,951 16 2.37% $316,464,180 14Virginia $284,578,558 17 2.10% $249,620,903 17Washington $244,478,658 18 1.81% $204,980,369 21Alabama $236,674,147 19 1.75% $226,105,163 18Wisconsin $232,326,359 20 1.72% $205,503,614 20Mississippi $231,735,360 21 1.71% $208,577,199 19South Carolina $224,962,203 22 1.66% $159,606,414 24Connecticut $186,593,992 23 1.38% $166,667,301 23Minnesota $173,602,492 24 1.28% $155,830,086 25Arkansas $150,891,615 25 1.12% $135,757,334 26West Virginia $148,962,081 26 1.10% $133,044,683 27Maryland $148,532,940 27 1.10% $172,701,280 22Iowa $147,115,884 28 1.09% $123,861,339 28Maine $121,771,298 29 0.90% $102,537,196 31Kansas $118,825,316 30 0.88% $104,628,978 30Colorado $110,159,725 31 0.81% $96,964,178 32Nebraska $92,558,539 32 0.68% $79,727,194 33Oregon $87,805,350 33 0.65% $73,216,753 34Utah $68,827,853 34 0.51% $50,825,675 37Rhode Island $61,401,958 35 0.45% $52,165,739 36New Hampshire $55,374,478 36 0.41% $45,361,780 38Idaho $54,971,097 37 0.41% $45,042,165 39Vermont $43,445,887 38 0.32% $44,291,004 40Montana $42,368,399 39 0.31% $35,470,912 42New Mexico $41,507,229 40 0.31% $63,345,896 35Delaware $41,350,537 41 0.31% $34,713,581 43District of Columbia $41,254,973 42 0.31% $37,512,355 41Hawaii* $39,623,380 43 0.29% - -Nevada $34,518,901 44 0.26% $26,652,299 46Alaska $32,887,828 45 0.24% $28,376,842 44South Dakota $31,106,511 46 0.23% $27,591,466 45North Dakota $27,619,684 47 0.20% $25,226,544 47Wyoming $17,138,952 48 0.13% $14,864,016 48Arizona $1,442,917 49 0.01% $1,855,672 49Tennessee $36 50 0.00% $1,118 50Oklahoma* - - - $110,880,182 29

*Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively.Source: HCFA, CMSO, HCFA-2082 Report, FY97, FY98.



Drugs as a Percentage of Total Vendor Payments, 1998

StateTotal

Drug PaymentsTotal

Vendor Payments% of Total

Vendor PaymentsNational Total* $13,521,707,689 $142,317,903,795 9.5%Alabama $236,674,147 $1,902,300,047 12.4%Alaska $32,887,828 $330,378,398 10.0%Arizona $1,442,917 $1,643,966,305 0.1%Arkansas $150,891,615 $1,375,797,421 11.0%California $1,553,598,462 $14,236,592,915 10.9%Colorado $110,159,725 $1,439,366,499 7.7%Connecticut $186,593,992 $2,420,791,474 7.7%Delaware $41,350,537 $419,732,143 9.9%District of Columbia $41,254,973 $731,292,552 5.6%Florida $933,782,041 $5,686,844,862 16.4%Georgia $370,562,935 $3,012,346,312 12.3%Hawaii $39,623,380 $507,433,146 7.8%Idaho $54,971,097 $424,512,387 12.9%Illinois $583,239,675 $6,172,865,261 9.4%Indiana $325,712,348 $2,564,005,047 12.7%Iowa $147,115,884 $1,288,770,390 11.4%Kansas $118,825,316 $916,323,608 13.0%Kentucky $319,983,951 $2,425,288,141 13.2%Louisiana $352,784,785 $2,383,508,985 14.8%Maine $121,771,298 $747,027,618 16.3%Maryland $148,532,940 $2,489,280,148 6.0%Massachusetts $497,146,531 $4,609,360,933 10.8%Michigan $374,145,567 $4,345,007,824 8.6%Minnesota $173,602,492 $2,924,447,719 5.9%Mississippi $231,735,360 $1,442,373,276 16.1%Missouri $382,512,566 $2,569,646,129 14.9%Montana $42,368,399 $361,238,668 11.7%Nebraska $92,558,539 $753,162,904 12.3%Nevada $34,518,901 $462,087,777 7.5%New Hampshire $55,374,478 $606,004,232 9.1%New Jersey $426,075,488 $4,218,822,993 10.1%New Mexico $41,507,229 $862,144,872 4.8%New York $1,368,451,273 $24,298,610,635 5.6%North Carolina $466,528,812 $4,013,996,742 11.6%North Dakota $27,619,684 $341,015,420 8.1%Ohio $645,118,962 $6,120,967,557 10.5%Oklahoma** - $1,177,853,941 -Oregon $87,805,350 $1,377,514,740 6.4%Pennsylvania $525,261,211 $6,080,191,710 8.6%Rhode Island $61,401,958 $919,353,410 6.7%South Carolina $224,962,203 $2,018,620,428 11.1%South Dakota $31,106,511 $355,833,902 8.7%Tennessee $36 $3,167,188,993 0.0%Texas $817,591,112 $7,139,928,843 11.5%Utah $68,827,853 $618,675,433 11.1%Vermont $43,445,887 $351,341,290 12.4%Virginia $284,578,558 $2,118,202,866 13.4%Washington $244,478,658 $2,044,234,831 12.0%West Virginia $148,962,081 $1,243,150,526 12.0%Wisconsin $232,326,359 $2,206,398,750 10.5%Wyoming $17,138,952 $192,004,819 8.9%

*National figures include Puerto Rico and the Virgin Islands.**Oklahoma did not submit detail drug information for 1998.Source: The Lewin Group analysis of HCFA, CMSO, HCFA-2082 Report, FY98



Drugs as a Percentage of Total Vendor Payments, Trend

State 1994 1995 1996 1997 1998National* 8.2% 8.1% 8.8% 9.7% 9.5%Alabama 12.4% 12.3% 13.9% 14.4% 12.4%Alaska 6.9% 7.3% 7.8% 8.8% 10.0%Arizona 0.6% 0.9% 1.2% 0.8% 0.1%Arkansas 7.0% 7.4% 9.4% 10.4% 11.0%California 11.2% 10.9% 11.0% 11.7% 10.9%Colorado 7.4% 7.4% 8.0% 8.6% 7.7%Connecticut 6.2% 6.8% 7.2% 8.3% 7.7%Delaware 6.6% 6.6% 9.0% 12.6% 9.9%District of Columbia 4.6% 4.9% 4.6% 5.4% 5.6%Florida 11.4% 11.6% 14.1% 15.8% 16.4%Georgia 9.2% 9.4% 10.3% 11.0% 12.3%Hawaii** 10.2% 9.6% 10.1% - 7.8%Idaho 8.9% 9.2% 10.1% 10.4% 12.9%Illinois 6.9% 7.9% 8.3% 9.1% 9.4%Indiana 10.3% 10.0% 11.0% 12.3% 12.7%Iowa 9.3% 9.4% 10.2% 11.4% 11.4%Kansas 9.1% 9.8% 10.5% 11.4% 13.0%Kentucky 12.2% 12.9% 14.1% 13.9% 13.2%Louisiana 10.0% 10.8% 12.1% 13.5% 14.8%Maine 7.9% 8.4% 11.6% 13.2% 16.3%Maryland 6.7% 6.9% 7.6% 7.8% 6.0%Massachusetts 8.2% 7.8% 8.0% 10.3% 10.8%Michigan 8.9% 9.2% 10.5% 10.2% 8.6%Minnesota 5.7% 5.8% 6.2% 6.6% 5.9%Mississippi 12.9% 12.9% 13.2% 14.6% 16.1%Missouri 12.6% 12.7% 14.0% 15.3% 14.9%Montana 8.7% 8.7% 9.3% 11.2% 11.7%Nebraska 9.4% 10.2% 10.5% 11.5% 12.3%Nevada 5.8% 6.1% 6.7% 7.1% 7.5%New Hampshire 7.3% 7.2% 7.7% 8.2% 9.1%New Jersey 8.5% 9.0% 10.0% 10.4% 10.1%New Mexico 7.5% 7.1% 7.0% 7.7% 4.8%New York 3.9% 3.7% 4.1% 5.1% 5.6%North Carolina 8.0% 8.7% 9.4% 10.7% 11.6%North Dakota 6.2% 6.6% 7.0% 7.7% 8.1%Ohio 8.3% 8.6% 9.4% 9.9% 10.5%Oklahoma** 9.2% 9.6% 9.6% 10.7% -Oregon 8.3% 6.2% 5.1% 5.0% 6.4%Pennsylvania 11.6% 11.7% 11.5% 11.8% 8.6%Rhode Island 5.8% 7.1% 6.7% 7.1% 6.7%South Carolina 7.9% 8.7% 9.4% 9.9% 11.1%South Dakota 6.7% 7.1% 7.6% 8.7% 8.7%Tennessee 3.9% 0.0% 0.0% 0.0% 0.0%Texas 8.3% 8.8% 9.7% 10.2% 11.5%Utah 8.8% 9.6% 11.4% 12.0% 11.1%Vermont 10.9% 10.5% 12.1% 14.4% 12.4%Virginia 11.4% 11.6% 12.5% 13.4% 13.4%Washington 10.7% 11.1% 12.4% 14.7% 12.0%West Virginia 9.7% 11.2% 11.1% 10.6% 12.0%Wisconsin 10.1% 10.1% 10.8% 10.9% 10.5%Wyoming 6.7% 7.0% 7.5% 8.1% 8.9%

*National figures include Puerto Rico and the Virgin Islands.**Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively.Source: The Lewin Group analysis of HCFA, CMSO, HCFA-2082 Report, FY94-FY98.



Share of Drug Payments, Top 5 Therapeutic Categories, 1999

StateAnalgesics and

Antipyretics AntibioticsCardiovascular

DrugsMiscellaneous

GI DrugsPsycho-

TherapeuticsNational Average 6.5% 5.4% 6.1% 8.8% 20.1%Alabama 5.1% 9.2% 8.1% 9.3% 14.9%Alaska 10.5% 5.8% 4.3% 8.3% 19.5%Arizona* - - - - -Arkansas 6.0% 6.4% 8.0% 9.0% 17.3%California 5.2% 3.6% 7.7% 8.6% 17.2%Colorado* - - - - -Connecticut 5.5% 3.5% 6.5% 7.4% 24.5%Delaware 7.0% 6.3% 5.1% 7.8% 15.0%District of Columbia 3.3% 4.1% 8.8% 3.6% 13.1%Florida 6.1% 5.8% 5.4% 8.4% 13.2%Georgia 6.8% 8.6% 7.4% 8.1% 15.4%Hawaii 6.1% 3.7% 7.6% 3.2% 19.5%Idaho 7.7% 5.4% 3.7% 11.2% 22.0%Illinois 5.3% 6.3% 6.4% 8.7% 18.6%Indiana 7.2% 5.2% 5.1% 9.9% 19.1%Iowa 5.6% 5.7% 5.3% 6.7% 22.6%Kansas 7.2% 5.5% 5.3% 10.1% 22.9%Kentucky 5.7% 6.7% 6.6% 13.1% 18.0%Louisiana 7.7% 7.9% 7.1% 8.4% 13.0%Maine 8.0% 4.0% 5.2% 11.4% 20.5%Maryland 4.0% 2.7% 6.2% 7.0% 28.0%Massachusetts 5.3% 3.9% 5.5% 7.9% 25.6%Michigan 7.3% 4.3% 7.2% 8.4% 19.4%Minnesota 5.1% 3.9% 4.2% 7.5% 28.7%Mississippi* - - - - -Missouri 7.1% 5.0% 6.1% 10.4% 19.8%Montana 7.1% 5.4% 4.5% 9.8% 21.0%Nebraska 7.2% 7.3% 5.0% 9.7% 19.4%Nevada 8.1% 7.0% 5.8% 8.7% 18.5%New Hampshire 6.9% 3.6% 4.4% 8.9% 25.9%New Jersey 6.1% 3.3% 6.1% 8.9% 15.6%New Mexico 7.5% 3.8% 7.2% 12.3% 16.9%New York 5.0% 5.0% 6.6% 7.1% 16.7%North Carolina 6.4% 6.6% 7.1% 10.6% 14.6%North Dakota 6.2% 5.4% 5.8% 8.9% 22.9%Ohio 7.1% 4.9% 6.2% 10.3% 20.1%Oklahoma 7.6% 6.7% 6.8% 8.8% 17.5%Oregon 5.2% 2.7% 3.6% 3.7% 47.2%Pennsylvania 5.9% 5.1% 6.7% 9.2% 19.3%Rhode Island 4.8% 3.8% 7.5% 10.1% 23.6%South Carolina 7.1% 6.5% 8.3% 9.8% 14.5%South Dakota 6.0% 7.7% 5.3% 9.1% 18.5%Tennessee* - - - - -Texas* - - - - -Utah 7.0% 7.4% 3.4% 8.7% 24.3%Vermont 7.4% 3.7% 6.3% 12.0% 18.8%Virginia 6.5% 5.4% 6.5% 10.6% 15.8%Washington 8.0% 3.6% 5.3% 9.6% 22.0%West Virginia 5.8% 8.0% 6.5% 5.8% 18.3%Wisconsin 6.9% 3.5% 6.2% 7.4% 24.7%Wyoming 6.9% 7.1% 4.2% 9.1% 20.7%*Data not reported for Arizona, Colorado, Mississippi, Tennessee, or Texas.

Source: The Lewin Group analysis of HCFA Drug Utilization data, FY99.



Total Drug Recipients‡

State 1994 1995 1996 1997 1998National Total* 24,473,189 23,723,349 22,585,295 20,954,163 19,337,543Alabama 409,406 404,581 412,511 412,739 395,290Alaska 40,812 40,076 40,839 42,174 43,734Arizona 63,944 66,860 63,103 80,450 56,796Arkansas 257,861 253,181 255,211 254,079 262,907California 3,796,517 3,656,783 3,565,667 3,158,386 2,644,430Colorado 209,290 196,737 173,707 156,631 147,033Connecticut 255,218 273,511 209,557 120,522 108,331Delaware 54,384 56,710 61,380 68,672 69,027District of Columbia 68,211 53,992 66,349 64,494 57,733Florida 1,197,915 1,111,466 1,079,467 1,024,555 1,014,372Georgia 825,875 875,647 891,335 846,963 805,923Hawaii** 95,805 28,971 29,657 - 32,222Idaho 81,394 81,755 84,553 79,961 86,775Illinois 1,054,436 1,134,214 1,028,753 1,008,740 959,472Indiana 480,648 428,116 401,042 352,814 323,811Iowa 237,667 231,256 230,749 221,061 215,173Kansas 184,400 186,362 179,653 170,167 155,875Kentucky 493,689 491,370 497,251 494,293 429,102Louisiana 604,163 598,579 593,415 563,864 552,481Maine 136,623 120,029 138,360 139,524 137,816Maryland 299,875 291,626 268,440 256,423 176,403Massachusetts 531,851 558,233 527,114 559,215 613,186Michigan 863,391 823,485 763,232 688,882 589,818Minnesota 294,307 305,363 294,589 227,027 203,220Mississippi 411,813 416,065 404,263 391,328 368,609Missouri 543,833 561,167 469,821 395,478 353,902Montana 68,661 67,244 66,465 62,092 58,641Nebraska 128,501 131,974 138,322 151,973 145,408Nevada 55,336 59,170 60,274 55,876 50,903New Hampshire 67,200 73,938 75,701 71,692 70,339New Jersey 611,638 612,074 518,833 347,105 309,849New Mexico 172,752 178,087 197,565 184,502 96,637New York 1,920,814 1,880,506 1,737,372 1,667,927 1,803,428North Carolina 653,792 737,558 764,482 779,229 764,886North Dakota 42,442 41,128 40,062 39,654 37,675Ohio 1,023,733 1,007,970 902,211 786,322 702,143Oklahoma** 283,428 285,654 245,075 207,441 -Oregon 227,825 181,553 154,801 149,461 148,258Pennsylvania 996,129 941,013 857,818 763,255 580,749Rhode Island 57,942 93,639 52,239 46,817 44,852South Carolina 355,545 365,571 365,409 359,910 401,611South Dakota 47,614 47,969 49,056 47,845 46,588Tennessee 454,323 1,395 18 3 1Texas 1,989,651 2,020,864 2,058,903 1,986,178 1,894,447Utah 120,093 119,776 114,321 105,676 126,953Vermont 74,224 78,694 78,376 83,057 58,037Virginia 470,048 480,405 417,580 396,719 383,880Washington 495,379 405,558 305,791 292,733 274,463West Virginia 273,714 295,210 299,967 280,550 267,398Wisconsin 342,705 329,711 309,582 265,987 221,508Wyoming 35,964 35,505 35,415 33,426 32,510

‡Recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs.*National figures include Puerto Rico and the Virgin Islands.**Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively.Source: HCFA, CMSO, HCFA-2082 Report, FY94-FY98.



Drug Payments Per Recipient‡

State 1994 1995 1996 1997 1998National* $363 $413 $474 $571 $699Alabama $398 $442 $494 $548 $599Alaska $410 $461 $530 $673 $752Arizona $18 $30 $39 $23 $25Arkansas $342 $403 $451 $534 $574California $296 $313 $343 $423 $587Colorado $337 $401 $475 $619 $749Connecticut $472 $531 $701 $1,383 $1,722Delaware $337 $378 $452 $505 $599District of Columbia $370 $486 $494 $582 $715Florida $404 $501 $610 $754 $921Georgia $315 $329 $358 $401 $460Hawaii** $360 $856 $905 - $1,230Idaho $361 $406 $485 $563 $633Illinois $314 $389 $434 $519 $608Indiana $484 $438 $671 $831 $1,006Iowa $384 $421 $483 $560 $684Kansas $387 $437 $505 $615 $762Kentucky $440 $512 $548 $640 $746Louisiana $445 $488 $501 $559 $639Maine $469 $532 $606 $735 $884Maryland $418 $477 $577 $674 $842Massachusetts $472 $552 $575 $712 $811Michigan $336 $379 $462 $530 $634Minnesota $387 $486 $510 $686 $854Mississippi $340 $391 $437 $533 $629Missouri $420 $463 $600 $811 $1,081Montana $382 $421 $493 $571 $723Nebraska $432 $468 $517 $525 $637Nevada $319 $360 $405 $477 $678New Hampshire $423 $461 $559 $633 $787New Jersey $504 $562 $721 $1,065 $1,375New Mexico $277 $284 $310 $343 $430New York $379 $436 $522 $654 $759North Carolina $329 $376 $451 $518 $610North Dakota $416 $479 $522 $636 $733Ohio $406 $476 $575 $738 $919Oklahoma** $315 $353 $401 $535 -Oregon $377 $455 $433 $490 $592Pennsylvania $491 $578 $626 $724 $904Rhode Island $686 $511 $874 $1,114 $1,369South Carolina $312 $341 $394 $443 $560South Dakota $399 $450 $492 $577 $668Tennessee $168 $137 $852 $373 $36Texas $257 $286 $324 $378 $432Utah $331 $371 $421 $481 $542Vermont $382 $428 $466 $533 $749Virginia $417 $444 $530 $629 $741Washington $340 $398 $565 $700 $891West Virginia $390 $442 $417 $474 $557Wisconsin $536 $578 $664 $773 $1,049Wyoming $291 $335 $385 $445 $527

‡Recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs.*National figures include Puerto Rico and the Virgin Islands.**Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively.Source: The Lewin Group analysis of HCFA, CMSO, HCFA-2082 Report, FY94-FY98.



Medicaid Drug Reimbursement Report, 1998

StateDrug

Payments1Drug

Recipients1Prescriptions

Processed2Average

Prescription Cost2

Alabama $236,674,147 395,290 7,852,261 $30.34Alaska $32,887,828 43,734 662,575 $51.73Arizona* $1,442,917 56,796 - -Arkansas $150,891,615 262,907 3,142,993 $37.44California $1,553,598,462 2,644,430 40,646,534 $40.56Colorado $110,159,725 147,033 1,431,595 $37.14Connecticut* $186,593,992 108,331 - -Delaware $41,350,537 69,027 830,829 $38.68District of Columbia $41,254,973 57,733 1,858,364 $43.83Florida $933,782,041 1,014,372 18,681,483 $47.86Georgia $370,562,935 805,923 9,284,700 $31.24Hawaii $39,623,380 32,222 1,119,545 $34.40Idaho $54,971,097 86,775 630,770 $42.21Illinois $583,239,675 959,472 17,981,685 $34.01Indiana $325,712,348 323,811 4,379,620 $40.46Iowa $147,115,884 215,173 4,457,957 $19.70Kansas* $118,825,316 155,875 - -Kentucky $319,983,951 429,102 9,630,473 $33.41Louisiana $352,784,785 552,481 20,664,690 $34.35Maine $121,771,298 137,816 2,868,068 $41.85Maryland $148,532,940 176,403 2,336,929 $42.54Massachusetts $497,146,531 613,186 12,598,550 $40.18Michigan $374,145,567 589,818 10,357,765 $34.23Minnesota $173,602,492 203,220 4,612,393 $35.23Mississippi $231,735,360 368,609 5,368,429 $40.27Missouri $382,512,566 353,902 9,860,308 $38.58Montana $42,368,399 58,641 1,179,484 $34.74Nebraska $92,558,539 145,408 2,991,257 $33.36Nevada $34,518,901 50,903 814,185 $43.14New Hampshire $55,374,478 70,339 1,572,638 $34.11New Jersey $426,075,488 309,849 8,400,194 $47.83New Mexico $41,507,229 96,637 1,176,851 $33.36New York $1,368,451,273 1,803,428 35,512,292 $44.45North Carolina $466,528,812 764,886 11,633,909 $41.24North Dakota $27,619,684 37,675 585,260 $35.44Ohio $645,118,962 702,143 19,983,451 $33.15Oklahoma** - - 3,449,399 $41.07Oregon $87,805,350 148,258 2,374,283 $40.56Pennsylvania $525,261,211 580,749 14,219,369 $38.75Rhode Island $61,401,958 44,852 1,570,662 $41.26South Carolina $224,962,203 401,611 3,555,427 $49.21South Dakota $31,106,511 46,588 762,406 $37.17Tennessee* $36 1 - -Texas* $817,591,112 1,894,447 - -Utah $68,827,853 126,953 2,063,349 $34.25Vermont $43,445,887 58,037 799,552 $39.94Virginia $284,578,558 383,880 8,098,755 $35.70Washington $244,478,658 274,463 6,552,127 $37.60West Virginia $148,962,081 267,398 5,370,453 $30.13Wisconsin $232,326,359 221,508 6,358,445 $36.87Wyoming $17,138,952 32,510 453,071 $39.98

*Data not reported for Arizona, Connecticut, Kansas, Tennessee, or Texas.**Oklahoma did not submit detailed information for 1998.Source: 1HCFA, CMSO, HCFA-2082 Report, FY98. 2The Lewin Group analysis of HCFA Drug Utilization data, Fiscal Year 1998.



MEDICAID DRUG REBATES

In 1990, Congress considered a number of proposals designed to reduce and control federal and state expendituresfor prescription drug products provided to Medicaid patients (S.2605, the Pharmaceutical Access and PrudentPurchasing Act; S.3029, the Medicaid Anti-Discriminatory Drug Act, sponsored by Senator David Pryor; andH.R.5589, the Medicaid Prescription Drug Fair Access and Pricing Act, sponsored by Representatives RonWyden and Jim Cooper). Following the introduction of this legislation, several pharmaceutical manufacturersvoluntarily offered rebates to the states in exchange for open access for their products, while the PharmaceuticalManufacturers Association proposed a set rebate amount in exchange for open formularies.

In the course of the budget debate, the Office of Management and Budget (OMB) incorporated variouscomponents of these proposals into the 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 andhave in effect a national rebate agreement with the Secretary of the Department of Health and Human Services(HHS) for States to receive federal funding for outpatient drugs dispensed to Medicaid patients.

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 isobtained for the exception. Existing rebate agreements qualify under the law if the state agrees to report allrebates to HHS and the agreement provides for a minimum aggregate rebate of 10% of the state’s expenditures forthe manufacturer’s products.

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

The drug rebate program is administered by HCFA's 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 ofthe average manufacturer’s price (AMP) or the difference between the AMP and the manufacturer’s "bestprice," and (2) an additional rebate for any price increase for a product that exceeds the increase in theConsumer Price Index (CPI-U) for all items since the fall of 1990. AMP is the average price paid bywholesalers for products distributed to the retail class of trade. The best price is the lowest price offeredto any other customer, excluding Federal Supply Schedule prices, prices to state pharmaceuticalassistance 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 eachproduct’s AMP.



Medicaid Drug Rebates

StateAllocation ofDrug Rebate Moneys1

1999Total Rebates2

1999Federal Share2

National Total $3,316,594,880 $1,899,896,508Alabama Medicaid Drug Budget $49,785,076 $34,533,102Alaska General Fund $7,050,981 $4,216,486Arizona* - - -Arkansas Medicaid General $37,931,853 $27,703,515California Medicaid Drug Budget $533,191,914 $278,960,679Colorado Medicaid General $25,150,259 $12,868,802Connecticut General Fund $38,656,394 $19,328,198Delaware Medicaid General $9,787,444 $4,945,369District of Columbia Medicaid General $8,379,982 $5,866,114Florida Medicaid Drug Budget $195,512,719 $109,644,101Georgia General Fund $94,903,175 $57,612,243Hawaii General Fund $8,378,292 $4,189,146Idaho Medicaid General $11,901,778 $8,313,393Illinois General Fund $121,540,781 $61,133,375Indiana General Fund $62,691,135 $38,247,862Iowa General Fund $32,369,409 $20,570,660Kansas General Fund $26,878,486 $16,184,126Kentucky Medicaid General $72,676,810 $51,258,954Louisiana Medicaid Drug Budget $76,147,317 $53,686,416Maine General Fund $30,032,364 $19,941,489Maryland Medicaid General $32,403,851 $16,274,193Massachusetts General Fund $140,102,747 $70,660,841Michigan Medicaid Drug Budget $75,674,128 $39,969,595Minnesota Medicaid General $37,389,033 $19,255,352Mississippi Medicaid Special Refund $49,332,307 $37,964,206Missouri Medicaid Drug Budget $84,620,799 $51,306,706Montana General Fund $9,290,653 $6,688,938Nebraska General Fund and Medicaid General $21,609,490 $13,454,079Nevada Medicaid Drug Budget $7,727,267 $3,882,559New Hampshire General Fund $12,956,727 $6,478,364New Jersey Medicaid Drug Budget $89,197,702 $44,750,228New Mexico General Fund $7,972,600 $5,818,404New York General Fund $356,088,488 $178,044,244North Carolina Medicaid General $111,326,116 $70,372,764North Dakota Medicaid General $5,954,387 $4,171,965Ohio Medicaid General $148,477,399 $86,502,933Oklahoma Medicaid General $31,992,100 $22,786,690Oregon General Fund $21,360,688 $13,062,439Pennsylvania Medicaid Drug Budget- $119,340,064 $64,407,705Rhode Island Medicaid General $14,440,971 $7,805,345South Carolina Medicaid Drug Budget $55,971,288 $39,382,765South Dakota Medicaid General $5,971,015 $4,094,537Tennessee - $22,434,760 $14,154,090Texas Medicaid Drug Budget $185,695,267 $116,237,687Utah General Fund $14,721,050 $10,566,770Vermont Medicaid General $10,579,999 $6,556,425Virginia Medicaid Medical Budget $67,715,512 $35,066,017Washington General Fund $54,331,249 $28,566,897West Virginia Medicaid General $35,941,495 $26,765,632Wisconsin Medicaid Drug Budget $38,644,764 $22,837,194Wyoming Medicaid Drug Budget $4,364,795 $2,806,914

*Does not apply for Arizona.Sources: 1As reported by state drug program administrators in the 2000 NPC Survey.2HCFA 64, Medicaid Financial Management Report, FY99.



Medicaid Drug Rebate Trends, 1995-1999

State1995

Drug Rebate1996

Drug Rebate1997

Drug Rebate1998

Drug Rebate1999

Drug RebateNational Total $1,795,369,481 $1,961,842,019 $2,212,579,458 $2,469,136,949 $3,316,594,880Alabama $26,713,236 $35,746,548 $47,135,670 $36,537,095 $49,785,076Alaska $3,392,270 $3,631,600 $4,900,641 $5,026,624 $7,050,981Arizona* - - - - -Arkansas $15,838,282 $19,942,216 $24,514,373 $22,518,230 $37,931,853California $214,571,699 $259,522,046 $307,645,326 $362,808,597 $533,191,914Colorado $16,164,945 $17,354,887 $16,950,071 $20,424,896 $25,150,259Connecticut $29,670,883 $30,787,226 $27,318,565 $32,128,587 $38,656,394Delaware $39,108,649 $4,424,652 $5,851,285 $7,096,836 $9,787,444District of Columbia $6,212,050 $5,669,258 $6,668,493 $7,100,983 $8,379,982Florida $99,995,743 $110,282,689 $128,466,755 $150,733,077 $195,512,719Georgia $51,400,489 $56,905,277 $59,756,017 $64,320,077 $94,903,175Hawaii $5,451,328 $3,720,038 $4,654,126 $5,992,722 $8,378,292Idaho $5,364,698 $6,534,816 $8,369,523 $8,614,444 $11,901,778Illinois $68,635,826 $85,146,120 $85,128,380 $100,811,862 $121,540,781Indiana $39,660,999 $45,845,822 $43,645,256 $50,710,861 $62,691,135Iowa $17,082,336 $18,770,263 $21,755,142 $25,265,390 $32,369,409Kansas $13,274,426 $16,682,962 $11,797,675 $19,852,439 $26,878,486Kentucky $42,282,025 $43,116,489 $59,890,925 $57,082,387 $72,676,810Louisiana $49,319,520 $55,702,577 $54,650,344 $65,994,910 $76,147,317Maine $13,111,934 $16,131,900 $18,246,061 $19,650,719 $30,032,364Maryland $25,339,673 $28,493,983 $34,567,082 $25,017,660 $32,403,851Massachusetts $53,656,921 $65,037,309 $73,047,452 $89,011,664 $140,102,747Michigan $64,564,101 $67,989,816 $74,116,928 $72,526,027 $75,674,128Minnesota N/A $6,992,875 $31,873,349 $31,058,740 $37,389,033Mississippi $30,380,557 $32,191,139 $37,108,638 $39,983,265 $49,332,307Missouri $45,080,603 $51,527,496 $54,614,194 $66,460,159 $84,620,799Montana $5,565,740 $6,031,657 $6,775,176 $7,378,206 $9,290,653Nebraska $10,418,227 $12,330,363 $14,931,313 $16,545,572 $21,609,490Nevada $4,038,721 $4,400,121 $5,391,025 $5,143,136 $7,727,267New Hampshire $5,046,055 $7,912,982 $8,788,296 $9,676,461 $12,956,727New Jersey $62,240,335 $65,377,388 $66,748,605 $70,992,525 $89,197,702New Mexico $9,071,911 $11,509,943 $13,367,028 $10,670,766 $7,972,600New York $151,313,836 $150,547,790 $200,157,978 $251,273,382 $356,088,488North Carolina $43,275,244 $57,099,702 $68,332,867 $81,211,796 $111,326,116North Dakota $3,548,429 $3,734,060 $4,651,348 $4,990,065 $5,954,387Ohio $97,259,136 $103,428,427 $84,238,194 $110,484,575 $148,477,399Oklahoma $18,519,577 $19,696,492 $20,776,998 $23,329,251 $31,992,100Oregon $18,887,522 $19,668,133 $13,852,833 $14,433,179 $21,360,688Pennsylvania $89,645,272 $99,204,380 $115,510,606 $95,692,149 $119,340,064Rhode Island $8,904,676 $9,336,162 $10,121,820 $11,041,552 $14,440,971South Carolina $27,588,863 $30,483,825 $34,643,502 $39,156,574 $55,971,288South Dakota $3,248,482 $3,248,037 $4,940,121 $5,070,643 $5,971,015Tennessee $1,110,475 $247,255 - $840 $22,434,760Texas $106,027,639 $114,442,343 $130,576,891 $145,635,499 $185,695,267Utah $7,608,692 $9,145,247 $8,374,299 $9,988,037 $14,721,050Vermont $7,363,796 $6,794,891 $8,255,707 $8,868,263 $10,579,999Virginia $49,153,407 $41,059,487 $45,240,474 $51,079,391 $67,715,512Washington $33,803,617 $33,586,091 $38,326,646 $39,191,376 $54,331,249West Virginia $20,248,539 $27,287,834 $26,079,819 $26,753,285 $35,941,495Wisconsin $32,786,506 $34,494,898 $37,146,544 $40,776,543 $38,644,764Wyoming $2,421,591 $2,624,507 $2,679,097 $3,025,632 $4,364,795

*Does not apply for Arizona.Source: HCFA 64, Medicaid Financial Management Report, FY95-FY99.





MEDICAID DRUG COVERAGE

In general, all prescription products sold by a manufacturer that has signed a drug rebate agreement are coveredoutpatient drugs reimbursable by Medicaid. Under the Omnibus Budget Reconciliation Act of 1993, a stateMedicaid program may require prior approval before dispensing of any drug product and may design andimplement a formulary intended to limit coverage for specific drugs. Drug formularies and prior authorizationprograms 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 officiallabeling 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 suchtreatment” over other drug products, and there is a written explanation (available to the public) of the basis for theexclusion. However, drug products excluded from the formulary under these conditions, nevertheless, must beavailable through prior authorization.

Drugs in certain specific classes may be restricted or excluded from coverage without regard to the formularyconditions 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 coughor colds, or for cessation of smoking.

• Vitamins and minerals (except prenatal vitamins and fluoride preparations) or non-prescription drugs.

• Drugs that require tests or monitoring services to be purchased exclusively from the manufacturer or hisdesignee.

• Barbiturates or benzodiazepines.

PRIOR AUTHORIZATION

Whether or not a drug product is on a formulary, states may require physicians to request and receive officialpermission before a particular product can be dispensed. This procedure is called Prior Authorization or PriorApproval.

States may not operate prior authorization plans unless the state provides for a response within 24 hours of arequest 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, butrather to make them available to the states for the purpose of controlling utilization of products that have verynarrow indications or high abuse potential.

The majority of states report the establishment of prior authorization programs and have plans to apply priorauthorization 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

Drug Utilization Review (DUR) is defined as a structured and continuing program that reviews, analyzes, andinterprets patterns of drug usage in a given health care environment against predetermined standards.

The two primary objectives of DUR systems are (1) to improve quality of care; and (2) to assist in containinghealth 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 thesystems currently in place (or envisioned) meet the two objectives outlined above.

OBRA `90 required that, by January 1, 1993, states had to establish a Drug Utilization Review (DUR) program,consisting of prospective and retrospective components as well as components to educate physicians andpharmacists on common drug therapy problems and assessments of whether usage complies with predeterminedstandards.

Prospective DUR is to be conducted at the point of sale (POS) before delivery of a medication by the pharmacistto the Medicaid recipient or caregiver. The state is to establish standards for counseling patients and will requirethe pharmacist to offer to discuss matters, which, in the exercise of the pharmacist’s professional judgement aredeemed 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 beencountered, 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 thefollowing 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 drugreactions, and a comprehensive list of medications and relevant devices; and

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

OBRA `90 required that retrospective review is to be ongoing, based on compendia standards and medicalliterature, and to include remedial strategies for educational outreach through a wide range of interventions. Eachstate is to establish a Drug Utilization Review board, consisting of no more than 51% physicians and at least one-third pharmacists.



Pharmacy Advisory Committees

State Pharmacy Advisory Committee Meetings Preferred Product Introduction ProcessAlabama Pharmacy & Therapeutic Committee Bi-Monthly Contact First Data BankAlaska None - Introductory letterArizona* - - Inform health plans directlyArkansas N/A - Introductory letterCalifornia Contract Drug Advisory Committee Ad Hoc Introductory letterColorado DUR Board advises Quarterly Introductory letterConnecticut None - Introductory letterDelaware DUR Board advises Bi-Monthly Introductory letterDistrict of Columbia N/A - Introductory letterFlorida DUR Board advises Quarterly Introductory letterGeorgia Yes Quarterly Introductory letterHawaii DUR Board advises Quarterly Introductory letterIdaho DUR Board advises Bi-Monthly Introductory letterIllinois No - Contact First Data BankIndiana DUR Board advises Quarterly Introductory letterIowa Medicaid Pharmacy Advisory Committee Semiannually Introductory letterKansas DUR Board advises Bi-Monthly Introductory letter, Formulary packetKentucky Drug Management Review Advisory Board Quarterly State form, Package insertLouisiana Benefits Management Advisory Committee Ad Hoc Introductory letterMaine DUR Committee Bi-Monthly Introductory letterMaryland No - Introductory letterMassachusetts DUR Committee Quarterly Introductory letterMichigan No - State formMinnesota Drug Formulary Committee Quarterly Introductory letterMississippi No - Introductory letterMissouri Pharmacy Subcommittee Quarterly Introductory letterMontana DUR Board advises Monthly Introductory letterNebraska Medicaid Pharmacy Advisory Committee Ad Hoc Introductory letterNevada None - Introductory letterNew Hampshire None - Introductory letter, FDA updatesNew Jersey None - Introductory letterNew Mexico N/A - Introductory letterNew York Pharmacy Advisory Committee Quarterly Introductory letterNorth Carolina None - Introductory letter, Package insertNorth Dakota None - Introductory letterOhio Pharmacy & Therapeutic Committee Quarterly Introductory letterOklahoma Yes Monthly Introductory letterOregon None Contact First Data BankPennsylvania Medical Assistance Advisory Committee Monthly Introductory letterRhode Island N/A - Introductory letterSouth Carolina None - Formulary packetSouth Dakota None - Introductory letterTennessee* - - -Texas None - Introductory letter, State formUtah DUR Committee Monthly Introductory letterVermont DUR Committee Bi-Monthly Introductory letterVirginia Pharmacy Liaison Committee Bi-Monthly Introductory letterWashington Drug Utilization and Education Council Bi-Monthly State formWest Virginia Medical Services Fund Advisory Council Quarterly Introductory letterWisconsin None - Introductory letterWyoming None Bi-Monthly Introductory letter, Contact First Data Bank

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drugdecisions.Source: As reported by state drug program administrators in the 2000 NPC Survey.



Pharmacy Benefit Design - Coverage

State Cosmetics Fertility Drugs Experiment DrugsAlabama PA Required Not Covered Not CoveredAlaska Not Covered Not Covered Not CoveredArizona* - - -Arkansas Not Covered Not Covered Not CoveredCalifornia Not Covered Not Covered Not CoveredColorado Not Covered Not Covered Not CoveredConnecticut Not Covered Not Covered Not CoveredDelaware Not Covered Not Covered Not CoveredDistrict of Columbia N/A N/A N/AFlorida Not Covered Not Covered Not CoveredGeorgia Not Covered Not Covered Not CoveredHawaii Not Covered Not Covered Not CoveredIdaho Not Covered Not Covered Not CoveredIllinois Not Covered Not Covered Not CoveredIndiana Not Covered Not Covered Not CoveredIowa Not Covered Not Covered Not CoveredKansas Not Covered Not Covered Not CoveredKentucky Covered Covered CoveredLouisiana Not Covered Not Covered Not CoveredMaine Not Covered Not Covered Not CoveredMaryland Not Covered Not Covered Not CoveredMassachusetts Not Covered Not Covered Not CoveredMichigan Not Covered Not Covered Not CoveredMinnesota Covered Covered CoveredMississippi Not Covered Not Covered Not CoveredMissouri Not Covered Not Covered Not CoveredMontana Not Covered Not Covered Not CoveredNebraska Not Covered Not Covered Not CoveredNevada Not Covered Not Covered Not CoveredNew Hampshire Not Covered Not Covered Not CoveredNew Jersey Not Covered Not Covered Not CoveredNew Mexico Not Covered Not Covered Not CoveredNew York Covered Covered CoveredNorth Carolina Not Covered Not Covered Not CoveredNorth Dakota Not Covered Not Covered Not CoveredOhio Not Covered Not Covered Not CoveredOklahoma Not Covered Not Covered Not CoveredOregon PA Required Not Covered Not CoveredPennsylvania Not Covered Not Covered Not CoveredRhode Island N/A N/A N/ASouth Carolina Covered Covered CoveredSouth Dakota Not Covered Not Covered Not CoveredTennessee* - - -Texas Not Covered Not Covered Not CoveredUtah Not Covered Not Covered Not CoveredVermont Not Covered Not Covered Not CoveredVirginia Not Covered Covered with Restrictions Not CoveredWashington Not Covered Not Covered Not CoveredWest Virginia Not Covered Not Covered Not CoveredWisconsin Not Covered Not Covered Not CoveredWyoming Covered with Restrictions Not Covered Not Covered

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drugdecisions.PA = Prior Authorization, DME = Durable Medical EquipmentSource: As reported by state drug program administrators in the 2000 NPC Survey.



Pharmacy Benefit Design – Coverage (Con’t)

State Prescribed InsulinDisposable Needles forInsulin Use

Syringe Combinationsfor Insulin Use

Blood Glucose TestStrips

Alabama Covered Covered Covered CoveredAlaska Covered Covered Covered CoveredArizona* - - - -Arkansas Covered with Restrictions Covered with Restrictions Covered Not CoveredCalifornia Covered Covered Covered CoveredColorado Covered Covered with Restrictions Covered with Restrictions Covered with RestrictionsConnecticut Covered Covered Covered CoveredDelaware Covered Covered Covered CoveredDistrict of Columbia N/A N/A N/A N/AFlorida Covered Covered Covered CoveredGeorgia Covered Covered Covered Covered with RestrictionsHawaii Covered Covered Covered CoveredIdaho Covered Covered Covered Covered as DMEIllinois Covered Covered Covered CoveredIndiana Covered Covered Covered CoveredIowa Covered Not Covered Not Covered Not CoveredKansas Covered Covered Covered CoveredKentucky Not Covered Covered Not Covered CoveredLouisiana Covered Covered Covered CoveredMaine Covered Covered Covered CoveredMaryland Covered Covered Covered Not CoveredMassachusetts Covered Covered Covered CoveredMichigan Covered Covered Covered CoveredMinnesota Not Covered Not Covered Not Covered Not CoveredMississippi Covered Not Covered Covered Covered as DMEMissouri Covered Covered Covered Covered as DMEMontana Covered Not Covered Not Covered Not CoveredNebraska Covered with Restrictions Not Covered Not Covered Not CoveredNevada Covered Not Covered Not Covered Not CoveredNew Hampshire Covered Covered Covered CoveredNew Jersey Covered Covered Covered CoveredNew Mexico Covered Covered Covered CoveredNew York Not Covered Not Covered Not Covered Not CoveredNorth Carolina Covered Not Covered Not Covered Not CoveredNorth Dakota Covered Covered Covered CoveredOhio Covered as DME Not Covered Not Covered Not CoveredOklahoma Covered as DME Covered as DME Covered as DME Covered as DMEOregon Covered Not Covered Covered with Restrictions Not CoveredPennsylvania Covered Covered Covered CoveredRhode Island N/A N/A N/A N/ASouth Carolina Not Covered Not Covered Not Covered CoveredSouth Dakota Covered Covered Covered CoveredTennessee* - - - -Texas Covered Covered with Restrictions Covered Not CoveredUtah Covered Covered Covered N/AVermont Covered Covered Covered CoveredVirginia Covered Covered Covered CoveredWashington Covered Covered Covered CoveredWest Virginia Covered Covered as DME Covered as DME Covered as DMEWisconsin Covered Covered as DME Covered Covered as DMEWyoming Covered Covered Covered Covered

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drugdecisions.PA = Prior Authorization, DME = Durable Medical EquipmentSource: As reported by state drug program administrators in the 2000 NPC Survey.



Pharmacy Benefit Design – Coverage (Con’t)

StateUrine KetoneTest Strips

TotalParenteral Nutrition

Interdialytic ParenteralNutrition

Alabama Covered Covered CoveredAlaska Covered Covered CoveredArizona* - - -Arkansas Not Covered Not Covered Not CoveredCalifornia Covered PA Required PA RequiredColorado Covered with Restrictions PA Required Not CoveredConnecticut Covered Covered CoveredDelaware Covered Covered Not CoveredDistrict of Columbia N/A N/A N/AFlorida Covered with Restrictions Covered Not CoveredGeorgia Covered with Restrictions Covered with Restrictions Covered with RestrictionsHawaii Covered Covered CoveredIdaho Covered as DME Covered as DME Covered as DMEIllinois Covered Not Covered Not CoveredIndiana Covered Covered CoveredIowa Not Covered Not Covered Not CoveredKansas Covered Covered Covered as DMEKentucky Covered Not Covered Not CoveredLouisiana Covered PA Required PA RequiredMaine Covered Covered CoveredMaryland Not Covered Covered Not CoveredMassachusetts Covered Covered CoveredMichigan Covered Covered as DME Covered as DMEMinnesota Not Covered Not Covered Covered with RestrictionsMississippi Covered as DME Covered as DME Covered as DMEMissouri Covered as DME Covered as DME Covered as DMEMontana Not Covered Not Covered Not CoveredNebraska Not Covered Not Covered Not CoveredNevada Not Covered Covered Not CoveredNew Hampshire Covered Covered CoveredNew Jersey Covered Covered CoveredNew Mexico Covered Covered CoveredNew York Not Covered Not Covered Not CoveredNorth Carolina Not Covered Not Covered Not CoveredNorth Dakota Covered Covered CoveredOhio Not Covered Covered as DME Covered as DMEOklahoma Covered as DME Covered with Restrictions Covered with RestrictionsOregon Not Covered PA Required PA RequiredPennsylvania Covered Covered CoveredRhode Island N/A N/A N/ASouth Carolina Covered Covered CoveredSouth Dakota Covered Not Covered Not CoveredTennessee* - - -Texas Not Covered Not Covered Not CoveredUtah Covered Not Covered Not CoveredVermont Covered Covered CoveredVirginia Covered Covered Covered as DMEWashington Covered Covered CoveredWest Virginia Covered as DME Covered as DME Not CoveredWisconsin Covered as DME Covered with Restrictions Covered with RestrictionsWyoming Covered Covered as DME Covered as DME

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drugdecisions.PA= Prior Authorization, DME = Durable Medical EquipmentSource: As reported by state drug program administrators in the 2000 NPC Survey.



Coverage of Injectables

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

State Physicians Office Home Health Care Extended Care FacilityAlabama PDP PDP PDPAlaska PP PDP PDPArizona* - - -Arkansas PP PDP PDPCalifornia PP PDP PDPColorado PP PDP PDPConnecticut PP PDP PDPDelaware PDP and PP PDP PDPDistrict of Columbia N/A N/A N/AFlorida PP PDP PDPGeorgia PDP and PP PDP PDPHawaii PDP and PP PDP PDPIdaho PDP and PP PDP PDPIllinois PDP PDP PDPIndiana PDP and PP PDP and PP PDP and PPIowa PP PDP PDPKansas PP PDP PDPKentucky PDP and PP PDP PDPLouisiana PDP and PP PDP PDPMaine PP PDP PDPMaryland PP PDP PDPMassachusetts PP PDP PDPMichigan PP PDP PDPMinnesota PP PDP and PP PDPMississippi PP PDP PDPMissouri PDP PDP PDPMontana PP PDP PDPNebraska PP PDP PDPNevada PP PDP PDPNew Hampshire PP PDP PDPNew Jersey PP PDP PDPNew Mexico PDP and PP PDP and PP PDP and PPNew York PP PDP PDPNorth Carolina PP PDP PDPNorth Dakota PDP PDP PDPOhio PP PDP PDPOklahoma PP PDP PDPOregon PP PP PPPennsylvania PDP PDP PDPRhode Island N/A N/A N/ASouth Carolina PP PDP PDPSouth Dakota PP PP PPTennessee* - - -Texas PP PDP PDPUtah PP PDP and PP PDP and PPVermont PP PP PPVirginia PP PDP PDPWashington PP PDP PDPWest Virginia PDP and PP PDP PDP and PPWisconsin PP PDP PDPWyoming PP PDP PDP*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drugdecisions.Source: As reported by state drug program administrators in the 2000 NPC Survey.



Coverage of Vaccines and Unit Dose

State Method for Vaccine Reimbursement ^ Reimbursement for Unit DoseAlabama EPSDT, VCP YesAlaska EPSDT, CHIP, VCP YesArizona* - -Arkansas VCP YesCalifornia VCP NoColorado VCP NoConnecticut CHIP NoDelaware VCP NoDistrict of Columbia EPSDT NoFlorida VCP YesGeorgia EPSDT, CHIP, VCP YesHawaii EPSDT, VCP YesIdaho EPSDT, CHIP, VCP YesIllinois Special Program NoIndiana EPSDT, CHIP, VCP NoIowa EPSDT, VCP YesKansas CHIP, VCP NoKentucky EPSDT, CHIP, VCP, Pharmacy Services YesLouisiana EPSDT, VCP NoMaine EPSDT YesMaryland EPSDT Yes, LTCMassachusetts EPSDT NoMichigan EPSDT, CHIP YesMinnesota EPSDT, CHIP, VCP YesMississippi EPSDT NoMissouri EPSDT, CHIP, VCP YesMontana EPSDT, CHIP, VCP YesNebraska EPSDT, CHIP, VCP NoNevada EPSDT YesNew Hampshire EPSDT, CHIP, VCP Yes, LTCNew Jersey EPSDT, VCP Yes, LTCNew Mexico VCP NoNew York EPSDT, VCP NoNorth Carolina Health Check YesNorth Dakota EPSDT NoOhio VCP NoOklahoma ESPDT, VCP YesOregon VCP YesPennsylvania EPSDT, CHIP, VCP, Pharmacy Services NoRhode Island N/A NoSouth Carolina VCP YesSouth Dakota VCP YesTennessee* - -Texas EPSDT YesUtah EPSDT, CHIP, VCP, Medical Services YesVermont EPSDT YesVirginia VCP, Health Dept. YesWashington EPSDT YesWest Virginia EPSDT, VCP YesWisconsin VCP YesWyoming EPSDT, CHIP, VCP No^ Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Children Health Insurance Program (CHIP), Vaccines for ChildrenProgram (VCP), or other.LTC = Long Term Care*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drugdecisions.Source: As reported by state drug program administrators in the 2000 NPC Survey.



Coverage of Over-the-Counter Medications

StateAllergy, Asthma,and Sinus Analgesics Cough and Cold Smoking Deterrents

Alabama Covered with Rx Covered with Rx Covered with Rx Not CoveredAlaska Not Covered Not Covered Not Covered Not CoveredArizona* - - - -Arkansas Limited Coverage Limited Coverage Limited Coverage Not CoveredCalifornia PA Required PA Required PA Required PA RequiredColorado Not Covered Limited Coverage Not Covered Limited CoverageConnecticut Not Covered Limited Coverage Limited Coverage Not CoveredDelaware Covered Covered Covered CoveredDistrict of Columbia N/A N/A N/A N/AFlorida Limited Coverage Limited Coverage Limited Coverage CoveredGeorgia Not Covered Limited Coverage Limited Coverage Not CoveredHawaii Limited Coverage Limited Coverage Limited Coverage Not CoveredIdaho Not Covered Not Covered Not Covered Not CoveredIllinois Not Covered PA Required PA Required CoveredIndiana N/A N/A N/A N/AIowa Covered with Restrictions Covered with Restrictions Covered with Restrictions Not CoveredKansas Not Covered Covered Limited Coverage Limited CoverageKentucky Covered with Restrictions Covered with Restrictions Covered with Restrictions CoveredLouisiana Not Covered Not Covered Not Covered Not CoveredMaine Covered with Restrictions Covered with Restrictions Not Covered CoveredMaryland Not Covered Not Covered Not Covered Not CoveredMassachusetts Covered Covered Covered with Restrictions Not CoveredMichigan Limited Coverage Limited Coverage Not Covered Limited CoverageMinnesota Limited Coverage Limited Coverage Limited Coverage Covered with RestrictionsMississippi Not Covered Limited Coverage Limited Coverage Not CoveredMissouri Covered Covered Covered Not CoveredMontana Not Covered Limited Coverage Not Covered Not CoveredNebraska Covered Covered Covered Not CoveredNevada Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with RestrictionsNew Hampshire Covered Covered Covered CoveredNew Jersey Limited Coverage Limited Coverage Limited Coverage Not CoveredNew Mexico Covered Covered Covered CoveredNew York Limited Coverage Limited Coverage Limited Coverage CoveredNorth Carolina Not Covered Not Covered Not Covered Not CoveredNorth Dakota Not Covered Covered Not Covered PA RequiredOhio Limited Coverage Limited Coverage Limited Coverage Limited CoverageOklahoma Not Covered Not Covered Not Covered Not CoveredOregon Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with RestrictionsPennsylvania Covered with Restrictions Covered Covered with Restrictions Not CoveredRhode Island N/A N/A N/A N/ASouth Carolina Covered with Restrictions Covered with Restrictions Covered with Restrictions CoveredSouth Dakota Not Covered Not Covered Not Covered Not CoveredTennessee* - - - -Texas Covered Covered Covered CoveredUtah Limited Coverage Covered Covered Not CoveredVermont PA Required PA Required PA Required PA RequiredVirginia Covered with Restrictions Covered Covered with Restrictions Not CoveredWashington Limited Coverage Limited Coverage Limited Coverage CoveredWest Virginia Limited Coverage Limited Coverage Limited Coverage PA RequiredWisconsin Not Covered Covered Covered with Restrictions Not CoveredWyoming Limited Coverage Covered Covered Not Covered

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drugdecisions.PA= Prior AuthorizationSource: As reported by state drug program administrators in the 2000 NPC Survey.



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

StateDigestive Products(no H2 antagonists) H2 Antagonists Feminine Products Topical Products

Alabama Covered with Rx Covered with Rx Not Covered Covered with RxAlaska Not Covered Not Covered Limited Coverage Limited CoverageArizona* - - - -Arkansas Limited Coverage Covered Limited Coverage Limited CoverageCalifornia PA Required PA Required PA Required PA RequiredColorado Not Covered Not Covered Not Covered Not CoveredConnecticut Covered Not Covered Covered Not CoveredDelaware Covered Covered Limited Coverage Limited CoverageDistrict of Columbia N/A N/A N/A N/AFlorida Not Covered Not Covered Covered with Rx Not CoveredGeorgia Not Covered Not Covered Not Covered Not CoveredHawaii Covered with Restrictions Covered with Restrictions Limited Coverage Limited CoverageIdaho Not Covered Not Covered Not Covered Not CoveredIllinois PA Required Covered Not Covered PA RequiredIndiana N/A N/A N/A N/AIowa Not Covered Not Covered Not Covered Covered with RestrictionsKansas Not Covered Covered Not Covered Not CoveredKentucky Covered with Restrictions Not Covered Covered with Restrictions Covered with RestrictionsLouisiana Not Covered Not Covered Not Covered CoveredMaine Covered with Restrictions Covered with Restrictions Not Covered Covered with RestrictionsMaryland Not Covered Not Covered Not Covered Not CoveredMassachusetts Covered Covered with Restrictions Covered Covered with RestrictionsMichigan Limited Coverage Limited Coverage Limited Coverage Limited CoverageMinnesota Limited Coverage Covered Limited Coverage Limited CoverageMississippi Not Covered Not Covered Not Covered Not CoveredMissouri Covered Covered Not Covered Limited CoverageMontana Covered Covered Not Covered Not CoveredNebraska Covered Covered Covered CoveredNevada Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with RestrictionsNew Hampshire Covered Covered Covered CoveredNew Jersey Not Covered Not Covered Not Covered Covered with RestrictionsNew Mexico Covered Covered Covered with Restrictions CoveredNew York Limited Coverage Covered Limited Coverage Limited CoverageNorth Carolina Not Covered Not Covered Not Covered Not CoveredNorth Dakota Not Covered Covered Not Covered Not CoveredOhio Limited Coverage Limited Coverage Limited Coverage Limited CoverageOklahoma Not Covered Not Covered Not Covered Not CoveredOregon Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with RestrictionsPennsylvania Covered with Restrictions Covered with Restrictions Covered CoveredRhode Island N/A N/A N/A N/ASouth Carolina Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with RestrictionsSouth Dakota Not Covered Not Covered Not Covered Not CoveredTennessee* - - - -Texas Covered Covered Covered CoveredUtah Covered Covered N/A Limited CoverageVermont PA Required PA Required PA Required PA RequiredVirginia Covered Covered Covered Limited CoverageWashington Covered Not Covered Limited Coverage Limited CoverageWest Virginia Limited Coverage Not Covered Covered CoveredWisconsin Covered with Restrictions Not Covered Not Covered Covered with RestrictionsWyoming Not Covered Covered Covered Limited Coverage




Prior Authorization Process and Procedures

State PA Procedure Prior Authorization Committee Members MeetingsAlabama Yes N/A N/A N/AAlaska Yes No - -Arizona* - - - -Arkansas Yes DUR Board N/A N/ACalifornia Yes No - -Colorado Yes Yes N/A N/AConnecticut No - - -Delaware Yes No N/A N/ADistrict of Columbia Yes N/A N/A N/AFlorida Yes No - -Georgia Yes Yes 14 QuarterlyHawaii Yes DUR Board 9 QuarterlyIdaho Yes Yes (Used only for Growth Hormones) 3 Ad hocIllinois Yes Committee on Drugs and Therapeutics Varies QuarterlyIndiana No - - -Iowa Yes No - -Kansas Yes No - -Kentucky Yes Prior Authorization Subcommittee 6 QuarterlyLouisiana No - - -Maine Yes No - -Maryland No - - -Massachusetts Yes No - -Michigan Yes No - -Minnesota Yes Drug Formulary Committee 9 QuarterlyMississippi No No - -Missouri Yes Prior Authorization Committee 7 QuarterlyMontana Yes NoNebraska Yes Utilization Review Committee 7 Ad hocNevada Yes No - -New Hampshire No - - -New Jersey Yes No - -New Mexico Yes No - -New York No - - -North Carolina No - - -North Dakota Yes No - -Ohio Yes No - -Oklahoma Yes DUR Board 10 MonthlyOregon Yes No 12 QuarterlyPennsylvania Yes No - -Rhode Island Yes No - -South Carolina Yes No - -South Dakota Yes No - -Tennessee* - - - -Texas Yes No - -Utah Yes No - -Vermont Yes No - -Virginia Yes Yes N/A Not ActiveWashington Yes Drug Utilization and Education Council 8 BimonthlyWest Virginia Yes DUR Board - -Wisconsin Yes No - -Wyoming No - - -




Prior Authorization Process and Procedures (Con’t)

State Initiated By: Annual Requests % ApprovedAlabama M.D., R.Ph. N/A N/AAlaska R.Ph. 3,634 74%Arizona* - - -Arkansas M.D., R.Ph. 126,248 83%California M.D., R.Ph. 1,200,000 87%Colorado M.D. 12,000 90%Connecticut N/A N/A N/ADelaware M.D., R.Ph. 50 N/ADistrict of Columbia N/A N/A N/AFlorida M.D., R.Ph. N/A N/AGeorgia M.D., R.Ph. 50,000 85%Hawaii M.D., R.Ph. N/A N/AIdaho M.D. 1,200 97%Illinois M.D., R.Ph. 670,000 N/AIndiana N/A N/A N/AIowa M.D., R.Ph. 30,000 80%Kansas M.D., R.Ph. 10,085 85%Kentucky M.D., R.Ph., Social Worker 298,244 70%Louisiana N/A N/A N/AMaine M.D. 1,500 90%Maryland M.D., R.Ph 8,640 95%Massachusetts M.D 14,000 95%Michigan M.D. 18,000 82%Minnesota R.Ph. 6,000 96%Mississippi M.D. 40000 99%Missouri M.D. 10,000 N/AMontana M.D., R.Ph., Nurse 12,078 84%Nebraska M.D., R.Ph. 2,500 80%Nevada M.D., R.Ph. 40,000 90%New Hampshire N/A N/A N/ANew Jersey R.Ph., DME Supplier 386,000 90%New Mexico M.D., R.Ph. 60 80%New York Order Provider N/A N/ANorth Carolina N/A 395 85North Dakota R.Ph. 625 96%Ohio M.D. 40,000 99%Oklahoma M.D., R.Ph. 6,000 75%Oregon M.D. 24974 70%Pennsylvania M.D. N/A N/ARhode Island R.Ph. 200 N/ASouth Carolina M.D., R.Ph. 4,200 90%South Dakota M.D., R.Ph. 50 95%Tennessee* - - -Texas M.D., R.Ph. N/A N/AUtah R.Ph. N/A N/AVermont M.D. N/A 99%Virginia M.D. N/A N/AWashington M.D., R.Ph. 82,480 80%West Virginia M.D., R.Ph. 153,235 73%Wisconsin R.Ph. 58,321 99%Wyoming N/A N/A N/A*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drugdecisions.Source: As reported by state drug program administrators in the 2000 NPC Survey.



Prior Authorization Process and Procedures (Con’t)

State Reviewer Review Time Response VehicleAlabama R.N., M.D., R.Ph. 24 hours Phone, fax, mailAlaska M.D., R.Ph., other Verbal-instant; paper-2 weeks Verbal, fax, mailArizona* - - -Arkansas Voice Response 1-3 minutes Voice Response SystemCalifornia R.Ph. 24 hours Fax or telephone inquiry systemColorado R.Ph., Fiscal Agent PA line Less than 1 working day PhoneConnecticut N/A N/A N/ADelaware R.Ph. 1 working day Phone, faxDistrict of Columbia N/A N/A N/AFlorida R.N., R.Ph., Other 10 minutes to 72 hours Verbal, fax, mailGeorgia R.Ph. 24 hours Phone, fax, mailHawaii R.N., M.D. 24 hours PhoneIdaho M.D., R.Ph. 24 hours or less Mail, faxIllinois M.D., R.Ph. 24 hours Automated phoneIndiana N/A N/A N/AIowa R.Ph. 24 hours or less Phone, faxKansas R.N., M.D., R.Ph. 24 hours or less PhoneKentucky R.N., M.D., R.Ph. Minutes to hours+ Phone, mailLouisiana N/A N/A N/AMaine M.D., R.Ph. 24 hours or less Phone, mailMaryland M.D., R.Ph. 24 hours or less PhoneMassachusetts R.Ph. 24 hours Phone, on-lineMichigan Health Care Analysts 24 hours or less PhoneMinnesota R.N. Within 10 days Phone, mailMississippi R.N., R.Ph., other 5-10 minutes PhoneMissouri R.N., Medicaid Tech. Within 24 hours Phone, faxMontana R.Ph. 10-15 minutes Phone, faxNebraska R.N., M.D., R.Ph. 1 hour Fax, mailNevada R.N., M.D., R.Ph. 24 hours Phone, fax, mailNew Hampshire N/A N/A N/ANew Jersey R.N., R.Ph. Minutes PhoneNew Mexico R.Ph. 3 minutes Requestor notified if PA is deniedNew York R.N., R.Ph., other Under 21 days PA sent to ordering providerNorth Carolina R.Ph. 24 hours FaxNorth Dakota R.Ph., M.D., R.N. 2-3 days MailOhio R.Ph. 24 hours Phone, faxOklahoma R.Ph. 5-20 minutes Phone, faxOregon R.Ph. 3-4 minutes Phone, faxPennsylvania R.N., M.D. Immediately to 24 hours PhoneRhode Island R.Ph. Within 72 hours N/ASouth Carolina R.Ph. Per OBRA '90 guidelines Phone, fax, mailSouth Dakota M.D. or R.Ph. 24 hours Phone, fax, mailTennessee* - - -Texas R.Ph. N/A Phone, fax, mail, e-mailUtah Nurse 24 hours Phone, fax, mailVermont R.N. 24 hours Phone, mailVirginia M.D., R.Ph. 24 hours Phone, fax, mailWashington R.N., M.D., R.Ph.# 24 hours Phone, fax; denial through mailWest Virginia R.Ph. 3 minutes to 2 hours Phone, faxWisconsin R.Ph. Immediate to a few days+ Phone, fax, mailWyoming N/A N/A N/A*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drugdecisions.+Depends on urgency.#Reviewer also includes Medical Claims Examiner.Source: As reported by state drug program administrators in the 2000 NPC Survey.



Prior Authorization

State Anabolic SteroidsAnalgesics,Antipyretics, NSAIDs Anorectics

Alabama Covered, PA Required Covered, PA Required Not CoveredAlaska Covered Covered Not CoveredArizona* - - -Arkansas Covered Covered, PA Required Not CoveredCalifornia Covered, PA Required Covered, Some PA Required Covered, PA RequiredColorado Covered, PA Required Covered Partial CoverageConnecticut Covered Covered Not CoveredDelaware Covered Covered Covered, PA RequiredDistrict of Columbia N/A N/A N/AFlorida Covered Covered Not CoveredGeorgia Covered, PA Required Partial Coverage, PA Required Covered, PA RequiredHawaii Covered, PA Required Partial Coverage Partial CoverageIdaho Covered Covered Not CoveredIllinois N/A N/A N/AIndiana Covered N/A N/AIowa Covered Covered, PA Required Not CoveredKansas Covered Covered Covered, PA RequiredKentucky Covered, PA Required Covered, Some PA Required Not CoveredLouisiana Covered Covered Not CoveredMaine Covered, PA Required Covered Covered, PA RequiredMaryland Covered Covered Not CoveredMassachusetts Covered Covered Covered, PA RequiredMichigan Not Covered Covered Not CoveredMinnesota Covered Covered Not CoveredMississippi Covered Covered, PA Required CoveredMissouri Covered Covered Not CoveredMontana Covered Covered, PA Required Covered, PA RequiredNebraska Covered Covered Not CoveredNevada Covered Covered Not CoveredNew Hampshire Covered Covered Not CoveredNew Jersey Partial Coverage Covered PA for ADD DiagnosisNew Mexico Covered Covered CoveredNew York Covered Covered Not CoveredNorth Carolina Covered Covered CoveredNorth Dakota Not Covered Covered Not CoveredOhio Covered, PA Required Covered Not CoveredOklahoma Not Covered Covered, PA Required Not CoveredOregon Covered Covered CoveredPennsylvania Covered Covered Not CoveredRhode Island N/A N/A N/ASouth Carolina Covered Covered Partial CoverageSouth Dakota Covered Covered Not CoveredTennessee* - - -Texas Covered Covered Not CoveredUtah Partial Coverage, PA Required Covered CoveredVermont Covered Covered CoveredVirginia Not Covered Partial Coverage Partial Coverage, PA RequiredWashington Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA RequiredWest Virginia Covered Covered, PA Required Not CoveredWisconsin Covered Covered Covered, PA RequiredWyoming Not Covered Covered Not Covered

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drugdecisions.PA = Prior AuthorizationSource: As reported by state drug program administrators in the 2000 NPC Survey.



Prior Authorization (Con’t)

State AntihistaminesAnxiolytics,Sedatives, and Hypnotics

PrescribedCold Medications

Alabama Covered, PA Required Covered CoveredAlaska Covered Covered Not CoveredArizona* - - -Arkansas Covered, PA Required Partial Coverage Partial CoverageCalifornia Covered, Some PA Required Covered, Some PA Required Covered, Some PA RequiredColorado Covered Covered Partial Coverage, Under 21Connecticut Covered Covered CoveredDelaware Covered Covered CoveredDistrict of Columbia N/A N/A N/AFlorida Covered Covered Not CoveredGeorgia Partial Coverage, PA Required Partial Coverage, PA Required Partial CoverageHawaii Covered, PA Required Covered, PA Required CoveredIdaho Covered Covered CoveredIllinois N/A N/A N/AIndiana N/A N/A N/AIowa Covered, PA Required Covered CoveredKansas Covered Partial Coverage, PA Required CoveredKentucky Covered, PA Required Covered, Some PA Required Covered, Some PA RequiredLouisiana Covered Covered Not CoveredMaine Covered Covered Not CoveredMaryland Covered Covered CoveredMassachusetts Covered Covered, PA for prolonged use Covered, PA RequiredMichigan Covered Covered Not CoveredMinnesota Covered Covered CoveredMississippi Covered Covered Not CoveredMissouri Covered Partial Coverage, PA Required CoveredMontana Covered Covered, PA Required CoveredNebraska Covered Covered CoveredNevada Covered Covered Covered, PA RequiredNew Hampshire Covered Covered CoveredNew Jersey Covered Covered CoveredNew Mexico Covered Covered CoveredNew York Covered Covered Partial Coverage, PA RequiredNorth Carolina Covered Covered CoveredNorth Dakota Covered Covered Partial CoverageOhio Covered Covered CoveredOklahoma Covered, PA Required Covered, PA Required Not CoveredOregon Covered, PA Required Covered Covered, PA RequiredPennsylvania Covered Covered Partial CoverageRhode Island N/A N/A N/ASouth Carolina Covered Covered CoveredSouth Dakota Covered Covered CoveredTennessee* N/A N/A N/ATexas Covered Covered CoveredUtah Covered Covered CoveredVermont Covered Covered CoveredVirginia Partial Coverage Covered Partial CoverageWashington Covered, PA Required Covered, PA Required Covered, PA RequiredWest Virginia Covered Partial Coverage Partial CoverageWisconsin Partial Coverage Covered Partial CoverageWyoming Covered Covered Covered




Prior Authorization (Con’t)

State Growth HormonesMiscellaneousGI Products

PrescribedSmoking Deterrents

Alabama Covered, PA Required Covered Not CoveredAlaska Covered, PA Required Covered Not CoveredArizona* N/A N/A N/AArkansas Covered Covered, PA Required Covered, PA RequiredCalifornia Covered, PA Required Covered, Some PA Required Covered, Some PA RequiredColorado Covered, PA Required Covered Covered, PA RequiredConnecticut Covered Covered Not CoveredDelaware Covered, PA Required Covered CoveredDistrict of Columbia N/A N/A N/AFlorida Covered, PA Required Covered CoveredGeorgia Covered, PA Required Covered Not CoveredHawaii Covered, PA Required Covered, PA Required Covered, PA RequiredIdaho Covered, PA Required Covered Not CoveredIllinois N/A N/A N/AIndiana N/A N/A N/AIowa Covered, PA Required Covered, PA Required Not CoveredKansas Covered, PA Required Covered CoveredKentucky Covered Covered Not CoveredLouisiana Covered Covered CoveredMaine Covered, PA Required Covered CoveredMaryland Covered, PA Required Covered CoveredMassachusetts Covered Covered, PA for prolonged use Not CoveredMichigan Covered, PA Required Covered Covered, PA RequiredMinnesota Covered Covered, PA Required CoveredMississippi Covered, PA Required Covered Not CoveredMissouri Not Covered Covered Not CoveredMontana Covered, PA Required Partial Coverage, PA Required Covered, PA RequiredNebraska Covered, PA Required Covered Not CoveredNevada Covered, PA Required Covered CoveredNew Hampshire Covered Covered CoveredNew Jersey Partial Coverage Covered Partial CoverageNew Mexico Covered Covered CoveredNew York Covered Partial Coverage, PA Required CoveredNorth Carolina Covered Covered CoveredNorth Dakota N/A Covered Covered, PA RequiredOhio Covered, PA Required Covered CoveredOklahoma Covered, PA Required Covered, PA Required Partial Coverage, PA RequiredOregon Covered, PA Required Covered, PA Required CoveredPennsylvania Covered Covered Not CoveredRhode Island N/A N/A N/ASouth Carolina Covered Covered Partial CoverageSouth Dakota Covered PA Required Covered Not CoveredTennessee* N/A N/A N/ATexas Covered Covered CoveredUtah Partial Coverage, PA Required Covered Not CoveredVermont Covered Covered Covered, PA RequiredVirginia Covered Covered CoveredWashington Partial Coverage, PA Required Covered, PA Required Not CoveredWest Virginia Covered, PA Required Covered, PA Required Covered, PA RequiredWisconsin Covered PA Required Covered, PA Required Covered, PA RequiredWyoming Covered Covered Not Covered




Drug Utilization Review

State State Contact Telephone In-House or ContractedPRODURImplemented

Alabama Louise Jones 334-242-5039 Contracted Jul-96Alaska Dave Campana, R.Ph. 907-273-3224 In-House and Contracted Jun-95Arizona* - - - -Arkansas Suzette Bridges, P.D. 501-324-9141 Contracted Mar-97California Vic Walker, R.Ph., B.C.P.P. 916-657-0785 In-House Aug-95Colorado Allen Chapman 303-866-3176 Contracted Dec-98Connecticut Elizabeth Geary, R.Ph. 860-424-5150 Contracted Sep-96Delaware Cynthia Denemark 302-453-8453 Contracted Feb-94District of Columbia Christopher Keeyes, Pharm.D. 301-572-1616 In-House NoFlorida Marie Donnelly-Stephens 850-487-4441 Contracted Jul-95Georgia Jean B. Cox, R.Ph. 404-657-7241 In-House Planned for 2000Hawaii Kathleen Kang-Kaulupali 808-692-8115 In-House N/AIdaho Gary Duerr, R.Ph. 208-364-1829 Contracted Jan-98Illinois N/A N/A In-House Jan-93Indiana Karen Baer 317-232-4391 Contracted Mar-96Iowa Cheryl Clarke, R.Ph. 515-270-0713 Contracted Jul-97Kansas Glenn McNees, R.Ph., M.S. 785-864-3164 Contracted Nov-96Kentucky Debra Bahr 502-564-6511 Contracted Sep-94Louisiana Melwyn Wendt 504-219-4154 Contracted Apr-96Maine Timothy Clifford, M.D. 207-287-2674 Contracted Dec-95Maryland Judy Geisler 410-767-1728 Contracted Jan-93Massachusetts Anna Morin 508-721-7104 Contracted Oct-95Michigan Mary Sandusky 517-335-5280 Contracted Jul-00Minnesota MaryBeth Reinke, Pharm.D. 651-215-1239 In-House Feb-96Mississippi James G. "Jack" Lee, R.Ph. 601-359-6296 Contracted Oct-95Missouri Jayne Zemmer 573-751-6963 Contracted Feb-93Montana Mark Eichler, R.Ph. 406-443-4020 Contracted Sep-94Nebraska Allison Jorgensen, Pharm.D., R.Ph. 402-420-1500 Contracted Apr-95Nevada Laurie Squartsoff, R.Ph. 702-687-4869 Contracted Planned for 2001New Hampshire Lisè Farrand 603-271-4419 Contracted Aug-95New Jersey Edward Vaccaro, R.Ph. 609-588-2721 In-House Oct-96New Mexico Chuck Reynolds 505-827-3174 Contracted Oct-93New York Michael Zegarelli 518-474-0691 In-House Mar-95North Carolina Sharman Leinwand 919-733-3590 In-House Oct-96North Dakota Pat Kramer 701-328-4893 In-House Jul-96Ohio Jan Lawson 614-466-7936 Contracted Feb-00Oklahoma John Crumly, M.H.A., R.Ph. 405-522-7300 Contracted Mar-93Oregon Mariellen Rich 503-391-1980 Contracted Mar-94Pennsylvania N/A - In-House Jun-93Rhode Island Paula Avarista 401-464-2183 Contracted Dec-94South Carolina Caroline Sojourner 803-898-2876 In-House and Contracted NoSouth Dakota Michael Jockheck 605-773-6439 In-House Planned for 2000Tennessee* - - - -Texas Curtis Burch 512-338-6922 In-House Feb-95Utah Duane Parke 801-538-6452 In-House Jun-95Vermont Gloria Jacobs 802-241-2763 Contracted Nov-93Virginia Marianne Rollins, R.Ph. 804-225-4268 Contracted Jul-94Washington Siri Childs 360-725-1564 In-House Mar-96West Virginia Peggy A. King, R.Ph. 304-588-1753 Contracted Mar-95Wisconsin Dr. Michael Mergener 608-258-3348 Contracted Planned for 2001Wyoming Debra Devereuax, R.Ph. 307-766-6120 Contracted Oct-95

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drugdecisions.PRODUR = Prospective Drug Utilization Review SystemSource: As reported by state drug program administrators in the 2000 NPC Survey.



Prescribing/Dispensing Limits

StateLimits onPrescriptions Limits on Number, Quantity, and Refills of Prescriptions

Alabama Yes 5 refills per RxAlaska Yes 30 day supply per RxArizona* - -Arkansas Yes 30 day supply per Rx; 3 Rx per month (extension to 6); 5 refills per Rx within 6 monthsCalifornia Yes 6 Rx per month without PA, other limitations specific to certain medicationsColorado No 100 day supply for maintenance medicationConnecticut No -Delaware Yes 34 day supply or 100 unit doses per Rx (whichever is greater)District of Columbia Yes 30 day supply per Rx, 3 refills per Rx within 4 mths. Max/min quantities for certain medsFlorida Yes Variable 6/8/10/12 Rxs per month (with exceptions); Max/min quantities for certain medsGeorgia Yes 30 day supply per Rx; 5 (adult)/6 (child) Rx per month; Per Rx limit: $1000/RxHawaii Yes 30 day supply or 100 unit doses per RxIdaho Yes 34 day supply per Rx (with exceptions); 3 cycles of birth controlIllinois Yes Medically appropriate monthly quantity; 11 refills per RxIndiana No -Iowa No -Kansas Yes 34 day supply per Rx, other limitations specific to certain medicationsKentucky Yes Maximum 5 refills in 6 months; one dispensing fee per month for maintenance medicationLouisiana Yes 30 day supply or 100 unit doses (whichever is greater); 5 refills per Rx within 6 monthsMaine No -Maryland Yes 34 day supply per Rx; 2 refills per RxMassachusetts Yes 5 refills within 6 months per RxMichigan Yes No refills for Schedule II drugs; Schedule III & V, 5 refills per 180 daysMinnesota Yes 30 day supply for maintenance drugs; max 3 month supplyMississippi Yes 34 day supply or 100 unit doses (whichever is greater); 5 Rx per month; 5 refills maximumMissouri Yes 34 day supply or 100 unit doses; up to 90 day per Rx maximumMontana Yes 34 day supply or 100 unit doses per Rx (whichever is greater)Nebraska Yes 3 month supply maximum, 5 refills per Rx within 6 months for controlled substancesNevada Yes 34 day supply per Rx; 3 Rx per monthNew Hampshire Yes 34 day supply or 100 unit doses per Rx (whichever is greater)New Jersey Yes 34 day supply or 100 unit doses per RxNew Mexico No 6 months supply maximumNew York Yes 5 refills per Rx; annual limit on number of Rx and OTC drugs avail. (potential override)North Carolina Yes 100 day supply per Rx; 6 Rx per monthNorth Dakota Yes 34 day supply per RxOhio Yes Consistent with State/Federal requirementsOklahoma Yes 3 Rx per month (21+; under 21 unlimited)Oregon Yes 34 day supply per RxPennsylvania Yes 34 day supply or 100 unit doses per Rx (whichever is greater); 5 refills within 6 monthsRhode Island Yes 30 day supply per Rx (non-maintenance); 5 refills per RxSouth Carolina Yes 100 day supply w/ unlimited Rx (children); 4 Rx per monthSouth Dakota No -Tennessee* - -Texas Yes 3 Rx per month with exceptions; unlimited Rxs for nursing home recipients or those < 21Utah Yes Monthly quantity limit, maximum varies per personVermont No -Virginia No -Washington Yes 34 day supply per Rx; usually 2 refills per month; 4 refills for antibiotics or scheduled drugsWest Virginia Yes 10 Rx per month; 5 refills per RxWisconsin No 34 day supply per RxWyoming Yes 90 day supply for maintenance drugs and birth control, 34 day supply for all others




PHARMACY PAYMENT AND PATIENT COST SHARING

Federal Medicaid regulations dictate the method for reimbursing prescription drugs. Reimbursement is made on aretrospective, fee-for-service basis, with payments limited to the lower of:

• The estimated acquisition cost (EAC) of the drug (the price generally and currently paid by providers fora particular drug in the package size most frequently purchased by providers), as determined by theprogram agency, plus a reasonable dispensing fee; or

• The providers’ usual and customary charge to the public for the drug.

Regulations require states to submit a state plan that describes their payment methods for prescribed drugs. Theregulations do not prescribe a preferred payment method, but states are required to submit assurances to HCFAthat the requirements are met.

The Health Care Financing Administration’s (HCFA) publishes a list of multiple-source drugs (generic drugs) towhich the upper limit payment formula applies (commonly referred to as the Federal Upper Limit List).Revisions to the list are provided periodically through Medicaid program issuances under the title “State MedicaidManual - Part 6, Payment for Services.” Any price revisions are included in these issuances. The current versionof this list is included as Appendix D: Specific Upper Limits for Multiple Source and “Other” Drugs. Theformula does not apply to any prescription for which the prescriber certified in his or her own handwriting that acertain brand of drug is “medically necessary” for the patient.

According to the regulations, as long as the state’s aggregate spending is at or below the amount derived from theformula, the state is free to maintain its current payment program or adopt other methods. States can alterpayment rates for individual drugs, balancing payment increases for certain products with payment decreases forother drugs so that, in the aggregate, the program does not exceed the established limit. State programsimplemented to comply with these requirements are frequently referred to as Maximum Allowable Cost (MAC)programs.

PATIENT COST SHARING

States are permitted to require certain recipients to share some of the costs of Medicaid by imposing on them suchpayments 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 andconditions under which states may impose cost-sharing, set forth minimum amounts and the methods fordetermining 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 themedically needy. Section 131 of the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 introducedmajor 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 anyservice offered under the state plan. Public Law 97-248, TEFRA, has been in effect since October 1982; itprohibits 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 formedical 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 bothcategorically 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 fornon-emergency services furnished in hospital emergency rooms. Such a waiver allows states to impose acopayment amount up to twice the current maximum for such services. Approval of a waiver request by HCFA isbased partly on the state’s assurance that recipients will have access to alternative sources of care.



Pharmacy Payment and Patient Cost Sharing

State Dispensing Fee Ingredient Reimbursement Basis CopaymentAlabama $5.40 AWP- 10%; WAC+9.2% $0.50 - $3.00Alaska $3.45 AWP-5% $2.00Arizona* - - -Arkansas $5.51 AWP-10.5% $0.50 - $3.00California $4.05 AWP-5% G: $1.00, B: $1.00Colorado $4.08 AWP-10% or WAC+18%, whichever is lowest G: $0.50, B: $2.00Connecticut $4.10 AWP-12% NoneDelaware $3.65 AWP-12.9% NoneDistrict of Columbia $3.75 AWP-10% $1.00Florida $4.23 AWP-13.25% NoneGeorgia $4.63 AWP-10% $0.50Hawaii $4.67 AWP-10.5% NoneIdaho $4.94 ($5.54 for unit dose) AWP-11% NoneIllinois G: $3.75, B: $3.45 AWP-10%, AWP-12% for multi-source drugs NoneIndiana $4.00 AWP-10% $0.50 - $3.00Iowa $4.13 - $6.42 AWP-10% $1.00Kansas $4.50 AWP-10% $2.00Kentucky OP: $4.75, LTC: $5.75 AWP-10% NoneLouisiana $5.77 AWP-10.5% $0.50 - $3.00Maine $3.35 (+ extra fees for compounding) AWP-10% $0.50 - $3.00Maryland $4.21 Lowest of :WAC + 10%, direct + 10%, AWP -10% $1.00Massachusetts $3.00 WAC+10% $0.50Michigan $3.72 AWP-13.5% (1 to 4 stores), AWP-15.1% (5+ stores) $1.00Minnesota $3.65 AWP-9% NoneMississippi $4.91 AWP-10% $1.00Missouri $4.09 AWP-10.43% $0.50 - $2.00Montana $2.00 - $4.20 AWP-10% G: $1.00, B: $2.00Nebraska $3.20 - $5.05 AWP-8.71% $1.00Nevada $4.76 AWP-10% NoneNew Hampshire $2.50 AWP-12% G: $0.50, B: $1.00New Jersey $3.73 - $4.07 AWP-10% NoneNew Mexico $4.00 AWP-12.5% NoneNew York B: $3.50 G: $4.50 AWP-10% G: $0.50, B: $2.00North Carolina $5.60 AWP-10% $1.00North Dakota $4.60 AWP-10% NoneOhio $3.70 AWP-11% NoneOklahoma $4.15 AWP-10.5% $1.00 - $2.00Oregon $3.91-$4.28 (based on annual # of Rx) AWP-11% NonePennsylvania $4.00 AWP-10% $1.00 - $2.00Rhode Island OP: $3.40, LTC: $2.85 WAC+5% NoneSouth Carolina $4.05 AWP-10% $2.00South Dakota $4.75 ($5.55 for unit dose) AWP-10.5% $2.00Tennessee* - - -Texas $5.27 + 2% of ingredient & dispensing fee AWP-15% or WAC+12%, whichever is lowest NoneUtah $3.90 - $4.40 (based on geographic area) AWP-12% $1.00 - $5.00Vermont $4.25 AWP-11.9% $1.00 - $2.00Virginia $4.25 AWP-9% $1.00Washington $4.06 - $5.02 (based on annual # of Rx) AWP-11% NoneWest Virginia $3.90 (+ extra fees for compounding) AWP-12% $0.50 - $2.00Wisconsin $4.88 AWP-10% $0.50 - $1.00Wyoming $4.70 AWP-4% $2.00WAC = Wholesalers Acquisition Cost; AWP = Average Wholesale Price; EAC = Estimated Acquisition Cost;G = Generic; B = Brand Name; OP = Outpatient; LTC = Long Term Care.*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drugdecisions.Source: As reported by state drug program administrators in the 2000 NPC Survey.



Maximum Allowable Cost (MAC) Programs

StateFederal UpperLimits

State-SpecificUpper Limits MAC Override Provisions

Alabama Yes Yes Brand medically necessaryAlaska Yes No Brand medically necessary and reason for medical necessityArizona* Yes No Brand necessaryArkansas Yes Yes Brand medically necessaryCalifornia Yes Yes Medically necessary and other products unavailable at MAC rateColorado Yes Yes Prior authorizationConnecticut Yes No Brand medically necessaryDelaware Yes Yes Brand medically necessaryDistrict of Columbia Yes No Brand medically necessaryFlorida Yes Yes If drug is on Florida Negative FormularyGeorgia Yes Yes Brand medically necessaryHawaii Yes No Brand necessary, prior authorizationIdaho Yes Yes Brand medically necessary, handwritten by M.D., prior authorizationIllinois Yes Yes Prior authorization request by M.D. or R.PhIndiana Yes No Brand medically necessaryIowa Yes No Brand medically necessaryKansas Yes Yes Brand medically necessary, prior authorizationKentucky Yes No Brand necessary, brand medically necessaryLouisiana Yes No Brand necessary or brand medically necessaryMaine Yes No Dispense as writtenMaryland Yes Yes Brand medically necessary and reason for medical necessityMassachusetts Yes No Dispense as written, brand medically necessaryMichigan Yes Yes Prior authorizationMinnesota Yes Yes Brand medically necessaryMississippi Yes No Brand medically necessaryMissouri Yes Yes Prior authorizationMontana Yes No Dispense as written, brand necessaryNebraska Yes Yes Brand medically necessary and MC-6 form signed by M.D.Nevada Yes No Brand medically necessaryNew Hampshire Yes No Brand medically necessaryNew Jersey Yes No Brand medically necessaryNew Mexico Yes No Brand medically necessaryNew York Yes No Dispense as written and brand necessary, or brand medically necessaryNorth Carolina Yes No Brand medically necessaryNorth Dakota Yes No Dispense as writtenOhio Yes Yes Prior authorizationOklahoma Yes Yes Brand medically necessaryOregon Yes No Brand necessary, medically necessary, or brand medically necessaryPennsylvania Yes Yes Brand necessary or brand medically necessary, plus prior authorizationRhode Island Yes No Dispense as written, brand medically necessarySouth Carolina Yes Yes Brand necessary or brand medically necessarySouth Dakota Yes No Brand medically necessaryTennessee* - - -Texas Yes Yes Brand necessary or brand medically necessaryUtah Yes No Dispense as written, brand medically necessary, or medical necessaryVermont Yes No Dispense as writtenVirginia Yes Yes Brand necessaryWashington No Yes Brand medically necessaryWest Virginia Yes No Brand medically necessaryWisconsin No Yes Brand medically necessaryWyoming No No -




Mandatory Substitution

StateIncentive Fee forGeneric Substitution

Dispensing of GenericMultisource Required

Dispensing of Lowest CostMultisource Required

Alabama No No NoAlaska No Yes NoArizona* - - -Arkansas No Yes NoCalifornia No No YesColorado No Yes (if FUL or State MAC) NoConnecticut $0.50 No NoDelaware No Yes NoDistrict of Columbia No No YesFlorida No Yes NoGeorgia No Yes (brand PA required) YesHawaii No Yes (if FUL) NoIdaho No Yes NoIllinois No No NoIndiana No Yes NoIowa No Yes NoKansas No No NoKentucky No Yes YesLouisiana No No NoMaine No Yes NoMaryland No No (payment based on generic) NoMassachusetts No Yes NoMichigan No No NoMinnesota No Yes YesMississippi No No NoMissouri No No NoMontana No No NoNebraska No No NoNevada No Yes YesNew Hampshire No Yes YesNew Jersey No Yes NoNew Mexico No Yes YesNew York Yes Yes (if M.D. allows substitution) NoNorth Carolina No Yes NoNorth Dakota No No NoOhio No No NoOklahoma No Yes NoOregon No Yes NoPennsylvania No Yes NoRhode Island No Yes NoSouth Carolina No Yes (if M.D. authorizes) YesSouth Dakota No No NoTennessee* - - -Texas No Yes NoUtah No Yes NoVermont No Yes NoVirginia No No NoWashington No No (except MAC drug, 3+ labelers) NoWest Virginia No Yes NoWisconsin No No NoWyoming No No No




Counseling Requirements and Payment for Cognitive Services

State Patient CounselingRequired1Medicaid Paymentfor Cognitive Services2

Alabama All NoAlaska All NoArizona All -Arkansas All NoCalifornia All NoColorado Medicaid Only NoConnecticut Medicaid Only NoDelaware All NoDistrict of Columbia Pending NoFlorida All NoGeorgia All NoHawaii Medicaid Only NoIdaho All NoIllinois All NoIndiana All NoIowa All NoKansas All NoKentucky All NoLouisiana All NoMaine All YesMaryland Medicaid Only NoMassachusetts All NoMichigan All NoMinnesota Medicaid Only NoMississippi All NoMissouri All NoMontana All NoNebraska All NoNevada All NoNew Hampshire All NoNew Jersey All NoNew Mexico All NoNew York All NoNorth Carolina All NoNorth Dakota All NoOhio All NoOklahoma All NoOregon All NoPennsylvania All NoRhode Island All NoSouth Carolina Medicaid Only NoSouth Dakota All NoTennessee All -Texas All NoUtah All NoVermont All NoVirginia All NoWashington All NoWest Virginia All NoWisconsin All YesWyoming All No

Source: 12000-2001 National Association of Boards of Pharmacy Law, Survey of Pharmacy Law; 2As reported by state drug programadministrators in the 2000 NPC Survey.



Prescription Price Updating

State Contact Telephone UpdatedAlabama First DataBank 650-588-5454 BiweeklyAlaska Dave Campana 907-273-3224 WeeklyArizona* - - -Arkansas First DataBank 650-588-5454 WeeklyCalifornia Electronic Data Systems 916-636-1000 MonthlyColorado Allen Chapman 303-866-3176 WeeklyConnecticut First DataBank 650-588-5454 WeeklyDelaware Cynthia Denemark 302-453-8453 BimonthlyDistrict of Columbia First DataBank 650-588-5454 MonthlyFlorida First DataBank 650-588-5454 WeeklyGeorgia Etta Hawkins 404-657-7239 MonthlyHawaii First DataBank 800-633-3453 MonthlyIdaho Gary Duerr 208-334-5795 BimonthlyIllinois First DataBank 650-588-5454 WeeklyIndiana First DataBank 317-469-5200 MonthlyIowa Sherry Swanson 515-327-0950 WeeklyKansas Karen Bramen 785-296-6968 WeeklyKentucky Unisys 502-226-1140 BimonthlyLouisiana Maggie Vick, Unisys Corp. 504-237-3251 WeeklyMaine Susan Curtis 207-287-1818 BimonthlyMaryland First DataBank 650-588-5454 WeeklyMassachusetts Christopher Burke 617-210-5592 WeeklyMichigan First DataBank 650-588-5454 WeeklyMinnesota First DataBank 650-588-5454 BimonthlyMississippi James G. Lee 601-359-6296 WeeklyMissouri First DataBank 650-588-5454 WeeklyMontana First DataBank 650-588-5454 WeeklyNebraska First DataBank 650-588-5454 WeeklyNevada First DataBank 650-588-5454 MonthlyNew Hampshire First DataBank 650-588-5454 BiweeklyNew Jersey First DataBank 650-588-5454 WeeklyNew Mexico Chuck Reynolds 505-827-3174 WeeklyNew York Carl Cioppa, Pharm.D.. 518-486-3209 MonthlyNorth Carolina Benny Ridout 919-857-4034 WeeklyNorth Dakota First DataBank 800-633-3453 BiweeklyOhio First DataBank 650-588-5454 MonthlyOklahoma Angela Thomasson 405-522-7307 WeeklyOregon Kathy Franklin, First DataBank 650-588-5454 BimonthlyPennsylvania First DataBank 800-633-3453 MonthlyRhode Island Paula Avarista 401-464-2183 BiweeklySouth Carolina First DataBank 650-588-5454 MonthlySouth Dakota Mark Petersen 605-773-3498 BimonthlyTennessee* - - -Texas Martha McNeill 512-338-6965 ContinuouslyUtah RaeDell Ashley 801-538-6495 BimonthlyVermont Christine Dapkiewicz 802-879-4450 BiweeklyVirginia David Shepherd 804-786-8057 MonthlyWashington Marilyn Mueller 360-725-1569 WeeklyWest Virginia Leslie Bratton 800-358-2381 WeeklyWisconsin First DataBank 800-633-3453 BimonthlyWyoming First DataBank 800-633-3453 Weekly






Section 5:StatePharmacy AssistancePrograms





State Pharmacy Assistance Programs

As of the end of December 2000, 26 states had authorized some type of program to provide pharmaceuticalcoverage or assistance to low-income elderly and/or persons with disabilities who do not qualify for Medicaid.These programs range from providing access to state-negotiated discounts to state subsidies and tax credits forprescription drug expenditures. These programs currently provide assistance to over 850,000 individuals, and anestimated 1.5 million more individuals are eligible for assistance.

Authorized State Pharmacy Assistance Programs

State Program Name Law EnactedCalifornia Discount Prescription Medication Program 1999

Connecticut Connecticut Pharmaceutical Assistance Contract to the Elderly andthe Disabled Program (ConnPACE) 1985

Nemours Pharmacy Assistance 1981Delaware Delaware Prescription Drug Assistance Program (DPAP) 1999Florida Pharmaceutical Expense Assistance Program 2000Illinois Pharmaceutical Assistance Program (PAP) 1985Indiana Indiana Prescription Drug Fund -- HoosierRx 2000Iowa Pharmaceutical Discount Program †‡Kansas Senior Pharmacy Assistance Program 2000†

Low Cost Drugs for the Elderly Program 1975Maine Maine Rx Program 2000†Maryland Pharmacy Assistance Program 1979Maryland Short-Term Prescription Drug Subsidy Plan 2000The Pharmacy Program 1996Pharmacy Program Plus 1999MassachusettsSubsidized Catastrophic Prescription Drug Insurance Program 2000†Michigan Emergency Pharmaceutical Program for Seniors (MEPPS) 1988Michigan State Medical Plan 1988

Minnesota Senior Citizen Drug Program 1997Missouri State Income Tax Credit for Legend Drugs 1999New Hampshire New Hampshire Senior Prescription Drug Discount Program ‡New Jersey Pharmaceutical Assistance to the Aged and Disabled (PAAD) 1975New York Elderly Pharmaceutical Insurance Coverage (EPIC) 1987Nevada Subsidy Program 1999North Carolina Prescription Drug Assistance Program 1999

Pharmaceutical Assistance Contract for the Elderly (PACE) 1984Pennsylvania PACE Needs Enhancement Tier (PACENET) 1996Rhode Island Rhode Island Pharmaceutical Assistance to the Elderly (RIPAE) 1985South Carolina SilverCard Program 2000

VSCRIPT 1989Vermont Health Access Program (VHAP) 1996VermontPharmacy Discount Program (PDP) 2000

Washington A Washington Alliance to Reduce Prescription-Drug Spending(AWARDS) ‡

West Virginia Senior Prescription Assistance Network II (SPAN II) ‡Wyoming Minimum Medical Program 1988†Program not yet operational.‡Not written into law. Program is either in pilot phase or under executive orders.



Nine states (Florida, Iowa, Kansas, Maine, Massachusetts, Nevada, South Carolina, Vermont, and Washington)have plans for new programs that are expected to commence in the year 2001 or later.

• Florida’s Pharmaceutical Expense Assistance Program: Florida’s program is designed to provide asubsidy, limited to $80 per month, to individuals over 65 who are dually-eligible for Medicaid and Medicarebut do not have pharmaceutical coverage. Participants will be required to pay a 10% coinsurance paymentfor each prescription. An estimated 30,000 individuals are eligible for this program. This program went intoeffect on January 1, 2001.

• Iowa’s Pharmaceutical Discount Program: Iowa legislators have acquired federal funds to establish ademonstration project to lower pharmaceutical costs for individuals and other purchasers through theestablishment of a prescription drug purchasing co-op. Individuals as well as local pharmacies would beeligible to join the co-op with additional participants eligible including employers, the self-employed,insurers and others. Participants would be required to a minimal fee to join the co-op. The State of Iowawould either directly or through a private sector contractor negotiate volume-purchasing discounts with drugmanufacturers. Members of the co-op would then pay the discounted rate when they purchase theirmedications. This project is scheduled to go into effect on July 1, 2001.

• Kansas’ Senior Pharmacy Assistance Program: This new law (HB 2814), signed into law in May 2000, isdesigned to provide direct subsidies to low-income seniors for the purchase of prescription drugs. Theminimum age for eligibility will be 67 years of age, and the income eligibility level will be 150% of thefederal poverty level. This program is scheduled to go into effect on July 1, 2001.

• Maine Rx Program: The Rx Program was created to provide a discounted price on prescription drugs for anyeligible resident who enrolls in the program. The law, which created the new program, also providesauthorization for the Commissioner of Human Services to establish maximum retail prices effective July2003 “if prices paid under the Maine Rx program for the most common drugs are not reasonably comparableto the lowest prices paid in the state.” The program is scheduled to commence on April 1, 2001.

• Massachusetts’s Subsidized Catastrophic Prescription Drug Insurance Program. Planned to replace thetwo programs currently in effect in Massachusetts, this new program will offer benefits to individuals 65years of age or older, or individuals under age 65 who work less than 40 hours per month and meet thedisability guidelines for CommonHealth. There will be no income eligibility requirement; however, monthlypremiums, deductibles, and copay will be based on income. This new program is scheduled to go into effecton April 1, 2001.

• Nevada’s Subsidy Program: Nevada’s SenioRx is a prescription insurance subsidy program that began onJanuary 1, 2001. The program is comprised of two plans: the Basic Plan and the Enhanced Plan, withmonthly premiums of $74.76 and $98.31 respectively, the latter covering some brand name drugs. Bothinclude a $100 yearly deductible, a $10 copayment for generic drugs, and a $5,000 maximum yearly benefit.Seniors with annual income of $12,700 or less would be eligible for a $40 monthly subsidy; seniors withincome up to $21,500 would be eligible for less. The state will pay a maximum of $480 per year toward thecost of the policy. The minimum age is 62. The program will be funded by the tobacco settlement.

• South Carolina’s SilverxCard Program: South Carolina’s new program went into effect on January 1, 2001.This program offers assistance to those who are 65 years or older, have income below 175% of the federalpoverty level ($14,612 for single; $19,678 for married), and have been South Carolina residents for 6 months.Total program funding for 2001 is estimated to be $20 million from the state’s tobacco settlement. Seniorcitizens enrolled in the SilverxCard program are not eligible for Medicaid and may not have otherprescription insurance coverage.



• Vermont’s Pharmacy Discount Program: The Pharmacy Discount Program is an expansion of the currentVermont Health Access Program. Under the new program, eligibility is expanded to include any Medicare-covered individual with income above 150% of federal poverty level without drug coverage and allindividuals with incomes up to 300% federal poverty level who do not have a benefit program that includesdrug coverage. Beneficiaries have the ability to purchase drugs at a price that is equivalent to the price that isavailable to the Medicaid program. Approximately 69,000 individuals are eligible for this program whichbegan on January 1, 2001.

• A Washington Alliance to Reduce Prescription-Drug Spending: The AWARDS program, in operation sinceJanuary 15, 2001, will offer Washington residents aged 55 and older significantly lower prescription drugcosts. Eligible beneficiaries will pay an annual fee of $15 per individual or $25 per family to join what willbe considered a “buyer's club.” Through combined agency purchasing power, beneficiaries can expect tosave anywhere from 12 percent to 30 percent of retail price for prescriptions.

The following pages provide profiles of 20 states that provided pharmacy assistance in 2000. Details wereprovided by state contacts on program characteristics, including eligibility criteria, funding and reimbursementinformation, and drug coverage.



CaliforniaDiscount Prescription Medication Program

Program Type: State-Negotiated DiscountsYear Operational: 2000

Estimated Eligibles (FY 00): 1,300,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+Eligible Income Level (Single): None Eligible Income Level (Married): NoneOther Eligibility Notes: Anyone who has a Medicare card is eligible

FUNDING AND REIMBURSEMENT

Funding Source: No funding, program offers state-negotiated discountsBudget (FY 00): N/ACost per Participant (FY 00): N/A# of Rx’s Per Participant (FY 00): N/AManufacturer Rebate Type: MedicaidIngredient Cost Calculation: AWP – 5%Enrollment Fee: NoneDeductible Amount: NoneCopayment Amount: NoneDispensing Fee: $0.15 per prescriptionNotes: All enrollees are eligible for discounts on prescriptions

DRUGS COVERAGE

Formulary: Open FormularyDrugs Covered: All prescription drugsDrug Coverage Restrictions: No formulary restrictions and no prior authorizationNotes: Pharmacies that participate in the Medi-Cal (Medicaid) program must

also allow Medicare recipients to purchase drugs for the same pricepaid by Medi-Cal. Pharmacies must participate in this program inorder to participate in the Medi-Cal program.

PROGRAM CONTACT

Department of Health Services714 P Street, Room 1253Sacramento, CA 95814

Phone: 916/657-4213



ConnecticutConnPACE

Program Type: Direct AssistanceYear Operational: 1986

Number of Recipients (FY 00): 31,666(Elderly: 27,434; Disabled: 4,232)


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+Eligible Income Level (Single): $14,700 Eligible Income Level (Married): $17,700Other Eligibility Notes: None


Funding Source: General Revenue FundBudget (FY 00): $39.6 millionCost per Participant (FY 00): $1,357.62# of Rx’s Per Participant (FY 00): 22.44Manufacturer Rebate Type: MedicaidIngredient Cost Calculation: AWP – 12%Enrollment Fee: $25.00/annualDeductible Amount: NoneCopayment Amount: $12.00/RxDispensing Fee: $4.10

DRUGS COVERAGE

Formulary: Open FormularyDrugs Covered: All prescription drugs and insulin, 120 unit or 30 day supply limit,

whichever is greaterDrug Coverage Restrictions: Restrictions on antihistamines, cough preparations, cosmetic, diet and

fertility/contraceptive drugs. Also restricted are multivitamins,smoking cessation gum and DESI drugs.

Prescription Drug Utilization: $39,417,855 program spending, 651,585 scriptsNotes: ConnPACE pays the difference between the copayment paid by the

enrollee and the cost of the drug.

PROGRAM CONTACT

Elizabeth A. Geary, R.Ph.Department of Social Services25 Siqourney StreetHartford, CT 06106

Phone: 860/424-5150Fax: 860/951-9544E-mail: [email protected]



DelawareNemours Pharmacy Assistance

Program Type: Private Discount ProgramYear Operational: 1981

Number of Recipients (FY 00): 26,000


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+Eligible Income Level (Single): $12,500 Eligible Income Level (Married): $17,125Other Eligibility Notes: U.S. Citizen, Resident of Delaware


Funding Source: Nemours Foundation (Program receives no state or federal funds)Budget: N/ACost per Participant (FY 99): $622.63# of Rx’s Per Participant (FY 99): 19.69Manufacturer Rebate Type: NoneIngredient Cost Calculation: NoneEnrollment Fee: NoneDeductible Amount: NoneCopayment Amount: 20% of drug costDispensing Fee: NoneNotes: Maximum yearly benefit: $2,000 based on average retail cost

DRUGS COVERAGE

Formulary: Open FormularyDrugs Covered: Prescription drugs, insulin syringes, and prescribed OTCsDrug Coverage Restrictions: Injectables, except for insulinPrescription Drug Utilization: Program spending, volume of scripts unknownNotes: One central pharmacy distributes all drugs by courier to branch

locations where citizens can pick up a 2-3 month supply. Formularylimited due to budgetary restraints.

PROGRAM CONTACT

W. Frank Morris, Jr.Nemours Clinic Pharmacy Assistance1801 Rockland RoadWilmington, DE 19803




DelawarePrescription Assistance Program (DPAP)


Number of Recipients (FY 00): 2,203(Elderly: 986; Disabled: 1,217)


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 21+Eligible Income Level (Single): $16,480 Eligible Income Level (Married): $22,120Other Eligibility Notes: Senior citizens eligible for the Nemours program are not eligible for

this program. Elderly and SSDI individuals who have income overthese amounts may also be eligible if they have drug costs that areover 40% of their yearly income.


Funding Source: Tobacco settlement (not subject to budget appropriation)Budget: $7.5 millionCost per Participant (FY 99): N/A# of Rx’s Per Participant (FY 99): N/AManufacturer Rebate Type: MedicaidIngredient Cost Calculation: AWP – 12.9%Enrollment Fee: NoneDeductible Amount: NoneCopayment Amount: Greater of $5 or 25% AACDispensing Fee: $2.65

DRUGS COVERAGE

Formulary: Open FormularyDrugs Covered: Similar to Medicaid but limited by state rebate participationDrug Coverage Restrictions: Annual limit of $2,500 per personPrescription Drug Utilization: N/ANotes: None

PROGRAM CONTACT

Cynthia DenemarkDivision of Social Services248 Chapman Road Suite 200Newark, DE 19702

Phone: 302/453-8453 ext. 211Fax: 302/454-7603E-mail: [email protected]



IllinoisPharmaceutical Assistance Program (PAP)




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 16+Eligible Income Level (Single): $21,218 Eligible Income Level (Married): $28,480Other Eligibility Notes: Widow(er) who turned 63 or 64 before deceased claimant’s death is

eligible


Funding Source: General Revenue Fund (subject to budget appropriations)Budget: $35 millionCost per Participant (FY 99): $207.84 annually# of Rx’s Per Participant (FY 99): 24.58Manufacturer Rebate Type: MedicaidIngredient Cost Calculation: AWP – 10% or MAC if generic is availableEnrollment Fee: $5 if below FPL, $25 if above FPLDeductible Amount: NoneCopayment Amount: No copayment if below FPL, then 20% of drug cost after program

pays $2,000 in a fiscal year.$3.00 copayment if above FPL, then 20% of drug cost after programpays $2,000 in a fiscal year.

Dispensing Fee: None

DRUGS COVERAGE

Formulary: Open FormularyDrugs Covered: Prescription medication used for cancer, Alzheimer’s disease,

Parkinson’s disease, glaucoma, lung disease and smoking-relateddiseases.

Drug Coverage Restrictions:Notes:

PROGRAM CONTACT

Sue CoombeIllinois Department of RevenueP.O. Box 19021Springfield, IL 62794-9021




IndianaPrescription Drug Fund “HoosierRx”

Program Type: RefundsYear Operational: 2000

Estimated Eligibles (FY 00): 66,000


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): N/AEligible Income Level (Single): $11,280 Eligible Income Level (Married): $15,192Other Eligibility Notes: None


Funding Source: National Tobacco FundBudget: $20 millionCost per Participant (FY 99): N/A# of Rx’s Per Participant (FY 99): N/AManufacturer Rebate Type: N/AIngredient Cost Calculation: N/AEnrollment Fee: NoneDeductible Amount: NoneCopayment Amount: NoneDispensing Fee: NoneNotes: Refunds based on monthly income.

DRUGS COVERAGE

Formulary: Open FormularyDrugs Covered: FDA-approved prescription drugs and insulinDrug Coverage Restrictions: Maximum benefit of $1,000 per yearNotes: Refund amount is limited to 50% of actual out-of-pocket expenses, up to

the maximum benefit, based on monthly income:Single Married Refund$940 or less $1,266 or less 50% refund up to $500 per year$835 or less $1,125 or less 50% refund up to $750 per year$696 or less $938 or less 50% refund up to $1,000 per year

PROGRAM CONTACT

Grace ChandlerHoosierRxP.O. Box 6224Indianapolis, IN 46206-6224

Phone: 866/267-4679



MaineLow Cost Drugs for the Elderly and Disabled Program




Eligibility Age (Elderly): 62+ Eligibility Age (Disabled): 55+Eligible Income Level (Single): $15,348 Eligible Income Level (Married): $20,461Other Eligibility Notes: If 40% of income goes to drugs the eligible incomes increase to

$19,185 for Single and $25,575 for Married.


Funding Source: General Revenue FundBudget: $7.6 millionCost per Participant (FY 99): $154.55# of Rx’s Per Participant (FY 99): N/AManufacturer Rebate Type: MedicaidIngredient Cost Calculation: AWP – 10%Enrollment Fee: NoneDeductible Amount: NoneCopayment Amount: Greater of $2 or 20% of drug costDispensing Fee: $3.35

DRUGS COVERAGE

Formulary: Open FormularyDrugs Covered: All drugs from participating manufacturers used for the chronic

treatment of diabetes, asthma, COPD, cardiac conditions, arthritisDrug Coverage Restrictions: N/ANotes:

PROGRAM CONTACT

Christine GeeDepartment of Human Services11 State House StationAugust, ME 04333-0011

Phone: 207/287-4018Fax: 207/287-8601



MarylandPharmacy Assistance Program




Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All agesEligible Income Level (Single): $9,650 Eligible Income Level (Married): $10,450Other Eligibility Notes: No age restriction on eligibility


Funding Source: General Revenue Fund (subject to budget appropriations)Budget: $37.3 millionCost per Participant (FY 99): $1,124# of Rx’s Per Participant (FY 99): 24.09Manufacturer Rebate Type: MedicaidIngredient Cost Calculation: WAC + 10%Enrollment Fee: NoneDeductible Amount: NoneCopayment Amount: $5.00Dispensing Fee: $3.73 - $4.07

DRUGS COVERAGE

Formulary: Open FormularyDrugs Covered: Specified categories of maintenance drugs used to treat chronic

conditions, anti-infective drugs, and insulin syringes and needlesDrug Coverage Restrictions: 75% utilization required before prescription refillNotes: The following groups are ineligible for participation: people detained

in a correctional (federal, state, local) system, Medicaid recipients,and non-residents

PROGRAM CONTACT

Paul A. Roeger, Division ChiefOffice of Operations & Eligibility-DHMH201 West Preston StreetBaltimore, MD 21201




MarylandShort-Term Prescription Drug Subsidy Plan

Program Type: Direct AssistanceEnacted: 2000



Eligibility Age (Elderly): 65+* Eligibility Age (Disabled): N/AEligible Income Level (Single): N/A Eligible Income Level (Married): N/AOther Eligibility Notes: *And eligible for Medicare+Choice. Limited to residents of 17

underserved counties


Funding Source: N/ABudget: N/ACost per Participant (FY 99): N/A# of Rx’s Per Participant (FY 99): N/AManufacturer Rebate Type: N/AIngredient Cost Calculation: N/AEnrollment Fee: $460/annuallyDeductible Amount: $50Copayment Amount: $10 for generics, $20 for branded productsDispensing Fee: N/A

DRUGS COVERAGE

Formulary: N/ADrugs Covered: N/ADrug Coverage Restrictions: Maximum benefit of $1,000 per yearNotes:

PROGRAM CONTACT

Secretary of Health and Mental Hygiene201 West Preston StreetBaltimore, MD 21201



MassachusettsThe Pharmacy Program

(formerly Senior Pharmacy Assistance Program)




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): N/AEligible Income Level (Single): $15,708 Eligible Income Level (Married): $21,576Other Eligibility Notes: Six month Massachusetts residency required; no enrollees receiving

drug coverage from MassHealth or CommonHealth; disabledparticipants must work 40 hours per month and meet guidelines forCommonHealth


Funding Source: Cigarette tax revenues and general revenue fundBudget: $30 millionCost per Participant (FY 99): $735# of Rx’s Per Participant (FY 99): N/AManufacturer Rebate Type: MedicaidIngredient Cost Calculation: WAC+10% or lowest and customary feeEnrollment Fee: $15.00/annuallyDeductible Amount: NoneCopayment Amount: $3.00 (generic), $10.00 (brand)Dispensing Fee: $3.00

DRUGS COVERAGE

Formulary: Open FormularyDrugs Covered: All therapeutic classes except those excluded from MassHealth. Some

prior authorizations are requiredDrug Coverage Restrictions: Annual limit of $1,250 per person

Medicaid (MassHealth) recipients are ineligible for the programNotes:

PROGRAM CONTACT

Sheila MartinSenior Pharmacy ProgramOne Ashburton Place, Room 517Boston, MA 02108

Phone: 617/727-7750Fax: 617/727-9368



MassachusettsPharmacy Program Plus




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+Eligible Income Level (Single): $41,220 Eligible Income Level (Married): $55,320Other Eligibility Notes: Eligibles must have spent at least 10% of gross monthly income on

prescription drugs in 3 of 6 months prior to enrollment and mustproject to have drug expenses greater than 5% of gross monthlyincome as long as eligible under program.


Funding Source: Cigarette tax revenues and general revenue fundBudget: N/ACost per Participant (FY 99): N/A# of Rx’s Per Participant (FY 99): N/AManufacturer Rebate Type: MedicaidIngredient Cost Calculation: WAC+10% or lowest and customary feeEnrollment Fee: NoneDeductible Amount: NoneCopayment Amount: $3 for generics, $10 for branded productsDispensing Fee: N/A

DRUGS COVERAGE

Formulary: Open FormularyDrugs Covered: All therapeutic classes except those excluded from MassHealth. Some

prior authorizations are requiredDrug Coverage Restrictions: N/ANotes: Once enrolled in The PHARMACY Program Plus and exhausted all

other prescription benefits, including Medicare HMO or ThePHARMACY Program prescription benefits, enrollees will receiveunlimited prescription coverage to pay for their prescriptionmedicines.

PROGRAM CONTACT

Sheila MartinSenior Pharmacy ProgramOne Ashburton Place, Room 517Boston, MA 02108

Phone: 617/727-7750Fax: 617/727-9368



MichiganEmergency Pharmaceutical Program for Seniors (MEPPS)




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligibleEligible Income Level (Single): $12,360 Eligible Income Level (Married): $16,596Other Eligibility Notes: Rx drug costs must be 10% (Single)/8% (Married) or more of the

monthly income


Funding Source: Construction taxBudget: $6 millionCost per Participant (FY 99): $33.00# of Rx’s Per Participant (FY 99): 6Manufacturer Rebate Type: MedicaidIngredient Cost Calculation: AWP – 13.5%Enrollment Fee: NoneDeductible Amount: NoneCopayment Amount: Voluntary copay: $0.25/RxDispensing Fee: $3.72

DRUGS COVERAGE

Formulary: Open FormularyDrugs Covered: All prescriptionsDrug Coverage Restrictions: • Coverage limited to 3 months per year

• Generics must be dispensed unless specified by the physician• No experimental or over-the-counter drugs

Notes: Funding cap on total spending set by legislature. Michigan also has atax credit program with a pro rata adjustment to tax credits basedupon funding cap set by legislature. Program will be phased out in2001 by the new Elder Prescription Insurance Coverage (EPIC)Program.

PROGRAM CONTACT

Alisa HamiltonOffice of Services to the Aging611 West Ottawa, P.O. Box 30676Lansing, Michigan 48909-8176

Phone: 517/373-7881Fax: 517/373-4092



MichiganState Medical Plan

Program Type: Tax CreditYear Operational: 1990



Eligibility Age (Elderly): None Eligibility Age (Disabled): Not eligibleEligible Income Level (Single): 150% of FPL Eligible Income Level (Married): 150% of FPLOther Eligibility Notes:


Funding Source: Construction taxBudget: N/ACost per Participant (FY 99): None# of Rx’s Per Participant (FY 99): N/AManufacturer Rebate Type: N/AIngredient Cost Calculation: N/AEnrollment Fee: N/ADeductible Amount: N/ACopayment Amount: N/ADispensing Fee: N/A

DRUGS COVERAGE

Formulary: Open FormularyDrugs Covered: All prescriptionsDrug Coverage Restrictions:Notes: Seniors are eligible to a refundable tax up to $600 for prescription

drug expenditures that exceed 5% of income. Program will be phasedout in 2001 by the new Elder Prescription Insurance Coverage (EPIC)Program.

PROGRAM CONTACT

Alisa HamiltonOffice of Services to the Aging611 West Ottawa, P.O. Box 30676Lansing, Michigan 48909-8176

Phone: 517/373-7881Fax: 517/373-4092



MinnesotaSenior Citizen Drug Program


Number of Recipients (00): 5,000


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligibleEligible Income Level (Single): $10,260 Eligible Income Level (Married): $13,740Other Eligibility Notes: Cannot have other prescription drug coverage in past four months or

Medigap. Legislative action will make certain qualifying disabledpersons under the age of 65 eligible for the program starting in 7/1/02


Funding Source: General Revenue Fund plus rebates (subject to budget appropriations)Budget: $19 million for FY 00 and FY 01Cost per Participant (FY 99): $725.30 (for the 2,167 elderly recipients in FY 99)# of Rx’s Per Participant (FY 99): 24.07 (for the 2,167 elderly recipients in FY 99)Manufacturer Rebate Type: Same as Medicaid minus any CPI add-onIngredient Cost Calculation: AWP – 9%Enrollment Fee: NoneDeductible Amount: $35/monthCopayment Amount: NoneDispensing Fee: None

DRUGS COVERAGE

Formulary: Closed FormularyDrugs Covered: Same drugs as paid under Medicaid if manufacturer signs rebate

agreement with Dept. of Human Services. Covers over-the-counterdrugs for antacid, insulin products, and vitamins

Drug Coverage Restrictions: Most other over-the-counter drugs are not coveredNotes:

PROGRAM CONTACT

Steven HamiltonDepartment of Human Services444 Lafayette RoadSt. Paul, MN 55155-3853




MissouriState Income Tax Credit for Legend Drugs

Program Type: Tax CreditYear Operational: 1999

Number of Recipients (FY 00): N/A


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): N/AEligible Income Level (Single): <$15,000 Eligible Income Level (Married): N/AOther Eligibility Notes:


Funding Source: N/ABudget: N/ACost per Participant (FY 99): N/A# of Rx’s Per Participant (FY 99): N/AManufacturer Rebate Type: N/AIngredient Cost Calculation: N/AEnrollment Fee: NoneDeductible Amount: NoneCopayment Amount: NoneDispensing Fee: N/ANotes: Income tax credit for legend drugs. Income up to $15,000 = $200

credit. Credit reduced by $2 for each addition $100 of income.

DRUGS COVERAGE

Formulary: N/ADrugs Covered: Legend drugs onlyDrug Coverage Restrictions: N/ANotes:

PROGRAM CONTACT

Department of Revenue301 West High StreetJefferson City, MO 65101

Phone: 573/751-4081



New HampshireSenior Prescription Drug Discount Program

Program Type: State-Negotiated DiscountsYear Operational: 2000

Estimated Number of Eligibles: 75,000


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligibleEligible Income Level (Single): None Eligible Income Level (Married): NoneOther Eligibility Notes: Must be a New Hampshire resident


Funding Source: Rebates and incentives from pharmaceutical manufacturersBudget: N/ACost per Participant (FY 99): N/A# of Rx’s Per Participant (FY 99): N/AManufacturer Rebate Type: N/AIngredient Cost Calculation: N/ADeductible Amount: NoneCopayment Amount: N/ADispensing Fee: N/A

DRUGS COVERAGE

Formulary: No FormularyDrugs Covered: Most frequently prescribed medication for this population for multiple

health problemsDrug Coverage Restrictions: N/ANotes: Discounts will vary depending on pharmacy and medication.

Discounts could be up to 40% for generics and up to 15% for brandedproducts

PROGRAM CONTACT

Health And Human ServicesDivision Of Elderly And AdultServices129 Pleasant StreetConcord, NH 03301

Phone: 800/351-1888



New JerseyPharmaceutical Assistance to the Aged and Disabled (PAAD)


Number of Recipients (FY 00): 187,358(Elderly: 163,958; Disabled: 23,400)


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+Eligible Income Level (Single): $18,587 Eligible Income Level (Married): $22,791Other Eligible Groups: Groups receiving Social Security Disability Benefits are eligible


Funding Source: State General Fund and Casino Revenue FundBudget: $273 millionCost per Participant (FY 99): Elderly: $1,313 (gross), $1,116 (net);

Disabled: $2,654 (gross), $1,974 (net)# of Rx’s Per Participant (FY 99): 30 Elderly; 43 DisabledManufacturer Rebate Type: Medicaid without CPI componentIngredient Cost Calculation: AWP – 10%, Federal MAC, or Usual & CustomaryEnrollment Fee: NoneDeductible Amount: NoneCopayment Amount: $5.00Dispensing Fee: $3.73 - $4.07

DRUGS COVERAGE

Formulary: No FormularyDrugs Covered: All legend drugs, syringes, needles, and diabetic testing materialsDrug Coverage Restrictions: DESI drugs, non-rebatable drugs, and over-the-counter drugsPrescription Drug Utilization: Branded: $273,946,609 (3,817,842 scripts)

Generic: $37,180,099 (2,455,755 scripts)

PROGRAM CONTACT

Kathleen MasonPAAD ProgramP.O. Box 715Trenton, NJ 08625




New YorkElderly Pharmaceutical Insurance Coverage (EPIC) Program




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligibleEligible Income Level (Single): $35,000 Eligible Income Level (Married): $50,000Other Eligible Groups: None


Funding Source: State General Fund and tobacco tax and settlement fundsBudget: $252.2 millionCost per Participant (FY 99): $890 (net state cost)# of Rx’s Per Participant (FY 99): 32Manufacturer Rebate Type: Same as Medicaid, with modified additional (CPI) rebatesIngredient Cost Calculation: AWP (less 5% for high volume pharmacies)Enrollment Fee: Lower income seniors only (<$20,000 if single, <$26,000 if married )

$8-$300 depending on total income and marital statusDeductible Amount: Upper income seniors only (over $20,000 single; over $26,000

married); $530-$1,715 depending on total income and marital statusCopayment Amount: $3 to $20 based on cost of prescriptionDispensing Fee: $2.75 ($3.00 for full-service pharmacies)Notes: Based on level of income, seniors may enroll in the Fee Plan or the

Deductible Plan.

DRUGS COVERAGE

Formulary: No FormularyDrugs Covered: All legend drugs, insulin, and insulin syringes and needlesDrug Coverage Restrictions: DESI drugs and non-participating manufacturers. Viagra limited to six

tables per monthPrescription Drug Utilization: 86% of prescription drug spending on branded; 16% spending on

generic61% of scripts were branded; 39% of scripts were generic.

PROGRAM CONTACT

Julie A. Naglieri, Acting DirectorNYS Department of Health, EPIC Program260 Washington Avenue Ext.One Corporate Plaza, Suite 101Albany, NY 12203




North CarolinaPrescription Drug Assistance Plan




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): N/AEligible Income Level (Single): 150% FPL Eligible Income Level (Married): 150% FPLOther Eligibility Notes: Individuals must have cardiovascular disease and/or diabetes


Funding Source: N/ABudget: $500,000Cost per Participant (FY 99): N/A# of Rx’s Per Participant (FY 99): N/AManufacturer Rebate Type: MedicaidIngredient Cost Calculation: AWP – 10%Enrollment Fee: NoneDeductible Amount: N/ACopayment Amount: $6.00Dispensing Fee: N/A

DRUGS COVERAGE

Formulary: N/ADrugs Covered: Only certain drugs used to treat cardiovascular disease and/or diabetesDrug Coverage Restrictions: Program will not pay for other drugsNotes: Prescriptions may be issued for up to a 100-day supply

PROGRAM CONTACT

Charles ReedDepartment of Health and HumanServices2001 Mail Service CenterRaleigh, NC 27699

Phone: 919-715-3338



PennsylvaniaPharmaceutical Assistance Contract for the Elderly (PACE)

Type of Program: Direct AssistanceYear Operational: 1984





Funding Source: State LotteryBudget: $290 million (subject to annual legislative appropriations)Cost per Participant (FY 99): $1,350# of Rx’s Per Participant (FY 99): 40Manufacturer Rebate Type: MedicaidIngredient Cost Calculation: AWP - 10%Enrollment Fee: NoneDeductible Amount: NoneCopayment Amount: $6.00Dispensing Fee: $3.50

DRUGS COVERAGE

Formulary: Open FormularyDrugs Covered: All federal legend drugs and insulin, insulin syringes and needles

manufactured by companies who participate in the PACE rebateprogram

Drug Coverage Restrictions: No experimental drugs or drugs for baldness and wrinkles, OTCs,most off-label uses; mandatory generic substitution for A-ratedproducts; DESI drugs require documentation of medical necessity.

Prescription Drug Utilization $243,112,901 program spending for brand drugs; 5,498,976 scripts.$63,066,626 program spending for generic drugs; 3,760,786 scripts.

Notes:

PROGRAM CONTACT

Thomas SneddenPA Department of Aging555 Walnut Street, 5th FloorHarrisburg, PA 17101-1919




PennsylvaniaPACE Needs Enhancement Tier (PACENET)






Funding Source: State LotteryBudget: $290 million (subject to annual legislative appropriations)Cost per Participant (FY 99): $330# of Rx’s Per Participant (FY 99): 10Manufacturer Rebate Type: Mandatory 17% of AMP on all units reimbursedIngredient Cost Calculation: AWP – 10%Enrollment Fee: NoneDeductible Amount: $500 per yearCopayment Amount: $15.00 brand name, $8.00 genericDispensing Fee: $3.50

DRUGS COVERAGE

Formulary: Open FormularyDrugs Covered: All federal legend drugs and insulin, insulin syringes and needles

manufactured by companies who participate in the PACE rebateprogram

Drug Coverage Restrictions: No experimental drugs or drugs for baldness and wrinkles, OTCs, mostoff-label uses; mandatory generic substitution for A-rated products;DESI drugs require documentation of medical necessity

Notes:

PROGRAM CONTACT

Thomas SneddenPA Department of Aging555 Walnut Street, 5th FloorHarrisburg, PA 17101-1919




Rhode IslandPharmaceutical Assistance for the Elderly (RIPAE)




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): N/AEligible Income Level (Single): <$35,000 Eligible Income Level (Married): <$40,000Other Eligible Groups: None


Funding Source: State General Revenue FundBudget: $8.5 million for FY 01 (subject to legislature and governor

appropriation yearly)Cost per Participant (FY 99): $123.99# of Rx’s Per Participant (FY 99): 19.5Manufacturer Rebate Type: MedicaidIngredient Cost Calculation: AWP – 13%Enrollment Fee: NoneDeductible Amount: NoneCopayment Amount: Copayment amount is based on yearly income:

Single Married Copayment$15,932 or less $19,916 or less 40%$15,933 to $20,000 $19,917 to $25,000 70%$20,001 to $35,000 $25,001 to $40,000 85%

Dispensing Fee: $2.75 per Rx

DRUGS COVERAGE

Formulary: Open FormularyDrugs Covered: Drugs for Alzheimer’s disease, anti-infectives, arthritis, asthma and

chronic respiratory conditions, cancer, circulatory insufficiency,depression, diabetes (including insulin syringes), heart problems, highcholesterol, hypertension, Parkinson’s disease, glaucoma, prescriptionmineral and vitamin supplements for renal patients, urinaryincontinence.

Drug Coverage Restrictions: Limited by therapeutic classNotes:

PROGRAM CONTACT

Denis CostaRhode Island Dept. of Elderly Affairs160 Pine St.Providence, RI 02903

Phone: 401/222-2858 x105Fax: 401/222-3389E-mail: [email protected]



VermontVSCRIPT




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Any ageEligible Income Level (Single): $18,540 Eligible Income Level (Married): $24,885Other Eligible Groups: None


Funding Source: Cigarette tax revenue and federal fundingBudget: $1.1 millionCost per Participant (FY 99): $232.00# of Rx’s Per Participant (FY 99): 4Manufacturer Rebate Type: MedicaidIngredient Cost Calculation: AWP – 11.9%Enrollment Fee: NoneDeductible Amount: NoneCopayment Amount: $1.00 to $2.00 based on prescription costDispensing Fee: $4.25

DRUGS COVERAGE

Formulary: No FormularyDrugs Covered: Maintenance drugs only.Drug Coverage Restrictions: No experimental or over-the-counter drugs.Notes: Health Trust Fund is paid for by an increase in the tobacco tax.

Program only covers maintenance drugs, not acute drugs.

PROGRAM CONTACT

Paul Wallace-BrodeurOffice of Vermont Health Access103 South Main StreetWaterbury, VT 05671-1201




VermontHealth Access Plan (VHAP)




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Any ageEligible Income Level (Single): $12,360 Eligible Income Level (Married): $16,590Other Eligible Groups: None


Funding Source: Cigarette tax revenue and federal fundingBudget: $9.94 millionCost per Participant (FY 99): $901.00# of Rx’s Per Participant (FY 99): 11Manufacturer Rebate Type: MedicaidIngredient Cost Calculation: AWP – 11.9%Enrollment Fee: NoneDeductible Amount: NoneCopayment Amount: $1.00 to $2.00 based on prescription costDispensing Fee: $4.25

DRUGS COVERAGE

Formulary: No FormularyDrugs Covered: Approved prescription medicationsDrug Coverage Restrictions: No experimental or over-the-counter drugsNotes: None

PROGRAM CONTACT

Paul Wallace-BrodeurOffice of Vermont Health Access103 South Main StreetWaterbury, VT 05671-1201




West VirginiaSenior Prescription Assistance Network II (SPAN II)

Program Type: State-Negotiated DiscountYear Operational: 2000



Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): N/AEligible Income Level (Single): <$25,050 Eligible Income Level (Married): <$33,750Other Eligibility Notes:


Funding Source: N/ABudget: N/ACost per Participant (FY 99): N/A# of Rx’s Per Participant (FY 99): N/AManufacturer Rebate Type: N/AIngredient Cost Calculation: N/AEnrollment Fee: NoneDeductible Amount: NoneCopayment Amount: N/ADispensing Fee: N/ANotes: Enrollees will receive discounts on prescription drugs

DRUGS COVERAGE

Formulary: No FormularyDrugs Covered: All FDA approved Federal legend pharmaceuticalsDrug Coverage Restrictions: Cannot be used in conjunction with other discount programs or

prescription drug coverage plansNotes:

PROGRAM CONTACT

WV Bureau of Senior Services1900 Kanawha Boulevard, EastHolly Grove, Building #10Charleston, WV 25305-0160

Phone: 877/987-4463



WyomingMinimum Medical Program


Number of Recipients (FY 00): 550


Eligibility Age (Elderly): Any age Eligibility Age (Disabled): Any ageEligible Income Level (Single): $8,350 Eligible Income Level (Married): 100% of FPLOther Eligible Groups: None


Funding Source: State General FundBudget: Approximately $600,000Cost per Participant (FY 99): $1,174# of Rx’s Per Participant (FY 99): N/AManufacturer Rebate Type: N/AIngredient Cost Calculation: AWP – 4%Enrollment Fee: NoneDeductible Amount: NoneCopayment Amount: $25.00/Rx (3 Rx/month cap)Dispensing Fee: $4.70

DRUGS COVERAGE

Formulary: Open FormularyDrugs Covered: Approved prescription medicationsDrug Coverage Restrictions: No smoking cessation agents, hair growth products, anorexiant

products, or fertility promotion agents.Notes: Health Trust Fund is paid for by an increase in the tobacco tax.

Program only covers maintenance drugs, not acute drugs.

PROGRAM CONTACT

Roxanne Homar, R.Ph.Community and Family HealthDivisionHathaway Bldg, Rm 1572300 Capitol Ave.Cheyenne, WY 82002






Section 6:State Pharmacy ProgramProfiles





Profiles of State Medicaid Drug ProgramsIn the following state profiles, we present a general overview of thecharacteristics of state programs together with detailed information on thepharmaceutical benefits provided. Specifically, the following information isprovided for each state:

A. Benefits Provided and Groups EligibleB. Expenditures for DrugsC. AdministrationD. Provision 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 CareF. State Contacts


1-Alabama National Pharmaceutical Council

ALABAMA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1

Type of Benefit Categorically Needy Medically Needy (MN) Other

OAA AB APTD MLIF OAA AB APTD AFDC Children <21 SFO

Prescribed Drugs

Inpatient Hospital Care

Outpatient Hospital Care

Laboratory & X-ray Service

Skilled Nursing Home Services

Physician Services

Dental Services **Dental Services EPSDT - under 21 years old.1See Appendix E, page E-29, for a list of acronyms.

B. EXPENDITURES FOR DRUGS1998* 1999*

Expended Recipients Expended RecipientsTOTAL $236,674,147 395,290

CATEGORICALLY NEEDY RECEIVINGMAINTENANCE ASSISTANCE, TOTALAgedBlindDisabledChildren-Families w/Dep. ChildrenAdults-Families w/Dep. ChildrenOther Title XIX Recipients

CATEGORICALLY NEEDY NOT RECEIVINGMAINTENANCE ASSISTANCE, TOTALAgedBlindDisabledChildren-Families w/Dep. ChildrenAdults-Families w/Dep. ChildrenOther Title XIX Recipients

MEDICALLY NEEDY TOTALAgedBlindDisabledChildren-Families w/Dep. ChildrenAdults-Families w/Dep. ChildrenOther Title XIX Recipients

Source: HHS State HCFA-2082 Reports.*1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.


National Pharmaceutical Council Alabama-2

C. ADMINISTRATION

Alabama Medicaid Agency.

D. PROVISIONS RELATING TO DRUGS

Benefit Design

Drug Benefit Product Coverage: Products covered:cosmetics; prescribed insulin, disposable needles andsyringe combinations for insulin; blood glucose test strips;urine ketone test strips; total parenteral nutrition; andinterdialytic parenteral nutrition. Prior authorizationrequired for: cosmetics, Retin A, Accutane, Dipyridamole. Products not covered: fertility drugs and experimentaldrugs.

Over-the-Counter Product Coverage: Products covered ifprescribed by a physician: allergy, asthma and sinusproducts; analgesics; cough and cold preparations;digestive products, topical products; antidiabetic products;prenatal vitamins; hemorrhoidal products. Products notcovered: smoking deterrent products and feminineproducts.

Therapeutic Category Coverage: Therapeutic categoriescovered: antibiotics; anticoagulants; anticonvulsants;antidepressants; antidiabetic agents; antilipemic agents;anxiolytics, sedatives, and hypnotics; cardiac drugs;chemotherapy agents; contraceptives; estrogens;hypotensive agents; misc. GI drugs; sympathominetics(adrenergic); thyroid agents. Prior authorization requiredfor: anabolic steroids; analgesics, antipyretics, NSAIDs;antihistamine drugs; anti-psychotics; ENT anti-inflammatory agents; growth hormones; nutritionalsupplements. Therapeutic categories not covered:anorectics; prescribed smoking deterrents.

Coverage of Injectables: Injectable medicinesreimbursable through the Prescription Drug Programwhen used in physician offices, home health care, andextended care facilities.

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

Unit Dose: Unit dose packaging reimbursable.

Formulary/Prior Authorization

Formulary: Open formulary.

Prior Authorization: State currently has a formal priorauthorization procedure. Review by Medicaid’s Assoc.Medical Director required for appeal of priorauthorization decisions.

Prescribing or Dispensing Limitations

Prescription Refill Limit: Maximum of five refills.


PRODUR system implemented in July 1996. Statecurrently has a DUR Board with a quarterly review.


Dispensing Fee: $5.40.

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

Prescription Charge Formula: Medicaid pays forprescribed legend and non-legend drugs authorized underthe program based upon and shall not exceed the lowestof:

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

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

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

Maximum Allowable Cost: State imposes Federal UpperLimits as well as state-specific limits on generic drugs.Override requires “Brand Medically Necessary.”

Incentive Fee: None.

Patient Cost Sharing: Variable copayment.

Drug Ingredient Cost Copayment$0.00 to $10.00 $0.50

$10.01 to $25.00 $1.00$25.01 to $50.00 $2.00$50.01 or more $3.00

Exemptions: No copayment amount is to be collected bythe pharmacy or paid by the recipient for recipients underage 18, pregnant or living in nursing facilities.

Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE

Does not use MCOs to deliver services to Medicaidrecipients.



F. STATE CONTACTS

State Drug Program Administrator

Louise F. JonesAlabama Medicaid Agency501 Dexter AvenueP.O. Box 5624Montgomery, AL 36103-5624T: 334/242-5039F: 334/353-7014E-mail: [email protected] Internet Address: www.medicaid.state.al.us

Prior Authorization Contact

Larry Tatum, 334/242-5489

DUR Contact

Louise Jones, 334/353-7014

Medicaid DUR Board

Keith Campagna, Pharm.D.Auburn UniversityMontgomery Family Medicine Residence Program4371 Narrow Lane Rd. Suite 100Montgomery, AL 36116334/613-3687

Betty McCamy, R.Ph.Wal-Mart Pharmacy102 Lanceleaf CourtDothan, AL 36303334/792-5131

Terry WingoMadison Drugs7131 University DriveHuntsville, AL 35806256/837-1747

Tim Covington, Pharm.D., ChairSamford University2024 Glen Eagle RoadBirmingham, AL 35242205/870-2988

Richard L. Bendinger, M.D.217 Dothan RoadAbbeville, AL 36310334/585-6421

Kelly S. Derbin, M.D.University of South AlabamaDepartment of Family Practice1504 Springhill AvenueMobile, AL 36604335/434-3489

Keith Fuller, D.O.2125 Executive Park DriveOpelika, AL 36801334/741-0075

William P. McCann, M.D.University of Alabama BirminghamSchool of Medicine3875 South Cove DriveBirmingham, AL 35213205/934-7047

John Searcy, M.D.Alabama Medicaid AgencyMedical Director501 Dexter AvenueMontgomery, AL 36130334/242-5619

Sara Redden, R.Ph.3654 Wiley RoadMontgomery, AL 36106334/286-3201

John E. Brandon, M.D.Intersection Highway 82 and 86P.O. Box 390Gordo, AL 35466205/364-7135

Larry Tatum, R.Ph.Alabama Medicaid AgencySenior Pharmacist334/242-5489

Mike Mikell, R.Ph.Mike’s PharmacyP.O. Box 1006Millbrook, AL 36054334/285-5154

Richard Freeman, M.D.411 B Opelika RoadAuburn, AL 36830334/821-4766




First DataBank1111 Bayhill Drive, Suite 350San Bruno, CA 94066650/588-5454

Medicaid Drug Rebate Contacts

Technical: Jim Morrison, 334/242-2323Policy: Larry Tatum, 334/242-5489Audits: Jim Morrison 334/242-2323

Claims Submission Contact

Ricky PopeAccount Manager, EDS301 Technacenter Dr.Montgomery, AL 36117334/215-0111

Medicaid Managed Care Contact

Vicki HuffDirector, Managed CareAlabama Medicaid Agency501 Dexter AvenueMontgomery, AL 36103-5624334/242-5011

Disease Management Program/Initiative Contact

Mary G. McIntyre, M.D.Associate Medical DirectorAlabama Medicaid Agency501 Dexter AvenueMontgomery, AL 36103-5624334/242-5574

Physician-Administered Drug Program Contact

Larry Tatum334/242-5472

Alabama Medicaid Agency Officials

W. Dale WalleyActing CommissionerAlabama Medicaid Agency501 Dexter AvenueP.O. Box 5624Montgomery, AL 36103-5624334/242-5600

John Searcy, M.D., DirectorProfessional ServicesAlabama Medicaid Agency501 Dexter Avenue; P.O. Box 5624Montgomery, AL 36103334/242-5619

Larry A. Tatum, R.Ph., Associate DirectorPharmaceutical ProgramsAlabama Medicaid Agency501 Dexter Avenue; P.O. Box 5624Montgomery, AL 36103334/242-5489

Title XIX Medical Care Advisory Committee

Medical Association of State of AlabamaMarsha D. Raulerson, M.D.1205 Belleville AvenueBrewton, AL 36426-1304334/867-3609

Roy T. Hager, M.D.Institute for Total Eye Care4255 Carmichael Ct. NorthMontgomery, AL 36106334/277-9111

Alabama Nursing Home AssociationFrank R. Brown, Jr.P.O. Box 190Cullman, AL 35056334/784-5573

Montgomery Area Council on AgingRose Posey115 East Jefferson StreetMontgomery, AL 36104334/263-0532

Alabama State Medical AssociationJefferson Underwood, III, M.D.1031 Oak StreetMontgomery, AL 36108

Recipient RepresentativeCharles G. Spradling, Jr.P.O. Box 11765Birmingham, AL 35202334/328-3540

American Academy of Family PhysiciansDr. John E. BrandonP.O. Box 390Gordo, AL 35466334/364-7135

S. T. Christian, Ph.D., ProfessorUniversity of Alabama at BirminghamSchool of Medicine/Behavioral NeurobiologyBirmingham, AL 35294



Alabama Pharmaceutical AssociationDanny Cottrell1335 McMillen, Box 259Brewton, AL 36426334/867-5454

Alabama State Nurses AssociationElizabeth Morris360 N. Hull StreetMontgomery, AL 36130334/262-8321

Alabama Institute for the Deaf and BlindTerry Graham, Ed.D.P. O. Drawer 698Talladega, AL 35160334/761-3274

Consumer RepresentativeRuth Smith4001 Meadowood DriveBirmingham, AL 35242334/290-5187

Mike WoodallDirector, Recreation Department450 GilmerTallassee, AL 36078334/283-4726

Dr. A. Z. Holloway2611 Woodley Park DriveMontgomery, AL 36116334/288-0009

Alabama Chap. American Academy of PediatricsDr. John Searcy1105 West MainDothan, AL 36301

Medicaid Recipient RepresentativeGladys StautnerRt. 4, Box 315Greenville, AL 36037334/382-6255

Sabrina Cooper218 Lands End AvenueSelma, AL 36701334/874-9001

West Alabama Health Services, Inc.Sandra Hullett, M.D., MPHHealth Services DirectorP.O. Box 711Eutaw, AL 35462334/372-3281

Pharmacy and Therapeutics Committee

A.Z. Holloway, M.D., Chair2611 Woodley Park DriveMontgomery, AL 36106334/288-0009

Richard L. Bendinger, M.D.217 Dothan RoadAbbeville, AL 36310334/585-6421

Richard Freeman, M.D.411 B Opelika RoadAuburn, AL 36830334/821-4766

Michael Hogue, Pharm. D.800 Lakeshore DriveBirmingham, AL 35229205/726-2669

Jimmy Crane413 19th Street WestEnsley, AL 35218205/787-4671

Edward Goldblatt3517 S. Lake ParkwayBirmingham, AL 35244205/802-6650

Phil Jenkins, R.Ph.12740 Country LaneNorthport, AL 35476205/391-3636

Roosevelt McCorvey, M.D.3088 Rosa L. Parks AvenueMontgomery, AL 36105334/262-0259

Ray Thweatt, M.D.801 Princeton Avenue, SWSuite 506Birmingham, AL 35211205/783-7060

Executive Officers of State Medical andPharmaceutical Societies

Medical Association of the State of Alabama (MASA)Cary Kuhlmann19 S. Jackson StreetP.O. Box 1900Montgomery, AL 36102-1900334/263-6441



Alabama State Medical AssociationJoel Powell, M.D.1408 5th Avenue, SESuite 1Decatur, AL 35601205/350-3405

Alabama Pharmacy Association (APA)William s. Eley, II1211 Carmichael WayMontgomery, AL 36106334/271-4222

Alabama Optometric AssociationAmanda JonesExecutive Director400 South Union Street, Suite 435Montgomery, AL 36104

State Board of PharmacyCharles Thomas1 Perimeter Park South, Suite 425Birmingham, AL 35243205/967-0130

Alabama Independent Drugstore Association (AIDA)Sharon Taylor400 Interstate Park DriveSuite 401Montgomery, AL 36109334/213-2432

Alabama Primary Health Care AssociationAl Fox6008 East Shirley Lane Suite AMontgomery, AL 36117334/271-7068

Alabama Quality Assurance Foundation (AQAF)Dr. James DeLongMedicaid Pharmacy Admin. Service1 Perimeter Park South, Suite 300Birmingham, AL 352431-888-Medicaid

Department of HealthJim McVay, Director343 Monroe StreetMontgomery, AL 36130-3017334/206-5226

Alabama State Nursing AssociationRuth Harrell360 North Hull StreetMontgomery, AL 36104-3658

Nursing Home AssociationMargie SellersExecutive Director4156 Carmichael RoadMontgomery, AL 36106334/271-6214

Alabama Hospital AssociationMichael HorsleyPresident, CEO500 North East Blvd.Montgomery, AL 36117334/272-8781

Alabama Pharmacy Coop, Inc. (APCI)Danny JohnsonP.O. Box 170747Birmingham, AL 35217-0747205/870-3301

Electronic Data Systems (EDS)John CraftP.O. Box 7600Montgomery, AL 36107334/834-8330

Alabama Retail AssociationCharles McDonaldPresident#2 North JacksonP.O. Box 1909Montgomery, AL 36102334/263-5757

Provider Notice Correspondence:Eckerd Corporation813/395-6145CVS/Revco205/424-3421 x447


1-Alaska National Pharmaceutical Council

ALASKA



OAA AB APTD AFDC OAA AB APTD AFDC Children <21 SFO

Prescribed Drugs





Physician Services

Dental Services 1See Appendix E, page E-29, for a list of acronyms.

B. DRUG PAYMENTS AND RECIPIENTS1998* 1999

Expended Recipients Expended RecipientsTOTAL $32,887,828 43,734 $41,149,318 51,631

CATEGORICALLY NEEDY CASH TOTAL $35,948,104 34,829Aged $5,527,030 3,993Blind $23,025,340 7,586Disabled $0 0Children-Families w/Dep. Children $2,038,831 13,499Adults-Families w/Dep. Children $5,356,902 9,751Other Title XIX Recipients $0 0

CATEGORICALLY NEEDY NON-CASH TOTAL $0 0Aged $0 0Blind $0 0Disabled $0 0Children-Families w/Dep. Children $0 0Adults-Families w/Dep. Children $0 0Other Title XIX Recipients $0 0

MEDICALLY NEEDY TOTAL $1,431,244 11,128Aged $6,860 6Blind $0 0Disabled $0 0Children-Families w/Dep. Children $1,152,027 9,076Adults-Families w/Dep. Children $272,355 2,046Other Title XIX Recipients $0 0

Source: HHS State HCFA-2082 Reports.*1998 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.


National Pharmaceutical Council Alaska-2

C. ADMINISTRATIONDepartment of Health and Social Services, Division ofMedical Assistance.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations used for insulin; blood glucose test strips;urine ketone test strips; total parental nutrition; andinterdialytic parenteral nutrition. Prior authorizationrequired for: Clorazil; Lupron Depot; ADC infant vitamins;some DME; Synagis; Pauretin; and Actig Naltrexone. Products not covered: cosmetics; fertility drugs; andexperimental drugs.

Over-the Counter Product Coverage: Products covered:feminine products (vaginal yeast drugs, miconazole,ctotrimazole); topical products (bacitracin ointment); andcalcium. Products not covered: allergy, asthma and sinusproducts; analgesics; cough and cold preparations; digestiveproducts; and smoking deterrent products.

Therapeutic Category Coverage: Categories covered:anabolic steroids; analgesics, antipyretics, NSAIDs;antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamine drugs;antilipemic agents; anti-psychotics; anxiolytics, sedatives,and hypnotics; cardiac drugs; chemotherapy agents;contraceptives; ENT anti-inflammatory agents; estrogens;hypotensive agents; miscellaneous GI drugs; and thyroidagents. Prior authorization required for: growth hormones. Categories not covered: anorectics; prescribed coldmedications; amphetamines (except for narcolepsy andhyperactivity); prescribed smoking deterrents;sympathominetics (adrenergic); cough suppressants; DESIdrugs; vitamins (except prenatal); and vitamins withfluoride.

Coverage of Injectables: Injectable medicines reimbursablethrough the Prescription Drug Program when used in homehealth care, extended care facilities and through physicianpayment when used in physician offices. No injectable druglist.

Vaccines: Vaccines reimbursable at cost as part of EPSDTservice, Children Health Insurance Program and theVaccines for Children Program.

Unit Dose: Unit dose packaging reimbursable when used inlong-term care.


Formulary: No formulary.

Prior Authorization: State currently has a formal priorauthorization procedure. Request for fair hearing requiredfor appealing coverage of an excluded product and PAdecision.


Monthly Quantity Limit: Prescriptions are limited to 30-daysupplies. Dispensing of generic multi-source product isrequired.


PRODUR system implemented in June 1995. Statecurrently has a DUR Board that meets nine times per year.


Dispensing Fee: No less than $3.45 and no more than the90th percentile of all dispensing fees determined under theformula:

1) $23,192 added to the number resulting frommultiplying total prescriptions filled by that pharmacyin the previous calendar year by 5.070;

2) to 1), add the result of multiplying total Medicaidprescriptions filled in the previous calendar year by12.44;

3) from 2), subtract the result of multiplying the total floorspace volume of the pharmacy in sq. ft. by 2.103;

4) divide 3) by total prescriptions filled by that pharmacy

5) add $0.73 to 4)

Ingredient Reimbursement Basis: EAC = AWP - 5%.

Maximum Allowable Cost: State imposes Federal UpperLimits on generic drugs. Override requires “BrandMedically Necessary” with the reason supplied.



Patient Cost Sharing: $2.00 copayment for branded andgeneric products.




3-Alaska National Pharmaceutical Council

F. STATE CONTACTS


Dave Campana, R.Ph.Division of Medical Assistance4501 Business Park Blvd., Suite 24Anchorage, AK 99503T: 907/273-3224F: 907/561-1684E-mail: [email protected]

Health and Social Services Department Officials

Karen PerdueDepartment of Health and Social ServicesPouch H-01, Juneau, AK 99811-6040907/465-3030

Bob Labbe, DirectorDivision of Medical Assistance, DHSSPouch H-07, Juneau, AK 99811907/465-3355

Jack Nielson, Deputy DirectorMedical Assistance4501 Business Park Blvd., Suite 24Anchorage, AK 99503907/561-2171


Dave Campana 907/273-3224

DUR Contact





Technical: Velma Drake, 907/561-2171Policy: Dave Campana, 907/273-3224Audit: Dave Campana, 907/273-3224


Rose-Ellen HopePharmacistFirst Health565 Union St. NE #205Salem, OR 97301T: 503/391-0184F: 503/391-1979


Bob LabbeDirector, Division of Medical AssistanceP.O. Box 110660Juneau, AK 99811-0660T: 907/465-3355F: 907/465-2204


Tom Porter, M.D.907/561-2171

Alaska Medical Care Advisory Committee

Dr. Patricia Connors Allen2231 N. Jordan AvenueJuneau, AK 99801

Alaska DUR CommitteeDave Campana, R.Ph.4501 Business Park Blvd., Suite 24Anchorage, AK 99503

Thomas Porter, M.D.4501 Business Park Blvd., Suite 24Anchorage, AK 99503

Richard Reem, M.D.231 IditarodFairbanks, AK 99701-3639

Linda Shull, R.Ph.1132 WolkoffKodiak, AK 99615

Arthur Hansen, D.D.S.1329 McGrath Rd.Fairbanks, AK 99712

Ted SummersP.O. Box 3126Palmer, AK 99645


National Pharmaceutical Council Alaska-4


Alaska State Medical AssociationJim Jordan4107 Laurel StreetAnchorage, AK 99508T: 907/562-2662F: 907/561-2063

Alaska Pharmaceutical AssociationErin Carey-Byrne, Executive SecretaryBox 10-1185Anchorage, AK 99510907/563-8880

Alaska State Board of PharmacyJosephine DawsonLic. ExaminerP.O. Box 110806Juneau, AK 99811-0806907/465-2589

Alaska State Hospital and Nursing Home AssociationHarlan R. KnudsonPres., CEO319 Seward Street, Suite 11Juneau, AK 99801907/586-1790

Alaska Osteopathic Medical AssociationByron Perkins, D.O.Secretary/TreasurerP.O. Box 870470Wasilla, AK 99687907/745-0170


1-Arizona National Pharmaceutical Council

ARIZONAARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

(AHCCCS - PRONOUNCED "ACCESS")

AHCCCS FEATURES

The Arizona Health Care Cost-Containment System(AHCCCS) is a Title XIX (Medicaid) demonstrationproject, jointly funded by the federal government and theState of Arizona. Begun in October 1982, it serves as amodel for providing medical services to the indigent in amanaged care system rather than through fee-for-servicearrangements. Typically, Medicaid programs haveincorporated the traditional hallmarks of the U.S. healthcare system: namely, independent providers and fee-for-service reimbursement. In contrast, organized healthplans and capitation mark the AHCCCS model.

In traditional Medicaid programs, the states assumeresponsibility for contracting with individual pharmaciesand reimbursing them. In the AHCCCS model however,the state contracts instead with pre-paid health plans,HMOs and HMO-like entities. These plans are paid on acapitation basis and are responsible for providing all ofthe services covered by the program. Thus, the deliveryof pharmacy services is the responsibility of each prepaidplan.

GENERAL INFORMATION

The Arizona Health Care Cost Containment System(AHCCCS), developed in Senate Bill 1001, was passed bythe Legislature and signed by the Governor in November1981. It contained six major mechanisms for restraininghealth care costs at the same time ensuring thatappropriate levels of quality health care services areprovided to eligible persons in a dignified fashion. Thegoal of these 6 items was to contribute to theestablishment of health care financing that is lessexpensive than conventional fee-for-service systems. Thesix mechanisms were:

• Primary Care Physicians Acting as Gatekeepers• Prepaid Capitated Financing• Competitive Bidding Process• Cost Sharing• Limitations on Freedom-of-Choice• Capitation of the State by the Federal

Government

Primary Care Physicians as Gatekeepers

AHCCCS legislation provided that all members must beunder the care and supervision of a primary care physicianwho assumed the role of gatekeeper. A statewide network

of primary care physicians was established to perform thegatekeeping function for the system. Because the primarycare physicians must approve all care, the primary carenetwork eliminated self-referrals to specialists anddiminished excessive use of emergency rooms -- both ofwhich have contributed substantially to high medicalcosts.

Prepaid Capitated Financing

It was the intent of the AHCCCS legislation that healthplans and their providers offer all covered services togroups of members within a geographical area for a fixedprice, for a definite period. The law allowed for theestablishment of a statewide bidding process toaccomplish this. Services are provided on a county-by-county basis, by prepaid health plans. Providers may bidon a prepaid capitated basis for covered services to beprovided within a particular county. The law allows forexpansion and contraction of bids to achieve the bestpossible system. In the event there are insufficient bidsfor a given area, the legislation permits capped fee-for-service arrangements. It is intended, however, that cappedfee-for-service will be authorized as a last resort only.

In essence, AHCCCS prepaid health plans (PHPs), healthmaintenance organizations (HMOs), and other types oforganized health delivery systems charge a fixed fee perindividual enrolled (i.e., a capitation rate) and assumeresponsibility for providing a broad array of health careservices to members.

Competitive Bidding Process

The statewide competitive aspect of the bid process forselecting providers and offering prepaid capitated servicesis the most unique feature of the AHCCCS model. Acompetition of this magnitude had never been attemptedin any other state. The AHCCCS administration believescompetitive bidding for health care service contracts, asopposed to conventional negotiation processes, providesaccessible cost-effective delivery of health care withoutsacrificing quality performance.

The AHCCCS administration issues an invitation toqualified health plans once every five years. Qualifiedhealth plans may bid to offer the full range of AHCCCSservices in one or more counties.


National Pharmaceutical Council Arizona-2

Cost Sharing

The fourth major device for containing costs in theAHCCCS model is a provision for cost sharing by users. A statewide co-payment schedule was developed for thispurpose, and the medically needy participate incoinsurance cost sharing. It is expected that theimposition of nominal co-payments will ensure optimaleffectiveness in the area of service utilization. The co-payment schedule accomplishes three objectives:curtailment of over-utilization; enhancement of patientdignity; and service utilization by members for trulyneeded health care. There is no co-payment for drugs andmedication, prenatal care including all obstetrical visits,members in long care facilities and for visits scheduled bythe primary care physician or practitioner, and not at therequest of the member.

Limitations On Freedom-of-Choice

The fifth major item for containing costs is a restriction onprovider/physician selection by AHCCCS members. Unlike conventional delivery models, Arizona does notrely on fee-for-service arrangements. The goal is to havethe state completely blanketed with prepaid capitatedarrangements. Members are linked to selected or assignedplans for definite durations of time. Freedom-of-choice ispermitted to the extent practicable for members to selectthe particular group with which to enroll, as well as theprimary care physician within the selected group. Cappedfee-for-service health service arrangements are used as alast resort, and only in areas not covered by prepaidcapitated plans.

CAPITATION BY THE FEDERALGOVERNMENT

The State of Arizona will itself be capitated by the FederalGovernment and therefore will be at financial risk forcontaining health care costs. Capitation rates will beestablished according to sound actuarial principles, andwill represent no more than 95 percent of the estimatedcost of services delivered in Arizona under conventionalfee-for-service arrangements. Capitation provides a keyincentive for the state to monitor health care costs on acareful and continuous basis.

IMPLEMENTATION OF AHCCCS

AHCCCS is based on plans that have been tested, in part,on smaller scales in different areas of the country. Bycombining a number of key mechanisms on a statewidebasis, AHCCCS represents a novel health care model. The purpose of this section is to present a discussion ofhow the key concepts embodied in the AHCCCSlegislation will be implemented and rendered operational.

Provider Participation

Providers may participate in AHCCCS in 2 differentways. First, they may contract with prepaid capitated plansas either full or partial benefit providers.

The second mode of participation is on a capped fee-for-service basis. Here, providers agree to accept capped feepayments as payments in full for services provided on aFFS basis.

Functions of the AHCCCS Administration

The Arizona Health Care Containment SystemAdministration (AHCCCSA) contracts with full benefitcapitated health plans to serve AHCCCS membersthrough a network of providers.

Contracting Health Plans

Under the Contracting Health Plan arrangement, plans aredefined in terms of explicit groups of providers organizedas entities that are more formal. These consortia, orformal entities, are capable of providing the full range ofAHCCCS benefits within a defined service area for allAHCCCS members who elect to join the plans, up to apredetermined capacity. This is the dominant mode ofoperation within AHCCCS -- with two or more competingplans wherever possible.

The Contracting Health Plans are delivery systems, notsimply insurance plans, but they need not be HealthMaintenance Organizations by any legal or conventionaldefinition of the term. The AHCCCS legislation providesfor the creation of provider consortia for the purpose ofparticipation in the program. The Contracting Health Planmay be a loosely organized system, but it must be capableof providing the full range of AHCCCS benefits to adefined population at a capitation rate.

The Organizational Role of AHCCCSAdministration

The AHCCCS Administration has been charged with thegeneral implementation and monitoring of the AHCCCSprogram.

The AHCCCS Administration develops the Rules andRegulations; manages the health plan bidding processes;awards the contracts; provides technical assistance toproviders for the purpose of forming consortia to contractwith AHCCCS; and monitors the overall operation of theprogram.


3-Arizona National Pharmaceutical Council

The Operational Role of the AHCCCSAdministration

Organizationally, the AHCCCS Administration assumesresponsibility for the oversight of every day operations.

The AHCCCS Administration has overall responsibilityfor the following activity areas:

• Promotion of AHCCCS• Procurement of Health Plans• Quality Management• Provider Management• Provider, Member, and Public Relations• Program Operations

AHCCCS became effective December 1, 1981, andservices commenced October 1, 1982. Services include:inpatient, outpatient, laboratory, x-ray, prescription drugs,medical supplies, prosthetic devices, emergency dentalcare including extractions and dentures, treatment of eyeconditions and EPSDT.

Though AHCCCS was a three-year experiment that was toend in October 1985, the federal government continues toextend funding for the program. In 1988, AHCCCSreceived a five-year extension from the federalgovernment and in 1993, it received an additional one-year extension. In 1994, AHCCCS received a three-yearextension and in 1998, it is expected to receive a one-yearextension.

MEDICAL PLANS AND ADMINISTRATORS

AHCCCS Contracted Health Plans

Access Blue Connection 602/864-44452444 W. Las Palmaritas DrivePhoenix, AZ 85021Contract terminated, effective 10/1/97

Arizona Health Concepts 602/331-51007600 N. 16th Street, Suite 150Phoenix, AZ 85020

Arizona Physicians IPA, Inc. 602/274-61023141 North 3rd AvenuePhoenix, AZ 85013

CIGNA Community Choice 602/942-446211001 North Black Canyon HighwayPhoenix, AZ 85029

DES/CMDP 602/351-2245CMDP-942-CCentury Plaza Building, 10th Floor3225 North Central AvenuePhoenix, AZ 85012

Doctor’s Health Plan, P.C. 520/428-7801517 Main StreetStafford, AZ 85546

Family Health Plan of NE Arizona 520/921-8944P.O. Box 2069Cottonwood, AZ 86326

Health Choice Arizona 602/968-6866Suite 2601600 West BroadwayTempe, AZ 85282-1136

Maricopa Managed Care Systems 602/681-87002516 East University DrivePhoenix, AZ 85034

Mercy Care Plan 602/230-99212800 North Central, Suite 400Phoenix, AZ 85004

Phoenix Health Plan 602/824-37002700 North 3rd StreetPhoenix, AZ 85004

Pima Health System 602/512-5500Suite A-2005055 East BroadwayTucson, AZ 85711

Regional AHCCCS Health Plan 520/426-66481955 North Casa Grande Avenue, #116Casa Grande, AZ 85222Contract terminated, effective 5/1/97

University Family Care 520/321-7248575 East River RoadTucson, AZ 85704

Phoenix Arizona Indian Health Services (IHS)Two Renaissance Square 602/640-212040 N. Central AvenuePhoenix, AZ 85004-5036

Phoenix Indian Medical Center 602/263-12004212 North 16th StreetPhoenix, AZ 85016

Indian Health Services (IHS) 520/295-2550Southern Region7900 J.J. Stock RoadTucson, AZ 85746

Navajo Area Indian Health Services (IHS)P.O. Box 9020 520/871-5880Window Rock, AZ 86515-9020


National Pharmaceutical Council Arizona-4

ALTCS Contractor List

Arizona Physicians IPA (ALTCS)242 West 28th Street, Suite AYuma, AZ 85364520/783-5691

Cochise Health SystemsCochise County Health & Social ServicesCochise Health Systems1415 West Melody Lane, Building ABisbee, AZ 85603520/432-9481

DES/DDD1789 West Jefferson, 4th FloorPhoenix, AZ 85034602/542-6866

Maricopa Managed Care Systems2516 East University DrivePhoenix, AZ 85034602/681-8700

Pima County LTCPima Health SystemSuite A-200, 5055 East BroadwayTucson, AZ 85711520/512-5500

Pinal County Health Plan - LTCP.O. Box 2140574 South Central AvenueFlorence, AZ 85232-2140520/868-6775

Ventana Health SystemsApache, Gila, Graham, Greenlee, Mohave,Navajo, LaPaz & Santa Cruz Counties7600 N. 16th St., Ste. 150Phoenix, AZ 85020602/331-5100

Yavapai County LTCYavapai County Department of Medical Assistance255 East Gurley Street, First FloorPrescott, AZ 86301 520/771-3560

AHCCCS FFS (ALTCS)Ventilator DependentCentral Office (Office of the Medical Director)602/417-4283

STATE CONTACTS

AHCCCS Officials

John H. Kelly, Acting DirectorAHCCCS801 E. JeffersonPhoenix, AZ 85034602/417-4680

Leonard Jasinski, M.D.Medical Director


Arizona Medical Association, Inc.Chic OlderExecutive Vice President810 West Bethany Home RoadPhoenix, AZ 85013602/246-8901

Arizona Pharmacy AssociationKathy BoyleExecutive Director1845 E. Southern Ave.Tempe, AZ 852-82-5831602/838-3385

Arizona Osteopathic Medical AssociationAmanda WeaverExecutive Director5150 N. 16th St., #A122Phoenix, AZ 85016602/266-6699

Arizona Board of PharmacyL. A. LloydExecutive Director5060 North 19th Avenue, Ste. 101Phoenix, AZ 85015602/255-5125

Arizona Hospital and Healthcare AssociationJohn R. RiversPres., CEO1501 West Fountainhead ParkwaySuite 650Tempe, AZ 85282602/968-1083


1-Arkansas National Pharmaceutical Council

ARKANSAS




Prescribed Drugs





Physician Services


B. EXPENDITURES FOR DRUGS1998* 1999


RECEIVING CASH ASSISTANCE, TOTAL $21,923,101 43,898Aged $15,746,553 15,658Blind/Disabled $979,341 919Child $3,073,535 20,352Adult $2,123,161 6,967Unemployed Parent-Child $64 1Unemployed Parent-Adult $445 1

MEDICALLY NEEDY, TOTAL $90,570,658 20,598Aged $82,938 4Blind/Disabled $86,427,655 12,882Child $1,886,271 7,512Adult $2,173,792 200

POVERTY RELATED, TOTAL $15,416,172 63,625Aged $124,995 4Blind/Disabled $890,988 4Child $13,586,659 63,573Adult $813,529 44

OTHER, TOTAL $59,618,981 42,100 $46,212,420 9,548

Source: HHS Report HCFA-2082, Sections A-4 and B-4.*1998 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

C. ADMINISTRATION

Department of Human Services, Division of MedicalServices, Pharmacy.


National Pharmaceutical Council Arkansas-2


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations used for insulin. Products not covered: blood glucose test strips; urine ketone test strips; totalparenteral nutrition, interdialytic parenteral nutrition;cosmetics; fertility drugs; and experimental drugs. Priorauthorization required for: nitroglycerin patches; agentsfor impotence; Synagis; and Respigam.

Over-the-Counter Product Coverage: Products covered:digestive products (H2 antagonist). Limited coverage for:allergy, asthma and sinus products; analgesics; cough andcold preparations; digestive products (non-H2 antagonist )(under 21 years and long-term care limited needs);feminine products; and topical products. Product notcovered: smoking deterrent products.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; antibiotics; anticoagulants;anticonvulsants; anti-depressants; antidiabetic agents;antilipemic agents; anti-psychotics; cardiac drugs;chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones;hypotensive agents; sympathominetics (adrenergic); andthyroid agents. Prior authorization required for:analgesics, antipyretics, NSAIDs; antihistamine drugs;misc. GI drugs; prescribed smoking deterrents. Therapeutic categories not covered: anorectics.

Coverage of Injectables: Injectable medicines arereimbursable through the Prescription Drug Programwhen used in home health care, extended care facilitiesand through physician payment when used in physiciansoffices. No injectable drug list.

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



Formulary: Closed formulary. General exclusionsinclude:

1. Agents used for hair growth.2. Vitamin products except prescription prenatal

vitamins.3. Drugs determined by the FDA to be ineffective

(DESI drugs).4. Sedatives and hypnotics in the benzodiazepine

category (partial coverage).5. Compounded prescriptions (mixtures of two or more

ingredients). States are not allowed to have statecodes such as 99999-9999-99. All drugs reimbursedby the State must be traced by NDC code and appearon the utilization report.

Prior Authorization: State currently has a priorauthorization procedure.


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

Monthly Quantity Limit: 30-day supply.

Monthly Prescription Limit: Three prescriptions permonth per recipient, except unlimited in certified LTCrecipients and recipients under 21 years old. Others canreceive extension of three more per month.


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


Dispensing Fee: $5.51 effective 7/1/99.

Ingredient Reimbursement Basis: EAC = AWP – 10.5%.

Prescription Charge Formula: Legend drugs: lower of theEAC plus a dispensing fee or CFA/state upper limit plus adispensing fee. Total charge may not exceed provider’scharge to the self-paying public.

Maximum Allowable Costs: State imposes Federal UpperLimits as well as state-specific limits on generic drugs. State-specific MAC list contains 200 drugs. Overriderequires “Brand Medically Necessary.” PA must beobtained once the pharmacy obtains the BNM Rx.



3-Arkansas National Pharmaceutical Council

Patient Cost Sharing: Effective 9/1/92, for eachprescription reimbursed, the Medicaid recipient isresponsible for paying a copayment based on thefollowing:

State Payment Copay$10.00 or less $0.50$10.01 to $25.00 $1.00$25.01 to $50.00 $2.00$50.01 or moreArKids

$3.00$5.00

Services to individuals under 18, pregnant women,nursing home residents, emergency services, familyplanning services, and services provided by an HMO to itsenrollees are excluded from the Medicaid copay policy.



An estimated 230,000 Medicaid recipients were enrolledwith managed care organizations PCP and ArKids. Pharmaceutical benefits are provided through the state.

F. STATE CONTACTS

Medicaid Drug Program Administrator

Suzette Bridges, P.D.Division of Medical ServicesDept. of Human ServicesP.O. Box 1437, Slot 4105Little Rock, AR 72203T: 501/324-9141F: 501/324-9140E-mail: [email protected]


Suzette Bridges501/324-9141

Dr. Judith McGhee501/682-6442DUR Contact

Suzette Bridges501/324-9141

DUR Board

Pharmacists:Steve Bryant, P.D.Bryant’s Pharmacy2000 Harrison StreetBatesville, AR 72501501/793-3999

Scott Harris, P.D.9601 I-630, Ext. 7Little Rock, AR 72205-1749501/202-1749

Benji Post, P.D.

PhysiciansThomas Lewellen, D.O.105 West WatermanDumas, AR 71639870/382-1188

Michael N. Moody, M.D.P.O. Box 829Salem, AR 72576501/895-2541

Charles Rodgers, M.D.4202 South UniversityLittle Rock, AR 72204501/562-4838

Medicaid PharmacistSuzette Bridges


First DataBank1111 Bay Hill DriveSan Bruno, CA 74066415/588-5454


Audits: Suzette Bridges, P.D., 501/324-9141PA: Mary Alice Easterling, EDS, 501/374-6608


John HerzogEDS Federal Corp.500 East Markham, Ste 400Little Rock, AR 72201501/374-6608


Bob PaladinoP.O. Box 1437, Slot 1102Little Rock, AR 772203


National Pharmaceutical Council California-1

CALIFORNIA

A. BENEFITS PROVIDED AND GOUPS ELIGIBLE1

Type of Benefit Categorically Needy Medically Needy (MN)

>21 Children <21

Prescribed Drugs





Physician Services

Dental Services

Note: Certain classifications of aliens in the above categories are eligible only for emergency and pregnancy-relatedbenefits.1See Appendix E, page E-29, for a list of acronyms.

B. EXPENDITURES FOR DRUGS1998 1999*

Expended Recipients Expended RecipientsTOTAL $1,553,598,462 2,644,430

CATEGORICALLY NEEDY, RECEIVINGASSISTANCE, TOTAL $1,181,162,264 1,564,857Aged $254,611,395 248,440Blind/Disabled $812,296,210 536,457AFDC-Children $35,413,433 383,891AFDC-Adult $47,289,063 188,195AFDC-Unemployed-Children $10,991,408 120,991AFDC-Unemployed-Adults $20,560,755 75,883

MEDICALLY NEEDY, TOTAL $281,093,222 566,080Aged $105,624,178 111,101Blind/Disabled $125,615,464 60,154AFDC-Children $23,988,641 283,220AFDC-Adult $24,884,939 111,605

POVERTY RELATED, TOTAL $14,965,593 163,798Aged $732,955 659Blind/Disabled $578,605 1,319AFDC-Children $12,486,033 139,977AFDC-Adult $1,168,000 21,843

OTHER, TOTAL $1,695,126 301,095

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.*1999 total and expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.


2-California National Pharmaceutical Council

C. ADMINISTRATION

Under the Health and Human Services Agency with directadministration by the Department of Health Services.

The Department of Health Services Pharmaceutical Unitof the Medi-Cal Policy Division monitors the full scopeand quality of pharmaceutical benefits covered under theprovisions of the California Medical Assistance Program.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations used for insulin; blood glucose test strips;and urine ketone test strips. Products covered with priorauthorization: total parenteral nutrition and interdialyticparenteral nutrition. Products not covered: cosmetics;fertility drugs; and experimental drugs.

Over-the-Counter Product Coverage: Products coveredwith prior authorization: allergy, asthma and sinusproducts; analgesics; cough and cold preparations; non-H2 antagonist digestive products; digestive products, H2antagonists; feminine products; topical products; andsmoking deterrent products.

Therapeutic Category Coverage: Therapeutic categoriescovered: chemotherapy agents and contraceptives. Priorauthorization required for: anabolic steroids; analgesics,antipyretics, NSAIDs; antibiotics; anticoagulants;anticonvulsants; antidepressants; antidiabetic agents;antihistamine drugs; antilipemic agents; anti-psychotics;anxiolytics, sedatives, and hypnotics; cardiac drugs;prescribed cold medications; ENT anti-inflammatoryagents; estrogens; growth hormones; hypotensive agents;misc. GI drugs; prescribed smoking deterrents;sympathominetics (adrenergic); and thyroid agents. Medi-Cal fee-for-service does not blanket exclude drug classes.Drugs for the treatment of cancer or AIDS are exemptfrom prior authorization.

Coverage of Injectables: Injectable medicinesreimbursable through the Prescription Drug Programwhen used in home health care, extended care facilitiesand through physician payment when used in physicianoffices.

Vaccines: Vaccines reimbursable by schedule as part ofthe Vaccines for Children Program. Vaccines for adultscovered through the prescription drug program.

Unit Dose: Reimbursable at buck prices.


Formulary: Closed formulary. Medi-Cal List of ContractDrugs: Over 600 drugs in differing strengths and dosageforms listed generically. A drug may be added to the liston contractual agreement by the manufacturer to providethe state a rebate based on the quantity reimbursed topharmacies for Medi-Cal recipients. The patient’sphysician or pharmacist may request prior authorizationfrom the field office Medi-Cal consultant for approval ofunlisted drugs or for listed drugs that are restricted tospecific use(s).

Examples of general limitations and exclusions (otheruses require prior authorization):

1. CNS stimulants, i.e., amphetamines andmethylphenidate, are restricted to attention deficitdisorder in individuals between 4 and 16 years of age.

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

3. Cimetidine, Famotidine are restricted to therapylasting up to 90 days from the dispensing date of thefirst prescription.

4. Most non-steroidal anti-inflammatory agents arerestricted to use for arthritis.

5. Many antibiotics have diagnostic and/or agerestrictions.

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

7. Codeine Combinations: payment to a pharmacy forASA or APAP with codeine 30 mg is limited to amaximum dispensing quantity of 45 tablets orcapsules and a maximum of 3 claims for the samebeneficiary in any 75-day period.

8. Excluded from coverage: multivitamins for personsover five years of age (except pre-natal vitamin-mineral products for pregnant women); cosmeticdrugs and fertility drugs; and most OTC householdremedies.

9. Enteral nutritional supplements or replacements arecovered, subject to prior authorization, if used as atherapeutic regimen to prevent serious disability ordeath in patients with medically diagnosed conditionsthat preclude the full use of regular foodstuffs.

10. Cancer, AIDS, and DESI Drugs: Any antineoplasticdrug approved by FDA for the treatment of cancerand any drug approved by FDA for the treatment ofAIDS or AIDS-related condition is covered throughthe Medi-Cal List of Contract Drugs; most DESI



drugs rated less-than-effective by FDA are notcovered.

Prior Authorization: State currently has a formal priorauthorization procedure. Medi-Cal frequently petitions toadd drugs to the list of contract drugs. Denials of thesepetitions can be appealed to the director of theDepartment of Health and Human Services by thepetitioner within 30 days after notice of the denial.Providers may appeal prior authorization decisions within60 days of notification to the local field office and then tofield services headquarters if necessary. Beneficiaries alsohave the ability to request a hearing to review the denialand must do so within 90 days of notification.

Approval may be obtained from a Medi-Cal consultantfor: covered items or services not included on the Medi-Cal List of Contract Drugs (including specialcircumstance override of multiple source drug priceceilings or minimum quantity/ frequency of billinglimitations); and for patients exceeding the 6 Rx permonth limit. Statewide mail and fax requests are acceptedin the Stockton and Los Angeles Medi-Cal Field Offices. Requests must include adequate information andjustification. Authorization may only be given for thelowest cost item or service that meets the patient’smedical needs.

Beneficiary or Prescriber Prior Authorization: On a caseby case basis, the Dept. of Health Services restricts,through the requirements of prior authorization, theavailability of designated prescription drugs to certainbeneficiaries or prescribers found by the Department toabuse those benefits.


Prescription Refill Limit: A prescription refill can bedispensed as authorized by prescriber. Exception isallowed for refill of a reasonable quantity when prescriberis unavailable (pursuant to California law). Fee is pro-rated so that total fee (for partial quantity and balance ofthe prescription after prescriber is contacted) does notexceed fee for same prescription when refilled as routineservice.

Monthly Quantity Limit: This is flexible, but should beconsistent with the medical needs of the patient. Limitedto 100 tabs on some drugs, 100 days’ supply on others. Many maintenance drugs are subject to minimum quantityor maximum frequency of billing controls.

Monthly Prescription Limit: Limited to 6 per monthwithout prior authorization. The limit does not apply tofamily planning drugs, patients in nursing facilities or toAIDS or cancer drugs.

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


PRODUR system implemented in August 1995. Statecurrently has a DUR Board with a quarterly review.


Dispensing Fee: $4.05, effective 8/85.

Ingredient Reimbursement Basis: EAC = AWP-5%, ordirect price for 11 specified manufacturers.

Prescription Charge Formula: Reimbursement is basedon the lowest of:

For Legend Drugs:1. Estimated Acquisition Cost (EAC) + dispensing fee,

less $0.25.2. Federal Upper Limit (FUL) + dispensing fee, less

$0.25.3. State Maximum Allowable Ingredient Cost (MAIC) +

dispensing fee, less $0.25.4. Pharmacy’s usual price to general public, less $0.25.

For Over-the-Counter Drugs:1. Estimated acquisition cost (EAC) x 1.5, less $0.50.2. Federal Upper Limit (FUL) x 1.5, less $0.50.3. State Maximum Allowable Ingredient Cost

(MAIC) x 1.5, less $0.50.4. Pharmacy’s usual price to the general public, less

$0.50.

(Reimbursement is reduced by $0.25 per claim line as ofJanuary 1, 2000.

Maximum Allowable Cost: State MACs are establishedfor 51 multi-source items. Override requires “MedicallyNecessary” or unavailability of drug products at or belowMAC. List is periodically revised and price limitschanged to reflect current market conditions.


Patient Cost Sharing: Copayment: $1.00 (optional).

Cognitive Services: Does not pay for cognitive services,but this is under consideration.




Approximately 2,500,000 total unduplicated number ofMedicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits through thestate and managed care plans.

Kaiser FoundationHealth Plan, Inc.Northern California Region1800 Harrison Street, 9th FloorP.O. Box 12916Oakland, CA 94612-2998

Omni Health Care2450 Ventura Oaks, Suite 300Sacramento, CA 95833-3292

Denticare125 Technology StreetIrvine, CA 92618

Universal Care1600 E. Signal Hill StreetSignal Hill, CA 90806-3682

County of Contra CostaContra Costa Health Plan595 Center Avenue, Suite 100Martinez, CA 94553

Western Health Advantage1331 Garden Highway Suite 100Sacramento, CA 95833-9754

CaliforniaCare Health Plans2000 Corporate Center Dr., Bldg. 7Newbury Park, CA 91320

Placer County Managed Care Network11730 Enterprise DriveAuburn, CA 95603

Sonoma County Medi-CalManaged care Network1221 Farmers Lane, Suite 200Santa Rosa, CA 95404-1705

Watts Health Foundation, Inc.United Health Plan3405 West Imperial Highway, Suite 600Inglewood, CA 90303

Orange County Organized Health SystemCalOptima1120 West La Veta Ave, 5th FloorOrange, CA 92668

Santa Cruz County -MontereyManaged Care CommissionSanta Cruz County Health Options375 Encinal Street, Suite ASanta Cruz, CA 95060

Sutter Senior Care1234 U StreetSacramento, CA 95816

Altamed Health Services Corp.500 Citadel Drive, Suite 490Los Angeles, CA 90040

CompCare Health Plan, Inc.3200 Fourth Ave, Suite 200San Diego, CA 92103

Blue Cross of California5151-A Camino RuizCamarillo, CA 93012

Kern Health SystemsKern Family Health care1600 Norris RoadBakersfield, CA 93308

LA Care Health Plan3530 Wilshire Boulevard, Suite 704Los Angeles, CA 90100

Inland Empire Health Plan303 E. Vanderbilt Way, Suite 400San Bernardino, CA 92408

San Francisco Health AuthoritySan Francisco Health Plan568 Howard Street, Fifth FloorSan Francisco, CA 94105

Health Plan of San Joaquin1550 W. Fremont StreetStockton, CA 95203-2643

Omni Healthcare Inc.2450 Venture Oaks, Suite 300Sacramento, CA 95833

Maxicare1149 South Broadway, Suite 819Los Angeles, CA 90015



UCSD Healthcare200 West Arbor Dr.San Diego, CA 92103

Delta Dental Plan of CA7687 Folsom BlvdSacramento, CA 95826

Western Dental Srvs., Inc. #424300 Plaza Alicante, Ste. 810Garden Grove, CA 92640Health Net3400 Data Drive, 1st Fl. WRancho Cordova, CA 95670

Molina Medical CentersOne Golden Shore DriveLong Beach, CA 90802

Orange County Organized Health SystemCalOptima1120 West la Veta Ave., 5th FloorOrange, CA 92668

San Mateo Health CommissionHealth Plan of San Mateo1500 Fashion Island Blvd., Suite 300San Mateo, CA 94404

Santa Barbara County Special Healthcare AuthoritySanta Barbara Health Initiative110 Castilian Dr.Goleta, CA 93117-3028

Solano County Medical Care CommissionSolano Partnership Health Plan421 Executive Court North, Suite ASuisun City, CA 94585

Solano-Napa CountyCommission on Medical CarePartnership HealthPlan of California421 Executive Court North, Suite ASuisun City, CA 94585

Santa Cruz-MontereyManaged Medical Care CommissionCentral Coast Alliance for Health375 Encinal Street, Suite ASanta Cruz, CA 95060

OnLok Senior Health Services1441 Powell StreetSan Francisco, CA 94133-3879

Center for Elders Independence1955 San Pablo AveOakland, CA 94612

HealthReach Family Care Center7237 Lennane Drive, Suite 200Sacramento, CA 95834

AIDS Healthcare Foundation6255 W. Sunset Blvd., 16th FloorLos Angeles, CA 90028-8073

Cohan Medical CorpTower Health Services200 Oceangate, Sixth Pl.Long Beach, CA 90802

Alameda Alliance for Health1850 Fairway DriveSan Leandro, CA 94557

San Francisco City & County Public HealthFamily Mosaic Project1309 Evans AvenueSan Francisco, CA 94124

Scan Health PlanSenior CareAction Network3780 Kilroy Airport Way, Suite 600Long Beach, CA 90806-2460

Santa Clara Family Health Plan4050 Moopark AvenueSan Jose, CA 95117

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

F. STATE CONTACTS


J. Kevin Gorospe, Pharm.D.Chief, Pharmaceutical UnitMedi-Cal Policy Division714 P Street, Room 1540Sacramento, CA 95814T: 916/657-4213F: 916/654-0513E-mail: [email protected] Internet Address: http://www.dhs.ca.gov




J. Kevin Gorospe, 916/657-4213

DUR Contact

Vic Walker, R.Ph. B.C.P.PSr. Pharmaceutical ConsultantMedi-Cal Policy Division714 P Street, Room 1540Sacramento, CA 95814T: 916/654-0785F: 916/654-0513E-mail: [email protected]

Medi-Cal Drug Utilization Review Board (DURBoard)

Timothy E. Albertson, M.D., Ph.D.University of California-DavisPulmonary/Critical Care Medicine4301 X Street, Professional Bldg., Room 2120Sacramento, CA 95817

Robert J. Matutat, Pharm.D.First DatabankAttn: inpatient Pharmacy1425 S. MainWalnut Creek, CA 94596

Janeen G. McBride, R.Ph.Rx America1500 South Anaheim Blvd.Anaheim, CA 92815-0017

Gary M. McCart, Pharm.D.University of California, San Francisco400 Parnassus Ave., Box 312San Francisco, CA 94143

Anoush Miridjanian, M.D.Southern California Permanente Medical GroupDepartment of Internal Medicine4647 Zion Ave.San Diego, CA 92120

Stephen M. Stahl, M.D., Ph.D.Clinical Neuroscience Research Center8899 University Center Lane, Ste. 130San Diego, CA 92122


EDSP. O. Box 13029Sacramento, CA 95813-4029916/636-1000


DUR: Vic Walker, R.Ph., B.C.P.P. 916/657-0785PA: J. Kevin Gorospe, Pharm.D., 916/657-4213


Dennis DwormanExecutive Program DirectorEDS-Medi-CalElectronic Data Systems3215 Prospect Park DriveRancho Cordova, CA 95670916/636-1000


Susanne HughesActing Division ChiefMedi-Cal Managed Care Division714 P Street, Room 650Sacramento, CA 95814T: 916/654-8076F: 916/657-2069E-mail: [email protected]


J. Kevin Gorospe, 916/657-4213


Fulton Lipscomb, M.D.916/657-1460

Health and Welfare Agency Officials

Grantland JohnsonSecretaryCalifornia Health and Human Services Agency1600 9th Street, Suite 460Sacramento, CA 95814

Diana Bonta, R.N., DirectorDepartment of Health Services714 P Street, P. O. Box 942732Sacramento, CA 95814

Gail L. Margolis, Acting Deputy DirectorMedical Care Services

Medi-Cal Contract Drug Advisory Committee

Michael B. Huff, M.D.314 West Fourth St.Oxnard, CA 93030



William B. Ness, M.D.65 North 14th StreetSan Jose, CA 95112

Gary M. McCart, Pharm.D.University of CaliforniaSchool of PharmacyDivision of Clinical PharmacyBox 0622San Francisco, CA 94143-0622

Adrian M. Wong, Pharm.D.17 Warren DriveSan Francisco, CA 94131415/731-6239

Richard H. White, M.D.U.C. California, DavisDivision of General MedicinePrimary Care Center, Room 31072221 Stockton Blvd.Sacramento, CA 95817

Shirley Ann Floyd131 Chester Ave., Suite ABakersfield, CA 93301

Executive Officers of State Medical andPharmaceutical Associations/Boards

California Medical AssociationJack C. Lewin, M.D.P.O. Box 7690San Francisco, CA 94120-7690415/541-0900

Osteopathic Physicians & Surgeons of CaliforniaGary A. Gramm. D.O.Executive Director1900 Point West Way, Suite 188Sacramento, CA 95815-4703916/561-0724

California Pharmacists’ AssociationCarlo Michelotti, R.Ph., M.P.H.Chief Executive Officer1112 I Street, Suite 300Sacramento, CA 95814-2865T: 916/444-7811F: 916/443-1915

State Board of PharmacyPatricia F. HarrisExecutive Officer400 R Street, #4070Sacramento, CA 95814916/445-5014


1-Colorado National Pharmaceutical Council

COLORADO




Prescribed Drugs





Physician Services




CATEGORICALLY NEEDY, RECEIVINGASSISTANCE, TOTALAgedBlind/DisabledAFDC-ChildrenAFDC-AdultAFDC-Unemployed-ChildrenAFDC-Unemployed-Adults

MEDICALLY NEEDY, TOTALAgedBlind/DisabledAFDC-ChildrenAFDC-Adult

POVERTY RELATED, TOTALAgedBlind/DisabledAFDC-ChildrenAFDC-Adults

OTHER, TOTAL

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.*1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.


National Pharmaceutical Council Colorado-2

C. ADMINISTRATION

Eligibility is determined by 63 County Departments ofSocial Services, and the Colorado Department of HealthCare Policy and Financing administers the drug program.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin. Products covered with restriction:disposable needles and syringe combinations used forinsulin; blood glucose test strips; urine ketone test strips,total parenteral nutrition; and interdialytic parenteralnutrition. Products not covered: cosmetics; DESI drugs;fertility drugs; prescribed vitamins (except prenatal); andexperimental drugs.

Over-the-Counter Product Coverage: Products coveredwith restriction: analgesics (ASA only); cough and coldpreparations (except >21) and smoking deterrent products.Products not covered: allergy, asthma and sinus products;digestive products (non-H2 antagonist); digestive products(H2 antagonist); feminine products; and topical products.

Therapeutic Category Coverage: Therapeutic categoriescovered: analgesics, antipyretics, NSAIDs; antibiotics;anticoagulants; anticonvulsants; antidepressants;antidiabetic agents; antihistamine drugs; antilipemicagents; anti-psychotics; anxiolytics, sedatives, andhypnotics; cardiac drugs; chemotherapy agents (given inhome); contraceptives; ENT anti-inflammatory agents;estrogens; hypotensive agents; misc. GI drugs;sympathominetics (adrenergic); and thyroid agents.Therapeutic categories partially covered: anorectics. Priorauthorization required for: anabolic steroids; prescribedcough and cold medication; growth hormones; vitamins;sexual dysfunction; Epogen; brand name and FUL drugs;and prescribed smoking deterrents.



Unit Dose: Unit dose packaging not reimbursable.


Formulary: Closed formulary

Prior Authorization: State currently has a formal priorauthorization procedure. There is an appeal process andre-review when appealing coverage of an excludedproduct and prior authorization decisions.


Monthly Quantity Limit: New prescriptions for chronic oracute conditions are prescribed at the discretion of thephysician. However, reasonable amounts for more than a30-day supply for chronic conditions are recommended.Maximum supply is 100 days for maintenance medication


PRODUR system implemented in December 1998.

Lock-In Review Procedures: The Department receivescomputer processed printouts designed to discover over-utilization of drugs prescribed by physicians, dispensed byvendors, and received by eligible recipients.


Dispensing fee: $4.08 as of July 1, 1990. Institutionalpharmacies will receive a dispensing fee equal to $1.89. Dispensing physicians shall not receive a dispensing feeunless their offices or sites of practice are located morethan 25 miles from the nearest participating pharmacy. Inthe latter case, physicians receive a fee equal to $1.89.

Ingredient Reimbursement Basis: EAC = AWP-10% orWAC (wholesaler acquisition cost) + 18%. Other: FUL,state Mac, usual and customary.

Prescription Charge Formula: Benefit drugs shall bereimbursed at the lesser of the Medicaid allowablereimbursement charge, or the provider’s usual andcustomary charge or whatever is accepted from any thirdparty, discounts, rebates, etc.

The Medicaid allowable reimbursement charge is the sumof the ingredient cost of the drug dispensed and theprovider’s dispensing fee.

Ingredient cost for retail pharmacies (estimatedacquisition cost) is the price of the drug actually dispensedas defined below or the MAC or the high volume EAC,whichever is less.

The ingredient cost for institutional and governmentpharmacies is defined as the actual cost of acquisition forthe drug dispensed or the MAC, or the high volume EAC,whichever is less.

Maximum Allowable Cost: The state MAC is themaximum ingredient cost allowed by the Department for



certain multiple-source drugs. The establishment of aMAC is subject, but not limited to, the followingconsiderations:

(1) Multiple manufacturers;(2) Broad wholesale price span;(3) Availability of drugs to retailers at the selected cost;(4) High volume of Medicaid recipient utilization;(5) Bioequivalence or interchangeability.

When federal MAC limits for multiple source drugs areannounced, they will be adopted if they are less than stateMACs or if no state MACs exist.

The ingredient cost of any drug subject to MAC shall belimited to MAC or wholesale price as determined by theDepartment, whichever is less. Exceptions that will allowreimbursement greater than MAC for a drug entity areobtained through a prior authorization mechanism. Anexception will be granted if the patient’s response to thegeneric drug is not therapeutic, an allergic reaction isinvolved, or any similar situation exists.

If a recipient requests a brand name for a prescription thatis subject to MAC, then he/she may pay the ingredientcost difference between the MAC and brand name drug. The recipient must sign the prescription stating that he/sheis willing to pay the difference in ingredient cost to thepharmacy. The pharmacy will be paid MAC plus adispensing fee or reimbursement charges, whichever islower.

High volume Estimated Acquisition Cost (EAC):Reimbursement for single source drugs or certain multiplesource drugs which are most frequently prescribed will bebased upon average wholesale prices (AWP) minus 10%,or direct manufacturers’ prices for package sizescontaining quantities greater than 100 dosage units or lessif not available in 100’s.

Basis for inclusion in the high volume estimatedacquisition cost list includes but is not limited to:

(1) Single source manufacturers;(2) High volume Medicaid recipient utilization;(3) Interchangeability problems with multiple sourcedrugs;(4) Package sizes in excess of 100.

Drug Pricing: The Department will maintain a drug-pricing file that will be updated at least monthly. Theaverage wholesale price of a drug as determined by theDepartment, MAC, and high volume EAC, will be thebasis for setting the prices in the drug pricing file.

The Department will determine the average wholesaleprice that will be placed in the drug-pricing file asfollows:

(1) The average wholesale price as it appears in the RedBook, its supplements, and Medi-Span will be the firstsource. However, if there is a difference between the twopublished average wholesale prices, the Department willset the price as the published amount which is the closestto the lowest average price charged by two drugwholesalers doing business in Colorado.

(2) If there is a price change which does not appearimmediately in the Red Book, its supplements, or in Medi-Span, then the Department will set the average wholesaleprice by averaging the wholesale prices of three drugwholesalers doing business in Colorado, until the price ispublished in the Red Book, its supplements, or in Medi-Span.

(3) If the prices or changes do not appear in thepublications or the wholesalers’ records, then thedistributors’ or manufacturers’ prices will be adjusted tothe wholesale pricing level and used in the drug pricingfile as the price of the drug.

If the difference between the pharmacist’s invoicepurchase price and the average wholesale price whichappears in the Red Book, its supplements, or Medi-Spanexceeds 18%, then the Department may adopt a lowerprice after a survey is conducted to determine the validityof the published prices. The price from the distributor ormanufacturer will be adjusted the same as in 3 above.

Special Note: The Maximum Allowable Cost shall bedetermined by the Division of Medical Assistance, basedupon professional determination of a quality productavailable at the least expense possible.

Exceptions to the above are:

- Shelf package size oral liquid medications, in pint sizeonly, or smaller package size when not packaged in pintsize.

- Shelf package size oral tablet and capsule medicationsin quantities of 100 only or smaller when not available inpackage size of 100.

- Prescriptions for less than minimum amounts will bedenied reimbursement of the professional fee unless thephysician notified the Department in writing of themedical need for amounts less than a 30-day supply. Medical consultation determines the decision.


Patient Cost Sharing: Copay is $2.00 for brand nameproducts and $0.50 for generic.



National Pharmaceutical Council Colorado-4


Approximately 210,000 total unduplicated number ofMedicaid recipients were enrolled in MCOs in FY 1999.Recipients receive pharmaceutical benefits throughmanaged care plans.

Managed Care Organizations

Total Long-term Care303 East 17th Avenue Suite 650Denver, Colorado 80203303/896-4664

HMO Colorado700 BroadwayDenver, Colorado 80273303/831-2374

Kaiser Permanente10350 East Dakota AvenueDenver, Colorado 80905303/344-7250

Rocky Mountain HMO2775 Crossroads boulevardGrand Junction, Colorado 81506800/843-0719

Colorado Access600 South Cherry STREET Suite 800Denver, Colorado 80222303/-355-6707

Community Health Plan of the Rockies400 South Colorado Boulevard Suite 300Denver, Colorado 80222303/355-3220

United Healthcare6251 Greenwood Plaza Blvd, Suite 200Englewood, Colorado 80111-4910303/267/3594

F. STATE CONTACTS


Allen Chapman, R.Ph., M.S.Department of Health Care Policy and Financing1575 Sherman Street, 5th FloorDenver, CO 80203T: 303/886-3176F: 303/866-2573

DUR Contact

Allen Chapman, 303/886-3176


Allen Chapman, 303/886-3176


Technical: Vince Sherry, 303/866-5408DUR & PA: Allen Chapman, 303/866-3176


Consultec, Inc.600 17th StreetSuite 600 NorthDenver CO 80203800/237-0757


Gary SniderDirector Managed Care ContractorDepartment of Health Care Policy and Financing1575 Sherman Street, 5th FloorDenver, CO 80203T: 303/886-3163F: 303/866-2573


Patti Campbell303/866-5459

Health Care Policy & Financing DepartmentOfficials

James T. Rizzato, Executive DirectorRichard Allen, Director Health Plan and Medical Services

Office of Medical AssistanceColorado Department of Health Care Policy & Financing1575 Sherman StreetDenver, Colorado 80203

Medical Advisory Council

Donald W. Schiff, M.D.600 Front Range RoadLittleton, CO 80120303/837-2745

Molly A. Markert11060 E. Wesley Pl.Aurora, CO 80014303/756-7234



Mary Jo Jacobs, M.D.7425 E. Kenyon Ave.Denver, CO 80237303/694-2878

Walter Daniels, D.D.S.1633 Filmore StreetDenver, CO 80206303/388-0989

Rodney Fair, O.D.105 Bridge StreetBrighton, CO 80601303/659-3036

Douglas ClinkscalesDenver Health and Hospitals777 Bannock StreetDenver, CO 80204303/426-7253

Cathy Corcoran15920 W. 66th PlaceGolden, CO 80403303/861-6256

Ernestine Kotthoff-Burrell6098 S. Iola Ct.Englewood, CO 80111303/270-8974

Carol BartleyDenver VNA3801 E. Florida Ave., Suite 800Denver, CO 80201303/753-7312

Mary Ellen Kuhlman, MSWSt. Mary’s Hospital & Medical CenterP.O. Box 1628Grand Junction, CO 81502970/244-2273

Dan StenersonShalom Park14800 E. BelleviewAurora, CO 80015303/680-5000

Mark Kunart, D.O.17200 E. Iliff AvenueAurora, CO 80013303/755-4111

Robert SlayJefferson Co. CCB7456 W. 5th AvenueLakewood, CO 80226303/233-3363 x366

Department ContactRichard Allen, DirectorHealth Plans and Medical Services303/866-6092

Legislative LiaisonDean WoodwardDepartment of Health Care Policy and Financing303/866-2708


Colorado Medical SocietySandra MahoneyExecutive Vice President7800 E. Dorado Pl.Englewood, CO 80111-2306303/779-5455

Colorado Pharmaceutical AssociationVal Kalnins5150 East Yale Circle, Suite 304Englewood, CO 80112-1360303/756-3069

Colorado Society of Osteopathic MedicineKathleen BrennanExecutive Director50 S. Steele Street, Suite 770Denver, CO 80209303/322-1752

State Board of PharmacyKent MountProgram Administration1560 Broadway, Suite 1310Denver, CO 80202-5146303/894-7750

Colorado Hospital AssociationLarry WallPresident2140 South Holly St.Denver, CO 80222-5607303/758-1630


National Pharmaceutical Council Connecticut-1

CONNECTICUT




Prescribed Drugs





Physician Services




CATEGORICALLY NEEDY, RECEIVINGASSISTANCE, TOTALAgedBlind/DisabledChildAdultUnemployed Parent-ChildUnemployed Parent-Adult

MEDICALLY NEEDY, TOTALAgedBlind/DisabledChildAdult

POVERTY RELATED, TOTALAgedBlind/DisabledChildAdult

OTHER, TOTAL



2-Connecticut National Pharmaceutical Council

C. ADMINISTRATION

State of Connecticut Department of Social Services throughfive regional offices and nine sub-offices.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin, disposable needles and syringecombinations for insulin; blood glucose test strips; urineketone test strips; total parenteral nutrition (except inNH); and interdialytic parenteral nutrition (except in NH).Products not covered: cosmetics; fertility drugs; andexperimental drugs.

Over-the-Counter Product Coverage: Products covered:digestive products (non-H2 antagonists); feminineproducts; analgesics; and cough and cold preparations(children < 19 years). Products not covered: smokingdeterrent products; allergy, asthma and sinus products;digestive products (H2 antagonists); topical products;iron; calcium; oral contraceptives; and some traceelements. For nursing home patients, the department willnot pay for OTC drugs used in nursing facilities (such drugsare covered in the per diem rate). Some drugs requirediagnosis for reimbursement such as CNS stimulants forADD and narcolepsy.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; analgesics, antipyretics,NSAIDs; antibiotics; anticoagulants; anticonvulsants;antidepressants; antidiabetic agents; antihistamine drugs;antilipemic agents; anxiolytics, sedatives, and hypnotics;cardiac drugs; chemotherapy agents; prescribed coldmedications; contraceptives; ENT anti-inflammatoryagents; estrogens; hypotensive agents; misc. GI drugs;sympathominetics (adrenergic); thyroid agents; andgrowth hormones. Therapeutic categories not covered:anorectics and prescribed smoking deterrents.

Coverage of Injectables: Injectable medicines reimbursablethrough the Prescription Drug Program when used in homehealth care, extended care facilities, and through physicianpayment when used in physicians offices. No injectabledrug list.

Vaccines: Vaccines reimbursable as part of the ChildrenHealth Insurance Program.



Formulary: Open formulary, however, the followingproducts are excluded from Medicaid prescriptioncoverage: experimental drugs, cosmetics, fertility drugs;smoking cessation products; DESI drugs, and drugsavailable free from the Department of Health Services.

Prior Authorization: State currently has no priorauthorization procedure.


Prescription Refill Limit: 6-month refill limit except fororal contraceptives, which have a 12-month limit. Controlled substances have a 5 refill or 6-month limit.

Monthly Quantity Limit: Maximum 240 tablets orcapsules. Oral contraceptives: 3 months supply may bedispensed at one time.

Physicians are encouraged to prescribe drugs generically,when possible.


PRODUR system implemented September 1996. RetroDUR since September 1991; the state currently has aDUR Board with a quarterly review.


Dispensing Fee: $4.10, effective 1/1/91.

Ingredient Reimbursement Basis: EAC = AWP-12%.

Prescription Charge Formula: Federal MAC or EAC plusdispensing fee; or usual and customary if lower.

Maximum Allowable Cost: State imposes Federal UpperLimits on generic drugs. Override requires “BrandMedically Necessary.”

Incentive Fee: The Department will pay an incentiveprofessional dispensing fee of $0.50 per prescription, inaddition to any other dispensing fee, for substituting agenerically equivalent drug product.

Patient Cost Sharing: None.



Connecticut has approximately 230,000 Medicaid recipientsenrolled in managed care and receive pharmaceuticalbenefits.


National Pharmaceutical Council Connecticut-3


Blue Cross / Blue Shield of CTBlue Care Family PlanJohn Brangi, DirectorMedicaid Managed Care370 Bassett RoadNorth Haven, CT 06473-4201203/985-6464860/951-9544

Community Health Network of CT290 Pratt - 2nd FloorMeriden, CT 06450203/237-4000

PHS Healthy OptionsJanice Perkins, Assistant VPGovernment Relations and ProgramsOne Far Mill Crossing, Box 904Shelton, CT 06484-0944203/239-7444 x664

HealthChoice of CTPreferred OneSylvia Kelley, VP, Executive Director23 Maiden LaneNorth Haven, CT 06473203/239-7444 x664(withdrawing from program as of 4th quarter of 2000)

F. STATE CONTACTS


Elizabeth A. Geary, R.Ph.Health Program SupervisorDept. of Social Services25 Sigourney StreetHartford, CT 06106T: 860/424-5150F: 860/951-9544E-mail: [email protected]

Department of Social Services AdministrativeOfficials

Patricia A. Wilson-CokerCommissionerDept. of Social Services25 Sigourney St.Hartford, CT 06016-5033

Rita Pacheco, Deputy Commissioner203/424-5055

Michael Starkowski, Deputy Commissioner860/424-5053

David Parrella, DirectorMedical Administration Policy203/424-5116

Michelle Parsons, ManagerAlternate Care Unit203/424-5177

James Linnane, ManagerBenefit Design Unit203/424-5111

Marcia Mains, ManagerMedical Operations203/424-5219

DUR Contact

Elizabeth A. Geary, R.Ph.860/424-5150

Connecticut DUR Board

Kenneth Fisher R.Ph.Brooks Pharmacy

Arturo Morales M.D.St. Francis Hospital860/714-2976

Lori Jane Duntz Lord R.Ph.Greenville Drug860/889-9857

Jeffrey J. Messina R.Ph.Fort Hill Pharmacy860/445-6431

Rick Carbray, R.Ph.16 Beacon StreetNewington, CT 06111860/529-6305

Frederick N. Rowland, M.D.St. Francis Hospital and Medical Center860/679-2281

Dennis Chapron, R.Ph., M.S.UConn Health Center860/679-2281


4-Connecticut National Pharmaceutical Council

Cynthia Huge, R.Ph.Lexicon Pharmacy Services800/233-7873800/342-4980


First Data Bank


Elizabeth GearyMedical Operations860/424-5150Ellen Arce, R.Ph., 860/832-5885 (Audits)


Twila SmithEDS Federal Corp.100 Stanley DriveNew Britain, CT 06053860/832-5800


James GaitoDepartment of Social Services25 Signourney St.Hartford, CT 06106860/424-5137E-mail: [email protected]

Elderly Drug Coverage Program Contact

Elizabeth Geary860/424-5150


Zanita McKinney, Medical Policy25 Sigourney StreetHartford, CT 06106860/424-535

State Pharmacy Commission

William Summa, P.D., Chairman


State Medical SocietyTimothy B. Norbeck, Executive Director160 St. Ronan StreetNew Haven, CT 06511203/865-0587

Connecticut Pharmacists AssociationMargherita R. Guiliano, R.Ph. Executive V.P.35 Cold Spring Road, Ste. 124Rocky Hill, CT 06067-3100203/563-4619

Osteopathic Medical SocietyLynne Freiburger-Epstein, D.O.Secretary/Treasurer225 Main StreetManchester, CT 06040860/645-7014

State Board of PharmacyMichelle Sylvestre, R.Ph.Board AdministratorState Office Building, Room G-1AHartford, CT 06106203/566-3290

Connecticut Hospital Association, Inc.Dennis P. MayPresident110 Barnes RoadP.O. Box 90Wallingford, CT 06492-0090203/294-7202

Prescription Price Adjustments and Updates

First Data Bank-Blue Book


National Pharmaceutical Council Delaware-1

DELAWARE




Prescribed Drugs





Physician Services




RECEIVING CASH ASSISTANCE, TOTALAgedBlind/DisabledAFDC-ChildrenAFDC-AdultAFDC-Unemployed-ChildrenAFDC-Unemployed-Adults

MEDICALLY NEEDY, TOTALAgedBlind/DisabledAFDC-ChildrenAFDC-Adult

POVERTY RELATED, TOTALAgedBlind/DisabledAFDC-ChildrenAFDC-Adults

OTHER, TOTAL



2-Delaware National Pharmaceutical Council

C. ADMINISTRATION

Division of Social Services, Department of Health andSocial Services, through three county offices of the stateagency.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations used for insulin; blood glucose test strips;urine ketone test strips; and total parenteral nutrition. Products not covered: cosmetics; fertility drugs;experimental drugs; and interdialytic parenteral nutrition.

Over-the-Counter Product Coverage: Products covered:allergy, asthma and sinus products; analgesics; cough andcold preparations; digestive products (non-H2 antagonist);digestive products (H2 antagonists); and smokingdeterrent products. Products covered with restriction:feminine products (antifungals) and topical products (anti-infectants).

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; analgesics, antipyretics,NSAIDs; antibiotics; anticoagulants; anticonvulsants;antidepressants; antidiabetic agents; antihistamine drugs;antilipemic agents; anti-psychotics; anxiolytics, sedatives,and hypnotics; cardiac drugs; chemotherapy agents;prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc.GI drugs; prescribed smoking deterrents;sympathominetics (adrenergic); and thyroid agents. Priorauthorization required for: anorectics and growthhormones.

Coverage of Injectables: Injectable medicinesreimbursable through the Prescription Drug Program andphysician payment when used in physician offices.Reimbursable only through the Prescription Drug Programwhen used in extended care facilities.

Vaccines: Vaccines reimbursable under the Vaccines forChildren program.

Unit Dose: Unit dose packaging not reimbursable. Noprice based on AWP.



Prior Authorization: State currently has a formal priorauthorization procedure.


Prescription Refills: Prescription blank has space forphysician to authorize renewals.

Monthly Quantity Limit: Greater of 34-day supply or 100dosing units.

Monthly Dollar Limits: None.


PRODUR system implemented in August 1994.



Ingredient Reimbursement Basis: EAC = AWP-12.9%.

Prescription Charge Formula: Payment is based onAWP-12.9% or maximum allowable cost (MAC) plus adispensing fee, or the usual and customary cost to thegeneral public, whichever is lower.

Maximum Allowable Cost: State imposes Federal UpperLimits as well as state-specific limits on generic drugs. State-specific MAC list contains 90 drugs. Overriderequires “Brand Medically Necessary.”





Approximately 68,000 total unduplicated number ofMedicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits through thestate.


DelawareCare2751 Centerville Road, Suite 400Wilmington, DE 19808215/937-8285

First State Health Plan1801 Rockland Road, Suite 300Wilmington, DE 19803302/576-7603



F. STATE CONTACTS


Phile SouléDelaware Health and Social Services1901 N. Dupont HighwayNew Castle, DE 19720T: 302/577-4900F: 302/577-4405Agency Internet Address:http://www.state.de.us/govern/agencies/dhss


Cynthia DenemarkPharmacist ConsultantEDS248 Chapman Road, Suite 200Newark, DE 197029720T: 302/453-8453F: 302/454-7603E-mail: [email protected]

DUR Contact

Cynthia Denemark , 302/453-8453

DUR Board

Calvin Freedman, R.Ph.302 Lark DriveNewark, DE 19713-1216

Marvin H. Dorph, M.D.614 Loveville RoadUnit E4H Coffee Run CondoHockessin, DE 19707

Daniel M. Hauser, Pharm.D.325 W. BroadstairDover, DE 19904

Victoria Paoletti153 Owenwood Dr.Lincoln University, PA 19352

Richard Steele2617 Epping Rd.Wilmington, DE 19810

Marcus Wilson, Pharm.D.29 Peninsula CourtBear, DE 19701

Sharon Wisneski, R.N., M.S.336 Pine Valley RoadDover, DE 19901

Carl Mulveny1941 Limestone Rd.Wilmington, DE 19808

Michael Glacken500 West 10th St.Wilmington, DE 19801




Technical: Ralph Dominica, 302/454-7622Policy: E. Beth Laucius, 302/577-4902Dispute Resolution: Jessica Bullion, 302/454-7622


Thomas IgnudoAccount ManagerEDS248 Chapman RdNewark, DE 19702



Health and Social Services Department Officials

SecretaryDept. of Health & Social ServicesDelaware State HospitalNew Castle, DE 19720302/577-4500

Philip P. Soulé, Sr.Deputy Director, Medicaid302/577-4901

Dr. James B. SalvaMedical Consultant302/577-4900

Medical Advisory Committee Members

Edward R. Sobel, D.O.1100 S. Broom StreetWilmington, DE 19805

Anne Aldridge, M.D.671 Clifton Dr.Bear, DE 19701

Sister Jeanne Cashman, O.S.U.Ursuline Academy Convent1104 Pennsylvania AvenueWilmington, DE 19806


4-Delaware National Pharmaceutical Council

Neil McLaughlinFernhook Community Mental Health14 Central AvenueNew Castle, DE 19720

Richard CherrinVisiting Nurses AssociationNew Castle Corporate CommonsOne Reads WayNew Castle, DE 19720

Steven A. Dowshen, M.D.A.I. duPont InstituteP.O. Box 269Wilmington, DE 19899

Bob WelchBureau Health Planning & Resource ManagementJesse Cooper Building, Suite 160Dover, DE 19901

John A. Forrest, Jr., M.D.195 Lynnhaven DriveDover, DE 19904

Mark MeisterMedical Society of Delaware1925 Lovering AvenueWilmington, DE 19806

Olga RamirezCommunity Legal Aid Society, Inc.913 Washington StreetWilmington, DE 19801

Penny D. ChelucciDe Counsel on Gambling Problems100 W. 10th StreetCommunity Service Bldg., Suite 303Wilmington, DE 19801

Joseph LetnaunchynDelaware Health Care Association1280 S. Governor’s AvenueDover, DE 19901

David AllenVice PresidentAmbulatory & Continuing Care ServicesMilford Memorial Hospital21 W. Clark Ave.Milford, DE 19963

George EnglishBlue Cross Blue Shield of DEOne Brandywine PlazaWilmington, DE 19899

Micheal Glacken, M.D.Medical DirectorConnections, CSP500 West 10th St.Wilmington, DE 19801

Daniese McMullin-PowellA.D.A.P.T24 S. Old Baltimore PikeNewark, DE 19702

Leonard Nitowski, M.D.Doctors for Emergency ServicesPO Box 3048Wilmington, DE 19804

Julia M. Pillsbury, D.O.Center for Pediatric and Adolescent Medicine125-1 Greentree DriveDover, DE 19904

Ulder Jane Tillman, M.D.Jesse Cooper Building417 Federal and Water StreetsDover, DE 19901

Yrene E. WaldronExecutive DirectorDE Health Care Facilities AssociationTwo Mill Rd., Suite 200Wilmington, DE 19806


Medical Society of DelawareMark Meister, Sr.Executive Director1925 Lovering AvenueWilmington, DE 19806302/658-7596

Delaware Pharmaceutical SocietyMartin GoldenExecutive DirectorTindell Square Professional Plaza1601 Milltown Road, Suite 8Wilmington, DE 19808302/892-2880



Osteopathic Medical SocietyEdward Sobel, D.O.Executive SecretaryP. O. Box 845Wilmington, DE 19899302/475-6881

State Board of PharmacyDavid Dryden, R.Ph., J.D.Executive SecretaryCooper BuildingFederal and Water StreetsDover, DE 19901302/739-4708

Association of Delaware HospitalsJoseph M. LetnaunchynPresident1280 South Governors AvenueDover, DE 19904-4802302/674-2853


1-District of Columbia National Pharmaceutical Council

DISTRICT OF COLUMBIA




Prescribed Drugs





Physician Services




CATEGORICALLY NEEDY CASH TOTALAgedBlindDisabledChildren - Families w/Dep. ChildrenAdults - Families w/Dep. Children

CATEGORICALLY NEEDY NON-CASH TOTALAgedBlindDisabledChildren - Families w/Dep. ChildrenAdults - Families w/Dep. ChildrenOther Title XIX Recipients

MEDICALLY NEEDY TOTALAgedBlindDisabledChildren - Families w/Dep. ChildrenAdults - Families w/Dep. ChildrenOther Title XIX Recipients



National Pharmaceutical Council District of Columbia-2

C. ADMINISTRATION

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


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations used for insulin; and ferrous sulfate. Priorauthorization required for: injectable drugs administeredon an outpatient basis; anorexic drugs for treatment ofnarcolepsy and minimal brain dysfunction in children;acute anti-ulcer drugs, and brand NSAIDS. Products notcovered: all other non-legend items.

Over-the-counter Product Coverage: Products covered:oral analgesics; oral antacids; contraceptive foams andjellies; prenatal vitamin formulations; geriatric vitamin formulations for recipients 65 and over; and multivitaminformulations for children 7 years of age and over.

Coverage of Injectables: Injectable medicinesreimbursable when used in physicians offices, homehealth care, and extended care facilities.

Vaccines: Vaccines reimbursable at cost as part of theEPSDT service.

Unit Dose: Unit dose packaging not reimbursable


Formulary: Open formulary


Monthly Quantity Limit: In general, amounts dispensedare to be limited to quantities sufficient to treat an episodeof illness. Maintenance drugs such as thyroid, digitalis,etc. may be dispensed in amounts up to a 30-day supplywith 3 refills that must be dispensed within 4 months.Antibiotic medications used in treatment of acuteinfections are not to be dispensed in excess of a 10-daysupply. Birth control tablets may be dispensed in 3-cycleunits with a maximum of 3 refills within one year.

Monthly Dollar Limits: $1,500 limit. Physicians are torequest prior authorization for prescriptions that exceedthis amount.


PRODUR system implemented in September 1996.



Ingredient Reimbursement Basis: AWP - 10%.

Prescription Charge Formula: The lesser of: Upper limitestablished by HCFA or the AWP - 10% plus thedispensing fee or usual and customary to the public.

Maximum Allowable Cost: State imposes Federal UpperLimits on generic drugs. Override requires “BrandMedically Necessary” with explanation.


Patient Cost Sharing: $1.00 copay by recipient. Does notapply to recipients under 18, prescriptions for familyplanning, nursing home patients, or pregnancy related.



Recipients enrolled in managed care receivepharmaceutical benefits through managed care plans.


Advantage Health Plan, Inc.P.O. Box 9596Washington, DC 20016202/686-8555

American Preferred Provider Plan Mid-Atlantic, Inc.1501 M Street, NW, Suite 500Washington, DC 20002202/408-0460

D.C. Chartered Health Plan820 First Street, NE, Ste. LL100Washington, DC 20002202/408-4710

Capitol Community Health Plan750 First Street, NE, Ste. 1120Washington, DC 20002202/408-0460

George Washington University Health Plan4550 Montgomery AvenueBeheads, MD 20814301/941-2044


3-District of Columbia National Pharmaceutical Council

Health Right, Inc.3020 14th Street, NWWashington, DC 20009202/518-2370

Prudential Health Care Plan2800 N. Charles StreetBaltimore, MD 21218410/554-7224

F. STATE CONTACTS


Donna BowelPharmacist ConsultantCommission on Health Care Finance2100 M.L. King Jr. Ave. SESuite 302Washington, DC 20020202/727-0753

District of Columbia DUR Board

Christopher Keeyes, Pharm.D. (Chair)President, Clinical Pharmacy Associates11710 Beltsville Drive, Suite 510Calberton, MD 20705301/572-1616

Martin Dillard, M.D. (Vice Chair)Assistant Dean for Clinical AffairsChief, Division of NephrologyHoward University Hospital2041 Georgia Avenue, NW, Suite 5C02Washington, DC 20060202/865-1191

Howard Robinson, R.Ph.Manager, Central PharmacyGreater Community Hospital1310 Southern Avenue, SEWashington, DC 20032

Dr. Kim BullockProvidence HospitalEmergency Room1150 Varuum St., NEWashington, DC 20017202/269-7863


Technical: Ken Boni, 202/965-7400Policy: Donna Bovell, 202/727-0753DUR: Donna Bovell, 202/727-0753


Donna Bovell202/727-0753

Department of Human Services Officials

Geraldine WilliamsDirectorDepartment of Human Services2700 MLK Avenue, SE(801 East Bldg.)Washington, DC 20023

Marlene Kelly, M.D.Acting DirectorDepartment of Health1660 L Street, NW12th FloorWashington, DC 20002

Paul OffnerDeputy Director, DOHMedical Assistance Administration2100 M.L. King Jr. Ave. SESuite 302Washington, DC 20020

Executive Officers of District Medical andPharmaceutical Societies

Medical Society of the District of ColumbiaK. Edward Shanbacker2215 M St., NWWashington, DC 20037-2059202/466-1800

Pharmaceutical AssociationHerbert Kwash, R.Ph., President6406 Georgia Ave, NWWashington, DC 20012202/829-1515

Osteopathic AssociationRoy Heaton, D.O., Secretary4001 N. 9th Street, Suite 216Arlington, VA 22203703/522-8404

DC Board of PharmacyCheryl A. Robinson, Chair614 H Street N.W., Rm. 904Washington, DC 20001202/727-7468


National Pharmaceutical Council District of Columbia-4

District of Columbia Hospital AssociationRobert Malson, President1250 Eye Street, NW, Suite 700Washington, DC 20005-3980202/682-1581

Fiscal Intermediary

Jack ZaeloFirst Health Services, Inc.122 C Street, N. W.Washington, DC 20001202/783-5610


1-Florida National Pharmaceutical Council

FLORIDA




Prescribed Drugs





Physician Services



Expended Recipients Expended RecipientsTOTAL $933,782,041 1,014,372 $1,089,866,582 982,886

RECEIVING CASH ASSISTANCE, TOTAL $710,423,515 555,823Aged $126,584,312 76,097Blind / Disabled $509,397,909 212,404AFDC-Child $26,292,425 151,467AFDC-Adult $36,189,923 69,409AFDC-Unemployed-Child $4,312,209 25,383AFDC-Unemployed-Adult $7,646,737 21,063

MEDICALLY NEEDY, TOTAL $46,363,601 19,024Aged $62,129 20Blind / Disabled $38,021,526 8,395AFDC-Child $2,782,675 3,521AFDC-Adult $5,497,271 7,088

POVERTY RELATED, TOTAL $193,659,597 282,166Aged $71,343,167 45,811Blind / Disabled $93,785,943 36,579AFDC-Child $22,471,261 145,201AFDC-Adult $6,059,226 54,575

OTHER $139,419,869 125,873

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.*1998 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

C. ADMINISTRATION

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


National Pharmaceutical Council Florida-2


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations used for insulin; blood glucose test strips;total parenteral nutrition; and urine ketone test strips forchildren under age 21. Prior authorization required for:Cytogam; Proleukin; Serostim; Albumin; Neutrexin;Provigil; Zoloft 50mg; Paxil 10mg; Panretin gel;Regranex (long term care); Botox; and nutritionalsupplements. Products not covered: cosmetics; fertilitydrugs; experimental drugs; and interdialytic parenteralnutrition.

Over-the-Counter Product Coverage: Products covered:smoking deterrents; allergy, asthma and sinus medication(limited); analgesics (aspirin); cough and coldpreparations (only children under 21 years); feminineproducts (prior Rx only); iron supplements; Guaifenesin;and vaginal antifungals. Products not covered: digestiveproducts (H2 antagonists) and topical products.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; analgesics, antipyretics,NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antipsychotics;anxiolytics, sedatives, and hypnotics; cardiac drugs;chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc.GI drugs; prescribed smoking deterrents (only childrenunder 21 years); sympathominetics (adrenergic); andthyroid agents. Prior authorization required for: growthhormones. Therapeutic categories not covered:anorectics.

Coverage of Injectables: Injectable medicinesreimbursable through the Prescription Drug Programwhen used in home health care and extended carefacilities, and through physician payment when used inphysician offices.




Formulary: Open formulary with the following limits andexclusions.

1. Vitamins and phosphate binders only for dialysispatients.

2. Prostheses; appliances; devices; and personal careitems.

3. Non-legend drugs (except for prescribed insulin,pancreatic enzymes, buffered and enteric coatedaspirin when prescribed as an anti-inflammatoryagent only, and single entity hematinics).

4. Anorexants unless the drug is prescribed for anindication other than obesity (i.e. narcolepsy,hyperkinesis).

5. Drugs with questionable efficacy as rated by FDA(DESI).

6. Investigational and experimental items.7. Oral vitamins with exception of fluorinated pediatric

vitamins prescribed for pediatric patients, vitaminsfor dialysis patients, prenatal vitamins.

8. Smoking cessation products only to EPSDT clientsunder age 21.

9. Nursing home floor stock drugs.

Prior Authorization: State currently has a formal priorauthorization procedure. An appeal hearing request isrequired to appeal prior authorization decisions.


Prescription Refill Limit:

1. Six (6) prescriptions monthly for community patients;8 prescriptions per month for institutionalizedpatients. Increased grants are available based on needand diagnosis.

2. Maintenance medication should be dispensed andbilled for at least a one-month supply.

3. Refills must be authorized by the prescriber and canbe made for up to one year, except that controlledsubstances can be refilled only in accordance withfederal and state regulations.

4. Anti-ulcer, anti-anxiety, and sedative hypnotic drugslimited to 1 per therapeutic class per month, 1 refillper prescription.

5. Nutritional supplements are covered with priorauthorization when the patient is otherwise at risk ofhospitalization.

6. Other third parties, including Medicare, must bebilled first




PRODUR system implemented in July 1994. Statecurrently has a DUR board with a quarterly review. Retrospective Drug Utilization Review has been in placesince 1982. The state Medicaid agency and the FloridaPharmacy Association, which performs the reviews, sharethe administration of the program.



Ingredient Reimbursement Basis: AWP-13.25 %.

Prescription Charge Formula: Lower of:

1. FUL (Federal Upper Limits or State MAC) plusdispensing fee.

2. EAC plus dispensing fee. 3. Usual and customary charge.4. In-house unit dose diff. + 0.015/dose.

Maximum Allowable Cost: State imposes Federal UpperLimits and State Specific Limits on generic drugs. Provisions for MAC override by physicians only if listedon negative formulary.

Incentive Fee: No incentive fee.

Patient Cost Sharing: No copayment



All Medicaid recipients receive pharmaceutical benefitsthrough managed care plans (inclusion of such benefits ismandated under state law).


Alpha Health Plan, Inc.

Beacon Health Plans, Inc.Contact: Ana M. Berenguer2511 Ponce de Leon Blvd., 5th FloorCoral Gables, FL 33134305/774-2599

Discovery PlanContact: Robert Wychulis3520 Thomasville Road, Suite 200Tallahassee, FL 32308850/894-0100 ext. 801

Florida 1st Health Plans, Inc.Contact: Frank Willis3425 Lake Alfred RoadWinter Haven, FL 33881941/293-0785

Foundation Health, A Florida Health Plan, Inc.Contact: Michael Comerford1340 Concord TerraceSunrise, FL 33323800/422-7335

HealtheaseContact: Christopher O’Connor6800 N. Dale Mabry Hwy., Suite 168Tampa, FL 33614-3988813/290-6358

Healthy Palm Beaches, Inc.

Humana Family Contact: Patricia L. Hubrigc/o Humana Medical Plan, Inc.3400 Lakeside Drive, 5th FloorMiramar, FL 33027305/626-5616

Jackson Memorial Health PlanContact: Taryn Davis1801 NW 9th Ave., Suite 700Miami, FL 33136305/575-3700

MedChoice Health PlanContact: Jeffery G. Keiser5300 West Atlantic AvenueDelray Beach, FL 33484-8190561/496-0505

Neighborhood Health Partnership, Inc.Contact: Heidi Etzold7600 Corporate Center Dr., Suite 300Miami, Fl 33126-1216305/715-4318

Personal Health PlanContact: Debi L. GavrasDr. Jeff Davis, D.O. (Interim)324 Datura Street, Suite 401West Palm Beach, FL 33401561/659-1270 ext. 5885



Physicians Healthcare Plans, Inc. Contact: Peter Jimenez2333 Ponce de Leon Blvd. Ste 303Coral Gables, FL 33134305/441-9400 ext. 125

Preferred Medical Plan, Inc.Contact: Tamara Meyerson4950 SW 8th StreetCoral Gables, FL 33134305/445-8373

St. Augustine Health Care, Inc.Contact: Mary Lynn LeachMail: P.O. Box 23160Location: 4300 NW 89th Blvd.Gainesville, FL 32606352/337-8650

Stay Well Health PlanContact: Nancy Gareau6800 N. Dale Mabry Hwy., Ste. 209-211Tampa, FL 33614813/290-6283

United Healthcare of Florida, Inc.Contact: Linna Van Nette800 North Magnolia Ave., Suite 600Orlando, FL 32803407/872-1000

United ElderCare Plan800 N. Magnolia Ave., #600Orlando, FL 32803800/643-5337

F. STATE CONTACTS


Jerry F. WellsPharmacy Program ManagerAgency for Health Care Administration2727 Mahan Drive, MS 38Tallahassee, FL 32308T: 850/487-4441F: 850/922-0685E-mail: [email protected]

Agency for Health Care Administration Officials

Ruben J. King-Shaw, Jr., DirectorAgency for Health Care AdministrationGary Crayton, Director for Medicaid850/488-3560


Linda Anthony, R.Ph.Senior PharmacistAgency for Health Care Administration2727 Mahan DriveTallahassee, FL 32308T: 850/922-0679F: 850/922-0685

DUR Contact

Coordinator: Marie Donnelly-StephensSenior Health Care Program AnalystAgency for Health Care Administration2727 Mahan DriveTallahassee, FL 32308T: 850/487-4441F: 850/922-0685

Medicaid DUR Board

Matthew Cohen, M.D.Bryan A. Bognar, M.D.David B. Levine, D.P.M., D.O.Richard Roberts, Pharm.D.Michael Thompson, Pharm.D.Earlene E. Lipowski, Ph.D.Mechelle LaWarre, Pharm.D.Larry L. Mattingly, D.O.L. Leanne Lai, Ph.D.Lynn G. Massey, Pharm.D.

Program Retro-DUR

Gaylon Fruit, R.Ph.Director Retro DUR Program

Prescribing Pattern Review Panel

J. David Moore, M.D.Walter Flesner, D.O.Daryl D. Wier, M.D.Mary Stelnicki, R.Ph.Stephen Clark, M.D.Dennis Penzell, D.O.B.L. Stalnaker, M.D.Cynthia Griffin, Pharm.D.


First Data Bank




Technical: Ralph Quinn, 850/488-9190Policy: Jerry Wells, 850/487-4441Audits: Jerry Wells, 850/487-4441Disputes: Greg Bracko, 850/488-9193


Mark SteckPBM DirectorConsultec, Inc.9040 Roswell Road, Suite 700Atlanta, GA 30350770/594-7799


Ralph Anderson, R.N.Agency for Health Care Administration2727 Mahan Drive, BLD 1, Rm 323Tallahassee, FL 32308T: 850/487-0640F: 850/414-5418


Hemophilia:Michael L. AnselAccordant Health Services5509-A West Friendly Avenue, Ste 101Greensboro, NC 27410T: 336/855-5870 ext.134F: 336/852-7413E-mail: [email protected]

George E. Hurrell, Jr.Director, Disease ManagementCaremark Inc.1127 Bryn Mawr AvenueRedlands, CA 92374T: 909/799-4160F: 909/7998-4335E-mail: [email protected]

AIDS:Peter D. ReisDirector of Business DevelopmentAIDS Healthcare Foundation6255 West Sunset Blvd, 16th Fl.Los Angeles, CA 90028T: 213/860-5200F: 213/860-5235E-mail: [email protected]

S. Shai Gold,Director, Business and Proposal Development CenterThe South Florida Community Care Network1801 NW 9th Avenue, Ste 700Miami, FL 33136T: 305/585-5187F: 305/585-3815E-mail: [email protected]

Diabetes:Virginia M. DollarCoordinated Care Solutions210 N. University Drive, Ste 700Coral Springs, FL 33071T: 954/344-2444F: 954/796-3688

Asthma:ITG (program sponsor)

Plans exist for disease management programs for End-Stage Renal Disease (ESRD) and congestive heart failure.Contact: Bob SharpeAssistant Deputy Director for MedicaidAgency for Health Care Administration2727 Mahan DriveTallahassee, FL 32308850/488-3560

Physician-Administered Drug Program

Laura Rutledge850/488-4481


Florida Medical Association, Inc.Charles S. Amorosino, Jr.P.O. Box 10269123 S. Adams St.Tallahassee, FL 32301904/224-6496

Florida Pharmacy AssociationMichael Jackson, R.Ph.Executive Vice President610 North Adams StreetTallahassee, FL 32301850/222-2400

Florida Osteopathic Medical AssociationLarry Mattingly, D.O.2007 Apalachee ParkwayThe Hull BuildingTallahassee, FL 32301850/878-7364



State Board of PharmacyJohn TaylorExecutive DirectorNorthWood Center1940 North Monroe Street, Suite 60Tallahassee, FL 32399-0775850/488-7546

Florida Hospital AssociationCharles F. Pierce, Jr.President307 Park Lake CircleP.O. Box 531107Orlando, FL 32853-1107407/841-6230


1-Georgia National Pharmaceutical Council

GEORGIA


Type of Benefit Categorically Needy Medically Needy (MN)* Other

OAA AB APTD AFDC OAA AB APTD AFDC** Children <21 SFO

Prescribed Drugs





Physician Services

Dental Services 1See Appendix E, page E-29, for a list of acronyms.*Aged, Blind & Disabled (all services) effective April, 1990**Pregnant Women Only



CATEGORICALLY NEEDY CASH TOTAL $242,900,444 344,678Aged $36,834,592 38,041Blind/Disabled $177,559,013 151,138Children-Families w/Dep. Children $14,661,159 108,295Adults-Families w/Dep. Children $13,845,680 47,204

CATEGORICALLY NEEDY NON-CASH TOTAL $41,423,040 330,361Aged $804,074 1,409Blind/Disabled $787,847 926Children-Families w/Dep. Children $32,698,175 257,296Adults-Families w/Dep. Children $7,132,944 70,730Other Title XIX Recipients $0 0

MEDICALLY NEEDY TOTAL $740,135 458Aged $75,378 57Blind/Disabled $657,789 372Children-Families w/Dep. Children $6,968 29Adults-Families w/Dep. Children $0 0Other Title XIX Recipients $0 0



National Pharmaceutical Council Georgia-2

C. ADMINISTRATION

Department of Community Health, Division of Medicaid


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; prescribed disposable needles; andsyringe combinations for insulin. Products covered withrestrictions: blood glucose test strips (100 per month);urine ketone test strips (100 per month); total parenteralnutrition (21 and younger); and interdialytic parenteralnutrition (21 and younger). Products requiring priorauthorization: Marinol; Epoetin; interferons; lactulose;neupogen; acutretin; top.vit.A derivatives; blood factors;toradol; H2RA full dose > 2months; Regranex; Viagra;PPIs; Sucralfate full dose after 2 months; brand names andmulti-source; and hemophilia clotting factors. Productsnot covered: cosmetics; fertility drugs; experimentaldrugs; prescription vitamins and minerals (except forprenatal and fluorides not in combination with othervitamins); barbituates (except Seconal); DESI drugs; andMiralax.

Over-the-Counter Product Coverage: Products covered:analgesics (Ibuprofen suspension) covered with restrictionfor ages less than 21; cough and cold preparations; PIN-X; NIX; iron; and meclizine. Products not covered:digestive products; feminine products; topical products;and smoking deterrent products.

Therapeutic Category Coverage: Therapeutic CategoriesCovered: antibiotics; anticoagulants; anticonvulsants;antidepressants; antidiabetic agents; antilipemic agents;antipsychotics; cardiac drugs; chemotherapy agents;contraceptives; ENT anti-inflammatory agents; estrogens;hypotensive agents; misc. GI drugs; sympathominetics(andrenergic); and thyroid agents. Prior authorizationrequired for: anabolic steroids; analgesics, antipyretics,NSAIDS for single source; anorectics; antihistamine drugsfor non-sedating >21yo; anxiolytics, sedatives, andhypnotics; growth hormones; and immunoglobulins.Therapeutic categories not covered: prescribed smokingdeterrents.

Coverage of Injectables: Injectable medicinesreimbursable through the Prescription Drug Programwhen used in home health care, extended care facilities,and through physician payment when used in physiciansoffices.

Vaccines: Vaccines reimbursable as part of the EPSDTservice, Children Health Insurance Program, and as partof the Vaccines for Children Programs.



Formulary: Closed formulary.

Prior Authorization: State currently has a formal priorauthorization procedure

Prescribing or Dispensing Limitations:

Prescription Refill Limit: Maximum of five refills foradults, six for children

Monthly Quantity Limit: Physicians are encouraged toprescribe a 31-day supply.

Monthly Dollar Limit: $1000, followed by manual review.


On-line PRODUR system implementation planned with aSept.1, 2000 start date. State currently has a DUR Boardunder development.




Prescription Charge Formula: Lower of averagewholesale price (AWP) minus 10% plus dispensing fee,MAC plus fee, or usual and customary.

Maximum Allowable Cost: State imposes Federal UpperLimits and State Specific Limits on generic drugs.Override requires “Brand Medically Necessary.”Approximately 55 drugs on the state-specific MAC list.


Patient Cost Sharing: $0.50 per prescription copayment(branded or generic).



Does not use MCOs to deliver services to Medicaidrecipients. Program discontinued October 1999.


3-Georgia National Pharmaceutical Council

F. STATE CONTACTS


Etta L. Hawkins, R.Ph.Department of Community Health-Medical Division2 Peachtree Street, 37th FloorAtlanta, GA 30303-3159T: 404/657-7239F: 404/656-8366E-mail: [email protected] Internet Address: http://www.state.ga.us/dch

Department of Community Health

Russ Toal, CommissionerDepartment of Community Health2 Peachtree StreetAtlanta, GA 30303-3159404/656-4479

Herb Weldon, Deputy CommissionerBill Connell, Interim DirectorDiv. of Professional ServicesDona Cole, DirectorDivision of Acute Car2 Peachtree StreetAtlanta, GA 30303-3159


Jean Cox, R.Ph.DUR/PA CoordinatorDCH Medicaid2 Peachtree Street, 37th floorAtlanta, GA 30303-3159T: 404/657-7241F: 404/656-8366E-mail: [email protected]

DUR Contact

Jean Cox, 404/657-7241

Medicaid DUR Board

John Stephen Antalis, M.D.Dalton Family Practice, P.C.1114 Professional Blvd.Dalton, GA 30720Term: 7/1/97-6/30/99

Edwin D. Bransome, Jr., M.D.Department of MedicineRoom BIW-542Medical College of GeorgiaAugusta, GA 30912-3185

Catherine E. Burley, M.D., Chairperson7365 Old National Hwy, Ste ARiverdale, GA 30296

Hal J. Henderson, R.Ph.Medical Arts Health Care1483-B Milstead Ave.Conyers, GA 30012

Randall T. Maret, R.Ph.Vice ChairpersonMaret’s Prescription Shop222 N. Pentz StreetDalton, GA 30720

J. Russell May, Pharm.D.Department of PharmacyMedical College of GeorgiaHospital and Clinics1120 15th StreetAugusta, GA 30912-5600

A. Thomas Taylor, Pharm.D.Medical College of GeorgiaCollege of PharmacyDepartment of Family Medicine4799 Hereford Farm RoadEvans, GA 30809

Earl S. Ward, Pharm.D.Mercer University School of Pharmacy3001 Mercer University DriveAtlanta, GA 30341

Gary C. Richter, M.D,Consultative Gastroenterology121 Linden Avenue, Suite 103Atlanta, GA 30308

Norman C. Moore, M.D.Brain Research Center655 First StreetMacon, GA 31201

John Dorland Rowlett, M.D.Children’s Hospital at Memorial Medical CenterPO Box 23089Savannah, GA 31403

J.Grady Strom, Jr. Ph.D.Mercer University School of Pharmacy3001 Mercer University DriveAtlanta, GA 30341-4155

Harry Strothers, M.D.505 Fairburn Rd. S.W.Atlanta, GA 30331


National Pharmaceutical Council Georgia-4

Reuben S. Roberts, Jr., M.D.Pulaski Professional BuildingP.O. Drawer 1237Hawkinsville, GA 31036


Etta L. Hawkins, 404/657-7239


Policy: Susan Oh, 404/657-9181PA: First Health Services, 770/916-9269Audits: Susan Oh, 404/657-9181


Cheryl CollierAccount Manager, EDS736 Park North BlvdP.O. Box 736Clarkston, GA 30021T: 404/297-3700F: 404/298-1031


Kathy DriggersDirector, Managed CareDepartment of Community Health2 Peachtree Street, N.W.Atlanta, Georgia 30303T: 404/657-7793F: 404/656-8366E-mail: [email protected]


Mark TrailDirector of Program PolicyDepartment of Community Health- Medicaid2 Peachtree Street, N.W.Atlanta, Georgia 30303T: 404/657-1502F: 404/656-8366E-mail: [email protected]


Shirley Benson2 Peachtree Street, N.E.Atlanta, Georgia 30303404/656-3961

Medical Assistance Advisory Committees

Representatives from each of the following groups:Medical Association of GeorgiaGeorgia Pharmaceutical AssociationAtlanta Medical AssociationGeorgia Health Care AssociationGeorgia Hospital AssociationGeorgia Dental AssociationGeorgia Osteopathic Medical AssociationNational Pharmaceutical Association


Medical Association of GeorgiaPaul ShanorExecutive Director938 Peachtree Street, N. E.Atlanta, GA 30309404/876-7535

Georgia Pharmaceutical AssociationOren “Buddy” HardenExecutive Vice President20 Lenox Pointe, P.O. Box 95527Atlanta, GA 30347404/231-5074

Osteopathic Medical AssociationJerome E. Mersberger, D.O.Secretary/Treasurer2160 Idlewood RoadTucker, GA 30084770/493-9278

State Board of PharmacyGregg W. SchuderExecutive Director166 Pryor Street, SWAtlanta, GA 30303404/656-3912

Medical Georgia AssociationKatherine DanielsExecutive DirectorMorehouse School of Medicine720 Westview Drive, S.W.Atlanta, GA 30310-1495404/752-1564

Georgia Hospital AssociationJoseph A. ParkerPresident1675 Terrell Mill RoadMarietta, GA 30067770/955-5801


1-Hawaii National Pharmaceutical Council

HAWAII




Prescribed Drugs





Physician Services




CATEGORICALLY NEEDY CASH TOTALAgedBlindDisabledChildren-Families w/Dep. ChildrenAdults-Families w/Dep. Children

CATEGORICALLY NEEDY NON-CASH TOTALAgedBlindDisabledChildren-Families w/Dep. ChildrenAdults-Families w/Dep. ChildrenOther Title XIX Recipients


Source: HHS Report HCFA-2082.‡This group accounts for the Aged, Blind and Disabled population only. 130,000 recipients are in managed care. Expendituresfor prescribed drugs total $250,000,000 and are included in the capitation rate.*1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.


National Pharmaceutical Council Hawaii-2

C. ADMINISTRATION

By the State Department of Human Services through itsMed-Quest Division and four county branch offices.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations for insulin; blood glucose test strips; urineketone test strips; total parenteral nutrition; andinterdialytic parenteral nutrition. Products requiring priorauthorization: Clorazil; Procardia XL; Norvasc; brandproducts on FUL price list; and Betaseron. Products notcovered: cosmetics; fertility drugs; and experimentaldrugs.

Over-the-Counter Product Coverage: Products covered:some allergy, asthma and sinus products; some analgesics;some cough and cold preparations; digestive products;some feminine products; and some topical products.Products covered with restrictions: some non-H2antagonist digestive products and H2 antagonist digestiveproducts (requires diagnosis of H. Pylori, GERD, etc.). Products not covered: smoking deterrent products.

Therapeutic Category Coverage: Prior authorizationrequired for: anabolic steroids; anorectics; antihistaminedrugs; anti-psychotics; anxiolytics, sedatives, andhypnotics; estrogens; misc. GI drugs; prescribed smokingdeterrents; proton pump inhibitors; single source NSAIDs;chemotherapy agents; and growth hormones.

Coverage of Injectables: Injectable medicinesreimbursable through the prescription drug program whenused in home health care, extended care facilities, andthrough physician payment when used in physiciansoffices.

Vaccines: Vaccines reimbursable as part of EPSDTservice if not covered by the Vaccines for ChildrenProgram.

Unit Dose: Unit dose packaging reimbursable



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


Quantity of Medication: Physicians are encouraged toprescribe a 30-day supply or 100 units.


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


Dispensing Fee: $4.67, effective May 9, 1990.

Ingredient Reimbursement Basis: EAC = AWP - 10.5%.

Prescription Charge Formula: Payment for prescriptionand OTC drugs listed in the formulary is limited to thefederally established MAC price, or EstimatedAcquisition Cost (EAC) plus dispensing fee, or billedamount, whichever is lowest.

Maximum Allowable Cost: State imposes Federal UpperLimits on generic drugs. Override requires “BrandMedically Necessary” and “Dispense As Written” as wellas prior authorization approval. Exclusions: anti-seizuremedication and oral contraceptives.


Patient Cost Sharing: No copayment.



Approximately 140,000 total unduplicated number ofMedicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits throughstate/managed care plans or both.


DentiCareWesley K.S. Mun900 Fort Street Mall, Suite 930Honolulu, HI 96813808/528-4904

Hawaii Medical Service Association (HMSA)Ms. Carolyn J. Gire, DirectorQUEST Administration818 Keeaumoku StreetHonolulu, HI 96808808/948-6588


3-Hawaii National Pharmaceutical Council

Queen’s Hawaii CareMr. Richard M. Jackson, General ManagerTwo Waterfront Plaza500 Ala Moana BoulevardHonolulu, HI 96813808/522-7522

Straub Clinic and Hospital, Inc.Deborah Stampfle, Executive Director641 Kailua RoadKailua, HI 96734 Tube 63808/266-6554

AlohaCare, Inc.Mr. John McComas1357 Kapiolani Blvd., Suite 1250Honolulu, HI 96814808/973-1650

Kaiser Foundation Health Plan, Inc.Ms. Virginia Vierra1441 Kapliolani Blvd, Suite 1600Honolulu, HI 96814808/944-0261

Kapliolani Health HawaiiPlan Administrator: Greg Oishi55 Merchant Street, 27th FloorHonolulu, HI 96813-4306808/535-7425

Behavioral Health ServicesCommunity Care Services (CCS)Sharon Yoshiura or Carolyn Gire810 N. Vineyard Blvd.Honolulu, HI 96817T: 808/ 948-5379F: 808/948-6588

F. STATE CONTACTS


Lynn Donovan, R.Ph.Medicaid Pharmacy ConsultantMed-Quest DivisionP.O. Box 339Honolulu, HI 96809-0339T: 808/692-8116F: 808/692-8131


Lynn S. Donovan808/692-8116

DUR Contact

Kathleen Kang-Kaulupali, 808/692-8115

Medicaid DUR Board

Myron Shirasu, M.D. (Internal Medicine)321 North Kuakini Street #200Honolulu, HI 96817808/523-8611

Gregory E.M. Yuen, M.D. (Psychiatry)Chair1154 Fort Street Mall, Suite 200Honolulu, HI 96813808/599-5050

Linda Tom MD (Geriatric Medicine)347 N. Kuakini Street, HPM-9Honolulu, HI 96817808/523-8461

James Lumeng, M.D. (Medicine/Pathology)850 West Hind Drive, #114Honolulu, HI 96821808/377-5485

Brian Matsuura (Medical Services Rep.)864 Kealahou St.Honolulu, HI 96825808/396-3974

Joy Higa, R.Ph. (Long Term Care)47-135 Heno PlaceKaneohe, HI 96744808/239-6353

Karen Huang, R.Ph. (Ambulatory Care)1010 Pensacola StreetHonolulu, HI 96814F: 808/597-2549Pager: 808/363-0838

Kerry Kitsu, R.Ph. (Community, chain)98-629 Nohoalii StreetAiea, HI 96701T: 808/536-5542F: 808/536-0659

Carl Mudrick, R.Ph. (Community, independent)2011 Coyne StreetHonolulu. HI 96826T: 808/739-1188F: 808/735-6545


National Pharmaceutical Council Hawaii-4


First Data Bank111 Bayhill Dr.San Bruno, CA 94066800/633-3453


Technical: Lynn Donovan, 808/692-8116Policy: Lynn Donovan, 808/692-8116Audits: Lynn Donovan, 808/692-8116DUR: Kathleen Kang-Kaulupali, 808/692-8115


HMSA - Medicaid Claims ServiceAttn: Luukia AbbleyP.O. Box 860Honolulu, HI 96808808/948-5361


Susan M. Chandler, DirectorDepartment of Human Services808/586-4997

Chuck DuarteAdministrator, Med-Quest Division


Hawaii Medical AssociationStephanie Averio, Executive Director1360 S. Beretania Street, Suite 100Honolulu, HI 96814808/536-7702

Hawaii Pharmaceutical AssociationTodd Inafuku, R.Ph.Executive DirectorP. O. Box 1198Honolulu, HI 96807808/941-8321

Association of Osteopathic Physicians and SurgeonsAlan R. Becker, D.O.Secretary/Treasurer122 Oneawa StreetKailua, HI 96734808/261-6105

State Board of PharmacyRuth GushikenExecutive SecretaryP. O. Box 3469Honolulu, HI 96801808/586-2698

Healthcare Association of HawaiiRichard E. MeiersPres., CEO932 Ward AvenueSuite 430Honolulu, HI 96814-2126808/521-8961


1-Idaho National Pharmaceutical Council

IDAHO




Prescribed Drugs





Physician Services




RECEIVING CASH ASSISTANCE, TOTAL $15,699,226 11,194Aged $2,228,943 1,434Blind / Disabled $12,543,258 6,397AFDC-Child $254,663 2,098AFDC-Adult $669,332 1,231AFDC-Unemployed-Child $501 10AFDC-Unemployed-Adult $2,529 24

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

POVERTY RELATED, TOTAL $26,669,496 26,219Aged $14,394,179 8,038Blind / Disabled $12,703,668 8,035AFDC-Child $857,649 6,575AFDC-Adult $1,714,000 3,571

OTHER $5,318,605 37,215



National Pharmaceutical Council Idaho-2

C. ADMINISTRATION

Idaho Medicaid Agency

By the State Department of Health and Welfare throughseven regional offices, each serves five or more of theState’s 44 counties.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations for insulin; blood glucose test strips; urineketone test strips; total parenteral nutrition; andinterdialytic parenteral nutrition. Products not covered:cosmetics; fertility drugs; and experimental drugs.

OTC Coverage: Products covered: prescribed insulin;disposable needles and syringe combinations used forinsulin; permethrin; and oral iron salts. Products notcovered: allergy, asthma, and sinus; analgesics, cough andcold preparations; digestive products; feminine products;topical products; and smoking deterrent products.

Therapeutic Category Coverage: Therapeutic Categoriescovered: anabolic steroids; analgesics, antipyretics,NSAIDs; antibiotics; anticoagulants; anticonvulsants;antidepressants; antidiabetic agents; antihistamine drugs;antilipemic agents; anti-psychotics; anxiolytics, sedatives,and hypnotics; cardiac drugs; chemotherapy agents;prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc.GI drugs; sympathominetics (adrenergic); and thyroidagents. Prior authorization required for: growthhormones. Therapeutic categories not covered: anorecticsand prescribed smoking deterrents.


Vaccines: Vaccines reimbursable as part of the ChildrenHealth Insurance Program, and the Vaccines for ChildrenProgram.

Unit Dose: Unit dose packaging reimbursable when usedin unit dose systems.

Formulary Authorization


Prior Authorization: State currently has a formal priorauthorization procedure and a Growth hormone priorauthorization committee. Written “notice of appeal”required for fair hearing.


Monthly Quantity Limit: Prescription drugs are limited toa 34-day supply. The following drugs are limited to a 100-day supply: Digoxin, thyroids, prenatal vitamins,nitroglycerin, fluoride, fluoride and vitamin combinations,non-legend oral iron salts and 3 cycles of birth control.


Contracted DUR through Idaho State University. PRODUR system implemented January 1998. Statecurrently has a DUR board with a quarterly review.


Dispensing Fee: $4.94 ($5.54 for unit dose), effectiveMarch 1999.

Ingredient Reimbursement Basis: EAC = AWP-11% asdetermined by First DataBank Data File Service ormanufacturer direct price for selected manufacturers.

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

Maximum Allowable Cost: State imposes Federal UpperLimits and state-specific limits on generic drugs. Overriderequires prior authorization.





Does not use MCOs to deliver services to Medicaidrecipients. Some Medicaid recipients are enrolled inprimary care case management and receive their benefitsfrom the state.


3-Idaho National Pharmaceutical Council

F. STATE CONTACTS


Gary Duerr, R.Ph.Medicaid PolicyAmericana Terrace, Suite 140P.O. Box 83720Boise, ID 83720-0036T: 208/364-1829F: 208/364-1846E-mail: [email protected]


Gary Duerr, 208/364-1829

DUR Contact

Gary Duerr, 208/364-1829

Medicaid DUR Board

Board Members:Bill Johns, R.Ph.Don Smith, R.Ph.Kent Jensen, R.Ph.Barbara Wells, R.Ph.John Lassere, M.D.E. Gregory Thompson, M.D.Robert Ting, M.D.Clayton Morgan, M.D., retired

Staff:Gary Duerr, R.Ph., Dept. Contact Vaughn Culbertson, Pharm.D. Project Dir.


First Data Bank


Technical: Gary Duerr, R.Ph. 208/364-1829Policy: Gary Duerr, 208/364-1829DUR: Gary Duerr, 208/ 364-1829PA: Gary Duerr, 208/ 364-1829Audits: David Mendoza, 208/ 364-1838


EDSP.O. Box 1168Boise, ID 83701208/395-2000


Pam MasonPrimary Physician Managed Care ProgramHealthy Connections ManagerP.O. Box 83720Boise, ID 83720T: 208/364-1890F: 208/364-1846E-mail: [email protected]


Robbie CharltonMedicaid PolicyPO Box 83720Boise, ID 83720-0036

Health and Welfare Department Officials

Karl Kurtz, DirectorDept of Health & Welfare, Medicaid DivisionTowers Building, 10th FloorPO Box 83720Boise, Idaho 83720-0036208/334-5500

Bureau of Medicaid Policy and ReimbursementDee Anne Moore, Bureau ChiefJoe Brunson, Medicaid AdministrationGary Duerr, R.Ph., Pharmacy Services SpecialistTom Young, M.D., Medical Consultant


Bob Beutler1217 Kirk DriveMoscow, ID 83943208/882-5536

Rep. Max C. Black3731 Buckingham DriveBoise, ID 83704208/327-3400

Marj Boren1002 E. BannockBoise, ID 83712208/342-4368

Sen. Hal Bunderson582 River Heights DriveMeridian, ID 83642208/888-7156


National Pharmaceutical Council Idaho-4

Loni Debbon, PresidentIdaho Head Start Association200 N. 4thBoise, ID 83702208/345-1182

Bonnie Haines, Senior Vice PresidentIdaho Hospital AssociationPO Box 1278Boise, ID 83701-1278208/338-5100

Steven HansonHuman Service Connection1380 BentonIdaho Falls, ID 83401208/523-2490

Cathy HartIdaho Office on AgingStatehouse, Room 108Boise, ID 83720-0007208/334-3833

Sally HigginsonBoise Alliance for the Mentally Ill331 N. AllumbaughBoise, ID 83704208/376-4304

Shirley Osborn5553 W. LockportBoise, ID 83703208/334-3110

Jim PeartIdaho Legal Aid, Caldwell Area Office708 Main Street, PO Box 1116Caldwell, ID 83606-1116208/345-2193

Cathleen Pierson3368 N. 34th StreetBoise, ID 83703208/385-7305

Rex Redden, PresidentIACORPO Box 50457Idaho Falls, ID 83405208/523-0053

Bob Seehusen, Executive DirectorIdaho Medical Association305 W. JeffersonBoise, ID 83702208/344-7888

JoAn Silva, DirectorRegion III Health & Welfare111 Poplar, PO Box 1219Caldwell, ID 83606208/459-7456

Acting Executive DirectorIdaho State Council on Developmental Disabilities280 N. 8th, Suite 208 StatehouseBoise, ID 83720208/334-2178

Scott SpearsIdaho Health Care AssociationPO Box 2623Boise, ID 83701208/343-9735


Idaho Medical AssociationRobert SeehusenExecutive Director305 West Jefferson, P.O. Box 2668Boise, ID 83702208/344-7888

Idaho State Pharmaceutical AssociationJo An CondieExecutive Director305 W. Jefferson, P.O. Box 140117Boise, ID 83714208/424-1107

Idaho Osteopathic Medical AssociationRon Higgenbotham, D.O.Secretary-Treasurer522 West Main StreetGrangeville, ID 83530208/983-1133

State Board of PharmacyRichard K. MarkusonExecutive Director3380 Americana Terrace #320Boise, ID 83706208/334-2356

Idaho Hospital AssociationSteven A. MillardPresident802 West Bannock St.Suite 500Boise, ID 83702-5842208/338-5100


1-Illinois National Pharmaceutical Council

ILLINOIS




Prescribed Drugs





Physician Services









National Pharmaceutical Council Illinois-2

C. ADMINISTRATION

Illinois Department of Public Aid, Division of MedicalAssistance.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations used for insulin; blood glucose test strips;and urine ketone test strips. Products not covered:cosmetics; DESI-ineffectives; fertility drugs; experimentaldrugs; total parenteral nutrition; and interdialyticparenteral nutrition.

OTC Coverage: Products covered: digestive products (H2antagonists) and smoking deterrent products. Productsrequiring prior authorization: analgesics; digestiveproducts (non-H2 antagonist); and topical products.Products not covered: allergy, asthma, and sinus; coughand cold preparations; and feminine products.

Coverage of Injectables: Injectable medicinesreimbursable through the Prescription Drug Programwhen used in physician offices, home health care, andextended care facilities.

Vaccines: Vaccines are reimbursable as part of a specialprogram.




Prior Authorization: State currently has a formal priorauthorization procedure and a Committee on Drugs andTherapeutics. Recipient must file an appeal with theirlocal office in order to appeal prior authorizationdecisions. To appeal the coverage of an excluded product,the recipient can request the opportunity to appear beforethe Committee on Drugs and Therapeutics.


Prescription Refill Limit: Maximum of eleven refills.

Monthly Quantity Limit: As medically appropriate.


PRODUR system implemented in January 1993. Statecurrently has a DUR board with a review on an as neededbasis.


Dispensing Fee: $3.75/$3.45 for generic/branded drugscosting up to $37.50; 10.46% of the drug cost for drugscosting $37.51 and more; maximum of $15.70/$15.40 forgeneric/branded drugs. Effective 7/1/99.

Ingredient Reimbursement Basis: EAC = AWP - 10%,AWP - 12% for multisource drugs.

Prescription Charge Formula: Lowest of 1) usual andcustomary, 2) Department's MAC plus fee. Professionalfee: $3.58 up to EAC of $35.80; above EAC of $35.80,fee is 10% of EAC.

Maximum Allowable Cost: State imposes Federal UpperLimits as well as state-specific limits on generic drugs. All drugs are interchangeable in Illinois but not for thosewith a Federal MAC. Other drugs appear on the IllinoisMAC list where the Federal MAC was inappropriate.Override requires prior authorization.





Approximately 158,000 Medicaid recipients werevoluntarily enrolled in MCOs in 1999. Recipients receivepharmaceutical benefits through managed care plans.


Americaid Community Care211 Wacker DriveSuite 1350Chicago, IL 60606-3101

United Health Care of IL233 N. Michigan Ave. 8th Fl-12th Fl.Chicago, IL 60601

Harmony Health Plan of Illinois125 South Wacker DriveSuite 2900Chicago, IL 60606-4402



Humana Health Plan30 South Wacker DriveSuite 3100Chicago, IL 60606

Illinois Masonic Community Health Plan836 West WellingtonChicago, IL 60657-5147

Family Health Network910 West Van Buren6th FloorChicago, IL 60607-3523

Neighborly Care Plan129 N. Eighth StreetEast St. Louis, IL 62201-2999

F. STATE CONTACTS


Marvin L. HazelwoodIllinois Department of Public AidDivision of Medical Assistance1001 N. Walnut St.Springfield, IL 62702T: 217/524-7112F: 217/524-7194E-mail: [email protected] E-mail Address: http://www.state.il.us/dpa/


Rick Mazzotti, R.Ph.217/787-6252

DUR Contact

Starlin Hayden Greatting, R.Ph.Pharmacy Consultant, DUR coordinatorIllinois Department of Public Aid1001 N. Walnut St.Springfield, Illinois 62702T: 217/524-7112F: 217/524-7194


First Data Bank111 Bayhill Dr.San Bruno, CA 94066


Technical: Marvin Hazelwood, 217/524-7112Policy: Marvin Hazelwood, 217/524-7112Audits: Alberta Levan, 217/782-5565Dispute Resolutions: Alberta Levan, 217/524-7161


Nelly RyanBureau ChiefIllinois Department of Public Aid201 S. Grand Avenue EastSpringfield, Illinois 62763T: 217/524-7478F: 217/524-7535

Elderly Expanded Drug Coverage Program

Cheryl PayneSupervisor, Circuit Breaker ProgramIllinois Department of Revenue101 W. Jefferson - Level 3- 250Springfield, Illinois 62794217/785-2097


Cheryl Bechner217/782-5565

Illinois Medicaid Agency Officials

Ann Patla, DR.HLIllinois Department of Public AidDivision of Medical Assistance201 South Grand Avenue, EastSpringfield, IL 62763-0001217/782-1200

Mary Ann Langston, AdministratorDivision of Policy

Norman L. Ryan, AdministratorDivision of General Services

Kenneth J. Durst, ChiefBureau of Research & Analysis

Matt Powers, AdministratorDivision of Medical Programs

Steve Bradley, ChiefBureau of Comprehensive Health Services


National Pharmaceutical Council Illinois-4

Patty Steward, R.Ph., Pharmacist ConsultantDepartment of Public AidP.O. Box 19117Springfield, IL 62794-9117217/782-5565

Title XIX Medical Care Advisory Committees

State Medical Advisory CommitteeArthur Traugott, M.D.32207 Weisiger WayUrbana, IL 61801

Committee on Drugs and TherapeuticsMarshall Blankenship, M.D., Chairman1555 Astor AvenueChicago, IL 60610708/636-3757

Nicholas C. Bellios, M.D.2504 WashingtonWaukegan, IL 60085708/249-3660

Armand Littman, M.D.Medical ServicesHines VA HospitalHines, IL 60141708/216-2006

Vincent A. Costanzo, Jr., M.D.7501 South Stony Island AvenueChicago, IL 60649312/995-1075

Theodore M. Kanellakes, M.D.229 N. Hammes AvenueJoliet, IL 60435815/744-2300

Patrick R. Staunton, M.D.156 N. Oak Park AvenueOak Park, IL 60301708/696-5887

Board of TrusteesPhillip D. Boren, M.D.Doctor's ClinicS. Plum StreetCarmi, IL 62821618/382-4193

Joan E. Cummings, M.D.Extended Care181 Hines VA HospitalBuilding 1, Room C-124DHines, IL 60141708/343-7200 ext. 5057

David B. Littman, M.D.1030 Old Elm RoadHighland Park, IL 60035708/433-3900

Richard P. Snodgrass, M.D.550 30th AvenueMoline, IL 61265309/764-1910

IDPA RepresentativeMarvin HazelwoodIllinois Department of Public Aid1001 N. Walnut St.Springfield, IL 62702217/524-7112

Illinois State Medical SocietyKenneth E. RyanDirector, Department of Economics20 N. Michigan Avenue, Suite 700Chicago, IL 60602312/782-1654

IDPH Representative:Ron Gottrich, R.PhIllinois Department of Public Health525 W. JeffersonSpringfield, IL 62761217/782-7532


Illinois State Medical SocietyAlexander R. LernerExecutive Vice President20 N. Michigan Avenue, Suite 700Chicago, IL 60602312/782-1654

Illinois Pharmacists AssociationMark Pilkington, R.Ph.Executive Director223 W. Jackson, Suite 1000Chicago, IL 60606-6908T: 312/939-7300 F: 312/939-7220



Illinois Assoc. of Osteopathic Physicians &Surgeons, Inc.Terrill K. Haws, D.O.Second Vice PresidentP.O. Box 22731015 La SalleOttawa, IL 61350815/434-5576

State Board of PharmacyJohn RosaPharmacy CoordinatorIllinois Department of Professional RegulationPharmacy Section320 West Washington Street, 3rd FloorSpringfield, IL 62786217/782-8556

Illinois Hospital and Health Systems AssociationKenneth C. RobbinsPresidentCenter for Health Affairs1151 East Warrenville RoadP.O. Box 3015Naperville, IL 60566-7015630/505-7777


National Pharmaceutical Council Indiana-1

INDIANA




Prescribed Drugs





Physician Services



Expended Recipients Expended Recipients

TOTAL $325,712,348 323,811

RECEIVING CASH ASSISTANCE, TOTALAgedBlind / DisabledAFDC-ChildAFDC-AdultAFDC-Unemployed-ChildAFDC-Unemployed-Adult

MEDICALLY NEEDY, TOTALAgedBlind / DisabledAFDC-ChildAFDC-Adult

POVERTY RELATED, TOTALAgedBlind / DisabledAFDC-ChildAFDC-Adult

OTHER



2-Indiana National Pharmaceutical Council

C. ADMINISTRATION

Office of Medicaid Policy and Planning


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations used for insulin; blood glucose test strips;urine ketone test strips; total parenteral nutrition; andinterdialytic parenteral nutrition. Products not covered:cosmetics; fertility drugs; and experimental drugs.

Over-the-Counter Product Coverage: Products covered ifprescribed by a physician: Indiana has a Medicaid OTCdrug formulary. Listed drugs are reimbursed based onState MAC.

Therapeutic Category Coverage: All coverage inaccordance with OBRA ’90 & ’93.

Coverage of Injectables: Covered.

Vaccines: Vaccines reimbursable as part of the EPSDTservice, the Children Health Insurance Program, and theVaccines for Children Program.

Unit Dose: In accordance with OBRA 1990Requirements. MCFA policy only.


Formulary: No formulary for legend drugs. All coveragein accordance with OBRA ’90 & ’93. No PA for drugs.

Prior Authorization: State currently does not have aformal prior authorization procedure.


Prescribing Refill Limit: None.




Dispensing Fee: $4.00, effective November 1989.


Legend Drug Reimbursement Methodology:

Lower/Lowest of:

1. Federal MAC, if applicable, plus a dispensing fee.2. EAC plus a dispensing fee.3. Pharmacy’s usual and customary charge to the

general public.

Maximum Allowable Cost: State imposes Federal UpperLimits. Override requires “Brand Medically Necessary.”


Patient Cost Sharing: Copayment varies from $0.50 to$3.00 for branded drugs and is $0.50 for generic drugs.

Cognitive Services: None.



F. STATE CONTACTS


Marc Shirley, R.Ph.Pharmacy Program DirectorOffice of Medicaid Policy and PlanningRoom W382Indiana State Government Center South402 W. Washington StreetIndianapolis, IN 46204-2739T: 317/232-4343F: 317/232-7382E-mail: [email protected]

*DO NOT CONTACT STATE DRUG PROGRAMADMINISTRATOR WITH SURVEYS. DIRECT ALLINDUSTRY/INDUCTRY CONTRACTORINQUIRIES IN WRITING TO:

EDS950 N. Meridian St, 10th FloorIndianapolis, IN 46704

NO PHONE SURVEYS WILL BE ACCEPTED



DUR Contact

Karen BaerDUR Board SecretaryOffice of Medicaid Policy & PlanningRoom W-382, Indiana Sate Government Center South,402 West Washington St.Indianapolis, IN 46204T: 317/232-4391F: 317/232-7382E-mail: [email protected]

Medicaid DUR Board

PhysiciansThomas Bright, M.D.Neil Irick, M.D.Patricia Treadwell, M.D.John J. Wienert, M.D.

PharmacistsPaula Ceh, R.Ph.Hamid Abbaspour, R.Ph.Thomas A. Smith, R.Ph.G. Thomas Wilson, R.Ph.

Health Care Economist(Vacant)

PharmacologistTerry Lindstrom, Ph.D.

Representative from Med CareKirby Davis, R.Ph.

Prescription Pricing Updating

First Data Bank


Marcia FinnMyers and Stauffer/EDS317/488-5000


EDS950 N. Meridian Street, 10th FloorIndianapolis, IN 46204


Sharon SteadmanManaged Care DirectorOffice of Medicaid Policy and Planning402 W. Washington StRoom W382, MS07Indianapolis, IN 46204T: 317/233-4697F: 317/232-7382


EDS950 N. Meridian Street, 10th FloorIndianapolis, IN 46204

Administration Officials

Kathleen D. GiffordAssistant SecretaryMedicaid Policy & PlanningIndiana Family & Social Services Administration402 W. Washington Street, Room W382Indianapolis, IN 46204317/233-4455

Sharon SteadmanManaged Care Director317/233-4697

Pat Nolting, DirectorMedicaid Program Operations317/232-4318

Medicaid Advisory Committee

John B. DeLap2365 Chestnut StreetColumbus, IN 47201

Deborah A. Freund1327 East First StreetBloomington, IN 47402

Eleanor DeArman Kinney5140 Reed RoadIndianapolis, IN 46254

Kayla Templin West1014 N. Arsenal AvenueIndianapolis, IN 46201

Edward A. White, D.O.410 North Main StreetPrinceton, IN 47670-1516


4-Indiana National Pharmaceutical Council

Beverly Richards, D.N.S., R.N.Indiana St. Nurses Association2915 North High School RoadIndianapolis, IN 46224-2969

David Giles, M.D.6934 Hillsdale CourtIndianapolis, IN 46250

L. Richard GohmanOne American Sq. - Ste 1100Indianapolis, IN 46204

Polly E. Hendricks, O.D.3222 Oceanline E. DriveIndianapolis, IN 46214

James F. Jones, M.S.101 W. Ohio Street - Ste 610Indianapolis, IN 46204

Mike WeberIndiana Health Care AssociationOne N. Capital, Ste 1115Indianapolis, IN 46204

Anna Schenk, Pres., ILPNA1501 W. 500 NorthMarion, IN 47952

Paul C. Johnson, D.D.S.8240 Naab RoadIndianapolis, IN 46260

Robin Taylor, R.Ph., PresidentHealthcare Prescription Svs, Inc.3830 E. Southport Road, Ste CIndianapolis, IN 46237

Greg Wilson, M.D.Developmental Pediatrics702 Barnhill Dr., Room 1601Indianapolis, IN 46202

Sen. Marvin Riegsecker801 S. 6th StreetGoshen, IN 46526

Rep. William CrawfordPO Box 18446Indianapolis, IN 46218-0446

Rep. Jeffrey K. Espich1250 W. Hancock Street, Box 158Uniondale, IN 46791

Vickie TroutDivision of Mental Health402 W. Washington - W 353Indianapolis, IN 46204

David Harris125 East 48th StreetIndianapolis, IN 46205

Donald Mulligan, Sr.6185 BroughtonPortage, IN 46368

Barry Delks21 Peregrine CourtWest Lafayette, IN 47906

Lula E. Baxter9710 East 38th StreetIndianapolis, IN 46236

R. Stanley Wilson, M.D.3 Hazelwood DriveVinciennes, IN 47591

Paul Schneider, Ph.D.6320 Latona CourtIndianapolis, IN 46278

Robert S. Mandresh, D.P.M.3351 N. Meridian #101Indianapolis, IN 46208

Chip Garver101 West Ohio, Suite 560Indianapolis, IN 46204

Michael SullivanInd. Assn. For Home Care, Inc.8888 Keystone CrossingSuite 1000Indianapolis, IN 46202

Louis Cantor, M.D.702 Rotary CircleIndianapolis, IN 46202

Joe D. Hunt, DirectorBureau of Policy DevelopmentState Department of Health1330 W. Michigan StreetIndianapolis, IN 46202




Indiana State Medical AssociationRichard R. KingExecutive Director322 Canal Walk, Canal LevelIndianapolis, IN 46202-3252317/261-2060

Indiana Pharmacists AssociationLarry SageExecutive Vice President156 E. Market Street, #900Indianapolis, IN 46204317/634-4968

Indiana Association of Osteopathic Physicians andSurgeons, Inc.Michael ClaphanExecutive Director3520 Guion Road, #202Indianapolis, IN 46222317/926-3009

State Board of PharmacyKristen BurchDirector

Indiana Health Professions Bureau402 West Washington Street, Room 041Indianapolis, IN 46204-2739317/232-1140

Indiana Hospital and Health AssociationKenneth G. StellaPresidentOne American SquareP.O. Box 82063Indianapolis, IN 46282


1-Iowa National Pharmaceutical Council

IOWA



OAA AB APTD AFDC OAA AB APTD AFDC* Children <21 SFO

Prescribed Drugs





Physician Services

Dental Services 1See Appendix E, page E-29, for a list of acronyms.*Pregnant women



RECEIVING CASH ASSISTANCE TOTAL $82,025,517 99,753Aged $11,582,919 8,054Blind / Disabled $57,606,338 33,570AFDC-Child $5,286,110 32,489AFDC-Adult $6,159,274 18,297AFDC-Unemployed-Child $492,801 3,817AFDC-Unemployed-Adult $898,075 3,526

MEDICALLY NEEDY, TOTAL $11,600,186 8,454Aged $4,661,291 3,388Blind / Disabled $5,986,116 2,540AFDC-Child $197,038 742AFDC-Adult $755,741 1,784

POVERTY RELATED, TOTAL $6,054,769 34,692Aged $1,201,194 1,478Blind / Disabled $1,355,437 1,060AFDC-Child $2,707,203 24,765AFDC-Adult $790,935 7,389

OTHER $46,573,607 67,074



National Pharmaceutical Council Iowa-2

C. ADMINISTRATION

State Department of Human Services, Division of MedicalServices.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin. Products covered requiring priorauthorization: PPIs; dipyridamole; epoetin; filgrastim;vitamins; ergotamine derivatives; narcotic agonist-antagonist nasal sprays; isotretinoin; oral antifungals; non-parenteral vasopressin derivatives; and Serotonin 5-HT1receptor agonists. Products not covered: fertility drugs;experimental drugs; cosmetics; disposable needles andsyringe combinations for insulin; blood glucose test strips;urine ketone test strips; total parenteral nutrition; andinterdialytic parenteral nutrition.

Over-the-Counter Product Coverage: Products coveredwith restriction (selected products): allergy, asthma andsinus products; analgesics; cough and cold preparations;H2 antagonists; and topical products. Products notcovered: digestive products; feminine products; andsmoking deterrent products.

The Iowa Department of Human Services adopted anadministrative rule that permits coverage for these non-prescription drugs:

− Aspirin: 325/650 mg Tabs; 81mg Chewable; AspirinEnteric Coated: 325/650mg Tabs; 81mg Chewable;Aspirin Tablets Buffered, 325 mg

− Acetaminophen: 325/500mg Tablets; 120mg/5ml and160mg/5mL Elixir; 100 mg/ml Solution; 120mgSuppositories

− Bacitracin Ointment 500 units/gm− Benzoyl Peroxide 5% and 10%, Cleanser, Lotion,

Cream, Gel− Chlorpheniramine Maleate Tablets 4 mg− Diphenhydramine Hydrochloride: 25 mg Capsules;

6.25mg/5mL and 12.5mg/5ml Liquid− Ferrous Sulfate: 300/325mg Tablets; 220mg/5ml

Elixir; 75 mg/0.6 ml Drops− Ferrous Gluconate: 300/325mg Tablets; 300mg/5ml

Elixir− Ferrous Fumarate Tablets 300 mg, 325 mg− Guafenesin 100 mg/5 ml with Dextromethorphan 10

mg/5 ml liquid− Meclizine Hydrochloride Tablets 15.5 mg, 25 mg− Miconazole Nitrate: Topical and Vaginal Cream 2%,

Vaginal Suppositories, 100mg− Nicotinic Acid (Niacin) Tablets: 25/50/100/250/500

mg− Pediatric Oral Electrolyte Solutions

− Permethrin Liquid 1%− Pseudoephedrine Hydrochloride: 30/60 mg Tablets;

30mg/5mg Liquid− Salicylic Acid Liquid 17%− Senokot: 326 mg/tsp Granules for children aged 20

and under; 187 mg Tablets for children aged 20 andunder

− Sodium Chloride Solution 0.9% for inhalation, withmetered dispensing valve 90 ml, 240 ml

− Tolnaftate 1% Cream, Solution, Powder− Nonprescription multiple vitamin and mineral

products specifically formulated and recommended foruse as a dietary supplement during pregnancy andlactation

− With prior authorization, nonprescription multiplevitamins and minerals under the conditions specifiedin subparagraph 78.1(2) “a” (3)

− Insulin− Oral solid forms of the above-covered items shall be

prescribed and dispensed in a minimum quantity of100 units per prescription or the currently availableconsumer package size except when dispensed via aunit dose system. When used for maintenance therapy,all of the above-listed items may be prescribed anddispensed in 90-day quantities

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; antibiotics; anticoagulants;anticonvulsants; antidepressants; antidiabetic agents;antilipemic agents; anti-psychotics; anxiolytics, sedatives,and hypnotics; cardiac drugs; chemotherapy agents;prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents;sympathominetics (adrenergic); and thyroid agents. Priorauthorization required for: analgesics, antipyretics,NSAIDs; amphetamines; antihistamine drugs; growthhormones; and misc. GI drugs. Therapeutic categories notcovered: anorectics and prescribed smoking deterrents.







Formulary: No formulary.

Prior Authorization: State currently has a formal priorauthorization procedure. State appeals and a fair hearingprocedure required for appeal of prior authorizationdecisions and coverage of an excluded product.

Prescribing and Dispensing Limitations:

Prescribing or Dispensing Limitations: None.


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


Dispensing Fee: $4.13 to $6.42, effective 7/1/00.


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



Patient Cost Sharing: Copayment of $1.00 branded andgeneric (federal exclusions).



Iowa Medicaid recipients receive pharmaceutical benefitsthrough the state.


United Health Care of the Midlands, Inc. /ShareKathy Ellithorpe2717 North 118th CircleOmaha, NE 68164402/445-5566

John Deere HealthplanCynthia GreeneAdministrator / Government ProgramsAttn: Government Programs1300 River Drive, Suite 200Moline, IA 61265309/765-7637

Coventry Health Care of IowaLou Garcia, Executive Director4600 Westown Parkway, Ste. 301Des Moines, IA 50392-0445515/225-1234

Iowa Health SolutionsPaul Carter, President2550 Middle Road, Ste. 405Bettendorf, IA 52722319/359-8999

F. STATE CONTACTS


Ronald Mahrenholz, R.Ph., M.S.Pharmacist ConsultantDivision of Medical ServicesDept. of Human ServicesHoover State Office Bldg.Des Moines, IA 50319T: 515/281-6199F: 515/281-6230E-mail: [email protected]


Randy Brentnall, R.Ph.Consultec, Inc.P.O. Box 14422Des Moines, IA 50306-3422T: 515/327-1322F: 515/327-0945

DUR Contact

Cheryl Clarke, R.Ph.DUR CoordinatorIowa Pharmacists Association8515 Douglas Ave, Suite 16Des Moines, IA 50322T: 515/270-0713F: 515/270-2979E-mail: [email protected]



Medicaid DUR Board

Ronnie Martin, R.Ph., D.O.Rick Wilkens, M.D.Ilyenn Wiesley, R.Ph.Sharon Meyer, Pharm.D., M.S.Ronald Miller, M.D.Stephen Elliott, D.O., Ph.D.R. Joe Mahrenholz, R.Ph., M.S.James F. Scott, R.Ph.Paul Perry, Ph.D.


Sherry SwansonDeputy Account ManagerConsultec, Inc.P. O. Box 14422Des Moines, IA 50306-3422T: 515/327-0950 ext. 1107F: 515/327-0945


Technical: Rocco Russo, 515/327-0950 ext. 1114Policy: Ron Mahrenholz, 515/281-6199Audits: Rocco Russo, 515/327-0950 ext. 1114DUR: Cheryl Clarke, 515/270-0713PA: Randy Brentnall, 515/327-0950 ext. 1322


Kristi SheakleyAccount ManagerConsultec, Inc.P. O. Box 14422Des Moines, IA 50306-3422T: 515/327-0950 ext. 1108F: 515/327-0945


Dann StevensMHC Program ManagerMedical Services- DHSHoover Building, 5th FloorT: 515/281-7269F: 515/281-6230


Sherry SwansonConsultec, Inc.P. O. Box 14422Des Moines, IA 50306-3422T: 515/327-0950 ext. 1107F: 515/327-0945

IPA Medicaid Advisory CommitteeJoe Cunningham608 5th St. SWWaukon, IA 52172319/568-4267

Robert Dean2725 S. PaxtonSioux City, IA 51106712/276-1307

Derek Duncan4836 71st StreetUrbandale, IA 50322515/266-3174

Helen Eddy209 S. 27th St.West Des Moines, IA 50265515/267-2800

Hal Jackson218 S. 4th Ave.Winterset, IA 50273515/462-2479

Patty Kumbera4704 80th PlaceUrbandale, IA 50322515/276-0679

Beverly McMahon625 Davis Ave.Corning, IA 50841515/322-3324

Mark Richards8119 Oakwood Dr.Urbandale, IA 50322515/278/0778

Kenneth HampsonPO Box 271Ames, IA 50010515/232-7315

Alan Shepley113 1st St. EastMount Vernon, IA 52314319/895-6248

Wally Tschopp861 1st St. SEHartley, IA 51346712/728-2563



John Swegle833 1st St. NWMason City, IA 50401515/422-0587

Iowa Human Services Department Officials

Jessie K. Rasmussen, DirectorDept. of Human ServicesHoover State Office Bldg.Des Moines, IA 50319515/281-8621

Denis Headlee, AdministratorDivision of Medical Services

Title XIX Medical Assistance Council

College of MedicineStacey T. CyphertUniversity HospitalsIowa City, IA 52242

House of RepresentativesPolly Bukta604 S. 32nd St.Clinton, IA 52732

Brad Hansen1015 Shoal Pointe Dr.Carter Lake, IA 51510

Iowa Nurses AssociationLinda Goeldner1501 42nd Street, Suite 471West Des Moines, IA 50266

Iowa Medical SocietySheryl Nuzum1001 Grand AvenueWest Des Moines, IA 50265

Opticians Assn. of IowaVacant

Iowa Assn. of Retarded CitizensBecky Godfrey715 E. LocustDes Moines, IA 50309

Iowa SenateSen. Maggie Tinsman3541 E. Kimberly RoadDavenport, IA 52857

Iowa SenateSen. Elaine Szymoniak2116-44th Street Des Moines, IA 50310

Iowa State Dept. of Public HealthDr. Edward SchorLucas State Office Bldg.Des Moines, IA 50319

Public RepresentativesVacantDiana Walvoord503 3rd Ave S.E.Spencer, IA 51301

Orvil Nelson1534 Second StreetBoone, IA 50036

Dr. Silvano Wueschner1722 Lake RoadOttumwa, IA 52501

Iowa Speech, Language & Hearing AssociationBarbara Vogen1401 50th Street, Suite 115West Des Moines, IA 50266

Association of Iowa Hospitals and Health SystemsTracy Warner100 E. Grand AvenueDes Moines, IA 50309

Iowa Health Care AssociationSteve Ackerson950 12th StreetDes Moines, IA 50309

Iowa Assn. for Home CareLarry Breeding1540 High Street, Suite 203-BDes Moines, IA 50309

Board of Chiropractic ExaminersDr. Terry BurkP.O. Box 370Huxley, IA 50124

Iowa Pharmacy AssociationCheryl Clarke, R.Ph.8515 Douglas, Suite 16Des Moines, IA 50322



Iowa Assn. of Homes for the AgingWilliam Thayer613 West North StreetMadrid, IA 50156

Community Mental Health Centers of IAMichelle Wray520 11th Street, N.W.Cedar Rapids, IA 52405

Iowa Dental AssociationRobert Harpster333 Insurance Exchange BuildingDes Moines, IA 50309

Iowa Council of Health Care CentersGeorge Appleby400 Homestead Building, Ste. 300Des Moines, IA 50309

Iowa Osteopathic Medical AssociationNorman Pawlewski950 12th St.Des Moines, IA 50309

Iowa Optometric AssociationGary Ellis1454 30th Street, Suite 204West Des Moines, IA 50266-1312

Iowa Pediatric Medical SocietyRick DelPrado, D.P.M.110 NW 9th, Suite 5Ankeny, IA 50021

Iowa Psychological AssociationMark PeltanNorth Iowa Mercy Health Center84 Beaumont DriveMason City, IA 50401-2921

Iowa Hearing Aid SocietyBev Thomas532 42nd St.DesMoines, IA 50312

Alliance for the Mentally Ill of IowaMargaret Stout5911 Meredith DriveUrbandale, IA 50322

Iowa Psych. Nurse Managers NetworkVacant

Iowa State Association of CountiesVirginia BordwellP.O. Box 889Washington, IA 52353

Iowa Governor’s Planning Council for DevelopmentalDisabilitiesRick Shannon, DD Council617 E. 2nd StreetDes Moines, IA 50309

Iowa Academy of Family PhysiciansDr. Dave Carlyle1215 Duff AvenueAmes, IA 50010

Iowa Physical Therapy AssociationSteven Clark2386 Scenic View Dr.Adel, IA 50003

Iowa Physician Assistant SocietyMichael Farley4524 Boulevard Pl.Des Moines, IA 50311

Iowa Association of Nurse PractitionersWanda Marshall2301 Beaver AvenueDes Moines, IA 50310

Iowa Association of Rural Health ClinicsEd Friedmann1013 1st Street, Box CRedfield, IA 50233

Iowa Occupational Therapy AssociationAngela Hanson-Abbas161 315th St.Perry, IA 50220


Iowa Medical SocietyMichael AbramsExecutive Vice-President1001 Grand AvenueWest Des Moines, IA 50265515/223-1401

Iowa Pharmacy AssociationThomas R. Temple, R.Ph., M.S.Executive Vice President8515 Douglas, Suite 16Des Moines, IA 50322



Iowa Osteopathic Medical AssociationNorman PawlewskiExecutive Director950 12th St.Des Moines, IA 50309-1001515/283-0002

State Board of Pharmacy ExaminersLloyd JessenExecutive Secretary/Director400 SW 8th St., Suite EDes Moines, IA 50319-4688515/281-5944

The Association of Iowa Hospitals and Health SystemsStephen F. BrentonPresident100 East Grand AvenueSuite 100Des Moines, IA 50309515/288-1955


National Pharmaceutical Council Kansas-1

KANSAS




Prescribed Drugs





Physician Services

Dental Services .................................................KAN Be Healthy (EPSDT) .................................................1See Appendix E, page E-29, for a list of acronyms.






OTHER



2-Kansas National Pharmaceutical Council

C. ADMINISTRATION

State Department of Social and Rehabilitation Services.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations used for insulin; blood glucose test strips;urine ketone test strips; and total parenteral nutrition.Products covered with restriction: interdialytic parenteralnutrition. Products not covered: cosmetics; fertility drugs;experimental drugs; DESI drugs; and drugs not rebated bythe manufacturer.

Over-the-Counter Product Coverage: Products covered:analgesics (for adults); digestive products (H2 antagonist);and antifungals. Products covered with restrictions: coughand cold preparations and smoking deterrent products.Products not covered: allergy, asthma and sinus products;digestive products (non-H2 antagonists); feminineproducts; and topical products.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; analgesics (for children),antipyretics (for children), NSAIDs; antibiotics;anticoagulants; anticonvulsants; antidepressants;antidiabetic agents; antihistamine drugs; anti-psychoticsantilipemic agents; cardiac drugs; chemotherapy agents;prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc.GI drugs; prescribed smoking deterrents;sympathominetics (adrenergic); and thyroid agents. Priorauthorization required for: anxiolytics, sedatives, andhypnotics; anorectics; and growth hormones.

Coverage of Injectables: Injectable medicinesreimbursable through the Prescription Drug Programwhen used in home health care, extended care facilities,and through physician payment program when used inphysician offices.

Vaccines: Vaccines reimbursed as part of the ChildrenHealth Insurance Program and the Vaccines for ChildrenProgram.




Prior Authorization: State currently has a formal priorauthorization procedure. The individual appealing mayrequest an administrative hearing to appeal a priorauthorization hearing by sending a request in writing to:

Administrative Hearing Office610 S. W. 10th Ave, 2nd FloorTopeka, KS 66612-1616


Prescription Refill Limit: As authorized by the prescriberand allowed by statute up to a one-year period from thedate of issuance of the prescription for non-controlleddrugs. No early refills (<75% Rx utilized).


Other: Narcotics, Viagra, and Relenza have other specificlimits.


PRODUR system implemented in November 1996. Statecurrently has a DUR Board with review every twomonths.


Dispensing Fee: $2.78-$6.71, average of $4.94, effective1/95.

Ingredient Reimbursement Basis: EAC = AWP - 10%.IV fluids, AWP - 50%. Blood fraction products,AWP - 30%.

Prescription Charge Formula: Pharmacies are reimbursedthe lesser of usual and customary, MAC, FUL, oracquisition cost (EAC) plus a dispensing fee.

Maximum Allowable Cost: State imposes a combinationof Federal Upper Limits and State Maximum AllowableCost (MAC).


Patient Cost Sharing: A recipient copay charge of $2.00(effective 7/1/94) applies to each new and refillprescription not specifically exempted under federalregulations.



National Pharmaceutical Council Kansas-3


Approximately 95,000 total unduplicated number ofMedicaid Recipients were enrolled in MCOs in FY 1999.Recipients receive pharmaceutical benefits throughmanaged care plans.


First Guard3801 Blue PkyKansas City, MO 64130

F. STATE CONTACTS


Karen Braman, R.Ph., M.S.Department of Social and Rehabilitation Services915 SW Harrison, Rm. 651-S DSOBTopeka, KS 66612-1570T: 785/296-6968F: 785/296-4813E-mail: [email protected] Internet Address: www.ink.org/public/srs/


Karen Braman, 785/296-6968

DUR Contact

Glenn McNees, R.Ph., M.S., BCPSDUR Program DirectorKU School of Pharmacy6052 Malott HallLawrence, KS 66045-2500T: 785/864-3264F: 785/864-5849

DUR Board

Michael Burke, M.D., Ph.D.Lawrence Davidow, Ph.D., R.Ph.Stanley Edlavitch, Ph.D., M.A.John Lowdermilk, R.Ph.Linda McAnarney, R.N.Janette McMillan, R.Ph.Kathy Miller-Lemke, R.Ph.Brenda Shewe, M.D.John Whitehead, D.O.


Karen Braman, 785/296-6968


Technical: Karen Braman, 785/296-6968Policy: Karen BramanDUR: Glenn McNees, 785/864-3264PA: Karen Braman


Blue Cross Blue Shield of KansasP.O. Box 3571Topeka, KS 66611800/933-6593


Bobbie Graff-HendrixsonManaged Care Team LeaderHealth Care Policy Division, Kansas Dept. of SRSTopeka, KS 66612-1570T: 785/296-3981F: 785/296-4813

Social and Rehabilitation Services DepartmentOfficials

Janet SchalanskySecretaryDepartment of Social and Rehabilitation ServicesDocking State Office Bldg.915 SW HarrisonTopeka, KS 66612-1570785/296-3981

Medical Care Advisory Committee Contact

Robert Day, Ph.D.Medicaid Policy/Medicaid DirectorHealth Care Policy DivisionKansas Dept of SRS915 SW HarrisonTopeka, KS 66612-1570785/296-3981


Kansas Medical SocietyJerry SlaughterExecutive Director623 SW 10th AvenueTopeka, KS 66612785/235-2383


4-Kansas National Pharmaceutical Council

Kansas Pharmaceutical AssociationRobert R. Williams, M.S., CAEExecutive Director1308 West 10th StreetTopeka, KS 66604-1299785/232-0439

Kansas Association of Osteopathic MedicineHarold Riehm, CAEExecutive Director1260 SW Topeka BoulevardTopeka, KS 66612785/234-5563

State Board of PharmacyLarry Froelich, R.Ph.Executive SecretaryLandon State Office Building900 Jackson, Room 513Topeka, KS 66612785/296-4056

Kansas Hospital AssociationDonald A. WilsonPresident215 Southeast Eighth StreetP.O. Box 2308Topeka, KS 66601-2308785/233-7436

Fiscal Manager

Rick SchultzHealth Care Policy DivisionKansas Dept. SRSRoom 651 S, Docking State Office BuildingTopeka, KS 66612-1570785/296-3981


National Pharmaceutical Council Kentucky-1

KENTUCKY




Prescribed Drugs





Physician Services







OTHER



2-Kentucky National Pharmaceutical Council

C. ADMINISTRATION

Department for Medicaid Services, within the Cabinet forHealth Services.


Benefit Design

Drug Benefit Product Coverage: Products covered:cosmetics; fertility drugs; experimental drugs; disposableneedles used for insulin; blood glucose test strips; andurine ketone test strips. Products not covered: prescribedinsulin; syringe combinations used for insulin; totalparenteral nutrition; and interdialytic parenteral nutrition.

Over-the-Counter Product Coverage: Products covered:smoking deterrent products. Products covered withrestrictions: allergy, asthma and sinus products;analgesics; cough and cold preparations; digestiveproducts (non-H2 antagonist); feminine products; andtopical products. Products not covered: digestiveproducts (H2 antagonists).

Therapeutic Category Coverage: Therapeutic categoriescovered: antibiotics; anticoagulants; anticonvulsants;antidepressants; antidiabetic agents; antilipemic agents;anti-psychotics; cardiac drugs; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc.GI drugs; sympathominetics (adrenergic); and thyroidagents. Prior authorization required for: anabolic steroids;analgesics, antipyretics, NSAIDs; antihistamine drugs;anxiolytics, sedatives, and hypnotics; chemotherapyagents; prescribed cold medications; and growthhormones. Therapeutic categories not covered: anorecticsand prescribed smoking deterrents.

Coverage of Injectables: Injectable medicinesreimbursable through the Prescription Drug Programwhen used in physicians offices, home health care andextended care facilities and through physician paymentwhen used in physician offices. Reimbursement is limitedto antineoplastic drugs with “J” codes in physician offices.

Vaccines: Vaccines reimbursable in the cost of thephysician visit as part of EPSDT service, Children’sHealth Insurance Program, Vaccines for ChildrenProgram and through the pharmacy.



Formulary: Closed Formulary. The Kentucky MedicaidProgram maintains a drug file of approximately 96,800drugs and covers all rebated products, some of whichrequire prior authorization.

Prior Authorization: State currently has a priorauthorization procedure and a Drug List and PriorAuthorization Sub-Committee. Review of writtendocumentation by a peer review contractor is required forappeal of prior authorization decisions. A formal appealsprocess is available if a request is denied.


Prescription Refill Limit: (1) No prescriptions may berefilled more than 5 times or more than 6 months after theprescription is written. (2) After initial filling, onedispensing fee per 30-day period for designatedmaintenance drugs.

Monthly Quantity Limit: For designated classes ofmaintenance drugs, refills of the original prescription andsubsequent prescriptions for these drugs must beprescribed and dispensed in quantities of not less than athirty-day supply unless the prescriber requests anexception to his policy.


PRODUR system implemented in September 1994. Statecurrently has a DUR Board with a quarterly review.


Dispensing Fee: $4.75 for outpatients and $5.75 for LTCfacility patients, effective July 1, 1991.


Prescription Charge Formula: Reimbursement consists ofthe lowest of: (1) the usual and customary charge; (2) theMAC, if any, plus a dispensing fee; or (3) the EAC plus adispensing fee.








Approximately 300,000 total unduplicated number ofMedicaid recipients were enrolled in MCOs in FY 1999.Recipients receive pharmaceutical benefits through thestate and managed care plans.

Region 3Passport Health Plan, Fincastle Bldg.305 W. Broadway, 4th FloorLouisville, KY 40202502/585-7900

F. STATE CONTACTS


Debra Bahr, R.Ph.Pharmacy Services Program ManagerDepartment for Medicaid ServicesCHR Building, 6th Floor275 East Main StreetFrankfort, KY 40621T: 502/564-6511F: 502/564-3852E-mail: [email protected]


Debra Bahr, R.Ph., 502/564-6511

Prior Authorization Subcommittee

Robert Hughes, M.D. (Chair)Marsha Adams, PACJames S. Davis, M.D.Nancy Stiles, M.D.

DUR Contact

Debra Bahr, R.Ph., 502/564-6511

DUR Committee

George Rodgers Jr., M.D.Richard Arnold, M.D.Phillip Baier, O.D.Patricia Freeman, R.Ph., Ph.D.Tim Jenkins, R.Ph.Marilyn Osborne, M.S.N., A.R.N.P.Vaughn Payne, M.D.Janet Poe Wright, Pharm.D.Ms. Kathy Wheeler, MSN, ARNP**

Industry Representatives:J. Scott Moody, Glaxo WellcomeKevin WeMett, Pharmacia & Upjohn

Drugs Technical Advisory Committee

Steve Adams, R.Ph.217 Lexington StreetLancaster, KY 40444

R. N. Smith, R.Ph.P. O. Box 247Burkesville, KY 42717

Clarence F. Sullivan III, R.Ph.1095 Tatesbrook DriveLexington, KY 40517

Paul Easley, R.Ph.9804 Springbark DriveLouisville, KY 40241

Gary Wientjes, R.Ph.496 Skaggs RoadMorehead, KY 40351

Drug Management Review Advisory Board

Robert C. Hughes, M.D., Chair300 S. 8th Street, Suite 480WMurray, KY 42071

Tim Jenkins, R.Ph., Vice Chair11502 Saratoga Ridge DriveLouisville, KY 40299-8316

Marsha Adams, P.A.-C792 Mt. Carmel RoadKirksey, KY 42054

Richard W. Arnold, M.D.300 East Pleasant StreetCynthiana, KY 41031

Phillip Baier, O.D.121 Franklin Square Shopping CenterFrankfort, KY 40601

James S. Davis, M.D.Department of Public Health275 East Main Street-2GWBFrankfort, KY 40621

Patricia Freeman, R.Ph., Ph.D.American Pharmacy Services Corp.975 Riverbend Road, Suite 1Frankfort, KY 40601


4-Kentucky National Pharmaceutical Council

Bill HoweGovernment Relations ManagerPfizer Inc.209 North Walnut, Suite CLansing, MI 48933

Ms. Marilyn Osborne, MSN, ARNPPerry County Health Center239 Lovern StreetHazard, KY 41701

Vaughn Payne, M.D.6420 Dutchman’s Pkwy.Louisville, KY 40205

George C. Rodgers, Jr., M.D.*4250 Georgetown-Greenville Rd.Georgetown, KY 47122-8816

Nancy Stiles, M.D.K512 Kentucky ClinicLexington, KY 40536-0284

Ms. Kathy Wheeler, MSN, ARNP**201 Ashby CircleVersailles, KY 40383-1549

Janet Poe Wright, Pharm.D.RR #2, Box 6Owenton, KY 40359-9601

Janet Poe Wright, Pharm.D.430 Roland AvenueOwenton, KY 40359-9601

*Proxy: Janice Sullivan, M.D.2908 Murray Hill PikeLouisville, KY 40242

**Proxy: Patricia Birchfield, ARNP, DSN171 Louisiana AvenueLexington, KY 40502

Association Contact:Robert L. Barnett, Jr., R.Ph.Executive DirectorKentucky Pharmacists Association, Inc.1228 Highway 127 SouthFrankfort, KY 40601502/227-2303

Medicaid Drug Rebate Contact

Marie CouchProgram CoordinatorCHR Building, 6th Floor275 East Main StreetFrankfort, KY 40621502/564-3476


Unisys Provider ServicesP.O. Box 2100Frankfort, KY 40602T: 502/226-1140F: 502/226-1860


Philip M. KremerDirector for Division of Physical HealthDepartment of Medicaid Services275 E. Main StFrankfort, KY 40621T: 502/564-5969F: 502/564-3852


Barbara Utter275 East Main StreetFrankfort, KY 40621502/564-2687

Department for Medicaid Services Officials

Jimmy D. Helton, SecretaryCabinet for Human ResourcesCHR Building, 4th Floor275 East Main StreetFrankfort, KY 40621502/564-7130

State Advisory Council on Medical Assistance

Chester L. Parker, Pharm.D., R.Ph.2086 Old NassauLexington, KY 40504606/277-5723

Chester A. Nava, Jr., D.P.M.110 North Hubbards LaneLouisville, KY 40207-3903502/897-2047



Carol J. Braun, D.D.S.2816 Veach RoadOwensboro, KY 42303502/683-7114

James A. BurchamP.O. Box 20Burlington, KY 41005606/431-2244

Leslie H. Rogers109 Daniel DriveHazard, KY 41701

William T. Watkins, M.D.125 Volunteer DriveSomerset, KY 42501606/679-2169

Frank A. Butler, Hospital DirectorUniversity of Kentucky Hospital800 Rose StreetLexington, KY 40536-0084606/323-5767

Faye Hensley, R.N.P.O. Box 85Manchester, KY 40962

Bettie Speicher Weyler3420 Grandview AvenueLouisville, KY 40207502/893-4964

Bob Gray2504 Duke Drive, Apt. 24Owensboro, KY 42301502/685-2976

Donnie Wilhite106 Creekstone CourtFrankfort, KY 40601502/223-1052

Betty Rose BoydApt. #19, Highland HeightsPrestonsburg, KY 41653606/886-0343

Marianne KellerThe Good Samaritan Center106177 Watterson TerraceJeffersontown, KY 40299502/267-7403

Patricia Conner-Young10409 Christina CourtLouisville, KY 40223502/5835034

Nancy Durham8900 Hawley-GibsonCrestwood, KY 40014502/241-9072

Vicki Prichard222 Ft. Mitchell AvenueFr. Mitchell, KY 41011606/344-0277


Kentucky Medical AssociationWilliam T. Applegate4965 U.S. Highway 42, Suite 2000Louisville, KY 40222-6301502/426-6200

Kentucky Pharmacists AssociationRobert Barnett, Jr., R.Ph.Executive Director1228 U.S. Highway 127 SouthFrankfort, KY 40601

State Board of PharmacyMichael MoneExecutive Director1024 Capital Center Drive, Suite 210Frankfort, KY 40601-8204502/573-1580

Kentucky Osteopathic Medical AssociationTom UnderwoodExecutive Director1501 Twilight TrailFrankfort, KY 40601502/223-5322

Kentucky Hospital AssociationMichael T. RustPresident1302 Clear Spring TraceP.O. Box 24163Louisville, KY 40224502/426-6220


1-Louisiana National Pharmaceutical Council

LOUISIANA




Prescribed Drugs





Physician Services




RECEIVING CASH ASSISTANCE, TOTAL $248,254,802 305,635Aged $73,418,794 48,320Blind / Disabled $147,147,115 121,962AFDC-Child $14,280,841 95,024AFDC-Adult $13,311,365 39,945AFDC-Unemployed-Child $40,778 235AFDC-Unemployed-Adult $55,909 149

MEDICALLY NEEDY, TOTAL $3,727,172 5,606Aged $1,348,745 1,031Blind / Disabled $1,275,027 1,246AFDC-Child $141,936 705AFDC-Adult $961,464 2,624

POVERTY RELATED, TOTAL $23,104,687 131,018Aged $630,135 1,161Blind / Disabled $248,094 438AFDC-Child $19,625,711 106,479AFDC-Adult $2,600,747 22,940

OTHER $77,698,124 110,222



National Pharmaceutical Council Louisiana-2

C. ADMINISTRATION

Department of Health and Hospitals.


Benefit Design

Drug Benefit Product Coverage: Products not covered:cosmetics; DESI drugs; and experimental drugs.

Over-the-Counter Product Coverage: Products notcovered: cough and cold preparations.

Therapeutic Category Coverage: Therapeutic categoriesnot covered: anorectics.

Coverage of Injectables: Injectable medicinesreimbursable when used in physician offices, home healthcare, and extended care facilities.

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






Prescription Refill Limit: Permitted as indicated byphysician within 6 months and not to exceed 5 refills.

Monthly Quantity Limit: New prescription must be issuedfor drugs given on a continuing basis, after 5 refills orafter 6 months. Maximum quantity for prescriptions shallbe either 30-day supply or 100 unit doses, whichever isgreater.

Other: Viagra and other drugs to treat impotence arelimited to 6 prescriptions per month.


PRODUR system implemented in April 1996.


Dispensing Fee: $5.77 maximum, effective 7/1/94.


Prescription Charge Formula: Medicaid reimbursementfor pharmacy services will be based on the lower of:

1. AWP minus 10.5% plus a dispensing fee for singlesource products or multiple source products with nomaximum allowable cost limitations or whenphysician authorizes “Brand Medically Necessary”for a brand name product which has a state MAC orFUL.

2. Louisiana Maximum Allowable Costs (LMAC) or theFederal Upper Limit plus the dispensing fee.

3. AWP for multi-source drugs when lower than FUL orLMAC.

4. The provider’s usual and customary charge to otherpayors.

Maximum Allowable Cost: State imposes Federal UpperLimits as well as state-specific limits on generic drugs. 414 drugs are listed on the state-specific MAC list. Override requires “Brand Necessary” or “BrandMedically Necessary.”


Patient Cost Sharing: $ 0.50 - $3.00 copaymentdependent of the cost of the drug, effective 7/13/95.

Cognitive Services: Does not pay for cognitive services



F. STATE CONTACTS


M.J. Terrebonne, P.D.Pharmacy Program DirectorP.O. Box 91030Baton Rouge, LA 70821T: 504/342-9479F: 504/342-3893E-mail: [email protected]

Department of Health and HospitalAdministration Officials

Thomas Collins, DirectorBureau of Health Services FinancingDepartment of Health and Hospitals1201 Capitol Access RoadBaton Rouge, LA 70821504/342-3891



David Hood, SecretaryDepartment of Health and Hospitals504/342-9500

Melwyn WendtPharmaceutical Consultant504/219-4154

DUR Committee

Region I:Lisa Chetta, P.D.Donald Fellows, P.D.Edward J. Lang, P.D.Paul Staab, M.D.

Region II:Leslie Day, P.D.Blake Pitre, P.D.Don Ramirez, P.D.Charles Raborn, M.D.

Region III:John Baker, P.D.Shawn McGee, P.D.Matthew Peterson, P.D.Lori Vidrine-Parks, M.D.

Region IV:Paul Chachere, P.D.W. Merwin McMahen, P.D.Donna White, P.D.Johnny Johnston, M.D.

Louisiana DUR Board Committee Members

Ken Ardoin, Senior ManagerState Government RelationsPfizer, Inc.7 Village Circle, Suite 400Westlake, TX 76262817/491-8410

Brad Belding, P.D.Director of PharmacyThibodaux Hospital402 Easy StreetThibodaux, LA 70301504/493-4786

Sylvia Heidingsfelder, M.D.5805 Highland RoadBaton Rouge, LA 70808225/358-1069

Susan Hinton, Pharm.D.7680 Dune DriveNew Orleans, LA 70128504/483-7570

Paul Staab, M.D.5216 Lapalco BoulevardMarrero, LA 70072504/348-4357

Nancy Toedter, Pharm.D.1701 McKean Place, Apartment 58Monroe, LA 71201318/329-4554

Charmaine Venters, M.D.Earl K. Long Hospital5825 Airline HighwayBaton Rouge, LA 70805225/358-1063


Technical: Susan Taskin, 504/342-3855Policy: M.J. Terrebonne, 504/342-9479Disputes: M.J. Terrebonne, 504/342-9479DUR: Dan Scholl, 504/237-3208


Kandis McDaniel504/342-0127

Medicaid Drug Program Committee

Cathi Fontenot, M.D.LSU Medical Center1542 Tulane AvenueNew Orleans, LA 70112504/568-4791

Naurang Agrawal, M.D.GastroenterologistTulane University School of Medicine1430 Tulane AvenueNew Orleans, LA 70112504/588-5838

Keith C. Ferdinand, M.D.1201 Poland AvenueNew Orleans, LA 70117504/943-1177


National Pharmaceutical Council Louisiana-4

Elvin G. Tubre, M.D.Internal Medicine3418 Medical Park DriveSuite 22Monroe, LA 71201318/361-0016

Milton C. Chapman, M.D.Pediatrician921 Shreveport-Barksdale Hwy.Shreveport, LA 71105318/865-5646

Merlin H. Allen, M.D.Family PracticeBox APonchatoula, LA 70454504/386-6198

Philip J. Medon, Ph.D.Northeast Louisiana UniversitySchool of PharmacyMonroe, LA 71201318/342-4174

Charles Trahan, P.D.721 East AcademyJennings, LA 70127381/824-1648Attn: Linda Foreman

Leon Richard, P.D.Pharmacy Center LTD.5310 Norgate DriveNew Orleans, LA 70127504/246-3620

Ken ArdoinPfizer Pharmaceuticals502 Fountain ParkwayGrand Prairie, TX 75050-1499214/647-0222

M. J. Terrebonne, P.D.Designee for the SecretaryDept. of Health & HospitalsP. O. Box 91030; BIN #24Baton Rouge, LA 70821-9030504/342-3956

Thomas Collins, DirectorP. O. Box 91030; BIN #24Baton Rouge, LA 70821-9030504/342-3956

Kathleen Kennedy, Pharm.D.Charity Hospital Pharmacy1532 Tulane AvenueDept. of MedicineNew Orleans, LA 70112


Louisiana State Medical SocietyDave L. TarverExecutive Director3501 North Causeway Boulevard, Suite 800Metairie, LA 70002-3673504/832-9815

Louisiana State Pharmacists AssociationExecutive Director4744 Jamestown, Suite 101Building 7-BBaton Rouge, LA 70808504/926-2666

Louisiana Association of Osteopathic PhysiciansGeorge Cowan, D.O.Secretary-Treasurer6018 Colbert StreetNew Orleans, LA 70124504/488-6743

State Board of PharmacyMalcolm BroussardExecutive Director5615 Corporate Boulevard, Suite 8EBaton Rouge, LA 70808-2537504/925-6496

Louisiana Hospital AssociationRobert D. MerkelPresident9521 Brookline AvenueBaton Rouge, LA 70898-0720504/928-0026

MANAGEMENT WORK GROUPKen Ardoin, DirectorState Government RelationsPfizer Inc.7 Village Circle, Suite 400Westlake, TX 76262817/491-8410

Barney Barnhill212 Forrest Lake LaneNatchitoches, LA 71457318/352-7037



Belaire BourgEckerd Drugs4530 S. Sherwood ForrestBaton Rouge, LA 70816504/291-0596

William Bourn, Dean or DesigneeNortheast Louisiana UniversitySchool of PharmacyMonroe, LA 71209-0470318/342-1600

Allan BrinkhausP.O. Drawer FSunset, LA 70584318/662-5411

Bob Broadus, ManagerState Government RelationsPharmacia and Upjohn7147 Creekwood DriveMandeville, LA 70471504/674-0058

Clovis BurchMedic Pharmacy271 E. 70th StreetShreveport, LA 71106318/865-0234

Horace BynumBynum and Sons3840 S. Bernard Ave.New Orleans, LA 70122504/288-4829

Marcellus Grace, DeanOr DesigneeXavier UniversityCollege of Pharmacy7325 Palmetto StreetNew Orleans, LA 70125504/483-7420

Tim JacksProfessional Pharmacy Services4106 Desiard StreetMonroe, LA 71203318/345-2891

Ruth “Cookie” JeanMedical Center of LADept. of Pharmacy2021 Perdido StreetNew Orleans, LA 70112504/588-3019

Marty McKayPearson’s Pharmacy74 FoxfireAlexandria, LA 71302318/443-8807

Angelo M. Rini, R.Ph.Louisiana Pharmacists Association504 Fairfield AvenueGretna, LA 70056504/362-9812

Andy SoileauMedicine Shoppe401 ½ E. St. Peters StreetNew Iberia, LA 70560318/365-6721

Kirt SoileauSoileau’s Vital Care Pharmacy2647 Riverview Blvd.Suite 115Gonzales, LA 70737800/522-5706

George TaylorCecilia PharmacyHwy 355, Box 309Cecilia, LA 70521318/667-6271

Carl Aron, PresidentLA Board of Pharmacy1209 North 18th StreetMonroe, LA 71201-5495

Fiscal Intermediary

UNISYSP.O. Box 91030Baton Rouge, LA 70821504/924-7051Claims Processing: Dan SchollPrice Updates: Maggie Vick


National Pharmaceutical Council Maine-1

MAINE




Prescribed Drugs





Physician Services

Dental Services * * 1See Appendix E, page E-29, for a list of acronyms.*Routine dental services; other categories eligible for non-routine dental service only.



CATEGORICALLY NEEDY CASH TOTALAgedBlindDisabledChildren-Families w/Dep. ChildrenAdults-Families w/Dep. ChildrenOther Title XIX Recipients





2-Maine National Pharmaceutical Council

C. ADMINISTRATION

State Department of Human Services.


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringecombinations used for insulin (not covered for nursinghome patients); blood glucose test strips; urine ketone teststrips; total parenteral nutrition; interdialytic parenteralnutrition; products not covered: vitamin and vitaminpreparations (except pregnancy); and injectables whenoral medication is available for equally effectivetreatment.

Over-the-Counter Product Coverage: Products covered:allergy, asthma, and sinus products (limited coverage after1/1/01); analgesics (limited coverage after 1/1/01); coughand cold preparations (limited coverage after 1/1/01);digestive products, H2 antagonists (limited coverage after1/1/01); topical products; smoking deterrent products (byRx only); products not covered: digestive products (notincluding H2 antagonists); feminine products.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; antibiotics; anticoagulants;anticonvulsants; antidepressants; antidiabetic agents;antilipemic agents; anti-psychotics; anxiolytics, sedatives,and hypnotics; cardiac drugs; chemotherapy agents;contraceptives; ENT anti-inflammatory agents; estrogens;hypotensive agents; misc. GI drugs; prescribed smokingdeterrents; sympathominetics (adrenergic); and thyroidagents. Prior authorization required for: analgesics,antipyretics, NSAIDs; anorectics; antihistamine drugs;prescribed cold medications; growth hormones.


Vaccines: Vaccines reimbursable based on cost as part ofthe EPSDT service (admin. fees) and as part of the Bureauof Health Immunization Program (vaccine fees).




Prior Authorization: May be obtained in the case ofnecessary exceptions. State has no formal priorauthorization committee.


Monthly Quantity Limit: 34 day for brand-name drugs and90 days for generic drugs per month.


PRODUR system implemented in 1996. State currentlyhas a DUR Board.


Dispensing Fee: $3.35 for stock supply, or for solutionsor lotions involving no weighing. $4.35 for compoundingointments and for solutions/lotions involving weighingone or more ingredients and making home IV solutions. $5.35 for compounding handmade supplies, pwd. papers,capsules and tablet priturates and for mixing home TPNhyperalimentation.


Prescription Charge Formula: Lowest of usual andcustomary, FUL, AWP-10%, or Maine MAC. MaineMAC includes approximately 50 drug products in additionto FUL products.

Maximum Allowable Cost: State imposes Federal UpperLimits as well as state-specific limits on generic drugs.Override requires “brand medically necessary” by thephysician and prior authorization for some drugs.


Patient Cost Sharing: Sliding copay scale based on cost:$0.50 to $3.00 for branded, $0.50-$2.00 for generic drugs.

Cognitive Services: State does not pay for cognitiveservices.


About 23,000 Medicaid recipients are enrolled in MCOs.


National Pharmaceutical Council Maine-3

F. STATE CONTACTS


Christine GeeDirector of Pharmacy ProgramsDepartment of Human ServicesBureau of Medical ServicesPharmacy ProgramsBuilding 205, 3rd Fl.11 State House StationAugusta, ME 04333-0011T: 207/287-4018F: 207/287-8601E-mail: [email protected] Internet Address:http://www.state.me.us/bms/bmshome.htm


Christine GeeBureau of Medical ServicesPharmacy ProgramsBuilding 205, 3rd Fl.11 State House StationAugusta, ME 04333-0011207/287-4018

DUR Contact

Christine Gee207/287-4018

Maine DUR Board

Timothy Clifford, M.D.Bureau of Medical Services11 State House StationAugust, ME 04333207/287-2674

William Alto, M.D.Maine Dartmouth Family Practice4 Sheridan DriveFairfield, ME 04937207/861-5000

John Grotton, R.Ph.Goold Health Systems24 Stone StreetP.O. Box 708Augusta, ME 04332207/622-7153

Paula Knight, R.Ph.31 Birch CircleSidney, ME 04330207/547-3881

Stephen McPike, R.Ph.15 Wildwood LaneGray, ME 04039207822-7627

Michael Ouellette, R.Ph.RFD 3Box 4235Winslow, ME 04901207/281-2727

Christine Gee207/287-4018

Non-voting:

Robert E. Carroll, Jr., R.Ph.Department of Professional and Financial RegulationOffice of Licensing and Registration35 State House StationAugusta, ME 04333-0035207/624-8689

Joe Bruno (President)Goold Health Systems24 Stone StreetP.O. Box 708Augusta, ME 04332207/622-7153

Dennis G. Lyons, R.Ph.255 Bear Hill Rd., 2nd Fl.Waltham, MA 02451


Kathy ChadwickFirst DataBank800/633-3453


Technical: Rossi Rowe, 207/287-1838Policy: Chris Zukas-Lessard, 207/624-5221Rebates: Rossi Rowe, 207/287-1838Audits: Vacant


4-Maine National Pharmaceutical Council


Marcia PykareManager of Data ProcessingGold Health SystemsP.O. Box 1090Augusta, ME 04332207/622-7153


Christine GeeMaine Drugs for the Elderly and Disabled Program207/287-2674http://www.state.me.us/sos/cec/rc/apa/10/chaps10.htm


Timothy Clifford, M.D.207/287-2674

Human Services Department Officials

Francis Finnegan, DirectorBureau of Medical Services207/287-2674

Susan CurtisDrug Program CoordinatorMedical Claims Review207/287-1818

Margaret Ross, DirectorMedicaid Surveillance/Utilization Review207/624-5220

Medical Assistance Advisory Committee

Robert PhilbrookMAC c/o BMS11 State House StationAugusta, ME 04333-0011


Maine Medical AssociationGordon Smith, Esq.Executive Vice PresidentP. O. Box 190Manchester, ME 04351-0190207/622-3374

Maine Pharmacy AssociationGregory JamisonExecutive DirectorP. O. Box 346Brewer, ME 04412-0346207/989-6190

Maine Osteopathic AssociationKellie P. MillerExecutive DirectorRR2, P.O. Box 1920Manchester, ME 04351207/623-1101

Maine Commission of PharmacySusan GreenlawBoard ClerkDepartment of Professional and Financial RegulationDivision of Licensing and EnforcementState House Station No. 35Augusta, ME 04333207/624-8603

Maine Hospital AssociationBruce J. RuebenPresident150 Capitol StreetAugusta, ME 04330207/622-4794


National Pharmaceutical Council Maryland-1

MARYLAND



OAA AB APTD AFDC OAA AB APTD AFDC Children <21 SFO*

Prescribed Drugs





Physician Services

Dental Services 1See Appendix E, page E-29, for a list of acronyms.*Effective December 1, 1992, all State-Only services except subsidized adoptions were discontinued. Prescription servicesfor these recipients were transferred to Pharmacy Assistance Program.






OTHER



2-Maryland National Pharmaceutical Council

C. ADMINISTRATION

State Department of Health and Mental Hygiene.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations used for insulin; and total parenteralnutrition. Products not covered: cosmetics; fertility drugs;experimental drugs; blood glucose test strips; urine ketonetest strips; interdialytic parenteral nutrition; DESI drugs;prescriptions and injections for central nervous system;food supplements or infant formulas; products for whichFederal Financial Participation is not allowed, i.e., "lessthan effective" drugs and products whose manufacturershave not signed rebate agreements; and (e) certain otheritems as specified in the state's Medicaid plan.

Over-the-Counter Product Coverage: Products covered:contraceptives; oral ferrous sulfide; and aspirin forarthritis. Products not covered: allergy, asthma and sinusproducts; analgesics; cough and cold preparations;digestive products (H2 and non-H2 antagonists); feminineproducts; topical products; and smoking deterrentproducts.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; analgesics, antipyretics,NSAIDs; antibiotics; anticoagulants; anticonvulsants;antidepressants; antidiabetic agents; antihistamine drugs;antilipemic agents; anti-psychotics; anxiolytics, sedatives,and hypnotics; cardiac drugs; chemotherapy agents;prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc.GI drugs; prescribed smoking deterrents;sympathominetics (adrenergic); and thyroid agents. Priorauthorization required for: growth hormones. Therapeuticcategories not covered: anorectics.

Coverage of Injectables: Injectable medicinesreimbursable through the Prescription Drug Programwhen used in home health care, extended care facilities,and through physician payment when used in physicianoffices.

Vaccines: Vaccines reimbursable as part of the EPSDTservice.

Unit Dose: Unit dose packaging reimbursable for nursinghome patients only for commercially available products.



Prior Authorization: State currently as a PriorAuthorization procedure. A general appeals procedure isrequired for appeal of prior authorization decisions.

Prior authorization required from the HealthChoice andAcute Care Administration when the usual and customarycharge exceeds $100 and the prescribed amount is a 34-day supply or more. Preauthorization is needed for anyprescription with a usual and customary charge exceeding$400. Prior authorization is also needed for early refills,nutritional supplements, and excessive quantities.


Prescription Refill Limit: Maximum of two refills. Theoriginal prescription and its refills may not exceed a 100-day supply except for birth control pills and oral sodiumfluoride preparations. Refills may not be dispensed after100 days of date of original prescription except for birthcontrol pills and oral sodium fluoride preparations

Monthly Quantity Limit: The amount of medication to bedispensed on a prescription at one time is limited to a lessthan 34-day supply except for specific maintenance drugsfor chronic conditions, where up to a 100-day supply maybe dispensed at one time.


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


Dispensing Fee: $4.21 as of July 1, 1996.

Ingredient Reimbursement Basis: Estimated AcquisitionCost (EAC) equals/lowest of:

1. Wholesale Acquisition Cost (WAC) plus 10%.2. Direct cost plus 10%.3. Distributor's price plus 10%.4. Average Wholesale Price (AWP) minus 10%.

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

Maximum Allowable Cost: State imposes Federal UpperLimits as well as state-specific limits on generic drugs. Approximately 1,000 drugs are listed on the state-specificMAC list. Override requires “Brand MedicallyNecessary” and a reason.




Patient Cost Sharing: Copayment = $1.00. Does notapply to managed care, family planning, nursing homeresidents or recipients under 21 years old.



Approximately 375,000 total unduplicated number ofMedicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits through thestate and managed care plans.


Chesapeake FamilyFirst 68,7856300 Security BoulevardBaltimore, MD 21207

FreeState Health Plan 97,363Blue Cross Blue Shield10455 Mill Run CircleOwings Mills, MD 21117-5559

Helix Family Choice, Inc. 18,0392330 W. Joppa RoadSuite 301Lutherville, MD 21093

Jai Medical Systems, Inc. 4,8175010 York RoadBaltimore, MD 21212

Maryland Physicians Care MCO 28,9587106 Ambassador RoadSuite 100Baltimore, MD 21244

Prime Health Corporation 15,4059602-C M.L.K., Jr. HwyLanham, MD 20706

Priority Partners MCO 55,349The Candler Building111 Market PlaceBaltimore, MD 21202

Ameri Group 85,393857 Elkridge Landing Road, #300Linthicum, MD 21040

F. STATE CONTACTS


Mr. Frank TetkoskiPharmacy Services ManagerDivision of Pharmacy and Clinic Services201 West Preston StreetBaltimore, MD 21201T: 410/767-1455F: 410/333-7049E-mail: [email protected]


Tuong Nguyen, P.D.Pharmacist ConsultantDHMH-Office of Health ServicesDivision of Pharmacy and Clinical Services201 W. Preston St., Rm. 132Baltimore, MD 21201T: 410/787-1455F: 410/333-7049E-mail: [email protected]

DUR Contact

Judy Geisler, P.D.Pharmacist ConsultantDHMH-Office of Health ServicesDivision of Pharmacy and Clinical Services201 W. Preston StreetBaltimore, MD 212010T: 410/767-1728

DUR Board

Scott A. Spier, M.D., ChairMedical DirectorOutpatient Chemical Dependency UnitMercy Medical Center Professional Building301 St. Paul Place, Room 812Baltimore, MD 21202410/332-9230

Bonnie Rosiak, Pharm.D., Chair8809 Heron’s FlightLaurel, MD 20723

Barbara A. Bartman, M.D., M.P.H.3972 Ducks Foot LaneEllicott City, MD 21042410/955-1314


4-Maryland National Pharmaceutical Council

Krishna Chary, R.Ph.804 Bear Cabin DriveForest Hill, MD 21050800/380-9342

Babette S. Duncan, Pharm.D., BCPSSenior Director, Clinical ServicesAdvance Paradigm, Inc.11350 McCormick RoadSuite 1000, Executive Plaza IIHunt Valley, MD 21031410/785-2182

Michelle A. Forrest-Smith, Pharm.D.1822 Chatfield TerraceSevern, MD 21144410/748-6291

Myron Miller, M.D.8201 Spring Bottom WayBaltimore, MD 21208410/653-7952

Richard D. Moore, M.D.Johns Hopkins Hospital1830 E. Monument Street, 8th floorBaltimore, MD 21205410/955-2144

Jill RachBeisel, MDUniversity of Maryland Medical System22 South Greene StreetS12A03Baltimore, MD 21201


First DataBank1111 Bayhill Dr.San Bruno, CA 94066T: 415/588-5454F: 415/827-4578


Technical: Jeffrey Gruel, 410/767-1455Policy: Jeffrey Gruel, 410/767-1455P/A: Lynette Lane, 410/767-1728Audits: Kenneth Smoot, 410/767-5186Disputes: Katherine Novak, 410/582-9305


First Health DataBankDivision of Claims ProcessingCharlotte Krueger, Chief201 W. Preston St.Baltimore, MD 21201T: 410/767-5347F: 410/333-7186

Medicare Managed Care Contact

Rosalie KosloffChief, Division of Health Choice ManagementOffice of Health Services201 W. Preston St.Baltimore, MD 21201410/767-5690


Paul RoegerManager, Pharmacy Assistance ProgramMedical Care Operations and Eligibility201 W. Preston StBaltimore, MD 21201T: 410/767-5394F: 410/333-7290


Edward Watters, M.D.201 W. Preston StreetBaltimore, MD 21201410/767-1482

Health and Mental Hygiene Department Officials

Georges C. Benjamin, M.D.SecretaryDepartment of Health and Mental Hygiene201 W. Preston StreetBaltimore, MD 21201

Debbie I. ChangDeputy SecretaryHealth Care Financing201 W. Preston StreetBaltimore, MD 21201

Joseph M. MillstoneExecutive DirectorOffice of Health Services201 W. Preston StreetBaltimore, MD 21201



Shelby BoggsDirector of Healthcare and Acute CareOffice of Health Services201 W. Preston StreetBaltimore, MD 21201

Jeffrey GruelChiefDivision of Pharmacy and Clinic ServicesOffice of Health Services201 W. Preston StreetBaltimore, MD 21201410/767-1455

Joseph Fine, P.D.ChiefDivision of RecoveriesMedical Care Operations and Eligibility201 W. Preston StreetBaltimore, MD 21201410/767-5795

Paul RoegerProgram ManagerPharmacy Assistance ProgramPO Box 386Baltimore, MD 21203410/767-5392

Medical Assistance Staff Committee Members

Judy Geisler, P.D.Division of Pharmacy and Clinic Services201 W. Preston StreetBaltimore, MD 21201

Mr. Frank Tetkoski, P.D., Manager, Pharmacy ServicesDivision of Pharmacy and Clinic Services201 W. Preston Street, Room 129Baltimore, MD 21201

Tuong Nguyen, P.D.Division of Pharmacy and Clinic Services201 W. Preston St., Rm. 132Baltimore, MD 21201


Medical/Chirurgical Faculty of MarylandT. Michael PrestonExecutive Director1211 Cathedral StreetBaltimore, MD 21201410/539-0872

Maryland Pharmacists Association

Howard SchiffExecutive Director650 West Lombard StreetBaltimore, MD 21201-1572

State Board of PharmacyLaVerne G. NaeseaExecutive Director4201 Patterson AvenueBaltimore, MD 21215-2299410/764-4755

Maryland Osteopathic Association, Inc.Francisco E. Ward, D.O.Secretary/TreasurerP.O. Box 6314Annapolis, MD 21401800/664-4274

The Maryland Hospital Association, Inc.Calvin M. Pierson, President1301 York Road, Suite 800Lutherville, MD 21093-6087410/321-6200


1-Massachusetts National Pharmaceutical Council

MASSACHUSETTS




Prescribed Drugs





Physician Services









National Pharmaceutical Council Massachusetts-2

C. ADMINISTRATION

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


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations used for insulin; blood glucose test strips;urine ketone test strips; total parenteral nutrition; andinterdialytic parenteral nutrition. Products covered withrestrictions: Ritalin and amphetamines are limited totreatment of hyperkinesis for children under age 17,except by prior authorization; and ADD by priorauthorization (not covered for appetite control). Productsnot covered: cosmetics; fertility drugs; experimentaldrugs; DESI drugs; legend vitamins not on Drug List,non-legend drugs not on Drug List; propoxyphene-containing products and products rated by the FDA asless-than-effective.

Over-the-Counter Product Coverage: Products covered:allergy, asthma and sinus products; analgesics; digestiveproducts (non-H2 antagonist); and feminine products.Products covered with restrictions: cough and coldpreparations (except in LTC facilities or PA); digestiveproducts (H2 antagonists) (90 days then PA required); andtopical products (acne preps require PA). Products notcovered: smoking deterrent products.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; analgesics, antipyretics,NSAIDs; antibiotics; anticoagulants; anticonvulsants;antidepressants; antidiabetic agents; antihistamine drugs;antilipemic agents; anti-psychotics; cardiac drugs;chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones;hypotensive agents; sympathominetics (adrenergic); andthyroid agents. Prior authorization required for:anorectics; anxiolytics, sedatives, and hypnotics;prescribed cold medications and misc. GI drugs.Therapeutic categories not covered: prescribed smokingdeterrents.


Vaccines: Vaccines reimbursable as part of the EPSDTservice if not provided by the Department of PublicHealth.

Unit Dose: Unit dose packaging reimbursable; however,will not pay extra for the packaging.



Prior Authorization: State currently has a priorauthorization procedure. A fair hearing process by therecipient on an individual basis is required for appealing aprior authorization decision.


Prescription Refill Limit: Prescription may be refilled, asauthorized, with a limit of up to 5 refills within 6 monthsfrom the filling of the original prescription.

Monthly Quantity Limit: Schedule II and III drugs arelimited to a 30-day supply, except Ritalin and Dexedrine,which may be dispensed up to a 60-day supply.



PRODUR system implemented in October 1995. Statecurrently has a DUR Board with a quarterly review.



Ingredient Reimbursement Basis: EAC = WAC + 10%.

Prescription Charge Formula: Payment shall be for thelowest of:

1. EAC plus dispensing fee;2. The usual and customary charge defined as the lowest

price charged or accepted by a provider for anypayor; or

3. FULP plus a dispensing fee.

Maximum Allowable Cost: State imposes Federal UpperLimits as well as state-specific limits on generic drugs. Override requires “Dispense as Written” and/or “BrandMedically Necessary.”

Patient Cost Sharing: Copayment = $0.50 with thefollowing exceptions:

− Institutionalized patients− Children under age 19− Pregnant and postpartum women− Hospice care− Family planning items


3-Massachusetts National Pharmaceutical Council




Approximately 500,000 total unduplicated number ofMedicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits throughmanaged care plans.

F. STATE CONTACTS


Gary Gilmore, R.Ph.Division of Medical Assistance600 Washington StreetBoston, MA 02111T: 617/210-5593F: 617/210-5597E-mail: [email protected] Internet Address: [email protected]


Anna Morin, Pharm.D.DVR Program DirectorUMASS Medical School11 Midstate HwyAuburn, MA 01501-1863T: 508/721-7104F: 508/721-7138E-mail: [email protected]

DUR Contact

Anna Morin, 508/721-7104

Medicaid DUR Board

Spencer Wilking, MD (Chairman)C. Michael Bliss, MDSarah Cheeseman, MDThomas Hewitt, MDAnne Marie McCloskey, R.Ph.Leo McKenna, R.Ph.Dave Morgan, R.Ph.Robert Portney, MDJames Scanlon, R.Ph.David Kosegarten, Ph.D.Gerry Longnecker, Pharm.D.


Christopher BurkePharmacy Program AnalystDept of Medical Assistance600 Washington StreetBoston, MA 02111T: 617/210-5592F: 617/210-5597E-mail: [email protected]


Technical: Paula McAree, R.Ph., 617/210-5594Policy: Paula McAree, R.Ph., 617/210-5594Audits: Policy: Paula McAree, R.Ph., 617/210-5594


Unisys CorpP.O. Box 9101Somerville, MA 02145617/576-4451


Pricilla PortisDirector, Primary and Specialty ServicesDivision of Medical Assistance600 Washington StreetBoston, MA 02111T: 617/210-5700F: 617/210-5597E-mail: [email protected]


Annette Hanson, MDMedical DirectorDivision of Medical Assistance600 Washington StreetBoston, MA 02111T: 617/210-5683F: 617/210-5597E-mail: [email protected]

Elderly Expanded Drug Coverage ProgramContact

Pricilla Portis, 617/210-5700

Executive Offices of Health and Human Services

William O’LearySecretaryExecutive Offices of Health and Human Services1 Ashburton PlaceBoston, MA 02108


National Pharmaceutical Council Massachusetts-4


Massachusetts Medical SocietyHarry L. Greene II, M.D.1440 Main StreetWaltham, MA 02154617/893-4610

Massachusetts PharmacistsLinda Barry617/736-0101

Massachusetts Osteopathic Society, Inc.Charles Radbill, D.O.Secretary100 Concord StreetFramingham, MA 01701508/872-8900

State Board of PharmacyLori BassingerExecutive Director100 Cambridge StreetRoom 1514Boston, MA 02202617/727-9953

Massachusetts Hospital AssociationRonald M. HollanderPresidentFive New England Executive ParkBurlington, MA 01803617/272-8000


1-Michigan National Pharmaceutical Council

MICHIGAN




Prescribed Drugs





Physician Services

Dental Services -----Limited for all eligibles-----1See Appendix E, page E-29, for a list of acronyms.


Expended Recipients Expended Recipients

TOTAL $374,145,567 589,818




OTHER



National Pharmaceutical Council Michigan-2

C. ADMINISTRATION

Michigan Department of Community Health, MedicalServices Administration.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations used for insulin; blood glucose test strips;and urine ketone test strips. Products covered withrestrictions: total parenteral nutrition (paid to medicalsuppliers) and interdialytic parenteral nutrition. Priorauthorization required for: brand name productsequivalent to MACs; Accutane & Retin-A; Dexedrine andAdderall; Persantine; Lactulose (Cephulac);Methylphenidate (selected ages); selectedbenzodiazepines; Epogen administered in the homesetting; dietary formulas; and drugs not listed on theformulary. Products not covered: cosmetics; fertilitydrugs; and experimental drugs.

Over-the-Counter Product Coverage: Products coveredwith restrictions (only selected products in each category):allergy, asthma and sinus products; analgesics; digestiveproducts (non-H2 and H2 antagonists); feminine products;topical products; and smoking deterrent products (patchesand gum). Products not covered: cough and coldpreparations.

Therapeutic Category Coverage: Therapeutic categoriescovered: analgesics, antipyretics, NSAIDs; antibiotics;anticoagulants; anticonvulsants; antidepressants;antidiabetic agents; antihistamine drugs; antilipemicagents; anti-psychotics; anxiolytics, sedatives, andhypnotics; cardiac drugs; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc.GI drugs; sympathominetics (adrenergic); and thyroidagents. Prior authorization required for: chemotherapyagents; growth hormones; and prescribed smokingdeterrents. Therapeutic categories not covered: anabolicsteroids; anorectics; and prescribed cold medications.


Vaccines: Vaccines reimbursable at cost plus a fee/orvaccine replacement as part of the EPSDT service and theChildren Health Insurance Program.




Prior Authorization: State currently has a formal priorauthorization procedure. In order to appeal priorauthorization decisions, a department appeals section inthe Medicaid program sets up hearings for beneficiaries.The beneficiary is sent a letter with instructions on theirappeal rights when appealing the coverage of an excludedproduct.


Prescription Refill Limit: Based on state law.

Monthly Quantity Limit: Prescribed quantities should belimited to an amount necessary to keep the recipientsupplied during the therapy regimen. In certain cases andconditions, more than a month’s supply will beappropriate. However, in no instance may more than 100days supply be dispensed per prescription.





Ingredient Reimbursement Basis: 1-4 stores = AWP-13.5%, 5 or more stores = AWP - 15.1%.

Prescription Charge Formula: Reimbursement for legenddrugs is limited to the lower of:

1. AWP - 13.5% for 1 to 4 stores & AWP - 15.1% for 5or more stores or LTC, plus dispensing fee minusselected $1.00 patient copay, or

2. The MAC rate, plus dispensing fee, or3. The provider’s usual and customary charge to the

general public.

Maximum Allowable Cost: State imposes Federal UpperLimits as well as state-specific limits on generic drugs. 800 drugs are listed on the state-specific MAC list. Override requires “Dispense as Written” and priorauthorization.




Patient Cost Sharing: Ambulatory recipients age 21 andolder are required to pay a $1.00 copayment for mostlegend drugs. If the recipient is unable to pay a requiredcopayment on the date of service, the pharmacy cannotrefuse to render the service. However, the pharmacy maybill the recipient for the copayment amount, and he/she isresponsible for paying it. If the recipient fails to pay acopayment, the pharmacy could, in the future, refuse toserve the recipient as a Medicaid recipient.

Drugs not requiring a co-payment include pregnancy-related and family planning products.

Recipients are not required to make a copayment if:

− They are under age 21, or− They reside in a long-term care facility (nursing

home, hospital long-term care facility, or medicalcare facility), or

− Health Maintenance Organization (HMO), or acapitated Clinic Plan.



Approximately 1,000,000 total unduplicated number ofMedicaid recipients were enrolled in MCOs in FY 1999.Recipients receive pharmaceutical benefits through thestate and managed care plans.


American Family Care2000 S. Woodward, Ste. 200Bloomfield Hills, MI 48302248/454-1070888/898-7969

Blue Care Network25925 Telegraph RoadSouthfield, MI 48086248/799-6674800/414-3457

Botsford Health Plan28050 Grand RiverFarmington Hills, MI 48336248/473-6190800/479-5122

Cape Health Plan17421 Telegraph, Suite 209Detroit, MI 48219888/354-2273

Care Choices HMO34605 Twelve Mile RoadFarmington Hills, MI 48331248/489-6000800/893-1113

Community Care Plan1925 Breton Road, SE, #204Grand Rapids, MI 49516616/252-4792800/807-5244

Community Choice Michigan2369 Woodlake DriveOkemos, MI 48864800/390-7102

DMC Clinic PlanCentrum Bldg., 7th Floor20901 Northwestern Hwy.Southfield, MI 48075

Family Health Plan of Michigan2200 Jefferson AvenueToledo, OH 43624800/231-8274734/457-5370 (Monroe Office)

Good Health Michigan2000 S. Woodward, Ste. 200Bloomfield Hills, MI 48302248/454-1070888/898-7969

Great Lakes Health Plan, Inc.17117 W. Nine Mile, Ste. 1600Southfield, MI 48075248/559-5656800/903-5253

Health Alliance Plan2850 W. Grand Blvd.Detroit, MI 48202313/664-8360800-801-1769

Health Plan of Michigan17515 W. Nine Mile, Ste. 650Southfield, MI 48075248/569-8640888/437-0606



Health Plus of Michigan2050 S. Linden RoadP.O. Box 1700Flint, MI 48501-1700810/230-2222800/322-9161

M-Care2301 Commonwealth Blvd.Ann Arbor, MI 48105-1573800/527-5549

McLaren Health Plan401 W. GreenlawnLansing, MI 48910517/346-4834888/327-0671

Midwest Health Plan5050 Schaefer RoadDearborn, MI 48126313/581-3700888/654-2200

North Med109 E. Front, Ste. 204Traverse City, MI 49684616/935-0550877/935-0599

Oakwood St. John Health Plan19853 W. Outer Drive, Ste. 301Dearborn, MI 48124313/791-5229888/493-4300

OmniCare Health Plan1155 Brewery Park Blvd.Suite 250Detroit, MI 48207313/259-4000800/955-4578

PHP of Mid-Michigan, Inc.P.O. Box 30377-7877Lansing, MI 48909-7877517/347-9425800/661-8299

PHP of South Michigan, Inc.209 E. Washington Ave., Ste. 315EP.O. Box 4055Jackson, MI 49204

PHP of Southwest Michigan, Inc.106 Farmers Alley, Ste. 400Kalamazoo, MI 49007

PHP of West Michigan, Inc.250 Morris Ave., Ste 5500Muskegon, MI 49440-1143

Priority Health1231 E. Beltline, NEGrand Rapids, MI 49525-4501616/942-0954888/975-8102

Pro-Care Health Plan3956 Mount ElliotDetroit, MI 48207313/925-4607888/861-0061

SelectCare HMO2401 W. Big Beaver RoadSuite 700Troy, MI 48084248/637-6777800/332-2365

Total Health Care3011 W. Grand Blvd., Ste. 1600Detroit, MI 48202313/871-2000800/826-2862

Ultimed HMO of Michigan2401 20th StreetDetroit, MI 48216313/961-1717800/242-7955

Upper Peninsula104 Coles Drive, Suite EMarquette, MI 49855906/225-7500888/904-7526

The Wellness Plan2875 W. Grand Blvd.Detroit, MI 48202313/875-4200800/875-9355



F. STATE CONTACTS


James Kenyon, R.Ph.Pharmacist ConsultantMDCH/Medical Services Administration400 South Pine StreetLansing, MI 48933T: 517/335-5265F: 517/335-5294E-mail: [email protected] Internet Address: www.michigan.fhsc.com

www.mdch.state.mi.us


James Kenyon, 517/335-5265

DUR Contact

Mary Sandusky, R.Ph.Pharmacist ConsultantMDCH- Medical Services Administration400 S. Pine St.Lansing, MI 48933T: 517/335-5280F: 517/241-7813E-mail: [email protected]

Medicaid DUR Board

Richard Henderson, M.D.34650 Versailles CourtFarmington Hills, MI 48331810/474-1397

Frank Check, M.D.St. Joseph Mercy Hospital900 Woodward AvenuePontiac, MI 48341313/858-3233

Duane Kirking, Ph.D.College of PharmacyUniversity of MichiganAnn Arbor, MI 48109-1065313/764-4483313/764-7312

William Overkamp2929 Walker, N.W.Grand Rapids, MI 49544

Karen Jonas, R.Ph.13121 Willow Grove RoadDewitt, MI 48820517/315-1243

James Kenyon, R.Ph.Michigan Department of Community HealthMedical Services AdministrationP.O. Box 30479Lansing, MI 48909

Otto Graesser, DO1421 W. Mt. HopeLansing, MI 48910


First DataBank1111 Bayhill DriveSan Bruno, CA 94066415/588-5454


Technical: Randy Rothfuss, 517/335-5040Audits: James Kenyon, 517/335-5265PA: Barbara Jones, 517/335-5061


First Health Services Corp4300 Cox Rd.Glen Allen, VA 23060


Rick Murdock, DirectorComprehensive Health Plan DivisionMDCH- Medical Services Administration400 S. Pine StreetLansing, MI 48933T: 517/241-7933F: 517/241-8231


Mary Sandusky, 517/335-5280

Elderly Expanded Drug Coverage Contact

Jean FriendMDCH- Aging, Community Services Division517/373-4064E-mail: [email protected]




Linda McCardelMedical Services AdministrationP.O. Box 30479Lansing, MI 48909517/335-5115

Michigan Dept. of Community Health (MDCH)

James HavemanDirectorMichigan Department of Community Health517/373-7720

Robert SmedesDeputy DirectorMedical Services AdministrationP. O. Box 30479Lansing, MI 48909

Formulary Review Committee

James Kenyon, R.Ph.Giovannino Perri, M.D.Debera Eggleston, M.D.Max Robins, D.O.Lawerence Nagel, D.D.S.Chris FarrellRobert Pheteplace, P.Ph. (Alternate)

Addresses for all members:Medical Services AdministrationMichigan Department of Community Health400 S. Pine StreetLansing, MI 48933


Michigan State Medical SocietyWilliam E. Madigan, Executive Director120 West SaginawEast Lansing, MI 48826-0950517/337-1351

Michigan Pharmacists AssociationLarry D. Wagenknecht, Executive Director815 N. Washington AvenueLansing, MI 48906517/484-1466

Michigan Association of Osteopathic Physicians &Surgeons, Inc.William Stevenson, Executive Director2445 Woodlake CircleOklemos, MI 48364517/347-1555 or 800/657-1556 (within Michigan)

State Board of PharmacyCarol JohnsonLicensing Administrator611 W. Ottawa, P.O. Box 30018Lansing, MI 48909517/373-0620

Michigan Health and Hospital AssociationSpencer C. JohnsonPresident6215 West St. Joseph HighwayLansing, MI 48917517/323-3443


1-Minnesota National Pharmaceutical Council

MINNESOTA




Prescribed Drugs





Physician Services




RECEIVING CASH ASSISTANCE, TOTAL $98,522,787 95,678Aged $7,783,421 7,013Blind / Disabled $83,068,585 45,306AFDC-Child $2,941,090 23,913AFDC-Adult $4,128,630 15,857AFDC-Unemployed-Child $173,682 2,006AFDC-Unemployed-Adult $386,451 1,487Other $40,928 96

MEDICALLY NEEDY, TOTAL $18,229,273 10,906Aged $6,333,476 5,072Blind / Disabled $11,739,504 5,030AFDC-Child $98,025 477AFDC-Adult $32,350 286Other $25,918 41

POVERTY RELATED, TOTAL $787,642 2,390Aged $184,259 414Blind / Disabled $377,806 360AFDC-Child $175,561 1,509AFDC-Adult $7,788 54Other $42,228 53

OTHER $56,062,790 94,246



National Pharmaceutical Council Minnesota-2

C. ADMINISTRATION

Minnesota Department of Human Services, Health CareManagement Division, Medical Assistance Program.


Benefit Design

Drug Benefit Product Coverage: Products covered:cosmetics; fertility drugs; and experimental drugs.Products covered with restriction: interdialytic parenteralnutrition. Prior Authorization required for: Desmopressin;Epoetin Alpha; Filgrastim; Interferon Alfa; InterferonGamma-IB; Ondansetron; Granisetron; and SargramostimProducts not covered: prescribed insulin; disposableneedles and syringe combinations used for insulin; bloodglucose test strips; urine ketone test strips; and totalparenteral nutrition.

Over-the-Counter Product Coverage: Products covered ifprescribed by a physician: digestive products (H2antagonists). Products covered with restrictions: allergy,asthma and sinus products; analgesics; cough and coldpreparations; digestive products (non-H2 antagonist);feminine products (antifungals covered); topical products;and smoking deterrent products (within deterrentprogram).

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; analgesics, antipyretics,NSAIDs; antibiotics; anticoagulants; anticonvulsants;antidepressants; antidiabetic agents; antihistamine drugs;antilipemic agents; anti-psychotics; anxiolytics, sedatives,and hypnotics; cardiac drugs; chemotherapy agents;contraceptives; ENT anti-inflammatory agents; estrogens;growth hormones; hypotensive agents; prescribedsmoking deterrents; sympathominetics (adrenergic); andthyroid agents. Prior authorization required for: misc. GIdrugs (proton pump inhibitor). Therapeutic categories notcovered: anorectics and tretinoin products (covered onlyfor acne).


Vaccines: Vaccines reimbursable when billed as part ofthe EPSDT service, the Children’s Health InsuranceProgram, and the Vaccines for Children Program.


Formulary/ Prior Authorization

Formulary: Open formulary with general exclusions.

Prior Authorization: State currently has a priorauthorization procedure and a Drug FormularyCommittee. Recipient has the right to appeal Priorauthorization decisions and coverage of an excludedproduct by appeals referee followed by an appeal in court.


Monthly Quantity Limit: 3 month supply. Minimum 30-days for maintenance drugs. Contraceptives may be filledto provide a 3-month supply.


PRODUR system implemented in February 1996. Statecurrently has a DUR Board with a quarterly review.




Prescription Charge Formula: Reimbursement is basedon the lesser of submitted AWP minus 9% plus adispensing fee, MAC plus a dispensing fee, or usual andcustomary.

Maximum Allowable Cost: State imposes Federal UpperLimits on generic drugs. Override requires “brandmedically necessary.”







Itasca Medical CareKaren Campbell123 1st Avenue SEGrand Rapids, MN 55744



Blue Plus/Blue Shield of MN Public ProgramsCynthia MacDonald, Director1200 Yankee Doodle Road, W4-43Eagan, MN 55121-2202

First Plan of Minnesota1601 London RoadDuluth, MN 55812

HealthPartners Government Programs8100 34th Avenue SouthP.O. Box 1309Minneapolis, MN 55414-1309

MedicaP.O. Box 9310Mail Route 80280Minneapolis, MN 55440-9310

Metropolitan Health PlanMail Code 611822 South 3rd Street, Suite 140Minneapolis, MN 55415

UCare Minnesota2550 University Avenue, WestSuite 330NSt. Paul, MN 55114

Altru Health Plan Minnesota3065 Demers AvenueGrand Forks, ND 58201-4018

F. STATE CONTACTS


Cody Wiberg, Pharm.D., R.Ph.Acting Pharmacy Program ManagerMinnesota Department of Human Services444 Lafayette RoadSt. Paul, MN 55155-3853T: 651/296-8515F: 651/282-6744E-mail: [email protected] E-mail Address: www.dhs.state.mn.us


Cody Wiberg, 651/296-8515

DUR Contact

Mary Beth Reinke, Pharm.D., R.Ph.DUR Coordinator444 Lafayette RoadSt. Paul, MN 55155-3853T: 651/215-1239F: 651/282-6744E-mail: [email protected]

Medicaid DUR Board

PhysiciansC. Dwight Townes, M.D.16 Meadow Lane, SouthMinneapolis, MN 55416612/377-8469

William P. Korchik, M.D.Veterans Affairs Medical CenterOne Veteran Drive (11L)Minneapolis, MN 55417612/725-2035

Michael F. Koch, M.D.Director, Child PsychiatryHennepin County Medical Center701 Park Avenue SouthMinneapolis, MN 55402612/347-2617

Health Care ProfessionalMarilyn M. Ulseth, MS, RN, CNP2909-33rd Ave SouthMinneapolis, MN 55406

PharmacistsLynne M. Schneider, R.Ph.12910 37th Avenue NorthPlymouth, MN 55441612/571-2220

Ron Johnson, R.Ph.Lloyd’s Pharmacy720 North SnellingSt. Paul, MN 55104651/645-8636

Micheal J. Barrett, PD-FASCPDirector of PharmacyLong Praire Memorial Hospital & Home20 Southeast Ninth StreetLong Prarie, MN 56347-1404


National Pharmaceutical Council Minnesota-4

Wendy L. St. Peter, Pharm.D.Hennepin County Medical CenterNephrology Analytical ServicesUSRDS Coordinating Center914 Eighth Avenue SouthMinneapolis, MN 55404

Consumers RepresentativeVacant

DHS StaffCody Wiberg, Pharm.D., R.Ph.Acting Pharmacy Program ManagerMinnesota Department of Human Services444 Lafayette Road, NorthSt. Paul, MN 55155-3853651/296-8515

Prescription Drug Updating

First DataBank


Audits: Jarvis Jackson, 651/282-5881Policy: Cody Wiberg, 651/296-8515



Elderly Expanded Drug Coverage ProgramContact



Chris ReisdorfDepartment of Human Services444 Lafayette RoadSt. Paul, MN 55155612/296-8822


Michael O’KeefeCommissionerDepartment of Human Services444 Lafayette RoadSt. Paul, MN 55155-3815651/296-2701

Mary KennedyMedicaid Director651/282-9921

Chris ReisdorfSupervisorPrimary Care Benefits Policy651/296-8822

Drug Formulary Committee

Al Heaton, Pharm.D., R.Ph.Senior DirectorPrime Therapeutics1020 Discovery Road No. 100Eagan, MN 55164

Charlene NusmanConsumer Representative2534 Lynn Avenue So.St. Louis Park, MN 55416

William P. Korchik, M.D.Veterans Affairs Medical CenterOne Veteran Drive (11L)Minneapolis, MN 55417612/725-2035

Jack Alexander, M.D.Fairview Red Wing Clinic2835 South Service ClinicRed Wing, MN 55066


Minnesota Medical AssociationJohn Van Etta, M.D., President3433 Broadway Street NE, Suite 300Minneapolis, MN 55413-1760612/378-1875

Minnesota Pharmacists AssociationKeith PearsonInterim Executive Director2550 University Avenue, WestMinneapolis, MN 55114612/644-3566

Minnesota Osteopathic Medical SocietyDrenda G. Wendell, D.O.Executive Director2912 80th Circle NorthBrooklyn Park, MN 55444-1644612/560-3346

State Board of PharmacyDavid HolmstromExecutive Director2829 University Avenue SE #530Minneapolis, MN 55414-3251612/617-2201



Minnesota Hospital and Healthcare PartnershipBruce RuebenPresident2550 University Avenue, WestSuite 350SSt. Paul, MN 55114651/641-1121


National Pharmaceutical Council Mississippi-1

MISSISSIPPI




Prescribed Drugs





Physician Services




CATEGORICALLY NEEDY CASH TOTAL $3,659,580 178,594Aged $774,913 26,072Blind $32,397 1,239Disabled $2,505,079 102,843Children-Families w/Dep. Children $8,373 988Adults-Families w/Dep. Children $338,818 47,452

CATEGORICALLY NEEDY NON-CASH TOTAL $862,937 143,942Aged $0 0Blind $0 0Disabled $0 0Children-Families w/Dep. Children $562,150 96,592Adults-Families w/Dep. Children $300,787 47,350Other Title XIX Recipients $0 0

MEDICALLY NEEDY TOTAL $0 0Aged $0 0Blind $0 0Disabled $0 0Children-Families w/Dep. Children $0 0Adults-Families w/Dep. Children $0 0Other Title XIX Recipients $0 0



2-Mississippi National Pharmaceutical Council

C. ADMINISTRATION

Division of Medicaid, Office of the Governor.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin, syringe combinations used for insulin;total parenteral nutrition; and interdialytic parenteralinsulin. Products not covered: cosmetics; fertility drugs;experimental drugs; disposable needles used for insulin;blood glucose test strips; and urine ketone test strips. Prior authorization required for: Sandimmune; Viagra;enteral feeding products; Clozaril (must be prescribed byBoard Certified or Board Eligible Psychiatrist);*Protropin and Humatrope;* all Antihemophilic Factorsincluding VIII and IX;* and all Home IV Drug Therapies.

* These products are covered only for children ages 0-21years through the Early and Periodic Screening, Diagnosisand Treatment Program (EPSDT).

Over-the-Counter Product Coverage: Products covered:ASA, generic Tylenol; generic Robitussin, Benadryl; ironsupplements; and calcium supplements. Products notcovered: allergy, asthma, and sinus products; digestiveproducts; feminine products; topical products; andsmoking deterrent products.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; anorectics; antibiotics;anticoagulants; anticonvulsants; antidepressants;antidiabetic agents; antihistamine drugs; antilipemicagents; anti-psychotics; anxiolytics, sedatives, andhypnotics; cardiac drugs; chemotherapy agents;contraceptives; ENT anti-inflammatory agents; estrogens;hypotensive agents; misc. GI drugs; sympathominetics(adrenergic); and thyroid agents. Prior authorizationrequired for: analgesics, antipyretics, NSAIDS; andgrowth hormones. Therapeutic categories not covered:prescribed cold medications and prescribed smokingdeterrents.


Vaccines: Vaccines reimbursable as part of the EPSDTprogram.



Formulary: Open formulary, however, general exclusionsinclude:

1. Drugs used for anorexia or weight gain.2. Drugs when used for the symptomatic relief of cough

and colds (except quaifenesin syrup 100 mg/5 ml,iodinated glycerol tablets 30 mg, which are covered).

3. Prescription vitamins and mineral products (exceptprenatal vitamins and fluoride preparations, which arecovered).

4. Covered outpatient drugs for which the manufacturerrequires (as a condition of sale) that associated testsor monitoring services be purchased exclusively fromthe manufacturer or its designee.

5. Barbiturates (except amobarbital, butabarbital,mephobarbital, pentobarbital, phenobarbital,secobarbital, which are covered).

6. Benzodiazepines (except Klonopin, Lorazapam,Diazepam and Temazepam which are covered).

7. DESI drugs (those drugs that are designated less thaneffective by the FDA).

Prior Authorization: Administrative hearing require toappeal prior authorization decisions.


Prescription Refill Limit: Limited to five (5).

Monthly Quantities Limit: 34-day supply or 100 units ordoses, whichever is greater. Birth control pills may besupplied in 3-month quantities.

Monthly Prescription Limit: Total prescriptions dispensedper month per recipient are limited to 5. With priorauthorization recipients may get up to 10.


PRODUR system implemented in 1993. No state DURBoard exists.



Ingredient Reimbursement Basis: EAC = AWP - 10%,effective July 1, 1990.

Prescription Charge Formula: Reimbursement for legenddrugs will be at the lessor of AWP-10% plus a dispensingfee or usual and customary charge. OTC drugs will bepaid at lessor of AWP plus a dispensing fee, AWP + 50%,or shelf price. OTC drugs are to be billed on pharmacyinvoice at shelf price.


National Pharmaceutical Council Mississippi-3



Patient Cost Sharing: Copayment $1.00.

Cognitive Services: Pays for Disease ManagementServices for arthritis, diabetes, hyperlipidemia, asthma,and coagulatory disorders (effective 8/1/98). Pays $20 foraverage 30-minute encounter.


No Medicaid recipients receive health benefits throughMCOs.

F. STATE CONTACTS


James G. (Jack) Lee, R.Ph.Division of Medicaid, Office of the Governor239 North Lamar St., Ste.. 801Jackson, MS 39201-1399T: 601/359-6296F: 601/359-4185E-mail: [email protected]://www.dom.state.ms.us

Division of Medicaid Official

Rica Lewis-PaytonDirector, Division of MedicaidSuite 801, Robert E. Lee Building239 North Lamar Street

DUR Contact

Jack Lee, R.Ph.T: 601/359-6296

Medicaid DUR Board

R. Terry Jackson, M.D.University of MS2500 North State St.Jackson, MS 39216

Robert Forbes, M.D.University of MS2500 North State St.Jackson, MS 39216

Robert McMurry, M.D.University of MS Medical CenterL525 Clinical Sciences Bldg.2500 North State St.Jackson, MS 39216601/362-4471 ext.1865

Cindy Nobel, Pharm.D.University of MSDepartment of Family Medicine2500 North State St.Jackson, MS 39216601/984-5425

Richard Ogletree, Pharm.D.University of MSDepartment of Pharmacy2500 North State St.Jackson, MS 39216601/984-2055

Jerry Perry, R.Ph.1700 Terry RoadJackson, MS 39204601/355-2438

Dennis Read, R.Ph.28 Wansley Rd.Laurel, MS 39440601/428-8839

Mike Vinson, Pharm.D.University of MSP.O. Box 1274University, MS 38677601/232-1052


Jack Lee, R.Ph.T: 601/359-6296


Technical: Terry Childress, 601/359-6050Rebate: Glenda Grant, 601/359-6050PA: Jack Lee, 601/359-6296


Terry ChildressDirector of Systems239 North Lamar StreetJackson, MS 39201T: 601/359-6050F: 601/359-6048E-mail: [email protected]


4-Mississippi National Pharmaceutical Council


Melzana FullerDirector of Provider and Beneficiary RelationsDivision of Medicaid, Office of the Governor239 North Lamar Street, Ste. 801Jackson, MS 39201T: 601/359-6063F: 601/359-4185E-mail: [email protected]


Patsy Crews, R.N.Director of Bureau of PolicyDivision of Medicaid239 N. Lamar StreetJackson, MS 39201601/359-5142


Mississippi State Medical AssociationCharles L. MathewsExecutive Director735 Riverside DriveJackson, MS 39202-6013601/354-5433

Mississippi Pharmacists AssociationBo Dalton, R.Ph.Executive Director341 Edgewood Terrace DriveJackson, MS 39206-6217601/981-0416

William L. Stevens, R.Ph.Executive DirectorP.O. Box 24507Jackson, MS 39225-4507601/354-6750

Mississippi Osteopathic Medical AssociationHenry B. Pace, Ph.D.Executive Director89 Jeff St.Oxford, MS 38655601/234-6551

Mississippi Hospital AssociationSam W. CameronPresident, CEO6425 Lakeover Rd.Jackson, MS 39213601/982-3251

Fiscal Intermediary

EDS111 Capitol St. Ste 390Jackson, MS 39201601/960-2800


National Pharmaceutical Council Missouri-1

MISSOURI




Prescribed Drugs





Physician Services

Dental Services 1See Appendix D, page D-29, for a list of acronyms.



RECEIVING CASH ASSISTANCE, TOTAL $48,782,537 64,528Aged $9,278,584 4,400Blind / Disabled $26,315,038 8,683AFDC-Child $5,053,612 32,774AFDC-Adult $8,135,303 18,671AFDC-Unemployed-Child $0 0AFDC-Unemployed-Adult $0 0



OTHER $312,696,271 188,916



2-Missouri National Pharmaceutical Council

C. ADMINISTRATION

Division of Medical Services of the State Department ofSocial Services.


Benefit Design

Drug Benefit Product Coverage: Categories or drugs thatare covered: prescribed insulin; disposable needles andsyringe combinations used for insulin; nonlegendophthalmic preparations; nonlegend acne preparations;nonlegend weight control preparations; hemorrhoidproducts; estazolam; halazepam; prazepam; andquazepam. Products covered through the DurableMedical Equipment Program: blood glucose test strips;urine ketone test strips; total parenteral nutrition; andinterdialytic parenteral nutrition. Prior authorizationrequired for: amphetamines; Isotretinoin; and RetinoicAcid.

Coverage of Injectables: Injectable medicinesreimbursable through the Prescription Drug Programwhen used in physician offices, home health care settings,and extended care facilities.

Vaccines: Vaccines reimbursable as part of EPSDTprogram, Children Health Insurance Program, andVaccines for Children Program.



Formulary: Open formulary with exclusions.

Prior Authorization: State currently has a priorauthorization procedure, and 7 committee members whomeet quarterly.


Prescription Refill Limit: Federal regulations must beobserved for all drugs on the formulary that are listed inBNDD Schedules 2, 3, 4, and 5. All other prescriptionsrefilled should be in accordance with the directions givenby the prescribing physician.

Monthly Quantity Limit: Physician encouraged toprescribe 34-day or 100 dose supply but may, at owndiscretion, prescribe up to a maximum 90-day supply.

Dose Limit: Prescriptions for the following must bedispensed for at least 200 units per prescriptions: Aspirin5 gr.; Aspirin buffered 5 gr.; Aspirin enteric-coated 5 gr.;Acetaminophen 5 gr. Prenatal vitamins must be dispensedin a quantity of at least 100.


PRODUR system implemented in 1993. State currentlyhas a DUR Board with a quarterly review.



Ingredient Reimbursement Rate: EAC = AWP - 10.43%.

Prescription Charge Formula:

1. Method of reimbursement payment is based onacquisition cost plus a dispensing fee of $4.09 perprescription filled. Acquisition may vary dependingwhether it is based on AWP and Federal or MissouriMAC.

2. Any drug that is not a federal or Missouri MAC drugwill be based on the AWP less 10.43%. The majorityof drugs listed are based on AWP. The method ofpricing will be taken from the NDC number.

Maximum Allowable Cost: State imposes Federal UpperLimits as well as state-specific limits on generic drugs. 32drugs are listed on the state-specific MAC list. Overriderequires prior authorization.


Patient Cost Sharing: Variable copayment:

Drug Ingredient Cost Copayment$0.00 to $10.00 $0.50

$10.01 to $25.00 $1.00$25.01 or more $2.00

Copayment retained by pharmacist.

Cognitive Services: Payment for cognitive services isunder consideration.




Approximately 270,000 Medicaid recipients are enrolledin managed care organizations. All receive pharmacyservices through managed care.


Healthcare USA100 South 4th Street, Suite 1100St. Louis, MO 63102314/444-7239Blue Advantage Plus Health PlanP.O. Box 4191302301 Main St.Kansas City, MO 64141816/395-3891

Mercy Health Plan1508 S. GrandSt. Louis, MO 63104314/214-8000

Care Partners Health PlanThe Clayton Center120 S. Central, 8th FloorSt. Louis, MO 63105314/505-5400

Community Care Plus Health Plan5615 Pershing Avenue, Suite 29St. Louis, MO 63112314/454-0055 ext. 234

HealthNet Health Plan2300 Main Street, Suite 700Kansas City, MO 64108816/221-8400

FirstGuard Health Plan3801 Blue ParkwayKansas City, MO 64130816/922-7250

Family Health Partners Health Plan215 W. Pershing Road, Suite 310P.O. Box 411806Kansas City, MO 64141816/855-1871

Missouri Care Health Plan2404 Forum Blvd.Columbia, MO 65203573/441-2100

F. STATE CONTACTS


Susan McCann, R.Ph.Pharmaceutical ConsultantDivision of Medical ServicesP.O. Box 6500Jefferson City, MO 65102-6500T: 573/751-6963F: 573/526-4650E-mail: [email protected]

Social Services Department Officials

Gary J. Stangler, DirectorDepartment of Social ServicesBroadway State Office BuildingP.O. Box 1527Jefferson City, MO 65102

Gregory Vadner, DirectorDivision of Medical Services615 Howerton Court, P.O. Box 6500Jefferson City, MO 65102


Allison Lauf, R.N.Nurse ConsultantDivision of Medical ServicesP.O. Box 6500Jefferson City, MO 65102573/751-3762

DUR Contact

Jayne ZimmerDUR CoordinatorDivision of Medical ServicesP.O. Box 6500Jefferson City, MO 65102573/751-6963

DUR Board

John W. Newcomer, M.D. (Chair)Assistant Professor of PsychiatryWashington University, School of MedicineCampus Box 8134660 S. EuclidSt. Louis, MO 63110

Ronald Graham, Pharm.D.Government Relations ManagerNovartis Corporation1311 Granite Creek DriveBlue Springs, MO 64015


4-Missouri National Pharmaceutical Council

Randall Huss, M.D.Rolla Family Practice910 W. 10th StreetRolla, MO 65401

Pamela C. Waggoner, MSN, R.N.539 Wyatt DriveSt. Peters, MO 63376

Joy S. Gronstedt, D.O.30580 Summers DriveSedalia, MO 65301

Joseph M. Yasso, D.O.3513 NW Primrose LaneLee’s Summit, MO 64064

Jacquelyn B. Dilworth, M.D.1101 Courtwood CircleBallwin, MO 63011

Karla Dwyer, R.Ph.901 Cherry LaneKirksville, MO 63501

Susan Abdel-Rahman, Pharm.D.Division of Clinical PharmacologyChildren’s Mercy Hospital2401 Gillham Road, Ste 0411Kansas City, MO 64108

Peggy Wanner-Barjenbrunch, M.D.Rt. 5, Box 82AMexico, MO 65265

Sandra Bollinger, R.Ph.112 E. TywappityBenton, MO 63736

Drug Prior Authorization Committee

Patrick J. Bryant, Pharm.D.Drug Information CenterSchool of PharmacyUniversity of Missouri - Kansas CityMG-200 Medical School Building2411 Holmes StreetKansas City, MO 64108-2792

M. Dale Terrell, M.D.Washington University School of MedicineDivision of Geriatric MedicineRoom M2381402 South Grand Blvd.St. Louis, MO 63104

Gene Forrester, R.Ph.2400 S. BlackthorneColumbia, MO 65201

Henry Petry, D.O.Laurie ClinicP.O. Box 1277Laurie, MO 65038

James E. Edwards, M.D.1000 Executive Pkwy, Suite 103St. Louis, MO 63141

Lorraine C. Brown, D.O.Rt. 2, Box 247CCamdenton, MO 65020

Conrad S. Balcer, D.O.1241 W. Stadium Blvd.Jefferson City, MO 65109


First DataBank1111 Bayhill Dr.San Bruno, CA 94066T: 650/588-5454


Technical: Julie Schulte, 573/751-7996Policy: Susan McCann, 573/751-6963Dispute Resolution: Lynn Hebenheimer, 573/751-2005Audits: Lynn Hebenheimer, 573/751-2005


Jim JudgeGTE Data Services905 Weathered Rock RoadJefferson City, MO 65101573/635-2434


Janice GentileRegional AdministratorDivision of Medical ServicesP.O. Box 6500Jefferson City, MO 65102573/526-4274


Pam JarrettDivision of Medical ServicesP.O. Box 6500Jefferson City, MO 65102-6500573/751-3277



Pharmacy Subcommittee Roster

Bill Fitzpatrick, R.Ph.Interlock Pharmacy Systems2292 Weldon ParkwaySt. Louis, MO 63146

Philip A. Bangert, R.Ph.Bangert Pharmacy, Ltd.13300 New Halls FerryFlorissant, MO 63033

Tom Beetem, R.Ph., Chairman1425 Eastview DriveHolts Summit, MO 65043

Robert D. Hurley, R.Ph.Walgreens440 N. Highway 67Florissant, MO 63031

Craig Leonard, R.Ph.Lee’s Summit Pharmacy615 W. 3rd StreetLee’s Summit, MO 64063


Missouri State Medical AssociationC. C. SwarensExecutive Secretary113 Madison Street, P.O. Box 1028Jefferson City, MO 65102573/636-5151

Missouri Pharmaceutical AssociationGeorge OestrichExecutive Director410 Madison StreetJefferson City, MO 65101-3189573/636-7522

Missouri Assoc. of Osteopathic Physicians/Surgeons, Inc.Bonnie BowlesExecutive Director1423 Randy Lane - P.O. Box 748Jefferson City, MO 65102573/634-3415

State Board of PharmacyKevin E. KinkadeExecutive DirectorP. O. Box 625Jefferson City, MO 65102573/751-0091

Missouri Hospital AssociationCharles L. BowmanPresident4712 Country Club DriveJefferson City, MO 65109-4544573/893-3700


1-Montana National Pharmaceutical Council

MONTANA




Prescribed Drugs





Physician Services







OTHER, TOTAL



National Pharmaceutical Council Montana-2

C. ADMINISTRATION

Department of Public Health and Human Services.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin. Products not covered: cosmetics;fertility drugs; experimental drugs; disposable needlesused for insulin, syringe combinations for insulin use;blood glucose test strips; urine ketone test strips; totalparenteral nutrition; and interdialytic parenteral nutrition. Prior authorization required for Dipyridamole; Carafate;Ambien; Sonata; Cilostazol; Pentoxifylline; Isoproterenol;Isoetherine; Viagra; Thalidomide; DMARDs; Mobic,Celebrex, and Vioxx; anti-obesity drugs; Duract; Stadol;Tretinoin; and Zoloft (50mg); migraine headache drugs;single-source non-steroidal anti-inflammatory drugs;growth hormones; smoking cessation; oral Ketorolac; H2-antagonists, proton pump inhibitors, single sourcebenzodiazepines; hair growth products; and fertilityagents.

Over-the-Counter Product Coverage: Products covered:analgesics (Aspirin only); digestive products; head licetreatment products (permethrin and pyrethrin combinationproducts); H-2 antagonists. Products not covered: allergy,asthma, and sinus products; cold and cough preparations;feminine products; topical products; and smokingdeterrent products.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; antibiotics; anticoagulants;anticonvulsants; antidepressants; antidiabetic agents;antihistamine drugs; antilipemic agents; anti-psychotics;cardiac drugs; chemotherapy agents; contraceptives; ENTanti-inflammatory agents; estrogens; hypotensive agents;sympathominetics (adrenergic); and thyroid agents. Priorauthorization required for: anorectics; anxiolytics,sedatives, and hypnotics; analgesics, antipyretics,NSAIDs; misc. GI drugs; growth hormones; andprescribed smoking deterrents.


Vaccines: Vaccines reimbursable as part of the EPSDTservice, the Children Health Insurance Program, and aspart of the Vaccines for Children Program.



Formulary: Open formulary. Drugs classified as less-than-effective (LTE) by the FDA are not covered. Drugswith no manufacturer rebate are not covered.

Prior Authorization: State has a formal prior authorizationprocedure. Prescriber letter documenting evidence for useof prescribed medication in treatment of disease isreviewed by DUR Board for appeal of excluded product. An appeal procedure through the Department possible forPA decisions.


Prescription Refill Limit: 25% grace period over a 3-month period is allowed.

Monthly Quantity Limit: 100 doses or 34-day supply,whichever is greater.


PRODUR system implemented in September 1994. StateDUR Board has 6 members and meets monthly.


Dispensing Fee: $2.00-4.20; effective 7/1/98. Additional$0.75 is added to prescriptions unit dosed by thepharmacy.

Ingredient Reimbursement Basis: EAC = AWP - 10%, ormanufacturer’s direct price, if available.

Prescription Charge Formula: The lower of EAC, theFederal MAC (plus a dispensing fee), or the providerusual and customary charge.

Maximum Allowable Cost: State imposes Federal UpperLimits on generic drugs. Override requires “BrandNecessary.”


Patient Cost Sharing: Copayment - $1.00 for all generic;$2.00 for all others; effective 5/1/94.



3-Montana National Pharmaceutical Council


HMO availability began November 1995, to FAIMrecipients. SSI and SSI-related clients were eligible toenroll October 1, 1997. HMO coverage ended June 30,2000.

F. STATE CONTACTS


Dorothy D. PoulsenPharmacy Program OfficerDepartment of Public Health and Human ServicesMedicaid Services BureauP.O. Box 2029511400 BroadwayHelena, MT 59624406/444-2738Fax 406/444-1861

Public Health and Human Services Officials

Laurie EkangerDirectorDepartment of Public Health and Human ServicesP.O. Box 2029511400 BroadwayHelena, MT 59624406/444-5622

Nancy Ellery, AdministratorHealth Policy and Services406/444-4141

Mary Dalton, Bureau ChiefMedicaid Services Bureau406/444-4144

Jeff Buska, SupervisorAcute Services Section406/444-4145

Mary Angela Collins, SupervisorManaged Care Section406/444-4146


Mark Eichler, R.Ph.DUR CoordinatorMountain Pacific Quality Health Foundation3404 Cooney DriveHelena, MT 59602T: 406/443-4020F: 406/443-4585E-mail: [email protected]

DUR Contact

Mark Eichler, R.Ph.406/443-4020

Montana DUR Board

Mark Eichler, R.Ph., FASCPDUR CoordinatorMountain Pacific Quality Health Foundation3404 Cooney DriveHelena, MT 59602406/443-4020

V. Lee Harrison, M.D.Richard Sargent, M.D.Nathan A. Munn, M.D.DeeDee Cress, Pharm.D.Marcella Barnhill, R.Ph.Ann Geidel, R.Ph.




Technical: Dan Forbes, 406/444-1794P & A: Betty DeVaney, 406/444-3457


Brett JakovacConsultec, Inc.34 N. Last Chance Gulch, Suite 200Helena, MT 59601T: 406/442-1837F: 406/442-4402E-mail: [email protected]


Mary Angela CollinsSupervisor, Managed Care SectionDept. of Public Health and Human ServicesMedicaid Services BureauP.O. Box 202951Helena, MT 59620-2951T: 406/444-4146F: 406/444-1861E-mail: [email protected]


National Pharmaceutical Council Montana-4


Dorothy PoulsenPharmacy Program OfficerDept. of Public Health and Human ServicesMedicaid Services BureauP.O. Box 202951Helena, MT 59620-2951T: 406/444-2738F: 406/444-1861E-mail: [email protected]


Randy BowsherP.O. Box 2029511400 BroadwayHelena, MT 59624406/444-3995


Montana Medical AssociationG. Brian ZinsExecutive Director2021 11th Avenue, Suite 1Helena, MT 59601-4890406/443-4000

Montana State Pharmaceutical AssociationJim SmithExecutive DirectorP. O. Box 4718Helena, MT 59604406/449-3843

State Board of PharmacyExecutive DirectorP.O. Box 200513Helena, MT 59620406/444-1698

Montana Osteopathic AssociationCathy Holmes, SecretaryMontana Building, Suite 401Lewistown, MT 59457406/538-7721

Montana Hospital AssociationJames F. AhrensPresident1720 Ninth AvenueHelena, MT 59601406/442-1911


1-Nebraska National Pharmaceutical Council

NEBRASKA




Prescribed Drugs





Physician Services









National Pharmaceutical Council Nebraska-2

C. ADMINISTRATION

State Department of Health and Human Services, Financeand Support, Medicaid Division.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin with prior approval on pre-filledsyringes. Products not covered: disposable needles andsyringe combinations for insulin; blood glucose test strips;urine ketone test strips; total parenteral nutrition;interdialytic parenteral nutrition; cosmetics; fertility drugs;and experimental drugs. Prior authorization required for:methadone; IV infusions; and protein replacementsupplements.

Over-the-Counter Product Coverage: Products covered:allergy, asthma, and sinus products; analgesics; topicalproducts; cough and cold preparations; digestive products(H2 antagonists); and feminine products. Products notcovered: smoking deterrent products.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; analgesics, antipyretics,NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamine drugs;antilipemic agents; anti-psychotics; anxiolytics, sedatives,and hypnotics; cardiac drugs; chemotherapy agents;prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc.GI drugs; sympathominetics (adrenergic); and thyroidagents. Prior authorization required for: growthhormones; sunscreens; Erythropoetin (e.g., Epogen,Procrit); modified versions of FUL or SMAC drugs;convenience packaged drugs (e.g., Refresh Ophthalmic0.3 ml and Novalin penfil insulin); drugs to prevent ortreat Respiratory Syncytial Virus Immune Globulin (e.g.,Palivizumab, RSV-IG); and drugs for sexual dysfunction(e.g., Sildenafil, Alprostadil). Therapeutic categories notcovered: anorectics and prescribed smoking deterrents.

Coverage of Injectables: Injectables reimbursable throughthe Pharmacy program when used medicine used in homehealth care, extended care facilities and through physicianpayment when used in physician offices.

Vaccines: Vaccines reimbursable by Medicaid forindividuals under 21 years of age through the Vaccines forChildren Program, the Children Health Insurance Programand as part of the EPSDT service.



Formulary: Open formulary. General exclusions include:

1. More than a three-month supply of birth controltablets;

2. Experimental drugs or non-FDA approved drugs;3. Drugs or items when the prescribed use is not for a

medically accepted indication;4. Liquors (any alcoholic beverages);5. DESI drugs and all identical, related, or similar

drugs;6. Personal care items (e.g. non-medical mouthwashes,

deodorants, talcum powders, bath powders, soaps,dentrifices, eye washes, and contact solutions);

7. Medical supplies and certain drugs for nursing facilityand intermediate care facility for the mentallyretarded (IDF/MR) patients;

8. Over-the-counter (OTC) drugs not listed on theDepartment’s Drug Name/License number Listingmicrofiche;

9. Baby foods or metabolic agents (Lofenalac, etc.,)normally supplied by the Nebraska Department ofHealth;

10. Drugs distributed or manufactured by certain drugmanufacturers or labelers that have not agreed toparticipate in the drug rebate program.

Drugs, items, or manufacturers that are identifiable asnon-covered are so designated on the NE-POP system,and on the Department’s Drug Name/License NumberListing microfiche.

Prior Authorization: The Department requires thatauthorization be granted prior to payment for certainproducts. Prior authorization can be verified through theNE-POP System, or by contacting the Department. (or itsdesignated contractor) if authorization is not verifiedthrough the NE-POP System.


Prescription Refill Limit: As authorized by the prescribingphysician. For controlled substances, maximum 5 refillsevery 6 months.

Monthly Quantity Limit: 90-day supply or 100 dosageunits, whichever is greater.


PRODUR system implemented in April 1995. Statecurrently has a DUR Board with a monthly review.




Dispensing Fee: $4.66. The Nebraska Department ofHealth and Human Services assigns a dispensing fee toeach individual pharmacy. The fee is calculated frominformation obtained through the Department’sPrescription Survey.

Ingredient Reimbursement Basis: EAC = AWP - 8.71%. Direct for some pharmaceutical companies.

Prescription Charge Formula: Lower of:

1. Product cost (EAC, SMAC, or FUL) plus adispensing fee, or

2. The usual and customary price to the general public.

Listed OTCs are reimbursed at the lower of:

1. Product cost (EAC, SMAC, or FUL) plus adispensing fee,

2. The usual and customary shelf price to the generalpublic, or

3. Product cost (EAC, SMAC, or FUL) plus a 50%mark-up.

Maximum Allowable Cost: State imposes Federal UpperLimits as well as state-specific limits on generic drugs. Approximately 450 drugs are listed on the state-specificMAC list. Override requires an MC-6 form signed by thephysician.


Patient Cost Sharing: Copayment = $1.00.

Cognitive Services: State provides additional payment forcognitive services, effective January 2000.


Approximately 122,006 unduplicated Medicaid recipientswere enrolled in managed care in 1999. None receivedpharmacy services through managed care.


Share AdvantageUnited HealthPlans of the Midlands2717 North 118th CircleOmaha, NE 68164

Wellness OptionExclusive Health Care, Inc.10250 Regency CircleSuite 250Omaha, NE 68114

Primary Care +

Blue Cross/Blue Shield of NebraskaP.O. Box 241739Omaha, NE 68124

Value Options Mental Health10330 Regency ParkwayOmaha, NE 68114

F. STATE OFFICIALS


Gary J. Cheloha R.Ph.Pharmaceutical ConsultantHealth and Human Services, Finance and SupportMedicaid Division, 5th Floor-NSOBP.O. Box 95026Lincoln, NE 68509T: 402/471-9379F: 402/471-9092E-mail: [email protected]

Health and Human Services Department Officials

Richard Raymond, M.D., Acting DirectorDepartment of Health and Human Services301 Centennial MallLincoln, NE 68509402/471-9105

Robert J. Seiffert, AdministratorMedicaid Division402/471-3121

Ms. Kris AzimiUtilization Review Consultant402/471-9365

Christine Wright, M.D., Medical DirectorMedicaid Division402/471-9136


John Franklin, Pharm.D., R.Ph.Clinical PharmacistHHSS-Medicaid DivisionP.O. Box 95026; NSOB 5th Fl.Lincoln, NE 68509-5026402/471-9301



DUR Contact

Allison Jorgensen, Pharm.D., R.Ph.DUR DirectorNebraska Pharmacists Association6221 South 58th; Ste ALincoln, NE 68516402/420-1500

Nebraska DUR Board

Pharmacist Members:Kevin Borcher, R.Ph.Janet Darnell, R.Ph.Patty Gollner, R.Ph.Duane Mines, R.Ph.John Guzallis, R.Ph.Kim Hamik, R.Ph.Shannon Nelson, R.Ph.Monty Scheele, R.Ph.Phillip Vuchetich, R.Ph.

Physician Members:Warren Bosley, MDKirk Muffly, MDThomas B. Murray, MDFred Ayers, MD




Technical: Arlene Ropers, 402/471-9159Policy: Gary Cheloha, R.Ph., 402/471-9379


Janice Jones, R.Ph.Clinical Pharmacy Manager4300 Cox RoadGlen Allen, VA 23060804/965-7517


David CyganManaged Care Program AdministratorHHSS-Finance & Support-Medicaid301 Centennial Mall SouthLincoln, ME 68509402/471-9050

Disease Management Initiative/Program Contact

Gay Jeffries, R.N., B.A.QI ManagerHHSS-Nebraska Medicaid301 Centennial Mall SouthLincoln, ME 68509402/471-9415


Lorelee Novak, R.N.Department of Health and Human Services301 Centennial Mall, 5th floor402/471-9368

Health and Human Services Department

Medical Care Advisory CommitteeMarlene BrondelLeague of Human Dignity1701 P StreetLincoln, NE 68508

Tim BrunerDirector of Fiscal ServicesLincoln General Hospital2300 South 16th StreetLincoln, NE 68502

Tom Dolan, R.Ph.Executive DirectorNebraska Pharmacists Association6221 South 58th Street, Suite ALincoln, NE 68502

Karen MillerHealth Insurance SpecialistRoom 227, Federal Building601 East 12th StreetKansas City, MO 64106

Edmund A. Schneider, O.D.Lincoln Vision Clinic810 North 48th StreetLincoln, NE 68504

Steven LorenzenDirector, Federal ProgramsBlue Cross/Blue Shield of NEMain P. O. Station Box 3248Omaha, NE 68180



John MilliganLegal Services of Southeast Nebraska825 Terminal BuildingLincoln, NE 68508

Joan Penrod, Ph.D.Department of Preventive and Social MedicineUNMCBox 984350, 600 S. 42nd StreetOmaha, NE 68198

Larry RenneckerNAHHS1640 L Street, Suite DLincoln, NE 68508

William SchellpepperExecutive SecretaryNebraska Medical AssociationFirst Bank Bldg., Suite 1512Lincoln, NE 68508

Pat SnyderExecutive DirectorNebraska Health Care Assoc.421 South 9th Street, Suite 137Lincoln, NE 68508

James Walker, D.D.S.1640 South 70th, Suite 200Lincoln, NE 68506

Medicaid Pharmacy Advisory Committee

Ken Kunce, R.Ph., Chairman1000 Reavis StreetFalls City, NE 68355

Will Davis, R.Ph.729 Walnut DriveWayne, NE 68787

David Brehm, R.Ph.1609 Custer StreetSt. Paul, NE 68873

Jacob Dering, R.Ph.P.O. Box 333Crete, NE 68333

Leroy Dinslage, R.Ph.Pac N’ Save1519 West Hwy 34Seward, NE 68434

John Franklin, R.Ph.4501 Elkridge RoadLincoln, NE 68516

Eric Hamik, R.Ph.19 Kings CourtKearney, NE 68845

Roger Kaczmarek, R.Ph.15763 Fountain Hills DriveOmaha, NE 68118

Duane Mines, R.Ph.202 North Main StreetHooper, NE 68031

Gordon Ockinga, R.Ph.1810 Stolley Park CircleGrand Island, NE 68803

Ran Varney, R.Ph.P.O. Box 70Broken Now, NE 68822

Michael Wendt, R.Ph.608 N 3rd StreetTecumseh, NE 68450

Beth Wilson, R.Ph.5601 South 72nd StreetLincoln, NE 68516


Nebraska Medical AssociationWilliam SchellpeperExecutive Secretary233 S. 13th Street, Suite 1512Lincoln, NE 68508-2091402/474-4472

Nebraska Pharmacists AssociationThomas R. Dolan, R.Ph.Executive Director6221 South 58th, Suite ALincoln, NE 68516402/420-1500

Nebraska Assn. of Osteopathic Physicians & SurgeonsArthur Weaver, D.O.SecretaryP.O. Box 24744W. Omaha StationOmaha, NE 68124402/333-2744

State Board of Pharmacy



C. Curt Barr, R.Ph.ChairmanP. O. Box 95007Lincoln, NE 68509402/471-2115

Nebraska Association of Hospitals and Health SystemsHarlan M. Heald, Ph.D.President1640 L St., Suite DLincoln, NE 68508-2509


1-Nevada National Pharmaceutical Council

NEVADA




Prescribed Drugs





Physician Services




CATEGORICALLY NEEDY CASH TOTAL $25,381,004 29,633Aged $5,265,564 5,071Blind $18,443,130 13,572Disabled $698,439 6,722Children-Families w/Dep. Children $913,482 3,898Adults-Families w/Dep. Children $0 0Other Title XIX Recipients $60,389 370

CATEGORICALLY NEEDY NON-CASH TOTALAged $156,978 710Blind $70,489 168Disabled $70,820 147Children-Families w/Dep. Children $11,385 272Adults-Families w/Dep. Children $4,284 123Other Title XIX Recipients $0 0

MEDICALLY NEEDY TOTAL $0 0Aged $0 0Blind $0 0Disabled $0 0Children-Families w/Dep. Children $0 0Adults-Families w/Dep. Children $0 0Other Title XIX Recipients $8,721,337 19,345



National Pharmaceutical Council Nevada-2

C. ADMINISTRATION

State Welfare Division of the Department of HumanResources.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin and total parenteral nutrition (priorpayment authorization). Products not covered: cosmetics;fertility drugs; experimental drugs; disposable needles andsyringe combinations for insulin; blood glucose test strips;and urine ketone test strips.

Over-the-Counter Product Coverage: Products coveredwith restrictions: digestive products (H2 antagonists);smoking deterrent products; allergy, asthma and sinusproducts; analgesics; cough and cold preparations; andtopical products. OTC Coverage: OTC drugs arereimbursed at EAC+$4.76 or the usual and customaryamount, whichever is less, and require prior paymentauthorization.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; antibiotics; anticoagulants;anticonvulsants; anti-depressants; antidiabetic agents;antihistamine drugs; antilipemic agents; anti-psychotics;anxiolytics, sedatives, and hypnotics; cardiac drugs;chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents;prescribed smoking deterrents; sympathominetics(adrenergic); and thyroid agents. Prior authorizationrequired for: analgesics, antipyretics, NSAIDs; growthhormones; and prescribed cold medication. Therapeuticcategories not covered: anorectics.

Coverage of Injectables: Injectable medicinesreimbursable through the Prescription Drug Programwhen used in home health care, extended care facilities, orthrough physician payment when used in physiciansoffices.

Vaccines: Vaccines reimbursable at cost plus anadministration fee ($3.83) as part of the EPSDT service.



Formulary: Open formulary. General exclusions include:

1. Agents used for cosmetic purposes or hair growth.2. Yohimbine (e.g., Yocon).3. Radiopaque agents (e.g., Telepaque, Hypaque,

Barium Sulfate).

4. Radiographic adjuncts (e.g., Perchloracap).5. Pharmaceuticals designed “ineffective,” or “less than

effective” (including identical, related, or similardrugs) by the FDA.

6. Non-rebated medications.

Prior Authorization: Prior authorization procedurescreening for individual drugs. Drugs requiring PAinclude:

1. Amphetamine (e.g., Dexedrine)2. Chorionic Gonadotropin (HCG)3. Dipyridamole (e.g., Persantine)4. Erythropoietin (e.g., Epogen, Procrit)5. Gonadotropin releasing hormone analog (e.g.,

Lupron, Zoladex)6. Growth hormone (e.g., Protropin, Nutropin)7. Interferon (all combinations manufactured by

recombinant DNA technology)8. Intravenous antibiotic therapy9. Methylphenidate (e.g., Ritalin)10. Non-legend pharmaceuticals11. Nutritional supplements or replacements12. Pemoline (e.g., Cylert)13. Pulmozyme14. Vitamins, vitamin/mineral combinations or

hematinics


Monthly Prescription Limit: Eligible Medicaid recipientsmay receive three outpatient prescriptions per month plusthose issued for EITHER prenatal OR family planningpurposes.

Monthly Quantity Limit: The maximum dispensablequantity is limited to a 34-day supply.


Plans to implement PRODUR system in February 2001.State currently has a DUR Board with a quarterly review.




Prescription Charge Formula: The lowest of (1) specificupper limit (SUL) plus a dispensing fee, (2) estimatedacquisition cost (EAC) plus a dispensing fee, or (3) thepharmacy's usual charge to the general public.


3-Nevada National Pharmaceutical Council






Approximately 38,614 Medicaid recipients are enrolled inMCOs; all receive pharmacy benefits through managedcare.


Health Plan of Nevada 9,894P.O. Box 15645Las Vegas, NV 89114

NevadaCare, Inc. 25,1641701 W. Charleston Blvd.Suite 420Las Vegas, NV 89102

United Healthcare 3,5561160 Town Center Drive, Suite 390Las Vegas, NV 89134

F. STATE CONTACTS


Laurie Squartsoff, R.Ph.Pharmaceutical ConsultantNevada Medicaid Office2527 N. Carson StreetCapitol ComplexCarson City, NV 89710T: 702/687-4869F: 702/687-8724E-mail: [email protected]

Human Resources Department Officials

Charlotte Crawford, DirectorDepartment of Human ResourcesState Capital Complex505 East King St. Room 600Carson City, NV 89710

Mary LoherryDeputy AdministratorNevada Medicaid Welfare Division2527 N. Carson StreetCarson City, NV 89710702/687-4378


Laurie Squartsoff, R.Ph.T: 702/687-4869

DUR Contact

Laurie Squartsoff, R.Ph.T: 702/687-4869

DUR Board

Joseph W. Johnson, M.D.110 E. Lake Mead Boulevard, #201Henderson, NV 89015702/565-8911

Steven W. Parker, M.D.75 Pringle Way, #603Reno, NV 89503702/329-0333

David England, R.Ph.University Medical Center Pharmacy1800 W. Charleston BoulevardLas Vegas, NV 89102702/383-2601

Lori Winchell, R.N.341 Pinnacle CourtHenderson, NV 89014702/895-3377




Technical: Phil Boord, 702/687-7029Policy: Laurie Squartsoff, 702/687-4869Rebate: Laurie Squartsoff, 702/687-4869


National Pharmaceutical Council Nevada-4


Anthem Blue Cross/Blue ShieldP.O. Box 12127Reno, NV 89510-2127775/448-4020


Hilary Jones, R.N.Medicaid Services Specialist III1100 E. Williams St., Ste 204Carson City, NV 89701775/687-4176


Laurie Squartsoff, R.Ph.Nevada Medicaid Office2527 North Carson StreetCarson City, NV 89710702/687-4869

Medical Care Advisory Group

Robert J. Burn77 Pringle WayReno, NV 89502

David England, Pharm.D.4430 N. CheiftainLas Vegas, NV 89129

Mary Guinan, M.D.Nevada State Health Officer505 East King Street, Room 201Carson City, NV 89701-4797

J. Gordon Kinard, D.D.S.4121 West Sahara AvenueLas Vegas, NV 89102

Jon Sasser650 TahoeReno, NV 89509

Mitchell Miller, M.D.762 14th StreetElko, NV 89801

Mike Rodolicco, Ed.D.1175 Harvard WayReno, NV 89520

Linda Gellinger1500 West Warm SpringsHenderson, NV 89014

James Boscacci3061 Conte DriveCarson City, NV 89701


Nevada State Medical AssociationLarry MatheisExecutive Director3660 Baker Lane, Suite 101Reno, NV 89509702/825-6788

Nevada Pharmaceutical AssociationMary Grear, R.Ph.Executive Director3006 S. Amryland Parkway, #400Las Vegas, NV 89109

Nevada Osteopathic Medical AssociationPatrick J. Boland, D.O.Secretary-Treasurer2950 E. Flamingo Road, Suite E-4Las Vegas, NV 89121702/731-0304

State Board of PharmacyKeith W. MacDonald, R.Ph.Executive Secretary1201 Terminal WaySuite 212Reno, NV 89502702/322-0691

Nevada Association of Hospitals and Health SystemsJeanette BelzPresident, CEO4600 Kietzke LaneSuite A-108Reno, NV 89502702/827-0184


1-New Hampshire National Pharmaceutical Council

NEW HAMPSHIRE




Prescribed Drugs





Physician Services




CATEGORICALLY NEEDY, RECEIVING ASSTAgedBlind/DisabledAFDC-ChildAFDC-AdultAFDC-Unemployed-ChildAFDC-Unemployed-Adult

MEDICALLY NEEDY, TOTALAgedBlind/DisabledAFDC-ChildAFDC-Adult

POVERTY RELATED, TOTALAgedBlindAFDC-ChildAFDC-Adult

OTHER, TOTAL



National Pharmaceutical Council New Hampshire-2

C. ADMINISTRATION

Office of Medical Services, Department of Health andHuman Services.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations for insulin; blood glucose test strips; urineketone test strips; total parenteral nutrition; andinterdialytic parenteral nutrition. Products not covered:cosmetics; fertility drugs; and experimental drugs.

Over-the-Counter Product Coverage: Products covered:allergy, asthma, and sinus products; analgesics; cough andcold preparations; digestive products (H2 antagonists),feminine products; smoking deterrents; and topicalproducts.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; analgesics, antipyretics,NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamine drugs;antilipemic agents; anti-psychotics; anxiolytics, sedatives,and hypnotics; cardiac drugs; chemotherapy agents;prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones;hypotensive agents; misc. GI drugs; sympathominetics(adrenergic); thyroid agents; and prescribed smokingdeterrents. Therapeutic categories not covered:anorectics.

Coverage of Injectables: Injectable medicinesreimbursable through the Prescription Drug Programwhen used in home health care, extended care facilitiesand though physician payment when used in physicianoffices.

Vaccines: Vaccines reimbursable as part of the EPSDT,CHIP, and VCP service. Childhood immunizationvaccine is provided to all children through the Division ofPublic Health Services. The Medicaid program does notreimburse providers for routine vaccines, although anadministration fee is allowed.

Unit Dose: Unit dose packaging reimbursable forresidents in long-term care facilities only.


Formulary: Open formulary. General exclusions includeanorectics, anorexiants (stimulants) except for treatmentof narcolepsy and hyperkinetic children, cosmetic agentsfor hair growth, experimental and fertility drugs.

Prior Authorization: No prior authorization procedure.


Monthly Quantity Limit: Limited to 30-day supply or 100-unit dosage, whichever is greater.





Dispensing Fee: AWP-12%+$2.50, effective 2/1/96.



1. Lower of usual and customary charge or AWP - 12%or HCFA Upper Limit plus a dispensing fee.

2. Maintenance medications are reimbursed by theabove formula once every 34 days per recipient perprovider: any refills of maintenance medicationswithin the 34-day period are reimbursed at cost only.



Patient Cost Sharing: Copayment - $0.50 to $1.00. Copayments apply to all recipients except nursing homepatients in SNF or ICF facilities; home and communitybased care waived recipients holding form 949; pregnantwomen; children under 18 years; and prescriptions forfamily planning drugs.



Approximately 5,000 Medicaid recipients are enrolled inMCOs. None receive pharmaceutical benefits throughmanaged care.


Anthem Blue Cross/Blue Shield of New HampshireMatthew Thornton Health Plan3000 Goffs Falls RoadManchester, NH 03103-6020

Tufts Associated Healthplans of New England333 Wyman StreetWaltham, MA 02254-9112


3-New Hampshire National Pharmaceutical Council

F. STATE CONTACTS


Lisè Farrand, R.Ph.Pharmaceutical Services SpecialistMedicaid Administration Bureau6 Hazen DriveConcord, NH 03301-6521T: 603/271-4419F: 603/271-4376E-mail: [email protected]

Department of Health and Human ServicesOfficials

Carol EarlyDirectorMedicaid Administration BureauOffice of Health Management6 Hazen DriveConcord, NH 03301-6521T: 603/271-8887

Donald ShumwayCommissionerDepartment of Health and Human Services

DUR Contact

Lisè Farrand, R.Ph.T: 603/271-4419

Medicaid DUR Board

James P. Pilliod, M.D.Elaine M. Silverman, M.D.Steve Lawrence, M.D.Paul S. Collins, M.D.Mark Henschke, D.O.John Zinka, R.Ph.Elizabeth Gower, R.Ph.Helen Pervanas, R.Ph.Jody Goodrich, A.R.N.P.Michael Smith, R.Ph.


First DataBank


Technical: Julie Simpson, 603/224-1747 ext. 3016Audits: Julie Simpson, 603/224-1747 ext. 3016


Gary PatanaudeEDS Federal Corp.7 Eagle Sq.Concord, NH 03301T: 603/224-1747


Brenda LovelyProgram SpecialistNH DHHS, Medicaid Administration Bureau6 Hazen DriveConcord, NH 03301T: 603/271-4350F: 603/271-4376E-mail: [email protected]


Colin McHughAdministrator IISpecial Medical Services6 Hazen DriveConcord, NH 03301T: 603/271-0546


Vacant

Executive Officers of State Medical andPharmaceutical Services

New Hampshire Medical SocietyPalmer P. JonesExecutive Vice President7 N. State StreetConcord, NH 03301-6389603/224-1909

New Hampshire Pharmaceutical Association2 Eagle SquareConcord, NH 03301-4956603/753-8758

New Hampshire Osteopathic Association, Inc.Barry Gendron, D.O.Vice PresidentP.O. Box 1624Derry, NH 03038603/625-1254


National Pharmaceutical Council New Hampshire-4

State Board of PharmacyPaul G. BoisseauExecutive Secretary57 Regional DriveConcord, NH 03301-8518603/271-2350

New Hampshire Hospital AssociationMichael J. HillPresident125 Airport RoadConcord, NH 03301-7300603/225-0900


1-New Jersey National Pharmaceutical Council

NEW JERSEY




Prescribed Drugs





Physician Services




CATEGORICALLY NEEDY, RECEIVING ASST $270,025,213 167,661Aged $42,974,940 30,587Blind / Disabled $219,896,088 100,921AFDC-Child $2,115,119 20,294AFDC-Adult $5,039,066 15,859AFDC-Unemployed-Child $0 0AFDC-Unemployed-Adult $0 0

MEDICALLY NEEDY $4,504,987 3,906Aged $3,708,823 2,543Blind / Disabled $527,195 171AFDC-Child $268,969 1,192AFDC-Adult $0 0

POVERTY RELATED $60,253,456 60,784Aged $21,199,966 15,320Blind / Disabled $36,779,674 13,728AFDC-Child $1,591,982 22,027AFDC-Adult $681,834 9,709

OTHER $91,291,832 77,498



National Pharmaceutical Council New Jersey-2

C. ADMINISTRATION

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


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations for insulin use; blood glucose test strips;urine ketone test strips; total parenteral nutrition; andinterdialytic parenteral nutrition. Products not covered:cosmetics; fertility drugs; and experimental drugs. Priorauthorization required for: methadone; IV infusions; andprotein replacement supplements.

Over-the-Counter Product Coverage: Products covered:allergy, asthma, and sinus products; analgesics; topicalproducts; and cough and cold preparations for childrenunder age 21. Products not covered: digestive products;feminine products; and smoking deterrent products.

Therapeutic Category Coverage: Therapeutic categoriescovered: analgesics, antipyretics, NSAIDs; antibiotics;anticoagulants; anticonvulsants; anti-depressants;antidiabetic agents; antihistamine drugs; anti-psychotics;anxiolytics, sedatives, and hypnotics; cardiac drugs;chemotherapy agents; prescribed cold medications;contraceptives; ENT anti-inflammatory agents; estrogens;hypotensive agents; misc. GI drugs; sympathominetics(adrenergic); and thyroid agents. Prior authorizationrequired for: antilipemic agents. Partial coverage for:anabolic steroids; anorectics (for ADD); growthhormones; and prescribed smoking deterrents.


Vaccines: Vaccines reimbursable at AWP as part of theEPSDT program and the Vaccines for Children Program.

Unit Dose: Unit dose packaging reimbursable in long-term care facilities only, not in retail settings (unless u/d isonly way item is packaged).


Formulary: Open formulary. General exclusions includeexperimental drugs, cosmetics, fertility drugs, DESIdrugs, and drugs for which FFP is not available (OBRA'90).

Prior Authorization: State currently has a formal priorauthorization procedure. Periodic review forreconsideration possible for excluded product fromformulary. Fair hearings possible for appealing priorauthorization decisions.


Prescription Refill Limit: 5 times within a 6-month period.

Monthly Quantity Limit: Originally, 34-day supply. Now,34 days or 100 units, whichever is more.


PRODUR system implemented in October 1996. Statecurrently has a DUR Board with a quarterly review.


Dispensing Fee: $3.73 for legend drugs. Additional add-ons per/Rx shall be given to pharmacy providers whoprovide the following:

1. 24-hr Emergency Service: add $0.11

2. Patient Consultation: add $0.08

3. Impact Area Location: add $0.15 (provider shall havea combined Medicaid, NJ KidCare and PAADprescription volume equal to or greater than 50% oftotal prescription volume.

Ingredient Reimbursement Basis: EAC = AWP - 10%,WAC + 30%. AAC for injectables, effective 5/1/00.

Prescription Charge Formula: “Maximum AllowableCost,” or Average Wholesale Price – 10% (reduction fromAWP is pharmacy specific) plus a dispensing fee or theprovider’s usual and customary charge, whichever islower.

Maximum Allowable Cost: State imposes Federal UpperLimits on generic drugs. Override requires “BrandMedically Necessary”.



Cognitive Services: State pays for cognitive services.


3-New Jersey National Pharmaceutical Council

E. USE OF MANAGED CAREApproximately 400,000 Medicaid recipients receivedpharmacy benefits through managed care. All receivepharmaceutical benefits from MCOs.


Amerigroup of NJ732/452-6002Aetna/US HealthCare610/251-6272

Physicians Health Services1-800-963-6286

Americhoice of NJ212/509-5999

Mercy Health Plan1-800-682-9091

University Health Plan1-800-564-6847

F. STATE CONTACTS


Carl Tepper, R.Ph.Chief, Pharmaceutical ServicesDepartment of Human ServicesDivision of Medical Assistance and Health ServicesP.O. Box 712, Bldg. 11-ATrenton, NJ 08625-0712T: 609/588-2724F: 609/588-3889E-mail: [email protected]


Michele GuhlCommissionerDepartment of Human ServicesCapitol Place 1Trenton, NJ 08625

Margaret MurrayDirectorDivision of Medical Assistance and Health Services

DUR Contact

Edward J. Vaccaro, R.Ph.Assistant Director, Office of Utilization ManagementDept. of Human Services, Div. of Medical Assistance andHealth ServicesP.O. Box 712, Bldg. 11-ATrenton, NJ 08625T: 609/588-2721F: 609/588-3839E-mail: [email protected]

Medicaid DUR Board

Christopher A. Cella, R.Ph.Alfred F. Sorbelo, D.O.Edith Kessler-Feinstein, R.Ph.Joseph Nicholas Micale, M.D.Charles DeFeri, Jr., Pharm. D.Thomas A. Cavalieri, D.O.Linda Gooen, R.Ph.Mary E Petit, Pharm.D.David Ethan Swee, M.D.




Technical: Daniel Upright, 609/588-2792Policy: Carl Tepper, 609/588-2724PA: Carl Tepper, 609/588-2724


P. RingelUnisysDeputy Project Director3705 Quakerbridge Rd. Suite 101Trenton, NJ 08619T:609/588-6000F: 609/584-8270E-mail: [email protected]


Edward VaccaroT: 609/588-2721


National Pharmaceutical Council New Jersey-4

Elderly Expanded Drug Coverage Contact

Kathleen MasonDirector of PAADDept. of Health and Senior ServicesP.O. Box 715Trenton, NJ 08625T:609/588-7032F: 609/584-7037


Edward Vaccaro609/588-2721


Medical Society of New JerseyWalter Kahn, M.D.Executive Director2 Princess RoadLawrenceville, NJ 08648-2302609/896-1766

New Jersey Pharmacists AssociationJoseph Morris3B Marlen DriveRobbinsville, NJ 08691609/584-9063

New Jersey Association of Osteopathic Physicians &SurgeonsJeff Kramer, FACHEExecutive Director1 Distribution WayMonmouth Junction, NJ 08852-3001732-940-8899

State Board of PharmacyH. Lee Gladstein, R.Ph.Executive DirectorP.O. Box 45013Newark, NJ 07101201/504-6450

New Jersey Hospital AssociationGary S. CarterPresident, CEO760 Alexander Road CN-1Princeton, NJ 08543-0001609/275-4000


1-New Mexico National Pharmaceutical Council

NEW MEXICO




Prescribed Drugs





Physician Services




CATEGORICALLY NEEDY CASH TOTALAgedBlindDisabledChildren-Families w/Dep. ChildrenAdults-Families w/Dep. ChildrenOther Title XIX Recipients





National Pharmaceutical Council New Mexico-2

C. ADMINISTRATION

Human Services Department (HSD).


Benefit Design

Drug Benefit Product Coverage: Prior Authorizationrequired for: amphetamines and stimulants for ADD.Products not covered: drugs for treatment of tuberculosis;cosmetics; experimental drugs; fertility drugs; drugs andimmunizations available from any other source;medications supplied by the New Mexico State Hospitalto clients on convalescent leave from hospital; legendmultiple vitamins; tonic preparations and combinationswith minerals, hormones, stimulants; hematinics (exceptnon-sustained release forms of Ferrous Sulfate, FerrousGluconate, Ferrous Fumarate); drugs classified by FDA as“ineffective”; and hypnotic drugs (barbiturates).

Over-the-Counter Product Coverage: insulin; antacids foractive gastric and duodenal ulcers; infant vitamin dropsfor up to 1 year; Salicylates and acetaminophen; non-sustained release forms of Ferrous Sulfate, FerrousGluconate, Ferrous Fumarate; Scabicides andPediculocides; Laxatives, stool softeners, calcium,nicotine replacement, ibuprofen, antihistamines,decongestants, expectorants, cough suppressants, anti-candida, and antifungals.


Vaccines: Vaccines reimbursable at acquisition cost plus35% as part of the EPSDT program.

Unit Dose: Does not reimburse for unit dose packaging.



Prior Authorization: State currently has a formal priorauthorization procedure screening for drug classes.


Prescription Refill Limit: Payment will be made to aparticular pharmacy only three times for the same drug forthe same client in a 90-day period.

Monthly Quantity Limit: 6-month supply maximum,excluding birth control pills.


PRODUR system implemented in October 1993.



Ingredient Reimbursement Basis: EAC = AWP - 12.5%,effective 7/1/97.

Prescription Charge Formula: Prescriptions reimbursedat the lesser of the following:

1. Cost (EAC or MAC) dispensed plus a dispensing feeor,

2. The usual and customary charge by the pharmacy tothe general public.

Maximum Allowable Cost: State imposes Federal UpperLimits as well as state-specific limits on generic drugs. Over 72 drugs are listed on the state-specific MAC list. Override requires “Brand Medically Necessary.”





Full-risk capitation managed care program implementedon July 1, 1997. Recipients receive pharmaceuticalbenefits through managed care plans.

F. STATE CONTACTS


Neil SolomonDrug Program AdministratorMedical Services BureauP. O. Box 2348Santa Fe, NM 87504-2398T: 505/827-3174F: 505/827-3185

Drug Education & Utilization Review Board

John A. Heaton, R.Ph.Corner Drug Store, Inc.201 W. FoxCarlsbad, NM 88220


3-New Mexico National Pharmaceutical Council

Fredrica Smith, M.D.Los Alamos Medical Center3917 West RoadLos Alamos, NM 87544

Charles T. Spalding, M.D., Ph.D.Lovelace Medical Center5400 Gibson, S.E.Albuquerque, NM 87108

William Troutman, Pharm. D.University of New Mexico Drug Information andPoison Control CenterUniversity of New MexicoAlbuquerque, NM 87131-0176

Lionel Anaya R.Ph.111 Coors Road N.W.Albuquerque, NM 87110


Technical: Sal Montano, 505/827-3143Policy: Sonya Miera, 505/827-7777DUR & PA: Chuck Reynolds, 505/827-3174

Human Services Department Officials

Robin O DozierSecretary DesignateP. O. Box 2348Santa Fe, NM 87504-2398T: 505/827-4072

Chuck MilliganDirectorMedical Assistance Division

Ross BeckerDeputy Director

Medical Advisory Committee Members

Linda SechovecExecutive DirectorNM Health Care6400 Uptown Blvd., NE, Suite 520-WAlbuquerque, NM 87110

Yvette Ramirez AmmermanPolicy AnalystNew Mexico Primary Care Association2309 Renard, S.E., Suite 209Albuquerque, NM 87106

Chris IsengardExecutive DirectorDevelopmental Disabilities Planning Council435 St. Michael’s Dr., Bldg. DSanta Fe, NM 87501

Michelle Lujan-GrishamNew Mexico State Agency on Aging228 East Palace AvenueSanta FE, NM 87501

Sam Cata, CommissionerOffice of Indian Affairs224 E. Palace AvenueSanta FE, NM 87501

Loyola Burgess1801 Dorothy Street, NEAlbuquerque, NM 87112

Walace Begay, Co-ChairmanPueblo Health Council/All Indian Pueblo CouncilP.O. Box 56New Laguna, NM 87038

Heather Wilson, SecretaryCYFD, PERA Building1120 Paseo de PeraltaSanta Fe, NM 87501

Rosalyn CurtisDirector of the Navajo NationDivision of HealthP.O. Box 1390Window Rock, AZ 86515

Lila Maples, R.N.2769 Villa VenadoSanta Fe, NM 87505

Clarice Pick, D.D.S1405 Luisa StreetSuite #2Santa Fe, NM 87505

Richard L. Ragel, D.O.1010 Bridge Blvd., SWSuite DAlbuquerque, NM 87105-3734

Kathy Minoli, C.F.N.P.1835 Solano, NEAlbuquerque, NM 87110


National Pharmaceutical Council New Mexico-4

Mary Lou Edward16 Applewood Lane, N.W.Albuquerque, NM 87107505/898-5103

Richard Honsinger, M.S.Los Alamos Medical CenterLos Alamos, NM 87544

Maureen BoshierNew Mexico Hospital Association2121 Osuna Road NEAlbuquerque, NM 87113

Joie GlenExecutive DirectorNew Mexico Association for Home Care3200 Carlisle N.E., Suite 115Albuquerque, NM 87110

Dr. Norton KalishmanChief Medical OfficerDepartment of HealthP.O. Box 26110Santa Fe, NM 87502-6110

Bert Umland, M.D.Division of Family PracticeUNM Medical CenterAlbuquerque, NM 87131505/277-2165


New Mexico Medical SocietyG. R. “Randy” MarshallExecutive Director7770 Jefferson NE, Suite 400Albuquerque, NM 87109505/828-0237

New Mexico Pharmaceutical AssociationDale TinkerExecutive Director4800 Zuni, S.E.Albuquerque, NM 87108-2898505/265-8720

New Mexico Osteopathic Medical AssociationFloyd F. SmithExecutive DirectorP. O. Box 90396Albuquerque, NM 87199-0396505/828-1905

State Board of PharmacyDavid Denoyer, Executive DirectorUniversity Towers1650 University Blvd., NE, Suite 400BAlbuquerque, NM 87102505/841-9102

New Mexico Hospitals and Health Systems AssociationMaureen L. BoshierPresident, CEO2121 Osuna Road, NEAlbuquerque, NM 87113505/343-0010

Fiscal Intermediary

Diane GatelyConsultec510 N. Guadelupe, Suite CSanta Fe, NM 87501505/983-5555


1-New York National Pharmaceutical Council

NEW YORK




Prescribed Drugs





Physician Services


B. EXPENDITURES FOR DRUGS1998 1999

Expended Recipients Expended RecipientsTOTAL $1,368,451,273 1,803,428 1,906,521,831 2,122,000

RECEIVING CASH ASSISTANCE, TOTAL $973,744,961 1,073,631 1,292,083,557 1,202,687Aged $185,897,780 145,227 220,345,467 147,162Blind / Disabled $688,950,800 390,585 893,845,203 421,594AFDC-Child $37,327,228 358,928 58,757,046 430,163AFDC-Adult $61,569,154 178,891 119,135,841 203,768AFDC-Unemployed-Child $0 0 0 0AFDC-Unemployed-Adult $0 0 0 0

MEDICALLY NEEDY, TOTAL $326,652,214 515,780 425,045,080 657,663Aged $98,546,169 80,929 117,455,198 85,432Blind / Disabled $174,038,100 81,238 219,616,402 88,679AFDC-Child $30,387,933 254,244 46,307,214 346,029AFDC-Adult $23,680,012 99,369 41,666,266 137,523

POVERTY RELATED, TOTAL $59,670,691 183,844 170,522,367 227,669Aged $0 0 0 0Blind / Disabled $0 0 0 0AFDC-Child $6,050,198 65,735 1,509,819 13,993AFDC-Adult $53,620,494 118,109 177,012,546 213,676

OTHER $8,383,406 32,173 10,870,828 33,981

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.


National Pharmaceutical Council New York-2

C. ADMINISTRATION

State Department of Health.


Benefit Design

Drug Benefit Product Coverage: Products covered:cosmetics; fertility drugs; and experimental drugs.Products not covered: prescribed insulin; disposableneedles and syringe combinations for insulin; bloodglucose test strips; urine ketone test strips; total parenteralnutrition; and interdialytic parenteral nutrition.

Over-the-Counter Product Coverage: Products covered:digestive products (H2 antagonists) and smoking deterrentproducts. Products covered with restrictions: allergy,asthma and sinus products; analgesics; cough and coldpreparations; digestive products (non H2 antagonist);feminine products; and topical products.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; analgesics, antipyretics,NSAIDs; antibiotics; anticoagulants; anticonvulsants;antidepressants; antidiabetic agents; antihistamine drugs;antilipemic agents; anti-psychotics; anxiolytics, sedatives,and hypnotics; cardiac drugs; chemotherapy agents;contraceptives; ENT anti-inflammatory agents; estrogens;growth hormones; hypotensive agents; prescribedsmoking deterrents; sympathominetics (adrenergic); andthyroid agents. Therapeutic categories partially covered:prescribed cold medication and misc. GI drugs.Therapeutic categories requiring prior authorization;medical/surgical supplies; orthopedic shoes; compressionstockings; and some DME items. Therapeutic categoriesnot covered: anorectics and agents used for hair growth.

Coverage of Injectables: Injectable medicinesreimbursable through the Prescription Drug Programwhen used in home health care, extended care facilitiesand through physician payment when used in physicianoffices. No special coverage policies exist for self-administered injectable medicines.

Vaccines: Vaccines are reimbursable under the EPSDTservice and the Vaccines for Children program.



Formulary: Open formulary. General Exclusions: NewYork State follows OBRA '90 guidelines in thereimbursement of prescription drugs.



Prescription Refill Limit: Cannot exceed 5, and the life ofa prescription cannot exceed 6 months.



PRODUR system implemented in March 1995. Statecurrently has a DUR Board with a review every othermonth.


Dispensing Fee: $3.50 for brand name drugs, $4.50 forgeneric drugs. Effective 8/1/98.



1. Payment for multiple source drugs must not exceedthe aggregate of the specified upper limit set by thefederal Health Care Financing Administration(HCFA), plus a dispensing fee, for a particular drug;and

2. Payment for brand name drugs and other multiplesource drugs not covered by clause (1) will be thelower of: EAC plus a dispensing fee; or

3. The billing pharmacy's usual and customary pricecharged to the general public.

Maximum Allowable Cost: State imposes Federal UpperLimits on generic drugs. Override requires “Dispense asWritten” and “Brand Necessary, ” or “Brand MedicallyNecessary.”


Patient Cost Sharing: Copayment is $2.00 for brand namedrugs, $0.50 for generic and OTC drugs. Exceptionsinclude psychotropic drugs as well as drugs FDAapproved for the treatment of tuberculosis and familyplanning drugs.



Approximately 670,000 total unduplicated number ofMedicaid recipients were enrolled in MCOs in FY 1999.Recipients receive pharmaceutical benefits through thestate.



Health Maintenance Organizations

− ABC− Bluechoice HMO Options− Broome MC− Bronx HP− Buffalo Com. Health− Careplus, LLC− CDPHP− Center Care, Inc.− Community Blue− Community Choice HP− Community Premier Plus− Compre-Care, Inc.− Capital Area CHP− Empire BCBS Healthnet− Fidelis− Genesis HP, Inc. − Health Choice− HealthFirst− Health Plus− HIP/Nassau− HIP/Westchester− HMO of Greater NY− HUM Healthcare Systems− IHA/WNY− Managed Healthcare Systems− Metropolitan Plus Health Plan− Neighborhood Health− NY Hosp CHP− Partners− Preferred Care− Suffolk Co PHSP− Total Care− United Healthcare Plan of NY, Inc.− United Healthcare of Upstate− Vytra− Wellcare− Westchester Prepaid Health Services Plan

F. STATE CONTACTS


Mark-Richard A. Butt, M.S., R.Ph.Director, Pharmacy Policy and OperationsDivision of Provider RelationsOffice of Medicaid ManagementNYS Department of Health99 Washington Ave., Suite 606Albany, NY 12210T: 518/486-3209F: 518/473-5508E-mail: [email protected]://www.health.state.ny.us

Formulary Contact

Mark-Richard A. Butt, 518/486-3209


Mark-Richard A. Butt, 518/486-3209

DUR Contact

Michael ZegarelliDUR Manager, Office of Medical ManagementNYS Department of Health99 Washington Ave. Suite 601Albany, NY 12237T: 518/474-6866F: 518/473-5332E-mail: [email protected]

DUR Committee

PhysiciansRichard S. Blum, M.D.25 Spruce DriveEast Hills, NY 11576

Ronald J. Dougherty, M.D.9429 Woodlawn DriveBrewerton, NY 13029-9724

Bernard Berkowitz, M.D.63 Franklin StreetSaratoga Springs, NY 12866

David F. Lehmann, M.D.Dept. of Medicine750 East Adams StreetSyracuse, NY 13210

PharmacistsJill Braverman-Panza, M.D.2 Executive Park DriveAlbany, NY 12203

Sidney Falow, R.Ph.12 Shore Park RoadGreat Neck, NY 11023-2033

Marilyn C. Fortin, R.Ph.NYS Department of HealthOffice of Continuing CareEPIC260 Washington AvenueAlbany, NY 12212

Marc L. Speert, R.Ph.110 Russell StreetCornwall, NY 12518



James R. Suhrbier, R.Ph.482 Mount Airy RoadNew Windsor, NY 12553

DUR ExpertsMary Andritz, Pharm.D., R.Ph.Albany College of Pharmacy106 New Scotland Ave.Albany, NY 12210

Robert A. Hamilton, Pharm.D., R.Ph.Albany College of Pharmacy106 New Scotland Ave.Albany, NY 12210

Department DesigneeLydia Kosinski, R.Ph.Division of Provider RelationsOffice of Medicaid ManagementNYS Department of Health99 Washington Ave., Suite 601Albany, NY 12210518/474-6866


Carl T. CioppaPharmacy Operations ManagerPharmacy Policy and OperationsNYS Dept. of Health, Office of Medicaid Management99 Washington Ave., Suite 606Albany, NY 12210T: 518/486-3209F: 518/473-5508E-mail: [email protected]


Audit & Policy: Mark-Richard Butt, 518/486-3209Disputes: Mark-Richard Butt, 518/486-3209PRODUR: Dennis Pidgeon, 518/474-6866


Computer Sciences Corporation (CSC)800 North Pearl St.Albany, NY 12204518/447-9200


Elizabeth MacfarlaneDirector, Bureau of Program PlanningNYS DOH Office of Managed CareRoom 1927, Corning Tower ESPAlbany, NY 12237-0064T: 518/473-0122F: 518/474-5886E-mail: [email protected]


Karen A. Fuller, Ph.D.Director, Bureau of Program GuidanceNYS Department of HealthOffice of Medicaid Management99 Washington Ave, Suite 606Albany, NY 12210-2806T: 518/474-9219F: 518/473-5508E-mail: [email protected]

Expanded Drug Program Contact

Julie NaglieriActing DirectorElderly Prescription Insurance Coverage (EPIC)1 Corporate Plaza, Suite 101260 Washington Ave., Ext.Albany, NY 12203T: 518/452-6828F: 518-452-6882E-mail: [email protected]


Karen A. Fuller, Ph.D., 518/474-9219

Department of Health Officials

Antonia C. Novello, M.D, M.P.H., Dr. Ph.CommissionerNYS Department of HealthCorning TowerThe Governor Nelson A Rockefeller Empire State PlazaAlbany, NY 12237

Kathryn KuhmerkerDeputy CommissionerOffice of Medicaid ManagementNYS Department of HealthCorning TowerThe Governor Nelson A. Rockefeller Empire State PlazaAlbany, NY 12237

Karen A. Fuller, Ph.D.Director, Bureau of Program GuidanceDivision of Provider Relations/Office of MedicaidManagement99 Washington Ave., Suite 606Albany, NY 12210618/474-9219



Carl Cioppa, R.Ph.Pharmacy Operations ManagerDivision of Provider RelationsOffice of Medicaid ManagementNYS Department of Health99 Washington Ave., Suite 606Albany, NY 12210

Marlene Dickson, R.Ph.Pharmacy Program SpecialistDivision of Provider Relations

Anita Murray, R.Ph.Pharmacy Program SpecialistDivision of Provider Relations

Joseph Maiello, R.Ph.Pharmacy Program SpecialistDivision of Provider Relations

Anne Budin, R.N.Pharmacy Program SpecialistDivision of Provider Relations

Sally Nelsen, R.Ph.Pharmacy Program SpecialistDivision of Provider Relations


John Hollomon, M.D.

27-40 Ericsson StreetE. Elmhurst, NY 11369

Roger W. Trifshauser, D.D.S., M.S.63 Ellicott AvenueBatavia, NY 14020

Ellen M. Vossler, D.D.S.57 High Park Blvd.Amherst, NY 14226

Charles Wisor, M.D.70 Mason StreetGeneva, NY 14456

Stoner E. Horey, M.D.20 Elm Street, Suite 6Hornell, NY 14823

Norman R. Loomis, M.D.7736 Tamarak LaneOntario, NY 14519

William O'Dwyer, M.D.14 Loudon ParkwayLoudonville, NY 12211

Elena Padilla, Ph.D.3 Washington Square VillageApt. 15-0New York, NY 10012

Hugo Morales, M.D. P.C.Medical DirectorBronx Mental Health CenterPsychiatry & Neurology1211 Gerard AvenueBronx, NY 10452

Ruben Cowart, D.D.S., ChairmanExecutive DirectorSyracuse Community Health Center819 South Salina StreetSyracuse, NY 13202

Randall Bloomfield, M.D.NYS Medical Society188 Lincoln RoadBrooklyn, NY 11225

Ellen ChiangPrestige Care150 W. 28th Street, Room 503New York, NY 10001

Tanton Mustapha, M.D.848 Columbia StreetHudson, NY 12534

Dennis P. Norfleet, M.D.40 West Mohawk StreetOswego, NMY 13126

Louis Goldberg, DDS.University at Buffalo School of Dental Medicine3435 Main St.Buffalo, NY 14214

Ann WilkinsonCHAP OfficeJamaica Hospital89th Avenue and Van Wyck ExpresswayJamaica, NY 11418

John Angerosa, M.D.11 Boyle RoadScotia, NY 12302



DSS Designee:Patricia Stevens, Deputy CommissionerNYS Office of Temporary and Disability AssistanceDivision of Temporary Assistance40 N. Pearl St., 7th floorAlbany, NY 12243

Pharmacy Advisory CommitteeJohn P. Navarra, ChairmanTown Total Nutrition45 East 30th StreetNew York, NY 10016212-213-5570

Patricia DonatoCapital Consultants251 New Karner RoadAlbany, NY 12205518/456-3216

John Westerman, Jr.14 Osprey Hill DriveNewburgh, New York 12550914/561-4890

Kandyce J. DaleyEckerd Drug Co. Inc.7245 Henry Clay BoulevardLiverpool, NY 13088315/451-8000 x2292

Thomas F. Golden, Jr.Eckerd Drug Co. Inc.1483 Route 9Halfmoon, NY 12065518/371-1513

Dilip Patel7 Rubinstein CourtNew Hempstead, NY 10977212-567-3384

Mohammed SalehM & I Pharmacy853 East New York AvenueBrooklyn, NY 11203718/493-8118

Stephen L. GirouxMiddleport Family Health Center81 Rochester Road, Box 188Middleport, NY 14105716/735-7550


Medical Society of the State of New York

Charles Aswad, M.D.Executive Vice President420 Lakeville RoadP.O. Box 5404Lake Success, NY 11042-5404516/488-6100

Pharmaceutical Society of the State of New YorkCraig Burridge, Executive DirectorPine West Plaza IVWashington Avenue ExtensionAlbany, NY 12205518/869-6595

New York State Osteopathic Medical Society, Inc.Christian M. HynesExecutive Director181 Weber Hill RoadCarmel, NY 10512800/841-4131

New York State Board of PharmacyLawrence H. MokhiberExecutive SecretaryCultural Education Center Rm. 3035Albany, NY 12230518/474-3848

Healthcare Association of New York StateDaniel SistoPresident74 North Pearl St.Albany, NY 12207518/431-7600

Greater New York Hospital AssociationSubsidiaries and AffiliatesKenneth E. RaskePresident555 W. 57th Street.15th FloorNew York, NY 10019212/246-7100


1-North Carolina National Pharmaceutical Council

NORTH CAROLINA




Prescribed Drugs





Physician Services




RECEIVING CASH ASSISTANCE, TOTAL $290,607,349 419,155Aged $102,046,805 75,511Blind / Disabled $137,208,166 103,517AFDC-Child $19,309,935 147,596AFDC-Adult $30,503,271 86,761AFDC-Unemployed-Child $276,357 2,188AFDC-Unemployed-Adult $1,262,815 3,582

MEDICALLY NEEDY, TOTAL $137,663,846 95,003Aged $58,286,777 38,339Blind / Disabled $74,389,528 45,957AFDC-Child $663,154 2,975AFDC-Adult $4,324,387 7,732

POVERTY RELATED, TOTAL $30,911,676 236,506Aged $0 0Blind / Disabled $0 0AFDC-Child $27,787,899 209,686AFCC-Adult $3,123,777 26,820

OTHER $7,345,941 14,222

Source: HHS State HCFA-2082 Reports, Section A-4 and B-4.*1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.


National Pharmaceutical Council North Carolina-2

C. ADMINISTRATION

Division of Medical Assistance, Department of HumanResources.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin. Prior authorization required for: Viagraand Serostim. Products not covered: cosmetics; fertilitydrugs; experimental drugs; disposable needles and syringecombinations used for insulin; blood glucose test strips;urine ketone test strips, total parenteral nutrition; andinterdialytic parenteral nutrition.

Over-the-Counter Product Coverage: Products notcovered: allergy, asthma and sinus products; analgesics;cough and cold preparations; non-H2 antagonist digestiveproducts; digestive products, H2 antagonists; feminineproducts; topical products; and smoking deterrentproducts.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; analgesics, antipyretics,NSAIDs; anorectics; antibiotics; anticoagulants;anticonvulsants; antidepressants; antidiabetic agents;antihistamine drugs; antilipemic agents; anti-psychotics;anxiolytics, sedatives, and hypnotics; cardiac drugs;chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens;growth hormones; hypotensive agents; misc. GI drugs;prescribed smoking deterrents; sympathominetics(adrenergic); and thyroid agents.

Coverage of Injectables: Injectable medicinesreimbursable through the Prescription Drug Programwhen used in home health care, extended care facility, andthrough physician payment when used in physicianoffices.

Vaccines: Vaccines reimbursable as part of the HealthCheck service.

Unit Dose: Unit dose packaging reimbursable if packagedin unit dose only.



Prior Authorization: State currently does not have aformal prior authorization procedure. A hearing officer isrequired to appeal prior authorization decisions.


Monthly Quantity Limit: 100-day supply maximum.

Monthly Prescription Limit: Six prescriptions per monthper recipient.

Prescription Dollar Limits: None.


PRODUR system implemented in May 1996. Statecurrently has a DUR Board with a quarterly review.


Dispensing Fee: $5.60, effective January 1992.


Prescription Charge Formula: The lowest price of AWPminus 10% or MAC, plus a dispensing fee for eachdifferent drug dispensed during a month, or AWP plus thelowest dispensing fee accepted from other third partypayers. The pharmacist filling the original prescriptionwill not be reimbursed for refills for the same drug withina calendar month.

Maximum Allowable Cost: State imposes Federal UpperLimits on generic drugs. 223 drugs are listed on the state-specific MAC list. Override requires “Brand MedicallyNecessary.”


Patient Cost Sharing: $1.00 copayment/Rx (includesrefills).



Approximately 689,000 total unduplicated number ofMedicaid recipients were enrolled in MCOs in FY 1999. Recipients receive pharmaceutical benefits through thestate.


The Wellness Plan of NC, Inc.Tim O’Brien1409 East Blvd, Ste. 204Charlotte, NC 28203-5476704/370-0090



United HealthCare of NCCharren Nelson2307 W. Cone Blvd.Greensboro, NC 28217

SouthCare/Coventry2815 Coliseum Center Dr.Charlotte, NC 28217

F. STATE CONTACTS


C. Benny Ridout, R.Ph.Pharmacist ConsultantNC Division of Medical Assistance1985 Umstead Drive2511 Mail Service CenterRaleigh, NC 27699-2511T: 919/733-4034F: 919/733-2796E-mail: [email protected]


C. Benny Ridout, 919/733-4034

DUR Contact

Sharman LeinwandDUR CoordinatorN.C. Division of Medical Assistance2515 Mail Service CenterRaleigh, NC 27699-2515T: 919/733-3590F: 919/715-7706

Medicaid Drug Utilization Review Board

Physicians:Patricia Burns, M.D.

Douglas Pritchard, M.D.Carolina Anesthesia AssociatesP.O. Box 801Statesville, NC 28677

Edward Treadwell, M.D.ECU School of MedicineDepartment of Medicine/RheumatologyGreenville, NC 27858

Pharmacists:Joseph S. Moose, R.Ph., Pharm. D.Moose Professional Pharmacy390 Copperfield BoulevardConcord, NC 28025704/784-9613Bruce R. Canaday, Pharm. D.

Jennifer Burch, Pharm. D.

Jeff Peterson, R.Ph.Glaxo207 Glen Abbey DriveCary, NC 27513919/460-9375

Penny S. Shelton, Pharm.D.113 Honeysuckle LaneDurham, NC 27703919/733-5266




Tech.: Dewey Cassell, 919/851-8888 x 158P & A: Benny Ridout, 919/857-4034Rebate Disputes: Sharon Greeson, 919/233-6829DUR: Sharman Leinwand, 919/733-3590


Sharon Greeson, R.Ph.Pharmacist Consultant, EDS4905 Waters Edge DriveRaleigh, NC 27606T: 919/233-6829F: 919/859-9703E-mail: [email protected]






Geneva FearringtonDepartment of Health and Human ServicesDivision of Medical Assistance1985 Umstead Drive2511 Mail Service CenterRaleigh, NC 27699-2511



Department of Human Resources Officials

Paul R. Peruzzi, DirectorDepartment of Health and Human ServicesDivision of Medical Assistance1985 Umstead Drive2517 Mail Service CenterRaleigh, NC 27699-2517Daphne O. LyonDeputy Director

H. David Bruton, M.D.SecretaryDepartment of Health and Human Services101 Blair Drive2001 Mail Service CenterRaleigh, NC 27699-2001

Department of Human Resources AdvisoryCommittees

Pharmaceutical Association, Third PartyWilliam Taylor8208 Brownleigh DriveRaleigh, NC 27612

Paul BisettePO Box 785Wilson, NC 27893-0785

David T. Hix235 Burke StreetGibsonville, NC 27249-2402

Jim LeCroy5454 Eastwind RoadWilmington, NC 28403

Jim Hall138 N. Churton StreetHillsboro, NC 27278

David S. Moody Jr.4100 Grove Ridge DriveDurham, NC 27703

Mickey Watts, LiaisonPO Box 39Concord, NC 28026

Vince Stevens8408 Inverness WayChapel Hill, NC 27516

John Zatti5 Porchlight CourtDurham, NC 27707

Benny RidoutBox 88Morrisville, NC 27560

William Holshouser13 Dogwood RoadSalisbury, NC 28144

George McLartyPO Box 1028High Point, NC 27261-1028

Walton P. O’Neal III302 Sunnyside DriveWashington, NC 27889

Health Care Access Committee II-3Jack R. Page, M.D., Chairman3 Hartley PlaceDurham, NC 27707

Donald T. Lucey, M.D. Vice-Chair2800 Blue Ridge Blvd., Suite 403Raleigh, NC 27607

H. David Burton, M.D.NC Department of Human Resources101 Blair DrivePO Box 29526Raleigh, NC 27626-0526

Lindsey E. deGuehery, M.D.1812 Glendale DriveWilson, NC 27893

Raphael J. DiNapoli, Jr., M.D.1985 Umstead Drive, P. O. Box 29529Raleigh, NC 27626-0529

E. Stephen Edwards, M.D.2800 Blue Ridge Blvd.Ste. 501Raleigh, NC 27607-6496

Brian R. Forrest6016 Farmgate RoadRaleigh, NC 27606

Shelton P. Hager2651 MacGregor Down RoadApt. KGreenville, NC 27858

Ann Faris2720 Bitting RoadWinston-Salem, NC 27104



Johnson H. Kelly, M.D.1001 N. Washington StreetShelby, NC 28150

Donald T. Lucy, M.D.2800 Blue Ridge Blvd., Ste. 403Raleigh, NC 27607

William O. McMillan, Jr., M.D.P.O. Box 9025Wilmington, NC 28402-9025

Edwin W. Monroe, M.D.104 W. Longmeadow Rd.Greenville, NC 27858-3714

William J. Murray, M.D.Duke University Medical CenterBox 3094Durham, NC 27710

Paul R. PeruzziDeputy DirectorMedical Assistance DivisionNC Dept. of Human ResourcesPO Box 29529Raleigh, NC 27626-0529

Kenneth G. Reeb, M.D.UNC School of Medicine, Family Practice DepartmentChapel Hill, NC 27599

C. Stewart Rogers, M.D.1200 N. Elm StreetGreensboro, NC 27401-1020

William J. Spencer, M.D.851 Brookleigh CourtWinston-Salem, NC 27104

Delford L. Stickel, M.D.Duke University, Box 3917Durham, NC 27710

James D. BernsteinRural Health and Resources Development OfficeDepartment of Human Resources311 Ashe AvenueRaleigh, NC 27606

James A. Clarke, Ed.D.Associate State DirectorPO Box 37067Raleigh, NC 27627

Lee B. HoffmanChiefCertificate of Need SectionFacility Services DivisionNorth Carolina Department of Human ResourcesP.O. Box 29530Raleigh, NC 27626-0530

Jeffrey A. Katz18 Cherry Grove RoadHickory, NC 28602

Barbara D. MatulaDirectorMedical Assistance DivisionNC Department of Human ResourcesP.O. Box 29579Raleigh, NC 27626-0529

David E. RiceSara Lee CorporationP.O. Box 2760Winston-Salem, NC 27102-2760

Pam Silberman, JD2108 Umstead DriveRaleigh, NC 27603


North Carolina Medical SocietyBob Seligson, M.B.A., CAEExecutive Vice President222 North Person St., P.O. Box 27167Raleigh, NC 27611-7167919/833-3836

North Carolina Pharmaceutical AssociationDan GarretteExecutive DirectorBox 151Chapel Hill, NC 27514-0151919/967-2237

North Carolina Osteopathic Association, Inc.Barbara Walker, D.O.President207 Viking DriveFayetteville, NC 28303910/864-7515



State Board of PharmacyDavid R. WorkExecutive DirectorP. O. Box 459Carrboro, NC 27510-0459919/942-4454

North Carolina Hospital AssociationWilliam A. PulleyPresidentP.O. Box 80428Raleigh, NC 27623-0428919/677-2400


1-North Dakota National Pharmaceutical Council

NORTH DAKOTA




Prescribed Drugs





Physician Services







OTHER

Source: HHS State HCFA-2082 Reports, Section A-4 and B-4.*1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.


National Pharmaceutical Council North Dakota-2

C. ADMINISTRATION

North Dakota Department of Human Services.


Benefit Design

Drug Benefit Product Coverage: Products not covered:cosmetics; drugs used for hair growth; prescriptionvitamins (except prenatal vitamins); and DESI drugs.Prior authorization required for: smoking cessation andnutritional supplements.

Over-the-Counter Product Coverage: Products covered:antacids; analgesics; iron supplements; artificial tears; andanti-ulcer medications.


Vaccines: Vaccines reimbursable as part of the EPSDTservice.




Prior Authorization:


Prescription Refill Limit: A prescription drug may berefilled for 12 months after the date of the originalprescription, provided that such refills have beenauthorized by the physician.




PRODUR system implemented in July 1996.




Prescription Charge Formula: Acquisition Cost plus adispensing fee per prescription or the usual and customaryretail charge, whichever is lower. Acquisition Cost =EAC or MAC.

Maximum Allowable Cost: State imposes Federal UpperLimits on generic drugs. Override requires “Dispense AsWritten.”

Incentive Fee: None..


Cognitive Services: Does not pay for cognitive services


!"#$%&&'(((%)#*+,-+*%$#,+.+#/01%2#$#%#/$344#*%+/

5-/-6#*%,-$#%+/%7889:%%;3/#%$#,#+"#*%.<-$5-,=%1#$"+,#1

0<$3>6<%5-/-6#*%,-$#.

F. STATE CONTACTS


Rick Detwiller, R.Ph.Administrator, Pharmacy ServicesDepartment of Human Services600 East Boulevard Avenue, Dept. 325Bismarck, ND 58505-0261701/328-4023Fax 701/328-1544

Pat Kramer, R.Ph.Director, Utilization ManagementPharmacy Services, Medical ServicesDepartment of Human ServicesState Capital600 East Boulevard AvenueBismarck, ND 58505-0261701/328-4893

DUR Board

Mark Biel, R.Ph.517 W. Reno Ave.Bismarck, ND 58504701/223-0936

Patricia M. Churchill, R.Ph.103 West Ave. BBismark, ND 58501701/663-5188



Gregory L. Culver, M.D.Towner County MedCenterP.O. Box 579Cando, ND 58324701/968-3337

Community Practice Medical Resident(rotational contact: Susan Thompson)UND Family Practice Center515 Broadway AvenueBismarck, ND 58501701/328-9950

Delbert J. Hlavinka, M.D.MeritCare Mayville Clinic730 E Main StreetMayville, ND 58257701/786-4503

James H. Irsfeld, R.Ph.1042 West 4th AveDickinson, ND 58601701/225-4858

Karen K. Iverson, R.Ph.Student Health Service PharmacyNorth Dakota State UniversityPO Box 5313Fargo, ND 58105-5313701/231-7332

Anthony T. Johnson, M.D.102 Mandan Ave.Mandan, ND 58554701/667-5005

Marty Meese, Pharm.D., R.Ph.St. Alexis Pharmacy900 East BroadwayBismarck, ND 58501701/224-7378

Pierre Rioux, MD307 5th Ave SoutheastMinot, ND 58701701/852-0735

Ex-Officio MembersPatricia A. Kramer, R.Ph.Director, Utilization ManagementMedical Services, DHS600 East Boulevard Ave, Dept 325Bismarck, ND 58505-0261701/328-4893

Joseph Cleary, M.D.Medical ConsultantND Department of Human ServicesState Capitol - Judicial WingBismarck, ND 58505-0250701/328-2321

Rick Detwiller R.Ph.Administrator, Pharmacy ServicesMedical Services, DHS600 East Boulevard Ave, Dept 325Bismarck, ND 58505-0261701/328-4023


Technical: Rick Detwiller, 701/328-4023Policy: Rick Detwiller, 701/328-4023DUR: Pat Kramer, 701/328-4893PA: Pat Kramer, 701/328-4893


Carol OlsonExecutive DirectorND Dept. of Human ServicesCapitol BuildingBismarck, ND 58505

LeRoy BollingerAdministratorResearch and Statistics

Dave ZentnerMedicaid Director

Department of Human Services AdvisoryCommittees

Medical Care Advisory CommitteeJon Rice, M.D.State Health OfficerState Health Department600 East BoulevardBismarck, ND 58505701/328-2372

Joseph W. Cleary, M.D.104 Seminole AvenueBismarck, ND 58501

Robert A. Schindler, D.D.S.Northbrook Mall1929 N. WashingtonBismarck, ND 58501701/223-3694


National Pharmaceutical Council North Dakota-4

Howard Anderson, R.Ph.PO Box 70Turtle Lake, ND 58575701/448-2542

Delores Farrell401 North 14th StreetBismark, ND 58501

Patricia Carlson172 Boise AvenueBismarck, ND 58504701/222-1822

Arne Springan, O.D.1203 Oahe BendBismarck, ND 58504

Christine BeckerHCO4 Box 12Mandan, ND 58554701/663-2659

Commission on Socio-Economic AffairsRobert F. Szczys, M.D., ChairmanGrand Forks Clinic Ltd.Grand Forks, ND 58206

Russel J. Kuzel, M.D., Vice ChairmanDakota Clinic Ltd.Fargo, ND 58103

Bipin B. Amin, M.D.Mid Dakota ClinicBismarck, ND 58502

William W. Barnes, M.D.307 5th Avenue, SEMinot, ND 58701

Norman E. Bystol, M.D.Dakota Clinic Ltd.Fargo, ND 58108

James R. Carpenter, M.D.Meritcare Medical GroupFargo, ND 58123

Stanley T. Diede, M.D.Heart and Lung ClinicBismarck, ND 58502

Harold W. Evans, M.D.Grand Forks Clinic Ltd.Grand Forks, ND 58206

Gregory A. Gapp, M.D.Grand Forks Clinic Ltd.Grand Forks, ND 58206

Stephen H. Goldberger, M.D.Grand Forks Clinic Ltd.Grand Forks, ND 58206

Genevieve M. Goven, M.D.Meritcare Clinic Valley CityValley City, ND 58072

Mark B. Hart, M.D.The Bone and Joint CenterBismack, ND 58504

George H. Hilts, M.D.Dakota Eye InstituteBismarck, ND 58504

Mark O. Jensen, M.D.300 Main AvenueFargo, ND 58103

Donald R. Lamb, M.D.100 4th Street, S., Ste. 504Fargo, ND 58103

Gregory J. Post, M.D.Meritcare Medical GroupFargo, ND 58123

David A. Rinn, M.D.Towner County MedcenterCando, ND 58324

Pierre A. Rioux, M.D.307 5th Avenue, SE Ste. 300Minot, ND 58701

Thomas R. Templeton, M.D.Great Plains ClinicDickinson, ND

Brian C. Willoughby, M.D.West River Health ClinicsHettinger, ND 58639

Councilors AssignedDavid H. Lane, M.D.Anesthesia Associates Ltd.Grand Forks, ND 58208

Larry E. Johnson, M.D.Dakota Clinic Ltd.P. O. Box 1980Jamestown, ND 58402



Pharmacy Advisory Committee

Robert L. Treitline, Chair941 9th Avenue WestDickinson, ND 58601

Anton P. Welder, R.Ph.P.O. Box 835Bismarck, ND 58502

Doreen M. Beiswanger, R.Ph1140 SE 6 Street, Unit 10Valley City, ND 58072

David L. Just, R.Ph.P.O. Box 99Beulah, ND 58523

David J. Olig, R.Ph.2400 32nd Avenue SouthFargo, ND 58103

DuWayne Schlittenhard, R.Ph.3408 Par StreetFargo, ND 58102

Mary Beth Reinke, R.Ph.3530 SW 28 #301Fargo, ND 58104

Cindy Yeager, R.Ph.Box 9512Fargo, ND 58108


North Dakota Medical AssociationCathy RydellExecutive Vice President204 W. Thayer AvenueP.O. Box 1198Bismarck, ND 58502-1198701/223-9475

North Dakota Pharmaceutical AssociationGalen JordreExecutive Vice PresidentP.O. Box 5008, 405 E. BroadwayBismarck, ND 58502-5008701/258-9312

State Board of PharmacyHoward AndersonExecutive DirectorP. O. Box 1354Bismarck, ND 58502-1354701/328-9535

North Dakota Association of Osteopathic Physicians andSurgeonsJames WolffExecutive Director736 BroadwayFargo, ND 58123701/234-2400

North Dakota Hospital AssociationArnold R. ThomasPresident1120 College DriveP.O. Box 7340Bismarck, ND 58507-7340701/224-9732


National Pharmaceutical Council Ohio-1

OHIO




Prescribed Drugs





Physician Services




CATEGORICALLY NEEDY CASH TOTAL 40,749,264 149,166Aged 1,225,142 915Blind 16,198 12Disabled 13,101,026 6,316Children-Families w/Dep. Children 13,637,456 100,354Adults-Families w/Dep. Children 12,769,439 41,569

CATEGORICALLY NEEDY NON-CASH TOTAL 718,160,037 645,270Aged 261,686,553 134,410Blind 1,363,558 815Disabled 403,254,744 194,524Children-Families w/Dep. Children 32,170,912 233,067Adults-Families w/Dep. Children 17,540,711 72,849Other Title XIX Recipients 2,143,557 9,605

MEDICALLY NEEDY TOTAL 0 0Aged 0 0Blind 0 0Disabled 0 0Children-Families w/Dep. Children 0 0Adults-Families w/Dep. Children 0 0Other Title XIX Recipients 0 0



2-Ohio National Pharmaceutical Council

C. ADMINISTRATION

Ohio Department of Job and Family Services.


Benefit Design

Drug Benefit Product Coverage: Products covered underDME/med supply program: prescribed insulin; totalparenteral nutrition; interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs;experimental drugs; disposable needles and syringecombinations used for insulin; urine ketone test strips; andblood glucose test strips. Prior authorization required for:Ceredase; Cerebyx; Cerezyme; Clorazepates; Depo-Provera; Enbrel; immunoglobulins; Lioresal Intrathecal;Lodosyn; Methadone; Nascoral; Orgaran; OxandrinPanretin; Periostat; Priftin; Prolastin; Proleukin; Provigil;Psoralens; Rebetin; Remicade; Piluter; Rituxan; Stimate;Synagis; and Targretin.

OTC Coverage: Selected coverage for: allergy, asthma,and sinus products; analgesics; feminine products;smoking deterrent products; cough and cold preparations;non-H2 antagonist digestive products; digestive products,H2 antagonists; and topical products.

Therapeutic Category Coverage: Therapeutic categoriescovered: analgesics, antipyretics, NSAIDs; antibiotics;anticoagulants; anticonvulsants; anti-depressants;antidiabetic drugs; antihistamine drugs; antilipemicagents; anti-psychotics; anxiolytics, sedatives, andhypnotics; cardiac drugs; chemotherapy agents; prescribedcold medications; contraceptives; ENT anti-inflammatoryagents; estrogens; hypotensive agents; prescribed smokingdeterrents; sympathominetics (andrenergic); and thyroidagents. PA required for: anabolic steroids and growthhormones. Therapeutic categories not covered: anorectics;innovator multi-source drugs; certain antibiotics (last-linetherapies); selected high-risk drugs like (e.g., Accutane);and drugs used in special settings (e.g., outpatienthospital).





Formulary: Closed formulary with approximately 38,000NDC-specific trade and generic drugs. Products excludedinclude obesity, fertility, and experimental drugs.

Prior Authorization: Prior authorization is needed forcertain individual drugs (listed above).


Prescription Refill Limit: 11 for non-controlled drugs upto one year. Thirteen for birth control drugs up to oneyear. Five for Scheduled III, IV, V drugs up to sixmonths. None for Scheduled II drugs.

Monthly Quantity Limit: Maximum of 34-day supply foracute and 102-dosage units for chronic maintenancemedications. Amount designated in Ohio Medicaid drugformulary.


PRODUR system implemented in Feb 2000. Statecurrently has a DUR Board with a quarterly review.



Ingredient Reimbursement Basis: EAC = WAC+11%.

Prescription Reimbursement Formula: Reimbursementfor legend drugs and selected OTC products based on thelowest of:

1. Provider’s submitted charge, which should reflectusual and customary charge to the general public;

2. WAC+11% plus a dispensing fee.

3. Federal- or state-established Maximum AllowableCost (MAC), for specifically designated genericallyequivalent drugs plus a dispensing fee.

Non-legend drugs - reimbursement is based onWAC+11% plus a dispensing fee, or MAC if applicable.

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





National Pharmaceutical Council Ohio-3


!""#$%&'()*+,-.//0111-$2-3*4&5(&4-#*5&"&*6)7-8*#**6#$++*4-&6-'(6(9*4-5(#*-&6-:;;;<--!++-#*5*&=*4-">(#'(5,7*#=&5*7-)>#$?9>-'(6(9*4-5(#*-"+(67.


• Butler Health Plan• ChoiceCare• Community Health Plan• DayMed• Dayton Area Health Plan• Emerald HMO, Inc.• Family Health Plan• Genesis Health Plan of Ohio• Health Care USA• Health Power• HealthFirst• HMO Health Ohio• Paramount Care, Inc.• Personal Physician Care• QualChoice Health Plan, Inc.• SummaCare, Inc.• SuperBlue HMO• SuperMed HMO• Total Health Care Plan• United Health Care

F. STATE CONTACT


Robert P. Reid, R.Ph.Administrator, Pharmacy Services UnitOhio Department of Job and Family ServicesBureau of Health Plan Policy30 East Broad St., 27th FloorColumbus, OH 43266-0423T: 614/466-6420F: 614/466-2908E-mail: [email protected]

Medicaid Department Officials

Jacqueline Romer-Sensky, DirectorOhio Department of Job and Family Services30 East Broad Street, 32nd Flr.Columbus, OH 43266-0423

Barbara C. Edwards, Deputy DirectorOffice of Medicaid

Robyn Colby, ChiefBureau of Health Plan Policy

Sheila Fujii, ChiefBureau of Medical Assistance65 E. State St., 4th FloorColumbus, OH 43215614/466-2365


Robert P. Reid, R.Ph.614/466-6420

DUR Contact

Jan LawsonDUR AdministratorSUR65 E. State St. 4th Fl.Columbus, OH 43215

DUR Board

Thomas E. Gretter, M.D.Stephen Baez, M.D.Jacob F. Palomaki, M.D.Beth T. Tranen, D.O.Rob Kubasak, R.Ph.Suzanne Eastman, R.Ph.Jill Orn, R.Ph.Donald Sullivan, Ph.D.


Robert P. Reid, R.Ph.614/466-6420


Technical: JD Salvatore, 614/728-3955Policy: Robyn Colby, 614/486-6420Audits: Robert Reid, 614/486-6420


First Health Services4300 Cox RoadGlen Allen, VA 23060Richmond, VA800/884-2822


Cynthia BurnellBureau ChiefManaged Health CareOhio Department of Job and Family Services65 E. State St., 3rd Fl.Columbus, OH 43266614/466-4693


4-Ohio National Pharmaceutical Council

Physician Administered Drug Program Contact

Robert Reid, R.Ph.Bureau of Health Plan Policy30 East Broad St., 27th FloorColumbus, OH 43266-0423T: 614/466-6420F: 614/466-2908


(2 vacancies pending)

Robert P. Reid, R.Ph., ChairmanBureau of Health Plan Policy30 East Broad Street, 27th FloorColumbus, OH 43266-0423

Suzanne Eastman, R.Ph., M.S.3922 North Cliff LaneCincinnati, OH 43220

Charles B. May, D.O.2467 Plymouth AvenueColumbus, OH 43209

Ruth E. Purdy, D.O.100 West Third AvenueColumbus, OH 43201

Susan Baker, APN137 OtterbeinLexington, OH 44904

Mary Jo Walker, M.D.2231 North High StreetColumbus, OH 43210

Walter J. Wielkiewicz, M.D.5190 Heritage DriveNashport, OH 43830

James Visconti, Ph.D.410 W. Tenth AvenueColumbus, OH 43210

Tammie J. Stroup, R.Ph.30 E. Broad Street, 27th Fl.Columbus, OH 43266-0423


Ohio State Medical AssociationD. Brent Mulgrew1500 Lakeshore DriveColumbus, OH 43204614/486-2401

Ohio Pharmacists AssociationErnest “Ernie” BoydExecutive Director6037 Frantz Road, Ste. 106Columbus, OH 43017614/798-0037

Osteopathic AssociationJon F. WillsExecutive Director53 W. 3rd AvenueP.O. Box 8130Columbus, OH 43201614/299-2107

State Board of PharmacyWilliam WinsleyExecutive Director77 S. High Street, 17th FloorColumbus, OH 43266-0320614/466-4143

Ohio Hospital AssociationJames CastlePresident155 E. Broad St.Columbus, OH 43215614/221-7614

Formulary Contact Person

Robert P. Reid, R.Ph.Bureau of Health Plan Policy30 E. Broad Street, 27th FloorColumbus, OH 43266-0423T: 614/466-6420F: 614/466-2908E-mail: [email protected]


National Pharmaceutical Council Oklahoma-1

OKLAHOMA




Prescribed Drugs





Physician Services




CATEGORICALLY NEEDY CASH TOTAL $74,745,255 101,910Aged $21,639,323 22,550Blind $385,479 481Disabled $46,695,570 41,968Children-Families w/Dep. Children $3,587,811 26,473Adults-Families w/Dep. Children $2,437,072 10,438

CATEGORICALLY NEEDY NON-CASH TOTAL $56,590,131 78,701Aged $34,623,534 21,563Blind $53,640 34Disabled $14,102,481 7,749Children-Families w/Dep. Children $6,317,934 42,627Adults-Families w/Dep. Children $1,487,083 6,671Other Title XIX Recipients $5,459 57

MEDICALLY NEEDY TOTAL $846,239 2,128Aged $169,914 166Blind $6,048 1Disabled $383,769 344Children-Families w/Dep. Children $180,111 1,197Adults-Families w/Dep. Children $102,784 380Other Title XIX Recipients $3,613 40

Source: HHS State HCFA-2082 Reports, Section A-4 and B-4.*1999 expenditures broken down by maintenance assistance and basis of eligibility are unavailable.


2-Oklahoma National Pharmaceutical Council

C. ADMINISTRATION

Oklahoma Health Care Authority.


Benefit Design

Drug Benefit Product Coverage: Products covered (DMEbenefit): prescribed insulin, disposable needles andsyringe combinations for insulin; blood glucose test strips;and urine ketone test strips. Products covered withrestrictions: total parenteral nutrition (reimburse singlemost costly ingredient). Products not covered: cosmetics;fertility drugs; and experimental drugs.

Over-the-Counter Product Coverage: Products covered:birth control. Products not covered: allergy, asthma andsinus products; analgesics; cough and cold preparations;digestive products, feminine products; topical products;and smoking deterrent products.

Therapeutic Category Coverage: Therapeutic categoriescovered: antibiotics; anticoagulants; anticonvulsants;antidepressants; antidiabetic agents; antilipemic agents;anti-psychotics; cardiac drugs; chemotherapy agents;contraceptives; ENT anti-inflammatory agents; estrogens;hypotensive agents; sympathominetics (adrenergic); andthyroid agents. Prior authorization required for:analgesics, antipyretics, NSAIDs; antihistamine drugs(partially covered); anxiolytics, sedatives, and hypnotics;growth hormones; misc. GI drugs; and prescribedsmoking deterrents (partially covered). Therapeuticcategories not covered: anabolic steroids; anorectics;prescribed cold medications; and OBRA ’90 Drugsidentified as coverage optional.

Coverage of Injectables: Injectable medicinesreimbursable through the prescription drug program whenused in home health care, extended care facilities andthrough physician payment when used in physicianoffices.

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




Prior Authorization: State currently has a formal priorauthorization procedure and DUR Board. AgencyGrievance process exists for appeal of prior authorizationdecisions or coverage of an excluded product.

Prescription or Dispensing Limitations

Prescription Refills: Shall be provided only if authorizedby the prescriber, no more than 1 year.

Monthly Quantity Limits: Three prescriptions permonth/recipient. ICF-MR, Medicaid children, andnursing home recipients are allowed unlimited orders.

Quantity Limit per Prescription: 34-day supply or 100units.


PRODUR system implemented in 1993 with a new systemin 2000. State currently has a DUR Board with a quarterlyreview.




Prescription Charge Formula: Estimated AcquisitionCost (EAC) plus dispensing fee, or usual and customarycharge, whichever is lower. In no event shall charges tothe Welfare Department exceed charges made to thegeneral public for the same prescription or item.

Maximum Allowable Cost: State imposes Federal UpperLimits. Override requires “Medically Necessary” or“Brand Medically Necessary.”


Patient Cost Sharing: Copayment is $1.00 forprescriptions up to $29.99, $2.00 for prescriptions over$30.00.



!""#$%&'()*+,-:;@0@@@-)$)(+-?64?"+&5()*4-6?'A*#-$23*4&5(&4-#*5&"&*6)7-8*#*-*6#$++*4-&6-3BC7-&6-DE-:;;;<F*5&"&*6)7-#*5*&=*-A*6*2&)7-)>#$?9>-'(6(9*4-5(#*-"+(67<


Community CareP.O. Box 3249Tulsa, OK 74033

Heartland100 North Broadway, Ste. 1400Oklahoma City, OK 73102-8601


National Pharmaceutical Council Oklahoma-3

Prime Advantage1602 SW 82nd St.Lawton, OK 73505

UnicareP.O Box 268985Oklahoma City, OK 73126

F. STATE CONTACTS


John M. Crumley, R.Ph., MHAPharmacy Programs DirectorOklahoma Health Care Authority4545 N. Lincoln, Ste. 124Oklahoma City, OK 73105T: 405/522-7325F: 405/522-7378E-mail: [email protected] Internet Address: www.ohca.state.ok.us


John M. Crumley, 405/522-7325

DUR ContactJohn M. Crumley, 405/522-7325

Medicaid DUR Board

Rick Crensaw, D.O.Dick Robinson, R.Ph.Dorothy Gourley, R.Ph.Cliff Meece, R.Ph.Gary Kirk, R.Ph.Cathy E. Hollen, R.Ph.Francois DuToit, M.D.Thomas Whitsett, M.D. (Chair)Dan McNeill, Ph.D., PA-C(Vacant position pending OSMA recommendation)


Angela ThomassonPharmacy Claims SpecialistOklahoma Health Care Authority4545N Lincoln Blvd, Ste. 124Oklahoma City, OK 73105-9901T: 405/522-7307F: 405/522-7378E-mail: [email protected]


Technical: Judi Worsham, 405/530-3222Policy: Jim Hancock 405/530-3268Director: Tom Simonson 405-522-7327


Laura Dickey-HottelDP Analyst/Planning Specialist IIIOklahoma Health Care Authority4545 N. Lincoln, Ste. 124Oklahoma City, OK 73105-7378T: 405/522-7228F: 405/522-7378E-mail: [email protected]


John M. Crumley, 405/522-7325


Kathe Eastham, R.NNurse Manager IIIOklahoma Health Care Authority4545 N. Lincoln, Ste. 124Oklahoma City, OK 73105-9901T: 405/522-7115F: 405/522-7378E-mail: [email protected]


Lynn Mitchell, M.D.Medical Director4545 N. Lincoln, Ste. 124Oklahoma City, OK 73105405/530-3365

Oklahoma Health Care Authority Officials

Michael Fogarty, J.D.Chief Executive OfficerOklahoma Health Care Authority4545 N. Lincoln, Ste. 124Oklahoma City, OK 73105

Michael Fogarty, J.D.State Medicaid Director4545 N. Lincoln, Ste. 124Oklahoma City, OK 73105

Darcedia McCauley, Ph.D.Director of Quality Assurance405/530-3355


4-Oklahoma National Pharmaceutical Council

Advisory Committee on Medical Care for PublicAssistance Recipients

Frank Wilson, III, M.D., Chairman4545 N. Lincoln, Ste. 124Oklahoma City, OK 73105

Executive Officers of State Medical,Pharmaceutical, and Osteopathic Societies

Oklahoma State Medical AssociationKathy Musson601 W. I-44 Service RoadOklahoma City, OK 73118405/843-9571

Oklahoma Pharmaceutical AssociationJohn D. Donner, Executive DirectorBox 18731Oklahoma City, OK 73154405/528-3338

Oklahoma Osteopathic AssociationBob E. Jones, CAEExecutive Director4848 N. Lincoln BoulevardOklahoma City, OK 73105-3321405/528-4848

State Board of PharmacyBryan H. PotterExecutive Director4545 N. Lincoln Boulevard, Ste. 112Oklahoma City, OK 73105405/521-3815

Oklahoma Hospital AssociationJohn C. CoffeyPresident4000 Lincoln BoulevardOklahoma City, OK 73105405/427-9537

Fiscal Agent

UNISYS405/841-3400


National Pharmaceutical Council Oregon-1

OREGON




Prescribed Drugs





Physician Services









2-Oregon National Pharmaceutical Council

C. ADMINISTRATION

Office of Medical Assistance Programs (OMAP),Department of Human Services.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin and syringe combinations used forinsulin (when insulin filled). Prior authorization requiredfor: isotretionoin; acute anti-ulcer drugs; cosmetics; totalparenteral nutrition; and interdialytic parenteral nutrition.Products not covered: fertility drugs; experimental drugs;disposable needles used for insulin; urine ketone teststrips; and blood glucose test strips.

Over-the-Counter Product Coverage: Products covered:analgesics; feminine products; and smoking deterrentproducts. Products requiring prior authorization andphysician prescription: allergy, asthma, and sinus; coughand cold preparations; digestive products (non-H2antagonist); digestive products (H2 antagonists); andtopical products.

Therapeutic Category Coverage: Therapeutic categoriescovered: Anabolic steroids; analgesics, antipyretics,NSAIDs; anorectics; antibiotics; anticoagulants;anticonvulsants; anti-depressants; antidiabetic drugs;antilipemic agents; antipsychotics; anxiolytics, sedatives,and hypnotics; cardiac drugs; chemotherapy agents;contraceptives; ENT anti-inflammatory agents; estrogens;hypotensive agents; prescribed smoking deterrents;sympathominetics (andrenergic); and thyroid agents.Therapeutic categories requiring prior authorization:selected antihistamine drugs; prescribed cold medications(selected products); growth hormones; selectedantifungals; legend laxatives; coal tar preparations; andmisc. GI drugs (selected products).

Coverage of Injectables: Injectable medicinesreimbursable through physician payment when used inphysician offices, home health care, and extended carefacilities.

Vaccines: Vaccines reimbursable by Medicaid as part ofthe Vaccines for Children Program.




Prior Authorization: State currently has a formal priorauthorization procedure. Client may request anadministrative hearing to appeal a prior authorizationdecision or to appeal the coverage of excluded products.


Monthly Quantity Limit: 34-day supply per Rx.




Dispensing Fee: $3.91 - $4.28, effective 10/01/00.

1) $4.05 for providers filling between 15,000 and 30,000 total prescriptions annually;

2) $4.05 for providers filling 1-15,000 or providersfilling between 15,000 and 30,000 with greater than20% Medicaid prescription volume annually;

3) $4.28 for providers filling 1-15,000 totalprescriptions annually with greater than 20%Medicaid prescription volume annually or providersoperating with a True or Modified Unit DoseDelivery System.


Prescription Charge Formula: Estimated acquisition cost(EAC) defined as the lesser of: (1) AWP - 11% (2) HCFAupper limits for multiple source drugs or (3) the usual andcustomary charge plus a dispensing fee.








Approximately 400,000 total unduplicated number ofMedicaid Recipients were enrolled in MCOs in FY 1999.Recipients received pharmaceutical benefits through bothstate and managed care plans.

Care Oregon, Inc522 SW Fifth Ave, Ste. 200Portland, OR 97204(800) 224-4840

Cascade Comprehensive Care, Inc.900 Main Street, Suit APO Box 217Klamath Falls, OR 97601-0368(541) 883-2947

Central Oregon Independent Health Services, Inc.2650 NE Courtney DriveP0 Box 5729Bend, OR 97708-5729(800) 431-4155

Deschutes County CDODeschutes County Human Services Dept.Alcohol and Drug Treatment Program409 NE Greenwood AveBend, OR 97701

Doctors of The Oregon Coast South (DOCS)750 Central, Ste. 202PO Box 1096Coos Bay, OR 97420(541) 269-7400

Douglas County IPA500 SE Cass, Ste. 210Roseburg, OR 97470(541) 677-3453

Family Care, Inc2121 SW Broadway, Ste. 300Portland, OR 97201(800) 335-3205

Intercommunity Health Network, Inc3600 NW Samaritan DriveCorvallis, OR 97330(800)757-5114

Kaiser Permanente500 NE Multnomah, Ste. 100Portland, OR 97232-2099(800) 813-2000

Lane Individual Practice Association, Inc. (LIPA)1500 Valley Rive Drive, Ste. 370Eugene, OR 97401(541) 485-2155

Mid Rogue IPA Health Plan820 NE 7th StreetGrants Pass, OR 97526(541) 471-4106

ODS Health Plans601 SW 2nd AvePortland, OR 97204(800) 342-0526

Oregon Health Management Services1051 NE 6th Street, Ste. 2CGrants Pass, OR 97526(541) 471-4208

Providence Health Plan1235 NE 47th, Ste. 220Portland, OR 97213-2196(800) 898-8174

Regence HMO Oregon201 High Street SEPO Box 12625Salem, OR 97309(800) 541-8981

Tuality Health Alliance335 SE 8th AvenuePO Box 925Hillsboro, OR 97123-0925(800) 681-1901

F. STATE CONTACTS


Jesse AndersonOffice of Medical Assistance Programs (OMAP)Department of Human Resources500 Summer Street, NESalem, OR 97310-1014T: 503/945-6492F: 503/373-7689E-mail: [email protected] Internet Address: www.omap.hr.state.or.us


4-Oregon National Pharmaceutical Council


Jesse Anderson, 503/945-6492

DUR Contact

Mariellen Rich, R.Ph.Pharmacist Account ManagerFirst Health Service Corporation565 Union St., NE, Ste. 205Salem, OR 97310T: 503/391-1980F: 503/391-1979E-mail: [email protected]

Medicaid DUR Board

Todd L. Anderson R.Ph., FASCPBudget Pharmacy2829 Barclay RoadMedford, OR 97504

Rickland G. Asai DMD2375 SW Cedar Hills Blvd.Portland, OR 97225

Beverly CastorOffice of Medical Assistance Programs500 Summer Street NESalem OR 97310-1014

Marshall D. Bedder M.D., F.R.C.P. (C)Advanced Pain Management Group2625 LovejoyPortland, OR 97210

Charlene Charroll Clark M.D.Oregon State UniversityMC: Student Health Center OSU Campus ShuttleCorvallis, OR 97330

Mariellen Rich R.Ph.First Health565 Union Street NE, Ste. 205Salem OR 97301 2460

William H. Wilson M.D.Oregon Health Sciences University3181 SW Sam Jackson Park RoadMC: UHN –79Portland, OR 97201-3098

John E. Launer R.Ph.South Salem Pharmacy925 Commercial Street Se Ste. 100Salem, OR 97302

James W. Winde, M.D.1212 Aspen DriveLa Grande, OR 97850

Dean Haxby, R.Ph., Ph.D.Oregon Health Sciences University3181 SW Sam Jackson Park Rd., GH212Portland, OR 97201-3098

Nancy Elder, MDDept of Family Medicine3181 SW Sam Jackson Park Rd.Portland, OR 97201


Kathy FrankilnCustomer Support DepartmentFirst Databank, Inc.1111 Bayhill Drive NESan Bruno, CA 94066T: 650/588-5454F: 650/588-4003E-mail: [email protected]


Audits: Jesse Anderson, 5033/945-6492Disputes: Becky Smith, 503/391-1981


Mariellen Rich, R.Ph., 503/391-1980


(Vacant Position)Delivery Systems ManagerOffice of Medical Assistance Programs500 Summer Street, NESalem, OR 97310-1014T: 503/945-6497F: 503/947-5221


Jesse Anderson, 503/945-6492


(Vacant Position)Office of Medical Assistance ProgramsDepartment of Human Resources500 Summer Street, NESalem, OR 97310503/945-6490



Office of Medical Assistance Officials

Gary WeeksDirectorDepartment of Human Services500 Summer Street, NESalem, OR 97310-1012503/378-2263

Hersh CrawfordDirectorOffice of Medical Assistance Programs

Title XIX Medical Care Advisory Committees

Micheal Bierman, DMDBruce BliatoutRita CatapanoDonna CrawfordMaryann CurryJames DavisRosemari FittsMichael GarlandJohn HoganDavid StroughRick Wopat, MD

Consultants to Health and Social ServicesSection

Joseph Intile, M.D.Medical DirectorOffice of Medical Assistance ProgramsDepartment of Human Resources500 Summer Street, NESalem, OR 97310

Pharmacy Advisory Task Force

Tom Holt, ChairmanMike Dardis, R.Ph.Jim Waletich, R.Ph.Ed Hughes, R.Ph.Ron Dulwick, R.Ph.Jenny Kudna, R.Ph.Dennis Perry, R.Ph.Larry Cartier, R.Ph.Richard Hartmann, R.Ph.Chris Vorrath, R.Ph.Susie Morris, R.Ph.Tom Hornsby, R.Ph.Kathy Ketchum, R.Ph.John Mansfield, R.Ph.Dave Lewis, R.Ph.Dave Walden, R.Ph.Cynthia Wong, R.Ph.

Executive Officers of State Medical andPharmaceutical Associations

Oregon Medical AssociationRobert L. Dernedde, CAEExecutive Director5210 SW Corbett StreetPortland, OR 97201503/226-1555

Oregon State Pharmaceutical AssociationTom HoltExecutive Director1460 State StreetSalem, OR 97301-4296503/585-4887

Osteopathic Physicians and Surgeons of OregonJeff HeatheringtonExecutive Director2121 SW Broadway, Ste. 300Portland, OR 97201800/533-6776

State Board of PharmacyGary SchnabelExecutive DirectorState Office Bldg., Room 425800 NE Oregon St., #9Portland, OR 97232503/731-4032

Oregon Association of Hospitals and Health SystemsKenneth M. RutledgePresident4000 Kruse Way PlaceBuilding 2, Ste. 100Lake Oswego, OR 97035-2543503/636-2204


1-Pennsylvania National Pharmaceutical Council

PENNSYLVANIA




Prescribed Drugs





Physician Services




RECEIVING CASH ASSISTANCE, TOTAL $256,910,619 228,067Aged $59,380,437 41,206Blind / Disabled $176,079,255 105,477AFDC-Child $8,326,245 52,459AFDC-Adult $12,352,307 24,557AFDC-Unemployed-Child $223,436 2,450AFDC-Unemployed-Adult $548,939 1,918

MEDICALLY NEEDY, TOTAL $37,074,413 41,741Aged $31,035,505 19,173Blind / Disabled $2,050,862 970AFDC-Child $3,404,034 18,857AFDC-Adult $584,012 2,741

POVERTY RELATED, TOTAL $100,959,436 172,023Aged $88,149,940 53,584Blind / Disabled $215,515 341AFDC-Child $11,368,722 105,835AFDC-Adult $1,225,209 12,263

OTHER $130,272,301 138,810

Source: HHS State HCFA-2082 Reports, Section A-4 and B-4.*1999 total and expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.


National Pharmaceutical Council Pennsylvania-2

C. ADMINISTRATIONOffice of Medical Assistance, Department of PublicWelfare.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations used for insulin; blood glucose test strips;urine ketone test strips; interdialytic parenteral nutrition;and total parenteral nutrition. Products not covered:cosmetics; fertility drugs; and experimental drugs.

Over-the-Counter Product Coverage: Products covered:analgesics; feminine products; topical products; laxatives;oral electrolytes; allergy, asthma, and sinus (indication orprescribed); cough and cold preparations (indication otherthan C+C on Rx); digestive products (not including H2antagonists) (legend products only); and digestiveproducts (H2 antagonists) (PA > 90 days at acute dose). Products not covered: smoking deterrent products.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; analgesics, antipyretics,NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamine drugs;antilipemic agents; anti-psychotics; anxiolytics, sedatives,and hypnotics; cardiac drugs; chemotherapy agents;contraceptives; ENT anti-inflammatory agents; estrogens;growth hormones; hypotensive agents; misc. GI drugs;sympathominetics (adrenergic); and thyroid agents. Partially covered: prescribed cold medications.Therapeutic categories not covered: anorectics (unless fortreatment of hyperkinesis or narcolepsy); and prescribedsmoking deterrents.


Vaccines: Vaccines reimbursable at AWP – 10% as partof the Medical Assistance, Children Health InsuranceProgram, and the Vaccines for Children Program.




Prior Authorization: State currently has a priorauthorization procedure screening for drug classes andindividual drugs. Products that require PA include BMNbrand name drugs that have A-rate generics, anti-ulcerdrugs, and drugs for erectile dysfunction.


Quantity Limit: Not to exceed a 34-day supply or 100units, whichever is greater.

Refill Limit: Up to 5 within 6 months.


PRODUR system implemented in June 1993. DUR Boardhas 9 members (plus 1 vacancy) and meets quarterly.





1. Payment for single source drugs and thosemultisource brand name drugs certified as medicallynecessary will be the lower of the EAC dispensing feeor the pharmacy's usual and customary charge.

2. State MAC for the drug plus dispensing fee or thepharmacy's usual and customary charge.

3. For compound prescriptions, an additional fee of$1.00 is allowed to a pharmacy, bringing the totaldispensing fee to $5.00.

Maximum Allowable Cost: State imposes Federal UpperLimits as well as state-specific limits on generic drugs. 667 drugs are listed on the state-specific MAC list. Override requires “Brand Medically Necessary” or“Brand Necessary,” plus prior authorization.


Patient Cost Sharing: Copayment is $1.00. Thecopayment will not apply to those recipients who arefederally exempt, under 21 years of age, pregnancy casesand long-term care patients, plus patients receiving drugsin the following categories:

− Anticonvulsants− Antidiabetic agents− Antiglaucoma agents− Antihypertensive agents− Antineoplastic agents− Antiparkinson agents− Cardiovascular preparations− HIV/AIDS specific drugs− Psychotherapeutic agents





!""#$%&'()*+,[email protected]?64?"+&5()*4-3*4&5(&4-#*5&"&*6)78*#*-*6#$++*4-&6-'(6(9*4-5(#*-&6-:;;;<--!++-#*5*&=*4">(#'(5,-7*#=&5*70-4*"*64&69-$6-)>*&#-5()*9$#,-$2(77&7)(65*0-)>#$?9>-'(6(9*4-5(#*!


AmeriHealth HMO/Mercy Health Plan 18,3341901 Market Street, 45th FloorPhiladelphia, PA 19103

Keystone Mercy Healthplan 217,733200 Stevens Drive, Ste. 900Philadelphia, PA 19113-1570

Oaktree/Oxford Health Plan 57,501The Curtis Center, Ste. 900Independence Square WestPhiladelphia, PA 19106

Healthcare Management Alternatives 71,970The Wanamaker Building100 Penn Square East, Ste. 900Philadelphia, PA 19107

Health Partners of Philadelphia/Partnership 119,024841 Chestnut St. Ste. 900Philadelphia, PA 19107

Three Rivers Health Plans/MedPlus 115,318300 Oxford DriveMonroeville, PA 15146

UPMC Health Plan, Inc./Best 73,776Healthcare of Western PAOne Chatam Center112 Washington PlacePittsburgh, PA 15219

Gateway Health Plan 147,454Two Chatum Ctr, Ste. 500Pittsburgh, PA 15219

PhilCare Health Systems, Inc./Pennsylvania 19,103HealthMATE2005 Market Street, Ste. 500Philadelphia, PA 19103

F. STATE CONTACTS


Joseph E. Concino, R.Ph..Office of Medical Assistance ProgramsP.O. Box 8046Harrisburg, PA 17105T: 717/772-6341F: 717/772-6366

Welfare Department Officials

Feather O. HoustounSecretaryDepartment of Public WelfareHealth and Welfare BuildingHarrisburg, PA 17120

Peg J. Dierkers, Ph.D.Deputy Secretary for Medical Assistance Programs

Christopher P. Gorton, M.D.Medical Director

Robert KellyDirectorDivision of Data and Claims Management

Jeffrey BechtelDirectorBureau of Program Integrity

Suzanne LoveDirectorBureau of Policy, Budget, and Planning

Guy L. Ridge, IIIActing DirectorBureau of Fee-for-Service Programs

Christine M. BowserDirectorBureau of Managed Care Operations

Andrew MajorDirectorBureau of Long Term Care Programs

William M Peifer, R.Ph.Pharmacy ConsultantPharmacy Services Section

John Ferrara, R.Ph.DirectorDivision of Program Integrity



DUR Board

Richard D. Baltz, M.D.3028 Market StreetCamp Hill, PA 17011

Richard T. Bell, M.D.Chairman2016 Redwood AvenueWyomissing, PA 19610

Richard W. Sloan, M.D.Thomas Hart Family Practice CenterYork Hospital1001 South George StreetYork, PA 17405

Otto F. Wolke, R.Ph.Geisinger Health PlanGeisinger Office BuildingDanville, PA 17822

Patricia A. Keys, Pharm.D.1514 Scenery Ridge DrivePittsburgh, PA 15241

Marshall P. Burnside, R.Ph.6000 Bell RoadHarrisburg, PA 17111

Michael A. Zemaitis, Ph.D., R.Ph.133 Shadowlawn DrivePittsburgh, PA 15261

Bruce Pollock, M.D.7032 Meade PlacePittsburgh, PA 15208

Robert J. Kordella, R.Ph.145 Stilwell CourtMt. Lebanon, PA 15228


First Data Bank1111 Bayhill DriveSan Bruno, CA 94066800/633-3453


Technical: David Ehrhart, 717/772-6305Policy: Suzanne Love, 717/772-6142Disputes: Vacant, 717/772-6341


EDS275 Grandview AvenueCamp Hill, PA 17011(Calls with contractor must be made through stateagency.)


Michael JacobsDirector, Division of MCO Monitoring and ComplianceOffice of Medical Assistance ProgramsCherrywood Bldg, DPW Complex #2Harrisburg, PA 17105717/772-6977

Expanded Drug Coverage Program Contact

Thomas SneddenPACE ProgramPA Dept. of Aging555 Walnut St., 5th Fl.Harrisburg, PA 17101717/787-7313

Medical Assistance Advisory Committee

Peter D. ArcheyPA Association of Area Agencies on Aging4701 Devonshire Rd Ste. 102Harrisburg, PA 17109

Shirley BeerArmstrong County Low Income Rights OrganizationRD, #8, Box 134Kittanning, PA 16201724/543-5031

Kent D.W. Breams, M.D.Department of Family PracticeUniversity of Pennsylvania2 Gates, HUP, 3400 Spruce StreetPhiladelphia, PA 19104215/614-0523

Louise BrookinsPhiladelphia Welfare Rights4358 N. Franklin StreetPhiladelphia, PA 19122214/455-3497

Kevin CaseyPennsylvania Protection and Advocacy1414 Cameron Street, 2nd FloorHarrisburg, PA 17103717/236-8110



Michael D. ChambersCounty commissioners Association of Pennsylvania17 North Front StreetHarrisburg, PA 17101717/232-7554

Cindy W. Christian, M.D.The Children’s Hospital of Philadelphia34th Street and Civic Center Boulevard, Room 2416Philadelphia, PA 19104215/590-2058

Barbara CoffinPennsylvania Association of Area Agencies on AgainBerks County Office of AgingCounty Services Center633 Court StreetReading, PA 19601-4303610/478-6500

C. Lu ConserPennsylvania Community Providers Association2400 Park DriveHarrisburg, PA 17110717/657-7078

Barbara J. CusterClarion County Welfare Rights Organization4096 Master RoadEmlenton, PA 16373814/797-0060

Peg Dierkers (Ex-Officio Co-Chair)Pennsylvania Department of HealthOffice of Policy, Health and Welfare Building,Room 515Harrisburg, PA 17120

Shelley EppleyPennsylvania Mental Health Consumers Association4105 Derry StreetHarrisburg, PA 17111717/564-4930

Henry R. FiumelliExecutive DirectorPennsylvania Forum for Primary Health Care1017 Mumma Road, Ste. 209Wormleysburg, PA 17043717/761-6443 ext. 203

William L. Greene, R.Ph.Pennsylvania Pharmaceutical Association2020 Union BoulevardAllentown, PA 18103610/433-7577

Kathy HubertPennsylvania County Drug and AlcoholProgram Administrators17 North Front StreetHarrisburg, PA 17107717/232-7554

Christine KlejbukPA Assn. Non-Profit Homes for the AgingDir. of Public Policy4720 Old Gettysburg Road, Ste. 409Mechanicsburg, PA 17055717/763-5724

Sefi Knoble, M.D.Pennsylvania Medical Directors AssociationPhiladelphia, PA 19131215/581-0705

Kimberly KocklerVice-ChairManaged Care Association of Pennsylvania240 North Third Street, Ste. 203P.O. Box 12108Harrisburg, PA 17108-2108717/238-2600

Beverly MackerethHealthy York County Coalition1001 S. George StreetYork, PA 17405-7198717/851-2333

Donald McCoyPennsylvania Medical Society777 East Park DriveP.O. Box 8820Harrisburg, PA 17105-8820717/558-7823

Kearline McKellar-JonesHealth Partners841 Chestnut Street, Ste. 900Philadelphia, PA 19107215/991-4063

Richard R. OrlandiPennsylvania Medical Society777 East Park DrivePO Box 8820Harrisburg, PA 17105-8820717/558-7750



Kenneth J. PiercePennsylvania State Welfare Rights Organization119 Camp AvenueBraddock, PA 15104412/271-1426

Charles Pruitt, Jr.Seniorcare Solutions LLC1215 Hulton RoadOakmont, PA 15139412/826-6100

Mary Ellen RehrmanNational Alliance for the Mentally Ill2149 N. Second StreetHarrisburg, PA 17110717/268-1514

Virginia SchierscherHAP4750 Lindle RoadP.O. Box 8600Harrisburg, PA 17105-8600717/657-1222

David E. Shapter, D.D.S.Pennsylvania Dental Association4934 Peach StreetErie, PA 16509814/868-8673

Michael A. Yantis, Jr.Pennsylvania Department of Health Office of PolicyRoom 808, Health and Welfare BuildingHarrisburg, PA 17120717/787-4525

Dawn Guzik StockerGateway Health PlanTwo Chatham Center, Ste 500Pittsburgh, PA 15219412/255-4569

Jessie RohnerPA State Nurses Association2578 Interstate DriveHarrisburg, PA 17106717/657-1222

Executive Officers of State Medical andPharmaceutical Associations

Pennsylvania Medical SocietyRoger F. MecumExecutive Vice President777 E. Park DriveHarrisburg, PA 17105-8820717/558-7750

Pennsylvania Pharmaceutical AssociationCarmen A. DiCello, R.Ph.Executive Director508 North Third StreetHarrisburg, PA 17101-1199717/234-6151

Pennsylvania Osteopathic Medical AssociationMario E.J. LanniExecutive Director1330 Eisenhower BoulevardHarrisburg, PA 17111717/939-9318

Pennsylvania Podiatry AssociationNancy SullivanAssistant Executive Director757 Poplar Church RoadCamp Hill, PA 17011717/763-7665

State Board of PharmacyW. Richard MarshmanExecutive Secretary124 Pine St.P.O. Box 2549Harrisburg, PA 17105-2649717/783-7157

Hospital Association of PennsylvaniaCarolyn F. ScanlanPresident, CEO4750 Lindle RoadP.O. Box 8600Harrisburg, PA 17105-8600717/564-9200


1-Rhode Island National Pharmaceutical Council

RHODE ISLAND




Prescribed Drugs





Physician Services









National Pharmaceutical Council Rhode Island-2

C. ADMINISTRATION

State Department Human Services.


Benefit Design

Drug Benefit Product Coverage: Products not covered:DESI drugs; smoking cessation drugs; drugs for hairgrowth; and fertility drugs. Prior authorization requiredfor: anorexants; central nervous system stimulants forrecipients over 21 years of age; brand name vitamins; andhematinics and lipotropic preparations (selling for over$10 per 100 tablets/capsules or pint).

Over-the-Counter Product Coverage: analgesics; coughand cold preparations; and digestive products.


Vaccines: Limited coverage.





Prescription Refill Limit: Refills to a maximum of five areallowed for specified drugs: anti-hypertensives, diuretics,anti-convulsants, coronary vasodilators, tranquilizers,antidepressants, hormones, antibiotics, etc. Refills are notallowed for specified drugs, e.g., central nervous systemstimulants, narcotics (Schedule II, III), and pentazocine.

Monthly Quantity Limit: One month’s supply of drugs.

Maintenance Medication: The attending physician mayprescribe certain maintenance drugs of 100 tablets,capsules or pint of liquid or a 30-day supply of thesedrugs - whichever is greater.

Monthly Dollar Limits: None


PRODUR system implemented in December 1994.


Dispensing Fee: $3.40, effective in 1987.Dispensing fee for nursing homes = $2.85.

Ingredient Reimbursement Basis: EAC = WAC + 5%.


1. In accordance with federal regulation the upper limitfor payment for prescribed drugs will be based uponthe amount allowed by the Medical AssistanceProgram or the usual and customary charge to thegeneral public, whichever is lower.

2. Payment for over-the-counter drugs (non-legenddrugs) will be based upon the lower of either theallowable cost of the drug plus 50 percent, the usualand customary charge to the general public, or theallowable cost plus the professional fee for service.

Maximum Allowable Cost: State imposes Federal UpperLimits on generic drugs. Override requires “Dispense asWritten” or “Brand Medically Necessary.” Documentation must be submitted with a medical reasonwhy a generic cannot be used.





3(6(9*4-5(#*-#*5&"&*6)7-#*5*&=*-">(#'(5*?)&5(+-A*6*2&)7)>#$?9>-'(6(9*4-5(#*-"+(67<


− United Healthcare of New England− Coordinated Health Partners, Inc.− Neighborhood Health Plan of Rhode Island− Harvard/Pilgrim Healthcare of New England

F. STATE CONTACTS


Paula Avarista, R.Ph.Chief of PharmacyDepartment of Human Services600 New London AvenueCranston, RI 02920401/462-2183


3-Rhode Island National Pharmaceutical Council

Rhode Island DUR Board

Kimberly McDonough, Pharm.D.ChairpersonAdvanced Pharmacy Concepts, Inc.52 Grinnell StreetJamestown, RI 02835401/423-2542

Dr. James BurrillCo-Chairperson135 Cass AvenueWoonsocket, RI 02895401/765-3135

Paul Avarista, R.Ph.Chief of Pharmacy Rhode Island Department of Human Services600 New London AvenueCranston, RI 02920401/464-2183

Craig Bowen, Pharm.D.405 Lapham Farm RoadPascoag, RI 02859401/568-2536

Anne Hume, Pharm.D.233 Lepes RoadPortsmouth, RI 02871401/729-2760

Peter Jussila, RPH10 Henry Brown RoadWest Greenwich, RI 02817-2469401/397-6371

Peter Kogut, R.Ph.Harvard Pilgrim Health Plan1 Hoppin StreetProvidence, RI 02903401/331-3000 x.42150

John Pagliarini, R.Ph.Regional Director/Government ProgramsMedco Containment Services, Inc.One Gateway Center, Ste. 804Newton, MA 02158617/969-5371

John Stoukides, M.D.Roger Williams Medical Center825 Chalkstone AvenueProvidence, RI 02903401/456-2000

Dr. Craig WindermanHarvard Pilgrim Health Plan1 Hoppin StreetProvidence, RI 02903401/331-4034 x.42276

David Yoburn, M.D.1076 North Main StreetProvidence, RI 02904401/861-7711


Technical: EDSPolicy: Paula Avarista, 401/462-2183DUR: Paula Avarista, 401/462-2813PA: Paula Avarista, 401/462-2813


Don Sullivan600 New London AvenueCranston, RI 02910401/464-2176


Christine FergusonDirectorDepartment of Human Services600 New London AvenueCranston, RI 02920

John YoungAssociate DirectorMedical ServicesDepartment of Human Services600 New London AvenueCranston, RI 02920


Rhode Island Medical SocietyNewell E. Warde, Ph.D.Executive Director106 Francis StreetProvidence, RI 02903401/331-3207

Rhode Island Pharmaceutical AssociationDonald FowlerInterim Executive Director500 Prospect StreetIndependence SquarePawtucket, RI 02860401/725-4141


National Pharmaceutical Council Rhode Island-4

Society of Osteopathic Physicians and SurgeonsRobert Salk, D.O.PresidentP.O. Box 2344Woonsocket, RI 02895401/647-9150

State Board of PharmacyNorman PhelpsAdministrator3 Capitol HillRoom 304Providence, RI 02908-5097401/277-2837

Hospital Association of Rhode IslandGerald G. McClurePresidentWeld BuildingSecond Floor880 Butler DriveSte. OneProvidence, RI 02906401/453-8400


1-South Carolina National Pharmaceutical Council

SOUTH CAROLINA




Prescribed Drugs





Physician Services

Dental Services 1See Appendix E, page E-29, for a list of acronyms.Medically Needy Program was discontinued effective October 1, 1992.



RECEIVING CASH ASSISTANCE, TOTAL $120,899,672 156,910Aged $35,789,672 33,696Blind / Disabled $74,950,233 68,329AFDC-Child $4,327,091 36,715AFDC-Adult $5,833,129 18,170AFDC-Unemployed-Child $0 0AFDC-Unemployed-Adult $0 0



OTHER $20,177,225 67,193



National Pharmaceutical Council South Carolina-2

C. ADMINISTRATION

South Carolina Department of Health & Human Services.


Benefit Design

Drug Benefit Product Coverage: Products covered:cosmetics; fertility drugs; experimental drugs; bloodglucose test strips; urine ketone test strips; total parenteralnutrition; and interdialytic parenteral nutrition. Productsnot covered: prescribed insulin; disposable needles andsyringe combinations used for insulin.

Over-the-Counter Product Coverage: Products covered:smoking deterrent products. Products covered withrestrictions: allergy, asthma and sinus products;analgesics; cough and cold preparations; digestiveproducts (non-H2 antagonist); digestive products (H2antagonists); feminine products; and topical products.

OTC Coverage: The following OTC medications and theirgeneric equivalents are covered by the Medicaid programprovided the manufacturer rebates the pharmaceuticaldispensed. Federal or state upper limits of paymentrestrictions apply to several of these medications.

− Acetaminophen, all strengths and forms− Actifed Tablets− Alternagel Liquid− Ascriptin, All Strengths and Forms− Aspirin, All Strengths and Forms− Axid AR Tablets− Basaljel, All Strengths and Forms− Cerose DM Syrup− Contraceptive Condoms− Contraceptive Products (i.e., foams, creams, films)− Debrisan Beads− Dimenhydrinate Tablets/Liquid− Dimetane Extentabs− Gaviscon Tablets/Suspension− Gaviscon-2 Tablets− Hydrocortisone 0.5% Cream/Ointment− Insulin, all forms− Insulin Syringes− Iron Preparations− Routinely covered for females of childbearing age

and children− Maalox Tablets/Suspension− Maalox Extra Strength Suspension− Maalox Plus Suspension− Micatin 2% Cream− Multivitamins

− Routinely covered for females of childbearing age− Mylanta Tablets/Liquid− Mylanta Double Strength Tablets/Liquid− Niacin 50 mg Tablets− Niacin 100 mg Tablets− Parepectolin Suspension− Pepcid AC Tablets− Riopan Plus Tablets/Suspension− Robitussin AC− Robitussin DAC− Robitussin DM− Tagamet HB Tablets− Titralac Tablets− Zantac 75 Tablets

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; analgesics, antipyretics,NSAIDs; antibiotics; anticoagulants; anticonvulsants;antidepressants; antidiabetic agents; antihistamine drugs;antilipemic agents; anti-psychotics; anxiolytics, sedatives,and hypnotics; cardiac drugs; chemotherapy agents;prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones;hypotensive agents; misc. GI drugs; prescribed smokingdeterrents; sympathominetics (adrenergic); and thyroidagents. Therapeutic categories partially covered:anorectics.

Coverage of Injectables: Injectables reimbursable throughthe Prescription Drug Program when used in home healthcare, extended care facilities and though physicianpayment when used in physician offices.

Vaccines: Vaccines reimbursable based on CDC price aspart of the Vaccines for Children Program (age under 21).




With certain drug classifications excluded.

General Exclusions:

1. Anorexants.2. Investigational pharmaceuticals or products.3. Immunizing agents.4. Pharmaceuticals determined by the FDA to be less

than effective and identical, related, or similar drugs.5. Injectable pharmaceuticals administered by the

practitioner in the office in a clinic, or in a mentalhealth center (Synagis is reimbursable through thePhysician Services Program and is non-coveredthrough Pharmacy Services).

6. Fertility Products.7. Smoking cessation products whether legend or OTC.



8. Pharmaceuticals which are not rebated.9. Nutritional supplements which are administered

orally.10. Pharmaceuticals used for cosmetic purposes or hair

growth.

Prior Authorization: State currently has a formal priorauthorization procedure. To appeal a prior authorizationdecision, further documentation may be furnished to thepharmacy services program by the pharmacy provider.The pharmacist or physician may request coverage for thefollowing medications, which require specialauthorization (SA) by completing the SpecialAuthorization Request form and submitting it to theDepartment of Pharmacy Services:

1. Vitamins and vitamin combinations for the treatmentof vitamin deficiencies for male patients as well asfemale patients of non-childbearing age. Oral dosageforms of iron preparations, multivitamins (whetherlegend or OTC) and folic acid are routinely coveredfor females of childbearing age. Oral ironpreparations prescribed for children in the preventionand treatment of iron deficiency are routinelycovered. The category of oral iron preparationsincludes: ferrous fumarate, ferrous gluconate, ferroussulfate, and polysaccharide-iron complex. Specialauthorization is necessary in order for Medicaid toreimburse for vitamins and vitamin/mineralcombination products dispensed to children. Fluoridevitamins for children are routinely covered.

2. Compounded prescriptions when the primary or mostexpensive ingredient is NOT a routinely coveredproduct. Special authorization requests should not besubmitted for compounds that are commerciallyavailable in similar formulations.

3. Non-routinely covered OTC medications.

4. The following home-administered injectableproducts: Intravenous hydration therapies, injectableimmune serums, injectable vitamins, andSerostim.Immunosuppressants such as CellCept,Imuran, Neoral, Prograf, Sandimmune,Zenapax, and Simulect.

5. Prior Authorization: Medicare for a period of 36months from the date of discharge following ahospital stay during which the Medicare coveredorgan or tissue transplant surgery was performed.

6. Pharmaceutical products used to treat erectiledysfunction (ED) regardless of route ofadministration. This category of products currentlyincludes pharmaceuticals such as alprostadil andsildenafil citrate. Special authorization will only beconsidered for males, age 21 and older, diagnosedwith ED resulting from a defined organic cause,medical condition, and/or a specific disease. Special

authorization requests must be accompanied by acurrent, written statement from the prescriberdetailing: 1) patient’s diagnosis and prognosis, 2)documentation regarding the defined organic cause,medical condition, or specific disease state resultingin the patient’s condition, including, but not limitedto: age of the patient, date of onset of disease causingED, date of ED diagnosis, statement verifying that thepatient is not on nitrates, if requesting Medicaidreimbursement for sildenafil citrate.


Prescription Refill Limit: The prescriber authorizes thenumber of refills.

Monthly Quantity Limit: Children (birth to age 21) areallowed unlimited prescriptions per month. Recipientsover the age of 21 are limited to a maximum of fourprescriptions per month.

Quantity Limit per Prescription: 100-day supplymaximum. In chronic conditions and for maintenancedrugs, a minimum of a 30-day supply where appropriate.

Monthly Dollar Limit: None.


Plans are under development for PRODUR system. Statecurrently has a DUR Board with a monthly review.




Prescription Charge Formula: Medicaid reimbursementfor pharmacy services will be based on the lowest of: theEstimated Acquisition Cost (EAC); federal or statemaximum allowable cost (MAC); or the provider'ssubmitted usual and customary charge.

Maximum Allowable Cost: State imposes Federal UpperLimits as well as state-specific limits on generic drugs. Override requires “Brand Necessary” or “BrandMedically Necessary” handwritten certification by theprescriber.


Patient Cost Sharing: $2.00 copayment per prescription.



National Pharmaceutical Council South Carolina-4


!""#$%&'()*+,-.H0@@@-)$)(+-?64?"+&5()*4-6?'A*#-$23*4&5(&4-#*5&"&*6)7-8*#*-*6#$++*4-&6-3BC7-&6-DE-:;;;<F*5&"&*6)7-#*5*&=*-">(#'(5*?)&5(+-A*6*2&)7-)>#$?9>'(6(9*4-5(#*-"+(67<


Select Health of South Carolina, Inc.Patricia Marquis, Chief Operating OfficerP.O. Box 40024Charleston, SC 29403843/569-1759

F. STATE CONTACTS


James M. Assey, R.Ph.Pharmacy Services, DME & Legislative LiaisonS.C. Department of Health & Human ServicesP.O. Box 8206,Columbia, SC 29202-8206T: 803/898-2876F: 803/898-4517E-mail: [email protected] Agency Internet Address: www.dhhc.state.sc.us


Caroline Y. Sojourner, R.Ph.Department HeadDepartment of Pharmacy ServicesS.C. Department of Health and Human ServicesP.O. Box 8206Columbia, SC 29202-8206T: 803/898-2876F: 803/898-4517E-mail: [email protected]

DUR Contact

Caroline Y. Sojourner, 803/898-2876

DUR Committee

Gwendolyn Cambron, M.D.F. Joseph Hodge, R.Ph.Henry Rose, R.Ph.Leslie M. Stuck, M.D.Caroline Sojourner, R.Ph.Michele Burnett, R.Ph.Ira Horton, M.D.


First Data Bank, Inc.The Hearst Corporation1111 Bayhill Dr.San Bruno, CA 94066T: 650/588-5454F: 650/588-4003


Technical: Rod Davis, 803/898-2610Policy: James Assey, 803/898-2876DUR & PA: Caroline Sojourner, 803/898-2876Disputes: Kathy Bass, 803/898-2974


Rod DavisBureau Chief, Bureau of Information SystemsS.C. Department of Health and Human ServicesP.O. Box 8206Columbia, SC 29202-8206803/898-2610E-mail: [email protected]


Rosina BrownDepartment of Managed CareS.C. Department of Health and Human ServicesP.O. Box 8206Columbia, SC 29202-8206803/898-2650E-mail: [email protected]


Sharon ParkerS.C. Department of Health and Human ServicesP.O. Box 8206Columbia, SC 29202-8206803/898-3021E-mail: [email protected]


Mary BarnettS.C. Department of Health & Human ServicesP.O. Box 8206Columbia, SC 29202-8206803/898-2645



South Carolina Department of Health and HumanServices Officials

J. Samuel Griswold, Ph.D.DirectorSouth Carolina Department of Health & Human ServicesP.O. Box 8206Columbia, SC 29202-8206803/898-2500

Darlynn ThomasChiefBureau of Health Services803/898-2870

Caroline Y. Sojourner, R.Ph.Department HeadDepartment of Pharmacy ServicesSouth Carolina Department of Health and Human ServicesP.O. Box 8206Columbia, SC 29202-8206803/898-2876


South Carolina Medical AssociationWilliam F. MahonExecutive Vice President3210 Fernandina Rd.P. O. Box 11188Columbia, SC 29211803/798-6207

South Carolina Pharmacy AssociationJames R. BracewellExecutive Vice President1405 Calhoun Street, Ste. 200Columbia, SC 29201-2509803/254-1065

State Board of PharmacyCheryl A. RuffAdministrator, South Carolina Board of PharmacyP. O. Box 11927Columbia, SC 29211-1927803/898-4700

South Carolina Hospital AllianceKenneth A. Shull101 Medical CircleP.O. Box 6009West Columbia, SC 29171-6009803/796-3080


National Pharmaceutical Council South Dakota-1

SOUTH DAKOTA




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

1See Appendix E, page E-29, for a list of acronyms.+Renal Disease



RECEIVING CASH ASSISTANCE, TOTAL $17,382,625 18,645 $20,094,115 19,620Aged $2,111,867 1,976 $2,473,792 1,930Blind / Disabled $14,081,986 8,867 $15,974,007 8,857AFDC-Child $614,756 5,279 $769,033 5,747AFDC-Adult $572,236 2,504 $874,164 3,043AFDC-Unemployed-Child $489 8 $1,873 22AFDC-Unemployed-Adult $1,291 11 $1,246 21

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

POVERTY RELATED, TOTAL $1,677,158 14,610 $2,158,960 15,499Aged $0 0 $0 0Blind / Disabled $0 0 $0 0AFDC-Child $1,505,739 12,477 $1,964,103 13,506AFDC-Adult $171,419 2,133 $194,857 1,993

OTHER $12,046,728 13,333 $14,159,290 13,950

Source: HHS State HCFA-2082 Reports, Section A-4 and B-4.


2-South Dakota National Pharmaceutical Council

C. ADMINISTRATION

Department of Social Services, Office of MedicalServices.


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringecombinations used for insulin; blood glucose test strips;and urine ketone test strips. Products not covered:cosmetics; DESI drugs; fertility drugs; experimentaldrugs; total parental nutrition; drugs for impotence; andinterdialytic parenteral nutrition.

Over-the-Counter Product Coverage: Products notcovered: allergy, asthma and sinus products; analgesics;cough and cold preparations; digestive products; feminineproducts; topical products; and smoking deterrents.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; analgesics, antipyretics,NSAIDs; antibiotics; anticoagulants; anticonvulsants;antidepressants; antidiabetic agents; antihistamine drugs;antilipemic agents; anti-psychotics; anxiolytics, sedatives,and hypnotics; cardiac drugs; chemotherapy agents;contraceptives; ENT anti-inflammatory agents; estrogens;hypotensive agents; misc. GI drugs; sympathominetics(adrenergic); and thyroid agents. Prior authorizationrequired for: growth hormones. Therapeutic categories notcovered: anorectics; nutritional supplements; andprescribed smoking deterrents.

Coverage of Injectables: Injectable medicinesreimbursable through physician payment when used inphysicians offices, home health care, and extended carefacilities.

Vaccines: Vaccines reimbursable with HCPC code as partof the Vaccines for Children Program.




Prior Authorization: State currently has a formal priorauthorization procedure.


Prescription Dollar Limit: None.Monthly Quantity Limit: None.


PRODUR system implemented in 1998. State has a DURBoard with annual review.


Dispensing Fee: $4.75 to $5.55, effective 7/1/1991

Ingredient Reimbursement Basis: EAC = AWP-10.5%.

Prescription Charge Formula: Payment is the lower of:

1. FUL, state MAC plus a dispensing fee, or2. EAC plus a dispensing fee, or usual and customary

charge to the general public.



Patient Cost Sharing: Copayment is $2.00.



Does not use MCOs to deliver pharmacy services toMedicaid recipients.

F. STATE CONTACTS


Office of Medical ServicesMark Petersen, R.Ph.Department of Social Services700 Governors DrivePierre, SD 57501T: 605/773-3495F: 605/773-5246


Mark Petersen, R.Ph., 605/773-3495

DUR Contact

Mike Jockheck, R.Ph.Pharmacy ConsultantSD Dept of Social Services700 Governors Dr.Pierre, SD 57501605/773-6439E-mail: [email protected]


National Pharmaceutical Council South Dakota-3

Steering Committee (Medicaid DUR Board)

Damian Prunty (Program Administrator)Tom Carlson, R.Ph.Richard Holm, M.D.Pam Jones, R.Ph.Bruce Lushbough, M.D.




Technical/Policy: VacantDisputes/Audits:Helen RokusekRebate CoordinatorDept. of Social Services700 Governors DrPierre, SD 57501605/773-3653


Meredith HeermanDept. of Social Services700 Governors DrPierre, SD 57501T: 605/773-3495F: (605) 773-5246E-mail: [email protected]



South Dakota Medicaid Agency Officials

James EllenbeckerSecretaryOffice of Medical ServicesDepartment of Social Services700 Governors DrivePierre, SD 57501

Damian PruntyProgram AdministratorMedical Services

Medical Advisory Committee

Paul Engbrecht, ChairmanTieszen Memorial Home437 State StreetMarion, SD 57043605/648-3384

John Jones, Vice ChairmanDivision of Health, Medical & Laboratory ServicesHealth Laboratory Building615 E. 4th Streetc/o 500 E. Capitol AvenuePierre, SD 57501605/773-3737

Jud Bergan, O.D.103 South EaganMadison, SD 57042

Sheryl Petersen218 W. Third StreetPierre, SD 57501

James D. M. RussellHospital Admin.St. Mary's Hospital803 E. DakotaPierre, SD 57501605/224-3100

Herb McClellan, Jr., D.D.S.Box 189Mobridge, SD 57601-0189

Lynn GreffApothecary Shop at Medical Arts719 St. Francis StreetRapid City, SD 57701

Stephen Schroeder, M.D.Hand Co. clinicP.O. Box 287Miller, SD 57362

Michelle MillerMcKennan Home Health800 E. 21st StreetSioux Falls, SD 57105-1016

A.A. Lampert, M.D.13075 Bogus Jim RoadRapid City, SD 57702-9720

Evaluation Committee

V. R. Brandenburg, M.D.Dennis Hodge, Pharm.D.Helen Fiechtner, Pharm.D.Jane Mort, Pharm.D.James Clem, Pharm.D.Marc Aldrich (Physician)


4-South Dakota National Pharmaceutical Council


South Dakota State Medical AssociationRobert D. JohnsonChief Executive Officer1323 Minnesota AvenueSioux Falls, SD 57105605/336-1965

South Dakota Pharmaceutical AssociationRobert Coolidge, R.Ph.Secretary222 East Capitol, Box 518Pierre, SD 57501-0518605/224-2338

South Dakota Osteopathic AssociationDavid A. Lauer, D.O.Secretary-Treasurerc/o MASSA-Berry ClinicSturgis, SD 57785605/347-3616

State Board of PharmacyDennis JonesSecretary4305 S. Louise Ave., Ste. 104Sioux Falls, SD 57106605/362-2737

South Dakota Association of Healthcare OrganizationsFrank M. DrewPresident3708 Brooks PlaceSte. 1Sioux Falls, SD 57106605/361-2281


National Pharmaceutical Council Tennessee-1

TENNESSEE -- TennCare

In 1994, Tennessee made history by withdrawing from theMedicaid Program and implementing an innovative newhealth care reform plan called TennCare. TennCarereplaced the existing Medicaid Program with a program ofmanaged health care. TennCare required no new taxesand extended health coverage not only to the nearly800,000 Tennesseans in the Medicaid population, but alsoto an approximately 400,000 uninsured or uninsurablepersons using a system of managed care. Enrollment wasopen in 1994 to eligible persons in the uninsured,uninsurable, and Medicaid-eligible categories.

On January 1, 1995, TennCare reached 90% of its targetenrollment and closed enrollment in the uninsuredcategory. However, on April 1, 1997, enrollment in theuninsured category re-opened to children under the age of18 who do not have access to health insurance through aparent or guardian. On May 21, 1997, TennCareenrollment became available for eligible dislocatedworkers. Enrollment remains open to persons and theirdependents who have lost access to a COBRA insuranceplan and do not have access to other health insurance. Inan effort to expand coverage to more of Tennessee'suninsured children, the Bureau of TennCare openedenrollment on January 1, 1998 to uninsured Tennesseansunder the age of nineteen (19) with access to healthinsurance whose individual family incomes are below200% of the poverty level. Effective January 1, 1998,uninsured children under age nineteen (19) who meet theTennCare criteria for uninsured are being allowed toenroll in TennCare indefinitely. The Bureau of TennCareeliminated deductibles and limited co-payments to 2% forthese new eligibility populations and all uninsuredchildren under eighteen (18) years of age who enrolled inTennCare during previous open enrollment periods.Enrollment remains open to persons who are Medicaid-eligible or who are uninsurable as determined by aninsurance company's denial (for medical reasons) of healthinsurance to the individual. Current enrollment (5/30/00)is approximately 1,316,216, of which 795,968 areMedicaid eligibles and 520,248 are in theuninsured/uninsurable categories.

The State of Tennessee was granted approval by theHealth Care Financing Administration for a five-yeardemonstration project under Section 1115 of the SocialSecurity Act. State rules were promulgated to assist inadministering the statewide program (TSOP). The initialfive-year demonstration project ended December 31,1998. HCFA approved a waiver extension for three yearsbeginning January 1, 1999 through December 31, 2001.

TennCare services are offered through managed careorganizations (MCOs) and behavioral health organizations(BHOs) under contract with the State. These MCOs,spread out over the twelve regions of Tennessee, are paida fixed amount which averages $116 per enrollee permonth for the MCO services. BHOs are paid $319.41 forpriority participants and a variable rate for all otherTennCare enrollees and state onlys. The MCOs and BHOsnegotiate payment rates with individual providers.Enrollees have a choice of MCOs (and theircorresponding BHO partner plan) from those available intheir geographic area. Effective January 1, 1997, allservices are delivered within a strict "gatekeeper" modelsystem requiring primary care providers to manageenrollees' health care.

TennCare services, as determined medically necessary bythe MCO, cover inpatient and outpatient hospital care,physician services, prescription drugs, lab and x-rayservices, medical supplies, home health care, hospice care,and ambulance transportation. Excluded from TennCaremanaged care services are long-term care services andMedicare cross-over payments which are continuing asthey were under the former Medicaid system.

TennCare is financed by pooling current federal, state andlocal expenditures for indigent health care, which include$2.4 billion for the TennCare/Medicaid Program in the1998-99 fiscal year's budget. Pooled resources total$3.779 billion, including $226 million in local CertifiedPublic Expenditures. Within this budget, $1.418 billion isidentified as funding for long-term care programs, Homeand Community Based Services Waiver programs,Medicare cross-overs through the Medicaid system,Medicare premiums, and administration for the totalprogram. The remaining $2.361 billion has been identifiedto fund the current year of the TennCare Program. In thefuture, competition among managed care networks,combined with the enrollment cap, should enableTennCare to grow at a predictable rate not exceeding theannual rate of growth in state spending.

Source: TennCare Home Page on the World Wide Web,last updated 08/09/00. http://www.state.tn.us/tenncare/

ELIGIBILITY FOR TENNCARE COVERAGE

Currently, Medicaid eligible persons, children under age19 with no access to health insurance, dislocated workerswho previously had health insurance through employersand become uninsured due to a bona fide closure of abusiness or plant, and persons with proof ofuninsurability, are eligible for TennCare coverage. To


2-Tennessee National Pharmaceutical Council

provide proof of uninsurability, one must have a letter ofdenial from an insurance company, on company letterheadstationary, that is licensed in the State of Tennessee. TheTennCare applicant may then send in their applicationalong with a copy of this letter to the address provided onthe TennCare application.

Someone is not uninsurable if they cannot afford healthinsurance. Someone is not a dislocated worker if they arelaid-off or terminated at a plant that continues to operate.The Tennessee Department of Human Services makesdecisions for most Medicaid eligibility categories. TheSocial Security Administration makes decisions regardingeligibility for Medicaid for disabled individuals. TheTennessee Department of Labor determines bona fideclosures of businesses or plants. In some TennCareeligibility categories, persons may be eligible in caseswhere COBRA coverage is offered. In some TennCareeligibility categories, persons may not be eligible untiltheir opportunity to purchase COBRA coverage hasexpired. Contact the TennCare Hotline with questions.

A TennCare application can be received by calling theTennCare Hotline at 1-800-669-1851 or by visiting thelocal Tennessee Department of Health office. There is alocal Health Department office in every Tennesseecounty. For the applicants' convenience, the HealthDepartment will make a copy of the application, datestamp it, and keep it on file. If the applicant mails theapplication from their home, they should keep a copy fortheir personal files.

Source: TennCare Home Page on the World Wide Web,last updated 08/07/00. http://www.state.tn.us/tenncare/

A. ADMINISTRATION

Tennessee Department of Health, Bureau of TennCare

B. PROVISIONS RELATING TO DRUGS

Benefit Design

Pharmacy services are provided by the managed careorganizations. Pharmacy services are to be covered asmedically necessary, excluding DESI, less than effectiveand IRS drugs and some drugs for which TennCare doesnot mandate coverage (e.g., drugs for infertility, weightreduction, cosmetic purposes, hair growth products,products for symptomatic relief of cough and colds,smoking cessation products, and most OTCs). Growthhormone products and oral contraceptives requireapproval by the TennCare Prior Approval Unit. While theMCOs may participate in the drug rebate program, theState does not.

Formulary: Varying formularies used by the individualMCOs. Most are closed formularies. MCO formulariesmust conform to TennCare guidelines. TennCare mustapprove formulary additions/deletions.

Prior Authorization: Prior authorization procedures areadministered by the individual MCOs.

Copayment: Deductibles and copayments apply toservices other than preventive services (e.g.,immunizations) based on a sliding scale according toincome. Medicaid recipients and persons or families withincome under 100% of the federal poverty level are notrequired to pay premiums, deductibles, or copayments inorder to participate in the TennCare program.

C. USE OF MANAGED CARE

Medicaid recipients and the uninsured/uninsurable areenrolled in MCOs through the TennCare program. Allreceive pharmacy benefits through managed care.


Heritage National Health Plan of Tennessee, Inc. (John Deere Health Care/Heritage National Health Plan)Executive Tower I, Ste. 400408 N. Cedar Bluff RoadKnoxville, TN 37923

Memphis Managed Care Corporation(TLC Family Care Healthplan)P.O. Box 49Memphis, TN 38101

OmniCare Health Plan, Inc.1991 Corporate Ave. 5th FloorMemphis, TN 38132

Preferred Health Partnership of Tennessee, Inc.1420 Centerpoint Blvd.Knoxville, TN 37932

Tennessee Managed Care Network(Access...MedPlus)210 Athens WayNashville, TN 37228

Xantus Health Plan of Tennessee, Inc.3401 West End Ave., Ste. 470Nashville, TN 37203

VUMC Care, Inc.(VHP Community Care)210 Westwood Place, Ste 200Brentwood, TN 37027


National Pharmaceutical Council Tennessee-3

MCO/BHO "Partners"

Premier Behavioral Systems of Tennessee (800-325-7864)

• Blue Care (except in East Tennessee and KnoxCounty)

• John Deere Health Plan• OmniCare Health Plan• Xantus Gold• VHP Community Care

Tennessee Behavioral Health, Inc. (800-447-7242)• Access...Med Plus• Blue Care (in East Tennessee and Knox County)• Preferred Health Partnership (PHP)• Prudential Community Care• TLC Family Care Healthplan

D. STATE CONTACTS


Leo Sullivan, D.Ph.Director of Pharmacy ServicesBureau of TennCare729 Church StreetNashville, TN 37243T: 615/741-8155F: 615/532-3479

TennCare Officials

Karen Oldham, M.D., C.M.C.M.Chief Medical Officer, Bureau of TennCare729 Church StreetNashville, TN 37243T: 615/253-3262F: 615/741-0064

Susie BairdDirector of Programs

Ken Okolo, FACHEDirectory of Quality Oversight

Keith GaitherFiscal DirectorOffice of Business, Finance & Research

Joanna DamonsDivision of Long Term Care

TennCare Information Line800-669-1851


Consultec, Inc.T: 877/296-1935


– Director of the Bureau of TennCare– TennCare Medical Director– TennCare Pharmacy Director– TennCare Associate Medical Director– Associated Medical Director of the

TennCare Grievance Unit– Medical Director of the TennCare Grievance

Intervention Unit– One Public Health Physician– One Physician who is a TennCare

participating provider– One Pharmacist who is a TennCare

participating provider

Each MCO is required to have its own Pharmacy andTherapeutics Committee.

Pharmaceutical Care Advisory Board

A statewide TennCare Pharmaceutical Care AdvisoryBoard is being created. Board members are to beappointed by the Commissioner of Health.


Tennessee Medical AssociationDonald H. Alexander2301 21st Avenue, S.P.O. Box 120909Nashville, TN 37212-0909615/385-2100

State Board of PharmacyKendall M. Lynch, DirectorVolunteer Plaza, Second Floor500 James Robertson ParkwayNashville, TN 37243-1149615/741-2718


4-Tennessee National Pharmaceutical Council

Tennessee Osteopathic Medical AssociationCathy M. GarrisExecutive Director1900 The ExchangeSte. 380Atlanta, GA 30339404/955-5538

THS-An Association of Hospitals and Health SystemsCraig A. BeckerPresident500 Interstate Boulevard, S.Nashville, TN 37210-4634615/256-8240


National Pharmaceutical Council Texas-1

TEXAS




Prescribed Drugs





Physician Services



Expended Recipients Expended RecipientsTOTAL $817,591,112 1,894,447

RECEIVING CASH ASSISTANCE, TOTAL $484,567,470 804,227Aged $148,567,470 156,181Blind / Disabled $254,181,888 229,124AFDC-Child $41,448,918 265,634AFDC-Adult $34,025,698 116,765AFDC-Unemployed-Child $3,946,327 22,624AFDC-Unemployed-Adult $2,948,361 13,899

MEDICALLY NEEDY, TOTAL $9,740,942 25,564Aged $0 0Blind / Disabled $0 0AFDC-Child $3,806,777 6,185AFDC-Adult $5,934,165 19,379

POVERTY RELATED, TOTAL $103,719,857 708,576Aged $497,968 865Blind / Disabled $416,683 625AFDC-Child $92,122,948 597,641AFDC-Adult $10,682,258 109,445

OTHER $219,562,843 356,080

Source: HHS State HCFA-2082 Reports, Section A-4 and B-4.*1999 recipient data broken down by maintenance assistance status and basis of eligibility are unavailable.


2-Texas National Pharmaceutical Council

C. ADMINISTRATION

Texas Department of Health. Vendor drug program wasimplemented September 1, 1971.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles (pen needles only)and syringe combinations used for insulin. Products notcovered: cosmetics; fertility drugs; experimental drugs;total parenteral nutrition; and interdialytic parenteralnutrition; blood glucose test strips; urine ketone test strips. Prior authorization required for: human growth hormonesand dextramphetamines.

Over-the-Counter Product Coverage: Products covered:feminine products; topical products; allergy, asthma, andsinus products; analgesics; cough and cold preparations;digestive products (non-H2 antagonist); smoking deterrentproducts; digestive products (H2 antagonists). CertainOTC drugs are covered on a prescription basis except asotherwise provided in the reimbursement formula andvendor payment to hospitals, nursing homes andinstitutions.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; antibiotics; authorization:analgesics, antipyretics, NSAIDs; anticoagulants;anticonvulsants; anti-depressants; antidiabetic drugs;antihistamine drugs; antilipemic agents; antipsychotics;anxiolytics, sedatives, and hypnotics; cardiac drugs;chemotherapy agents; contraceptives; prescribed coldmediation; ENT anti-inflammatory agents; estrogens;hypotensive agents; misc. GI drugs; thyroid agents;prescribed smoking deterrents; and sympathominetics(adrenergic). Prior authorization required for: growthhormones. Therapeutic categories not covered: anorectics.

Coverage of Injectables: Injectable medicinesreimbursable through the Prescription Drug Programwhen used in home health care, extended care facilitiesand through physician payment when used in physiciansoffices.

Vaccines: Vaccines reimbursable as part of EPSDTservice, not under the Vendor Drug program.

Unit Dose: Unit dose packaging reimbursable only whenthere is not an added expense for the packaging.


Formulary: Open formulary; however, products must belisted in the Texas Drug Code Index. General exclusions(diseases, drug categories, etc.) include: amphetamines,appliances, durable medical equipment (bedpans, etc. -either rental or purchase), elastic stockings, first aidsupplies, medical supplies, oxygen, supports andsuspensories, and trusses.

Prior Authorization: Prior authorization procedurescreening for drug classes and individual drugs.


Prescription Refill Limit: Five refills, but total amountmay not exceed 6-month supply.

Monthly Quantity Limit: Prescribed quantity cannotexceed 6-month supply.

Monthly Prescription Limit: Limited to 3 per monthexcept for recipients under age 21 and nursing homerecipients.

Other Limit: Recipients in managed care pilots receiveunlimited prescription coverage.


PRODUR system implemented in February 1995. Statecurrently has a DUR board with a quarterly review.


Dispensing Fee: $5.27 +2%. The dispensing fee,including all costs of filling a prescription, wasestablished by cost accounting and service evaluation ofthe expenses involved in dispensing a prescription. Therefore, fees paid to providers who experience differentcost and service factors considered in arriving at the feemay receive more or less than actual costs incurred indispensing.

Ingredient Reimbursement Basis: EAC = AWP-15% orWAC + 12%, whichever is lower, AAC for hospitals andpublic health providers.

Prescription Charge Formula: Average dispensingexpense (ADE) formula for payment:

1. (EAC + 5.27) divided by 0.980 = amount paid +$0.15 delivery service.

2. DEAC only for Wyeth-Ayerst.

Insulin and approved non-legend drugs on prescription:pharmacists and dispensing physicians will be reimbursedon the basis of usual charges to the general public or cost


National Pharmaceutical Council Texas-3

plus 50% of cost, whichever is lower; 50% of cost not toexceed assigned variable dispensing fee.

Maximum Allowable Cost: State imposes Federal UpperLimits as well as state-specific limits on generic drugs. 465 drugs are listed on the state-specific MAC list. Override requires “Brand Necessary” or “BrandMedically Necessary.”





An undisclosed number of Medicaid recipients areenrolled in MCOs (all of whom are AFDC/AFDCrelated).


Physician Corporation of America8303 Mopac, Ste. 450Austin, TX 78759-8370

Vista, Inc.9310 North LomarAustin, TX 78753

Primary Care Case Management

F. STATE CONTACTS


Robert Harriss, DirectorTexas Department of Health1100 W. 49th StreetAustin, TX 78756T: 512/338-6961F: 512/338-6910


Reyn Archer, M.D.CommissionerTexas Department of Health1100 W. 49th StreetAustin, TX 78756

Linda WertzMedicaid DirectorTexas Health & Human Services CommissionP. O. Box 13247Austin, TX 78711512/502-3200

Debbie BlountDeputy Commissioner for Health Care Financing


Barbara Dean, R.Ph.Pharmacist IIITexas Department of Health1100 W. 49th StreetAustin, TX 78756-3174512/338-6920E-mail: [email protected]

Vendor Drug Program

Martha McNeill, R.Ph.Director, Product Enrollment DivisionTexas Department of Health1100 W. 49th StreetAustin, TX 78756-3174512/338-6965E-mail: [email protected]

Patsy Napier, R.Ph.Pharmacy Field Coordinator512/338-6992

DUR Contact

Curtis Burch, R.Ph.Director, Drug Utilization Review DivisionTexas Department of Health1100 W. 49th StreetAustin, TX 78756-3174T: 512/338-6922F: 512/338-6910E-mail: [email protected]

DUR Board

Robert Barr, M.D., R.Ph.Chairman2414 Florence AvenuePasadena, TX 77502

Leroy Knodel, Pharm.D., Vice ChairmanDrug Information ServiceDepartment of PharmacologyThe University of Texas Health Science Center7703 Floyd Curl DriveSan Antonio, TX 78284-7766

Thomas Lee Kurt, M.D., M.P.H.3645 Stratford AvenueDallas, TX 75205


4-Texas National Pharmaceutical Council

Mark S. Gittings, D.O., R.Ph.4327 Grants GlenWichita Falls, TX 76309

Robert L. Hogue, M.D.101 A South Park DriveBrownwood, TX 75801

Daniel Saylak, D.O.4607 LocksfordBryan, TX 77802

Mary Spies Maxwell, M.D.4526 Burnet RoadAustin, TX 78731

Adelina Barbosa, R.Ph.#10 Casa De PalmasBrownsville, TX 78521

Anita Martinez, R.Ph.2819 Burning HillSan Antonia, TX 78247

James B. Hills, R.Ph.Lava Rock Apothecary1907 E. Southmore StreetPasadena, TX 77502

Robert T. Reilly, Pharm.D.Thomason HospitalDepartment of Pharmacy4815 Alameda Avenue, P. O. Box 2009El Paso, TX 79998

W. Perry Flowers6607 Sandie Dr.Amarillo, RX 79109


Martha McNeill, R.Ph.512/338-6965

Medicaid Program Contacts

Technical: Matt Sneed, 512/231-5604 (claims)Policy: Patricia Gladden, 512/338-6967Rebate: Heather Murphy, 512/338-6963Claims: Patsy McElroy, 512/338-6909


Susan P. Milam, Ph.D.Chief, Bureau of Managed CareTexas Department of Health1100 W. 49th StreetAustin, TX 78756T: 512/794-6836www.tdh.state.tx.us/hcf/mcstart.htm


Rodger Love, Director1100 W. 49th StreetAustin, TX 78756-3168512/338-6505


Texas Medical AssociationJ. James Rohack, M.D.President401 W. 15th StreetAustin, TX 78701-1680512/370-1300

Texas Pharmaceutical AssociationLonnie Hollingsworth, R.Ph.Interim Executive DirectorP. O. Box 14709- 1624 E. Anderson LaneAustin, TX 78761-4709512/836-8350

Texas Osteopathic Medical AssociationTerry BoucherExecutive Director, Secretary/Treasurer1415 LavacaAustin, TX 78701-1634(512) 708-8662

State Board of PharmacyGay DodsonExecutive Director/SecretaryWilliam P. Hobby BuildingSte. 3-600333 Guadalupe St.Box 21Austin, TX 78701-3942512/305-8000

Texas Hospital AssociationTerry TownsendFACHE, CAE, President, CEO6225 US Highway 290 E.P.O. Box 15587Austin, TX 78761-5587512/465-1000


National Pharmaceutical Council Utah-1

UTAH




Prescribed Drugs





Physician Services




CATEGORICALLY NEEDY CASH TOTALAgedBlind/DisabledChildren-Families w/Dep. ChildrenAdults-Families w/Dep. Children

CATEGORICALLY NEEDY NON-CASH TOTALAgedBlind/DisabledChildren-Families w/Dep. ChildrenAdults-Families w/Dep. ChildrenOther Title XIX Recipients

MEDICALLY NEEDY TOTALAgedBlind/DisabledChildren-Families w/Dep. ChildrenAdults-Families w/Dep. ChildrenOther Title XIX Recipients



2-Utah National Pharmaceutical Council

C. ADMINISTRATION

Division of Health Care Financing, State Department ofHealth.


Benefit Design

Drug Benefit Product Coverage: Prior authorizationrequired for: Relenza; human growth hormones; and anti-ulcer drugs. Products not covered: hair growth products.

Over-the-Counter Product Coverage: Products covered:

− Acetaminophen, All dosage forms− Acetone tests (e.g., Acetest, Chemstrip-K, Ketostix)− Antacid liquid and tablets− Aspirin, All dosage forms− Contraceptive creams, foams, tablets and sponges− DSS caps liquid and syrup− DSS concentrate drops 5%− Ferrous fumerate, All dosage forms− Ferrous gluconate, All dosage forms− Ferrous sulfate, All dosage forms− Glucose blood tests (e.g., Chemstrip, BG, Dextrostix,

Visidex)− Glucose urine tests (e.g., Clinitest, Clinistix, Diatrix,

Tes Tape, Chemstrip G)− Insulin− Insulin syringes/needles/disposable− Kaolin w/pectin suspension (e.g., Kaopectate)− Lactobacillus acidophilus (e.g., Bacid, Lactinex)− Nutrients (all nutrients require prior approval)− Pedialyte liquid− Prophylactics male− Psyllium muciloid powder− Quinine, 5 gr.

Products not covered: vitamins (except for expectantmothers and children to age 5); smoking deterrentproducts; and

Therapeutic Category Coverage: Products not covered:anorectics (except for amphetamines and derivatives onlyfor specific indications of narcolepsy and hyperkinesis).

Coverage of Injectables: Injectable medicinesreimbursable when used in home health care, andextended care facilities, and through physician payment.

Vaccines: Vaccines reimbursable at AWP minus 12% plusa fee as part of the EPSDT service, Children HealthInsurance Program, and the Vaccines for ChildrenProgram.

Unit Dose: Manufacturer unit dose packagingreimbursable.



Prior Authorization: Prior authorization procedurescreening for individual drugs.


Prescription Refill Limit: Limited to five.

Monthly Quantity Limit: In general, the quantity ofmedication shall be limited to a supply not to exceed 30days.


PRODUR system implemented in June 1995.


Dispensing Fee: $3.90 for urban, $4.40 for rural, effective1993.


Prescription Charge Formula: Lowest of:

1. EAC/MAC plus a dispensing fee, or2. Usual and customary charges to the private sector for

legend and generic legend drugs.

Formula for OTCs is AWP minus 12% plus $1.00dispensing fee.



Patient Cost Sharing: Copayment = $1.00, maximum is$5.00 per month.



An unavailable number of Medicaid recipients areenrolled in managed care; however the number ofenrollees is listed for some of the following MCOs. Thepharmacy benefits are through the state.


National Pharmaceutical Council Utah-3


Altius10421 S. Jordan GatewaySouth Jordan, UT 84095

American Family Care2120 South 13th East #303Salt Lake City, UT 84106

IHC AccessP.O. Box 116670Salt Lake City, UT 84147

Med Utah HealthwiseP.O. Box 30804Salt Lake City, UT 84130-0804

PHS35 West BroadwaySalt Lake City, UT 84101

United Medchoice7910 South 3500 EastSalt Lake City, UT 84121

U of U Health Network35 W. BroadwaySalt Lake City, VT 84101

F. STATE CONTACTS


RaeDell AshleyPharmacy DirectorDivision of Health Care FinancingDepartment of Health288 N. 1460 WestSalt Lake City, UT 84114-2906T: 801/538-6495F: 801/538-6099

DUR Board

Dennis Beasley, R.Ph.76 North 1100 EastAmerican Fork, UT 84003801/756-5866

Lowry Bushnell, M.D.University of Utah Neuropsychiatric Institute501 Chipeta WaySalt Lake City, UT 84108801/584-2034

Carter BurkeHoechst Marion Roussel1912 Lawrence CircleSouth Jordan, UT 84065801/254-9026

Jeff Coursey774 5th AvenueSalt Lake City, UT 84103801/537-7219

Larry Dent, Pharm.D.11756 S. Briarglen DriveSandy, UT 84092801/571-4155

Terry Frank, R.Ph.Apothecary Shoppe1002 East South TempleSalt Lake City, UT 84102

Bradford D. Hare, M.D.Department of Anesthesiology50 North Medical DriveSalt Lake City, UT 84132801/585-7246

Jeff Jones, R.Ph.Riverton Drug1741 West 12600 SouthRiverton, UT 84065801/254-3911

Richard Martinez, D.D.S.2936 Highland DriveSalt Lake City, UT 84106801/467-6555

J. Brent Muhlestein, M.D.Department of CardiologyEighth Avenue and C StreetSalt Lake City, UT 84143801/321-5013

Lynda Oderda, Pharm.D.Assistant Professor (Clinical)Department of Pharmacy PracticeUniversity of Utah College of PharmacySalt Lake City, UT 84112801/581-6304

Rodney A. Pollary, M.D.Nighttime PediatricsAttention: Lynda Stuart7001 S. 900 E. Ste. 400Midvale, UT 84047-1761801/256-6483


4-Utah National Pharmaceutical Council

John M. Tudor, Jr., M.D.Cigna Healthcare of Utah5295 South 320 WestSte. 280Salt Lake City, UT 84107801/261-7502


Technical: RaeDell Ashley, 801/538-6495Policy: RaeDell Ashley, 801/538-6495PA: RaeDell Ashley, 801/538-6495DUR: Duane Parke, 801/538-6495


RaeDell AshleyDivision of Health Care FinancingDepartment of Health288 N. 1460 WestSalt Lake City, UT 84114-2906801/538-6495


Rod Betit, MDExecutive DirectorDepartment of Health288 N. 1460 WestSalt Lake City, UT 84116801/538-6151


Utah State Medical AssociationJ. Leon SorensonExecutive Director540 East 500 SouthSalt Lake City, UT 84102801/355-7477

Utah Pharmaceutical AssociationC. Neil JensenExecutive Director1062 East 21st St. S., Ste. 212Salt Lake City, UT 84106801/484-9141

Utah Osteopathic Medical AssociationT. Scott Smith, D.O.Secretary/Treasurer70 E. 1100 NRichfield, UT 84701801/896-8254

State Board of PharmacyTheresa Whitney160 E. 300 SouthP.O. Box 45802Salt Lake City, UT 84145801/530-6740

Utah Association of Healthcare ProvidersRichard B. KinnersleyPresident127 South 500 EastSte. 625Salt Lake City, UT 84102801/364-1515


National Pharmaceutical Council Vermont-1

VERMONT




Prescribed Drugs





Physician Services




RECEIVING CASH ASSISTANCE, TOTAL $19,492,508 19,702Aged $2,902,730 2,146Blind / Disabled $15,354,411 9,295AFDC-Child $450,223 5,058AFDC-Adult $723,299 2,754AFDC-Unemployed-Child $20,536 315AFDC-Unemployed-Adult $21,409 138

MEDICALLY NEEDY, TOTAL $4,238,401 4,630Aged $1,155,290 504Blind / Disabled $2,504,106 1,174AFDC-Child $207,975 1,378AFDC-Adult $371,029 1,274

POVERTY RELATED, TOTAL $13,092,099 24,197Aged $7,569,978 7,308Blind / Disabled $4,295,028 2,357AFDC-Child $875,242 9,514AFDC-Adult $351,851 5,018

OTHER $5,053,540 8,019

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.*1999 total and expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.


2-Vermont National Pharmaceutical Council

C. ADMINISTRATION

Agency of Human Services.


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringecombinations used for insulin; blood glucose test strips;urine ketone test strips; total parenteral nutrition; andinterdialytic parenteral nutrition. Products not covered:cosmetics and experimental drugs.

Over-the-Counter Product Coverage: Products coveredwith prior authorization: allergy, asthma and sinusproducts; analgesics; cough and cold preparations;digestive products (H2 antagonists); feminine products;topical products; and smoking deterrent products.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; analgesics, antipyretics,NSAIDs; anorectics; antibiotics; anticoagulants;anticonvulsants; anti-depressants; antidiabetic agents;antihistamine drugs; antilipemic agents; anti-psychotics;anxiolytics, sedatives, and hypnotics; cardiac drugs;chemotherapy agents; prescribed cold medications;contraceptives; ENT anti-inflammatory agents; estrogens;hypotensive agents; misc. GI drugs; sympathominetics(adrenergic); and thyroid agents. Prior authorizationrequired for: prescribed smoking deterrents.


Vaccines: Reimbursable at AWP minus 10% as part ofEPSDT service.



Formulary: Open formulary. General exclusions includecosmetics and experimental drugs.

Prior Authorization: Prior authorization procedurescreening for drug classes. PA is required for non-pregnancy multi-vitamins, smoking deterrents,amphetamines, food supplements, and OTC drugs.


Prescription Refill Limit: Up to 5 may be authorized by aphysician.

Monthly Quantity Limit: Initial prescription should besufficient to allow for the determination of the patient’stolerance of the medication without creating unnecessarywaste (expense) to the program. This quantity could beup to a 60-day supply on all maintenance medicationprescriptions.


PRODUR system implemented in November 1993. Statecurrently has a DUR board with a bimonthly review.



Ingredient Reimbursement Basis: EAC = AWP – 11.9%.

Prescription Charge Formula: Pharmacies bill their usualand customary charge. Medicaid pays the lower of:

1. Usual and customary charge;2. EAC plus a dispensing fee; or3. Maximum allowable cost plus a dispensing fee.

Maximum Allowable Cost: State imposes Federal UpperLimits and State-specific limits on generic drugs. Override requires “Dispense as Written.”


Patient Cost Sharing: Copayment of $1.00 perdispensation required (excluding standard federalexemptions). Copayment of $2.00 when ingredient costexceeds $29.99.


E. USE OF MANAGED CARE!""#$%&'()*+,-JI0J;.-)$)(+-3*4&5(&4-#*5&"&*6)7-(#**6#$++*4-&6-3BC7<--K$6*-#*5*&=*4-">(#'(5,-7*#=&5*7)>#$?9>-'(6(9*4-5(#*<-

F. STATE CONTACTS


Pat HouseOperations ManagerOffice of Vermont Health Access103 South Main StreetWaterbury, VT 05671T: 802/241-2765F: 802/241-2974E-mail: [email protected]


National Pharmaceutical Council Vermont-3

Agency of Human Services Officials

Jane M. KitchelSecretaryAgency of Human Services103 South Main StreetWaterbury, VT 05650-1201802/241-2880

Eileen ElliottCommissionerDepartment of Social Welfare

John DickPolicy & Procedures802/241-2880


Pat House802/241-2765

DUR Contact

Gloria JacobsOperations AdministratorOffice of VT Health Access103 S. Main St.Waterbury, VT 05671T: 802/241-2763F: 802/241-2974E-mail: [email protected]

DUR Board

John Low, R.Ph.Chairman10 Greenbriar Dr.Essex Junction, VT 05452

Richard Harvie, R.Ph.Brooks Pharmacy60 Main StreetMontpelier, VT 05602

Norman Ward, M.D.P.O. Box 1150Burlington, VT 05402

Dr. James Gray253 Stratton RoadRutland, VT 05701

Dennis Fortier, R.Ph.Pharmacy DepartmentSpringfield Hospital25 Ridgewood RoadSpringfield, VT 05156

Dr. Virginia HoodUVM, Nephrology UnitFAHC, Burgess 318111 Colchester AveBurlington, VT 05156


Christine DapkiewiczDrug Rebate Coordinator312 Hurricane LaneWilliston, VT 05495T: 802/879-4450F: 802/878-3440


Technical: Christine Dapkiewicz, 802/979-4450Policy: VacantDisputes: Shona M. Lothrop, 802/879-4450


EDSFiscal Agent312 Hurricane Lane, Ste 101Williston, VT 05495T: 802/879-4450F: 802/878-3440


Pat House802/241-2765


Shona Mossey-LothropPharmacy ConsultantEDS312 Hurricane Lane, Ste 101Williston, VT 05495T: 802/879-4450F: 802/878-3440E-mail: [email protected]


Pat House802/241-2765


Dr. Joseph JacobsMedical DirectorOffice of Vermont Health AccessDepartment of Social Welfare103 South Main StreetWaterbury, VT 05650-1201802/241-2745


4-Vermont National Pharmaceutical Council


Vermont Medical SocietyKaren MeyerExecutive Director136 Main StreetP.O. Box 1457Montpelier, VT 05602802/223-7898

Vermont Pharmacists AssociationFred DobsonExecutive DirectorP. O. Box 790Richmond, VT 05477802/434-3001

Vermont State Association of Osteopathic Physicians &Surgeons, Inc.John M. Peterson, D.O.Secretary-Treasurer72 Barre StreetMontpelier, VT 05602802/229-9418

State Board of PharmacyCarla PrestonSecretary of State’s OfficeOffice of Professional Regulation109 State Street, Pavilion Office BuildingMontpelier, VT 05609-1106802/828-2875

Vermont Hospital AssociationNorman E. WrightPresident148 Main StreetMontpelier, VT 05602802/223-3461


National Pharmaceutical Council Virginia-1

VIRGINIA




Prescribed Drugs





Physician Services

Dental Services All eligible recipients under age 211See Appendix E, page E-29, for a list of acronyms.








2-Virginia National Pharmaceutical Council

C. ADMINISTRATION

Department of Medical Assistance Services. Eligibilitydetermination by the Department of Social Services.


Benefit Design

Drug Benefit Product Coverage: Products not covered:fertility drugs; hair growth products; designated DESIdrugs; experimental drugs; non-legend drugs; and expireddrugs.

Over-the-Counter Drug Coverage: A majority of OTCdrugs reimbursable when used in nursing homes andcertain classes in outpatient populations.

Therapeutic Category Coverage: Prior authorizationrequired for: amphetamines and growth hormones.

Coverage of Injectables: Injectable medicinesreimbursable through physician payment when used inphysician offices (through physician payment), homehealth care, and extended care facilities.

Vaccines: Vaccines reimbursable based on HCPCS codeas part of the Health Department and Vaccines forChildren Program.

Unit Dose: Unit dose packaging reimbursable in nursinghomes.



Prior Authorization: Prior authorization procedurescreening for individual drugs.


Prescription Refill Limit: Physicians may authorize refillsaccording to legal requirements.

Monthly Quantity Limit: Physicians requested to prescribemaintenance drugs in quantities reflecting a 30-daysupply, or 100 units or doses.


PRODUR system implemented in July 1994.




Prescription Charge Formula: Based upon the lower ofMAC or EAC plus a fee if legend, or the usual andcustomary charge minus an applicable copayment.

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


Patient Cost Sharing: Copayment is $1.00/Rx for allqualifying prescriptions. Exclusions include less than 21years old, pregnancy related, family planning, and nursinghome patients.

Cognitive Services: Does not pay for cognitive services atpresent.


F*5&"&*6)7-#*5*&=*-">(#'(5*?)&5(+-A*6*2&)7-)>#$?9>'(6(9*4-5(#*-"+(67<

1) Medallion - primary care physicians,2) Options - optional enrollment for recipients into

HMOs, and3) Medallion II - mandatory HMOs in the Tidewater

region and the Richmond area.

F. STATE CONTACTS


David B. Shepherd, R.Ph.Pharmacy SupervisorDivision of Program OperationsDepartment of Medical Assistance Services600 East Broad Street, Ste. 1300Richmond, VA 23219T: 804/225-2773F: 804/786-0414


Policy: David Shepherd, 804/225-2773DUR: Marianne Rollings, 804/225-4268Disputes: Mike Beahm, 804/225-3359


Sally Rice804/786-9490


National Pharmaceutical Council Virginia-3

Department of Medical Assistance ServicesOfficials

Dennis SmithDirectorDepartment of Medical Assistance Services600 East Broad Street, Ste. 1300Richmond, VA 23219804/786-8099

Sally RiceManagerProvider RelationsDivision of Program Operations804/786-9490


Medical Society of VirginiaPaul KitchenExecutive Vice-President4205 Dover RoadRichmond, VA 23221-3267804/353-2721

Virginia Pharmaceutical AssociationRebecca SmeadExecutive Director5501 Patterson Ave., Ste. 200Richmond, VA 23226

State Board of PharmacyElizabeth Scott RussellExecutive Director6606 W. Broad Street, Ste. 400Richmond, VA 23230-1717804/662-9911

Virginia Osteopathic Medical AssociationPeter C. Gent, D.O.Secretary/Treasurer11900 Hull St. RoadMidlothian, VA 23112-2904804/744-3551

Virginia Hospital and Healthcare AssociationLaurens SartorisPresident4200 Innslake DriveGlen Allen, VA 23060P.O. Box 1394Richmond, VA 23294804/747-8600

Fiscal Intermediary

First Health ServicesP.O. Box 6987Richmond, VA 23230

Virginia Medicaid Pharmacy Liaison Committee(PLC)

Bill Hancock, R.Ph.PharmacistLong Term Care Pharmacy Coalition

Cindy Warriner, R.Ph.PharmacistCommunity Pharmacy Coalition

David Kozera, R.Ph.PharmacistVirginia Association of Chain Drug Stores

Rebecca Snead, R.Ph.PharmacistVirginia Pharmacists Association

Ellen FrankGovernment Relations Mtg.Pharmaceutical Research and Manufacturers of America


1-Washington National Pharmaceutical Council

WASHINGTON



OAA AB APTD AFDC OAA AB APTD AFDC Children <21* SFO

Prescribed Drugs





Physician Services

Dental Services 1See Appendix E, page E-29, for a list of acronyms.*Limited to children in foster care, subsidized adoption, SNH, IFC, ICMR or inpatient psychiatric facility.



RECEIVING CASH ASSISTANCE, TOTAL $150,637,488 149.823Aged $24,421,684 20,484Blind / Disabled $120,847,808 77,084AFDC-Child $1,203,115 21,981AFDC-Adult $3,447,197 21,817AFDC-Unemployed-Child $193,028 3,580AFDC-Unemployed-Adult $524,656 4,877

MEDICALLY NEEDY, TOTAL $21,855,285 10,368Aged $7,032,474 5,164Blind / Disabled $14,817,475 5,167AFDC-Child $4,148 25AFDC-Adult $1,188 12

POVERTY RELATED, TOTAL $2,687,631 27,700Aged $435,200 631Blind / Disabled $705,545 702AFDC-Child $1,052,246 17,157AFDC-Adult $494,640 9,210

OTHER $69,224,013 86,103



National Pharmaceutical Council Washington-2

C. ADMINISTRATION

Medical Assistance Administration, Department of Socialand Health Services.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin; disposable needles and syringecombinations for insulin; blood glucose test strips; urineketone test strips; total parenteral nutrition; andinterdialytic parenteral nutrition. Products requiring priorauthorization: Alzheimer drugs; MS drugs (betaseron);AIDS wasting drugs; non sedating histamines; andlaxatives. Products not covered: cosmetics; fertility drugs;DESI drugs; and experimental drugs.

Over-the-Counter Product Coverage: Products covered:digestive products (non-H2 antagonists) and smokingdeterrent products. Products covered with restrictions:allergy, asthma and sinus products (selected items);analgesics (ASA and Acetaminophen); cough and coldpreparations (selected items); feminine products (selecteditems); and topical products. Products not covered:digestive products (H2 antagonists).

Therapeutic Category Coverage: Therapeutic categoriescovered: antibiotics; anticoagulants; anticonvulsants;antidiabetic agents; antilipemic agents; cardiac drugs;chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents;sympathominetics (adrenergic); and thyroid agents. Therapeutic categories covered requiring priorauthorization: anti-depressants; antihistamine drugs; anti-psychotics; anxiolytics, sedatives, and hypnotics;prescribed cold medications; and misc. GI drugs. Therapeutic categories partially covered: anorectics. Therapeutic categories partially covered requiring priorauthorization: anabolic steroids; analgesics, antipyretics,NSAIDs; and growth hormones. Therapeutic categoriesnot covered: prescribed smoking deterrents and weightloss drugs.

Coverage of Injectables: Injectable medicinesreimbursable through the Physician Drug Program whenused in home health care, extended care facilities andthrough physician payment when used in physicianoffices.

Vaccines: Vaccines reimbursable at EAC as part ofEPSDT service.

Unit Dose: Unit dose packaging is reimbursable.



Prior Authorization: State currently has a priorauthorization procedure and a Drug Utilization andEducation Review Council. Recipients can request a fairhearing and exception to policy to appeal an excludedproduct or prior authorization decision.


Prescription Refill Limit: Two (2) refills in 30-day periodexcept for antibiotics, anti-asthmatics, Schedule II and IIIdrugs, anti-neoplastic, topicals, and any propoxyphene,which may have 4 refills.

Monthly Quantity Limit: No maximums, minimum of 34-day supply for maintenance medications.


PRODUR system implemented in March 1996. Statecurrently has a DUR Board with a bi-monthly review.


Dispensing Fee: $3.98 to $4.92, effective 7/1/99.

− $3.98 - Retail pharmacies, filling over 35,000 Rxsannually.

− $4.26 - Retail pharmacies, filling 15,000-35,000 Rxsannually.

− $4.92 - Retail pharmacies, filling 15,000 or less Rxsannually.

− $4.92 - Unit dose systems (nursing home Rxs).


Prescription Charge Formula: The amount shall notexceed the usual and customary charge to the public orEAC plus a dispensing fee. Any drug with more than 3labelers will be reimbursed according to the MaximumAllowable Cost.

Maximum Allowable Cost: State imposes State-specificlimits on generic drugs. Override requires “BrandMedically Necessary.”







Approximately 700,000 total unduplicated number ofMedicaid recipients were enrolled in MCOs in FY 1999.Recipients receive pharmaceutical benefits through thestate and managed care plans.


Aetna US Healthcare of Washington1400 One Union SquareSeattle, WA 98101

Clark United Providers/SWMD505 NE 87th Avenue, LL-46Vancouver, WA 98664800/325-7862

Community Health Plan of Washington401 Second Avenue, Ste. 400Seattle, WA 98104-2891800/444-1561

Group Health Cooperative12400 East Marginal Way SouthSeattle, WA 98111-3267206/901-4424

Kaiser Foundation HealthPlan of the Northwest500 NE Multnomah, Ste. 100Portland, OR 97232-2099800/813-2000

Kitsap Physician ServiceP.O. Box 339Bremerton, WA 98337800/552-7114

Northwest Washington Medical Bureau110 South 2nd

PO Box 699Mount Vernon, WA 98273-0699

Premera Blue CrossPO Box 327Seattle, WA 98111-0327

Qual-Med Health PlanP.O. Box 3387Bellevue, WA 98009-3387(2331 130th Ave. NE, Ste. 200Bellevue, Washington 98005)T: 800/423-9899F: 800/869-7175

Regence Blue Shield1800 Ninth AvenuePO Box 21267Seattle, WA 98111-3267206/464-3600

F. STATE CONTACTS


Siri Childs, Pharm D.Pharmacy Research SpecialistMedical Assistance Administration, DSHS805 Plum Street, SEP.O. Box 45506Olympia, WA 98504-5506T: 360/725-1564F: 360/664-3884E-mail: [email protected] Agency Address: http://maa.dshs.wa.gov


Siri Childs, 360/725-1564

DUR Contact


Department of Social and Health Services DrugUtilization and Education Council

Council MembersMarc Avery, M.D.2704 “I” Street, NEAuburn, WA 98002253/833-7444

Louis Saeger, M.D.2500 Cherry Street, Ste. 103Bremerton, WA 98310360/373-9026

Gerald N. Yorioka, M.D.Co-Chair805 164th SE, Ste. 100Mill Creek, WA 98012425/742-4242

Cara Marks, ARNP2025 1st Avenue, Ste. 790Seattle, WA 98121206/663-1808



Chris Wilkinson, PA-C833 NW 54th StreetSeattle, WA 98107206/783-2061

Teri L. Ferreira, R.Ph.13514 Lost Lake RoadSnohomish, WA 98296425/820-7600

Dana Hadfield, R.Ph.507 6th Avenue SouthEdmonds, WA 98020425/744-1793

Coordinating StaffTom K. Hazlet, Pharm.D., Ph.D.School of PharmacyUniversity of WashingtonP.O. Box 357630Seattle, WA 98195206/616-2732

Siri Childs, Pharm DDUR Program Coordinator805 Plum Street SEOlympia, WA 98504-5506360/725-1564

Joan BaumgartnerMedical ConsultantMAA, P.O. Box 45540Olympia, WA 98504-5540360/586-5274

Tim Fuller, R.Ph.Board of Pharmacy1948 Boyer Ave. EastSeattle, WA 98112360/753-6834

Support StaffJohnna Dodge206/586-5269

Drug Utilization and Education Council

Marc Avery, M.D.2704 “I” Street NEAuburn, WA 98002253/833-7444

Cara Marks, ARNP2025 First Ave., Ste. 790Seattle, WA 98121206/663-1808E-mail: [email protected]

Teri L. Ferreira, R.Ph.13514 Lost Lake RoadSnohomish, WA 98296425/820-7600E-mail: [email protected]

Louis Saeger, M.D.2500 Cherry, Ste. 103Bremerton, WA 98310360/373-9026E-mail: [email protected]

Chris Wilkinson, PA-C833 NW 54th StreetSeattle, WA 98107206/783-2061E-mail: [email protected]

Gerald N. Yorioka, M.D.805 – 164th SE, Ste. 100Mill Creek, WA 98012425/742-4242E-mail: [email protected]

Dana Hadfield, R.Ph.507 – 6th Avenue SouthEdmonds, WA 98020425/744-1793


Marilyn MuellerPharmacy Program ManagerMedical Assistance Administrator-DSHSP.O. Box 45506Olympia, WA 98504-5506360/725-1569E-mail: [email protected]


Manager: Sue Hilton, 360/586-7179Technical: Rich Boyesen, 360/586-2593Policy: Geo Sego, 360/753-4259Audits/Disputes: George Sego, 360/753-4259PA: Gini Egan 360/664-8140


Chris JohnsonClaims Processing ManagerMedical Assistance Administrator-DSHSP.O. Box 45506Olympia, WA 98504-5506T: 360/725-1067F: 360/586-4994E-mail: [email protected]




Diane WeedenDirectorDivision of Program Support- MAA/DSHS805 Plum St. S.E.Olympia, WA 98504-5506T: 360/725-1786F: 360/753-7315E-mail: [email protected]



Social and Health Services Department Officials

Lyle QuasimSecretaryDepartment of Social and Health ServicesPO Box 44Olympia, WA 98504

Tom BedellAssistant SecretaryMedical Assistance AdministrationP.O. Box 5500Olympia, WA 98504-5500

(Vacant)DRI Medical DirectorOffice of the Medical DirectorP.O. Box 5506Olympia, WA 98504-5506

Social and Health Services Department MedicalConsultants

Full-time:Joan Baumgartner, MDSam Salama, M.D.Nancy Anderson, M.D.Eric Houghton, M.D.

Part-time:James B. Hutchinson, DDS (Dental)Kevin Moss (Orthodontia)Jerrol R. Neupert, MD (Ophthalmology)

Department of Social and Health ServicesTitle XIX Advisory Committee

Janet Varon, Co-chair3303 E. HowellSeattle, WA 98122

Robert Wardell, Co-chair3815 N. Pearl Apt. K-1Tacoma, WA 98407

Elise ChayetHarborview Medical Center325 Ninth AvenueSeattle, WA 98104-2499

Ted Rudd, M.D.307 S. 12th Avenue #12Yakima, WA 98902

Andy AndersonFamily Health CenterP.O. Box 1340Okanogan, WA 98840509/422-1925

Errol Fife, DDS3999 EnglewoodYakima, WA 98902509/577-8277

Tom PriceP.O. Box 339Bremerton, WA 98337360/478-2608

Janene Jones-Heino12856 NE Central Valley RoadPoulsbo, WA 98370360/377-3753

Maxine Hayes, M.D.Department of HealthMS: 7880Olympia, WA 98504206/753-7021

Jane BeyerAssistant SecretaryMedical Assistance AdministrationP.O. box 45080Olympia, WA 98504-5080

Linda CastenPO Box 5200Tacoma, WA 98415-0200

Bonnie Kostelecky2000 Fort Vancouver WayVancouver, WA 98663



DSHS Staff MembersDebbie MeyerSecretaryMedical Assistance AdministrationP.O. Box 45080Olympia, WA 98504-5080

Pharmacy Drug Use Review Team Members

Siri Childs, Pharm.D.Gini Egan, R.N.Joan Baumgartner, M.D.Marilyn MuellerDebbie BellerudCeleste MooreJohanna DodgePatty Orth


Washington State Medical AssociationBob Perna Executive Director2033 Sixth Avenue, Ste. 1100Seattle, WA 98121206/441-9762

Washington State Pharmacists AssociationRod ShaferExecutive Director1420 Maple Avenue, Ste. 101Renton, WA 98055-3196206/228-7171

Washington Osteopathic Medical Association, Inc.Kathleen ItterExecutive DirectorP. O. Box 16486Seattle, WA 98116-0486206/937-5358

State Board of PharmacyDonald H. WilliamsExecutive DirectorDepartment of Health1300 Quince Street, SEP. O. Box 47863Olympia, WA 98504-7863360/753-6834

Washington State Hospital AssociationLeo F. GreenawaltPresident, CEO300 Elliott Avenue W., Ste. 300Seattle, WA 98119-4118206/281-7211


1-West Virginia National Pharmaceutical Council

WEST VIRGINIA




Prescribed Drugs





Physician Services




CATEGORICALLY NEEDY CASH TOTAL $115,591,878 152,428 $158,223,906 161,897Aged $30,914,085 21,877 $39,137,625 22,736Blind/Disabled $67,956,619 53,764 $98,120,814 59,192Children-Families w/Dep. Children $5,737,746 41,057 $7,672,107 42,241Adults-Families w/Dep. Children $8,792,794 24,769 $11,610,190 29,937AFDC Unemployed – Children (98) 690,594 5,584 $502,409 3,574AFDC Unemployed – Adult (98) $1,500,040 5,377 $1,180,758 4,217Other Title XIX Recipients $0 0 0 0

CATEGORICALLY NEEDY NON-CASH TOTAL - - $14,674,077 22,719Aged $399,304 321Blind/Disabled $12,610,179 8,880Children-Families w/Dep. Children $842,940 6,088Adults-Families w/Dep. Children $821,653 7,430Other Title XIX Recipients 0 0

MEDICALLY NEEDY TOTAL $3,652,798 3,544 $4,859,746 4,610Aged $306,383 312 $385,039 420Blind/Disabled $2,640,270 2,230 $3,781,126 3,027Children-Families w/Dep. Children $21,311 77 $18,428 81Adults-Families w/Dep. Children $684,834 925 $675,152 1,082Other Title XIX Recipients $0 0 0 0

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.


National Pharmaceutical Council West Virginia-2

C. ADMINISTRATION

Bureau for Medical Services, Department of Health &Human Resources.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin. Covered under DME program:disposable needles and syringe combinations used forinsulin; total parenteral nutrition; interdialytic parenteralnutrition; blood glucose test strips; and urine ketone teststrips. Products not covered: cosmetics; fertility drugs;and experimental drugs. Prior authorization required for:acute dosing of anti-ulcer medications, branded NSAIDS,Retin-A for adults, Ultram; ED drugs; and most injectablemedications.

Over-the-Counter Product Coverage: Products covered:feminine products and topical products. Selectedcoverage: allergy, asthma, and sinus products; analgesics;cough and cold preparations; digestive products (non-H2antagonist). Prior authorization for: smoking deterrentproducts. Products not covered: digestive products (H2antagonists).

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; antibiotics; anticoagulants;anticonvulsants; anti-depressants; antidiabetic drugs;antilipemic agents; antihistamine drugs; antipsychotics;anxiolytics, sedatives, and hypnotics (partial coverage);cardiac drugs; chemotherapy agents; contraceptives;prescribed cold mediation (partial coverage); ENT anti-inflammatory agents; estrogens; hypotensive agents; andthyroid agents. Therapeutic categories requiring priorauthorization: analgesics, antipyretics, NSAIDs; growthhormones; prescribed smoking deterrents; andsympathominetics (adrenergic). Therapeutic categoriesnot covered: anorectics; and hair growth products.

Coverage of Injectables: Injectable medicinesreimbursable when used in physician offices, home healthcare, and extended care facilities; most require priorapproval.




Formulary: Open formulary. General exclusions include:legend agents used for cosmetic purposes; DESI drugs.

Prior Authorization: Prior authorization procedurescreening for drug classes and home health care.


Prescriptions are limited to 10 per recipient per month. All covered outpatient drugs are reimbursed up to a 34-day supply and five refills.

Exceptions include:

1. Antibiotics are covered for a 14-day supply and onerefill.

2. Opiate agonists (excluding Schedule II drugs),analgesics and miscellaneous antipyretics are coveredfor 30 days and one refill.

3. Sedatives and hypnotics are covered for a 30-daysupply and one refill.




Dispensing Fee: $3.90, effective 1/1/96. For acompounded prescription, an additional $1.00 will beadded to the dispensing fee. A compound prescription isdefined as any legend medication requiring a combinationof any two or more substances to exclude normalreconstitution operations.


Prescription Charge Formula: Reimbursement based onthe lowest of:

1. The estimated acquisition cost (EAC) plus adispensing fee.

2. The maximum allowable cost (MAC) plus adispensing fee.

3. The usual and customary price charged by thepharmacy to the general public including any saleprice that may be in effect on the date of service.

4. Children under age of 18 years.

Maximum Allowable Cost: State imposes Federal UpperLimits on generic drugs. Override will require physiciancertification of “Brand Medically Necessary.”



3-West Virginia National Pharmaceutical Council

Patient Cost Sharing: Copayment varies - $0.50 to $2.00.Exclusions include:

1. Family planning services and supplies.2. Prescriptions originating with the Early and Periodic

Screening, Diagnosis and Treatment Program.

3. Nursing home residents.



!""#$%&'()*+,-::@0@@@-?64?"+&5()*4-3*4&5(&4-#*5&"&*6)78*#*-*6#$++*4-&6-3BC7-&6-:;;;<--K$6*-#*5*&=*4">(#'(5,-7*#=&5*7-)>#$?9>-'(6(9*4-5(#*<


Carelink Health Plans141 Summers SquareCharleston, WV 25301304/348-2041

The Health Plan of the Upper Ohio Valley52160 National Road, EastSt. Clairsville, OH 43950740/695-3585

Optimum Choice

Physician Assured Access System (PAAS)

F. STATE CONTACTS


Peggy A. King, R.Ph.Pharmaceutical CoordinatorWV Department of Human Services350 Capitol Street, Rm 251 Charleston, WV 25301-3707T: 304/926-1753F: 304/926-1993E-mail: [email protected]

Department of Health & Human ResourcesOfficials

Greg Clarke, M.D.Medical DirectorDivision of Medical CareWest Virginia Department of Human Services350 Capitol St., Rm 251Charleston, WV 25301-3707


Steve Small, R.Ph., M.S.Director, Rational Drug Therapy ProgramRobert C. Byrd Health Sciences CenterP.O. Box 9511Morgantown, WV 26506-9511800/847-3859E-mail: [email protected]

DUR Contact

Peggy A. King, R.Ph.T: 304/926-1753

Medicaid DUR Board

Steven C. Judy, R.Ph. (Chairman)Tom Robinette, R.Ph., M.S., Director, Pharm. Ser.Kevin W. Yingling, M.D.David P. Elliott, Pharm.D.Wallace Johnson, M.D.Bernard Lee Smith, R.Ph., MBA, MHAPatrick M. Regan, R.Ph.Karen Reed, R.Ph.Mary Nemeth-Pyles, M.S.N., R.N., C.S.Mitch Shaver, M.D.Myra Chiang, M.D.Matthew Watkins, D.O.John R. Vanin, M.D.Lester Labus, M.D.Ernest Miller, D.O.Carl Malanga, Ph.D.James M. Bennett, M.D.Kent Van Devender, PA-CLisa Hedrick, R.Ph.Daniel Dickman, M.D.


Leslie BrattonAccount ManagerConsultec, Inc.9040 Roswell Road, Ste 700Atlanta, GA 30350800/358-2381E-mail: [email protected]


Technical: Pharmacy Management Consultants, Inc.,304/558-1700Policy: Peggy A. King, 304/558-1753Rebate: Gail Goodnight, R.Ph., 304/558-1700


National Pharmaceutical Council West Virginia-4


Leslie Bratton800/358-2381


Randy MyersDirector, Office of Medicaid Managed CareBureau for Medical Services350 Capitol Street, Rm 251 Charleston, WV 25301-3708304/558-5974E-mail: [email protected]


Peggy A. King, R.Ph.T: 304/926-1753


Barbara WhiteWest Virginia Department of Human Services350 Capitol St., Rm 251Charleston, WV 25301-3707304/558-1700

Medical Services Fund Advisory Council

William A. Neal, M.D., ChairpersonMark B. Ayoubi, M.D.

Nursing Home RepresentativeJohn Elliot

Ex Officio Public Health MemberHenry Taylor, M.D.Commissioner, Bureau of Public Health

Consumer RepresentativeSheryl Kiser

MH/BH Health RepresentativeJohn RussellWest Virginia Behavioral Health Care ProvidersAssociation

Aging Program RepresentativeEarl JarvisChairKanawha Valley Senior Services

Home Health RepresentativeViolet BurdetteExecutive DirectorExtended Care, Inc.

Hospice RepresentativeCharlene FarrellExecutive DirectorHospice of Huntington, Inc.

Pharmacist RepresentativeWilliam McFarland, R.Ph.Loop Plaza Pharmacy

Consumer/Dental RepresentativeCharles Smith, D.D.S.

Hospital RepresentativeDan HoganAssistant Executive Director/CFOSt. Mary’s Hospital

Ex-Officio Bureau for Children and FamiliesRepresentativeJack FrazierCommissionerBureau for Children and Families


West Virginia State Medical AssociationGeorge Rider, Executive Director4307 MacCorkle Avenue SEBox 4106Charleston, WV 25364

West Virginia Pharmacists AssociationRichard D. Stevens, Executive Director2003 Quarrier St.Charleston, WV 25311

West Virginia Society of Osteopathic MedicineCharlotte Ann Cales PulliamExecutive DirectorP.O. Box 5266Charleston, WV 25361-0266

State Board of PharmacyWilliam T. Douglass, Jr.Executive Director236 Capitol StreetCharleston, WV 25301

West Virginia Hospital AssociationSteven J. SummerPresident100 Association DriveCharleston, WV 25311


1-Wisconsin National Pharmaceutical Council

WISCONSIN


Type of Benefit Categorically Needy Medically Needy (MN) Other*

OAA AB APTD AFDC OAA AB APTD AFDC Children <21 (SFO)

Prescribed Drugs





Physician Services




RECEIVING CASH ASSISTANCE, TOTAL $131,188,380 112,031Aged $15,629,581 14,671Blind / Disabled $113,162,140 78,454AFDC-Child $688,895 9,304AFDC-Adult $1,411,683 7,364AFDC-Unemployed-Child $66,343 881AFDC-Unemployed-Adult $229,718 1,357

MEDICALLY NEEDY, TOTAL $15,994,923 14,228Aged $6,454,692 5,408Blind / Disabled $9,336,436 4,489AFDC-Child $144,518 3,210AFDC-Adult $59,277 1,123

POVERTY RELATED, TOTAL $1,230,818 16,261Aged $466,539 727Blind / Disabled $0 0AFDC-Child $392,495 8,455AFDC-Adult $371,784 7,079

OTHER $83,881,774 78,454

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.*1999 expenditures are broken down by maintenance assistance status and basis if eligibility are unavailable.


National Pharmaceutical Council Wisconsin-2

C. ADMINISTRATION

State Department of Health and Family Services.


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin and syringe combinations for insulin.Products covered with restrictions: disposable needlesused for insulin (over 100/mo requires PA); blood glucosetest strips (over 100/mo requires PA); enteral nutrition(requires PA); alpha one proteinase inhibitors (requiresPA); urine ketone test strips (over 200/mo requires PA);total parenteral nutrition (must be billed as a compounddrug); and interdialytic parenteral nutrition (must be billedas a compound drug). Products not covered: cosmetics;fertility drugs; impotence treatment drugs; andexperimental drugs.

Over-the-Counter Product Coverage: Products coveredwith restriction: analgesics (not buffered); digestiveproducts (non-H2 antagonists) (general antacids); topicalproducts (generic antifungals, antibiotics, trocortisoneointment); insulin; ophthlubran; anti-lice; contraceptives;diphenhydramine; cough preps with/out DM; codeine;meclizine; psedoephed; and oral electrolyte replacementtherapy. Products not covered: allergy, asthma and sinusproducts; cough and cold preparations (psedoephedrinecovered); digestive products (H2 antagonists); feminineproducts; and smoking deterrent products.

Therapeutic Category Coverage: Therapeutic categoriescovered: anabolic steroids; antibiotics; anticoagulants;anticonvulsants; anti-depressants; antidiabetic agents;antihistamine drugs (legend only); antilipemic agents;anti-psychotics; anxiolytics, sedatives, and hypnotics;cardiac drugs; chemotherapy agents; prescribed coldmedications (legend only); contraceptives; ENT anti-inflammatory agents; estrogens; prescribed smokingdeterrents; sympathominetics (adrenergic); and thyroidagents. Therapeutic categories covered requiring priorauthorization: analgesics, antipyretics, NSAIDs (cox2inhibitor and brands for which no generic exists);anorectics; growth hormones; hypotensive agents (someACE inhibitors for which no generic exists); and misc. GIdrugs (Axid, Pepcid).


Vaccines: Vaccines provided plus reimbursement foradministrative fee as part of the Vaccines for ChildrenProgram.




Prior Authorization: State currently has a formal priorauthorization procedure. When appealing coverage of anexcluded product or prior authorization procedure, therecipient is notified of the denial and given instructions onhow to request a hearing.


Prescription Refill Limit: Maximum of 11 refills during a12-month period for non-scheduled medications.

Monthly Quantity Limit: Pharmacists may not dispensemore than 34-day supply of a legend drug. Certainexceptions for maintenance drugs (100-day supply).



Implementation of PRODUR system planned for 2001.State currently has a DUR Board with a quarterly review.


Dispensing Fee: $4.88 to a maximum of $40.11, effective7/1/98. Maximum of two dispensing fees per month, perdrug.


Prescription Charge Formula: Reimbursement at thelowest of:

1. AWP-10% plus dispensing fee; Maximum AllowableCost (MAC) plus dispensing fee; or providers usualand customary.

2. State MAC or direct price for selected manufacturers:Wyeth-Ayerst, Merck & Co., and Pharmacia &Upjohn.





Patient Cost Sharing: All legend drugs are subject to a$1.00 copay, limited to $5.00 per month maximum. OTCs and disposable medical supplies are subject to a$0.50 copay. Residents of Skilled Nursing Facilities(SNF) or Intermediate Care Facilities (ICF), subsidizedadoption recipients, children under age 18 and HMOenrollees are exempt from the copayment.

Cognitive Services: Provides payment for cognitiveservices.


!""#$%&'()*+,-:;@0@@@-)$)(+-?64?"+&5()*4-6?'A*#-$23*4&5(&4-#*5&"&*6)7-8*#*-*6#$++*4-&6-3BC7-&6-DE-:;;;<-F*5&"&*6)7-#*5*&=*-">(#'(5*?)&5(+-A*6*2&)7-)>#$?9>-'(6(9*4-5(#*-"+(67<


Atrium Health Plan, Inc.c/o Group Health Cooperative of Eau ClaireP.O. Box 3217Eau Claire, WI 54702-3217

Children ComefirstDane County Department of Human ServicesHuman services1202 Northpost DriveMadison, WI 53704

Compcare Health Services Insurance Corporation401 W. Michigan StreetMilwaukee, WI 53202

Community Care for the Elderly1555 South Layton Blvd.Milwaukee, WI 53215

Community Health Partnership2240 Fastridge CenterEau Claire, WI 54701

Community Living Alliance22 N 2nd St.Madison, WI 53704

Coordinated Care Health Plan of Wisconsin c/o Managed Health Services2040 W. Wisconsin Ave., Ste. 452Milwaukee, WI 53233

Dean Health Plan, Inc.P.O. Box 56099Madison, WI 53705

Eldercare of Dane County2802 International LaneMadison, WI 53704

Family Health Plan Cooperative11524 W. Theodore Trecker WayMilwaukee, WI 53214

Greater La Crosse Health Plans, Inc.P.O. Box 188La Crosse, WI 54602-0118

Group Health Cooperative of Eau ClaireP.O. Box 3217Eau Claire, WI 54702

Group Health Cooperative of South Central WisconsinP.O. Box 44971Madison, WI 53744-4971

Humana Wisconsin Health Organizations Ins. Corp.111 W. Pleasant StreetP.O. Box 12359Milwaukee, WI 53212-0359

Independent Care1555 N. Rivercenter Dr.Ste. 202 AMilwaukee, WI 53212-3958

Managed Health Services Insurance Corp.2040 W. Wisconsin Ave., Ste. 452Milwaukee, WI 53233

MercyCare Insurance CompanyP.O. Box 2770Janesville, WI 53547-2770

Network Health Servicesc/o Managed Health Services2040 W. Wisconsin Ave., Ste. 452Milwaukee, WI 53233

Physicians Plus Insurance CorporationP.O. Box 2078Madison, WI 53701-2078

PrimeCare Health Plan, Inc.10701 W. Research DriveMilwaukee, WI 53226

Security Health Plan of Wisconsin, Inc.P.O. Box 8000Marshfield, WI 54449


National Pharmaceutical Council Wisconsin-4

Touchpoint Health Plan5 Innovation CourtP.O. Box 507Appleton, WI 54912-0507

Unity Health Plans Insurance Corporation840 Carolina StreetSauk City, WI 53583-1374

Valley Health Plan2270 EastRidge CenterP.O. Box 3128Eau Claire, WI 54702-3128

Wraparound of Milwaukee9501 Watertown Plank Rd.Milwaukee, WI 53226

F. STATE CONTACTS


Roma Rowlands, R.Ph.Pharmacy Practices ConsultantDivision of Health Care FinancingDepartment of Health and Family ServicesOne West Wilson StreetP.O. Box 309Madison, WI 53701-0309T: 608/266-3753F: 608/266-1096E-mail: [email protected] Internet Address: www.dhfs.state.wi.us/medicaid


Roma Rowlands, 608/266-3753

DUR Contact

Michael A. Mergener, R.Ph., Ph.D.Chief PharmacistMeridian Resource Corporation10 East Duty St., Ste. 210Madison, WI 53703T: 608/258-3348F: 608/258-3359

Wisconsin Drug Utilization Review Committee

Robert M. Breslow, R.Ph.1926 N. Kollath RoadVerona, WI 53593

Ward Brown, M.D.1836 South AvenueLaCrosse, WI 54601608/782-7300, X2076

Mark E. Buhler, R.Ph.3905 Vista Drive,Racine, WI 53405

Daniel R. Erickson, M.D.146 Larabee StreetP.O. Box 127Horicon, WI 53032

Barry Hess, R.Ph.3209 Latham DriveMadison, WI 53713608/277-1110

Nancy E. Ness MD100 W. Monroe St,Mauston, WI 53948

Pamela Ploetz, R.Ph.

Lee C. Vermeulen, Jr., R.Ph., M.S.21 Lancaster CourtMadison, WI 53719

Mary Jo Willis, MS, NP2653 Stardust Trail,Verona, WI 53948


First Databank1111 Bayhill Dr.San Bruno, CA 94066T: 800/633-3453F: 415/588-6867


Audits: Roma Rowlands, 608/266-3753Disputes: Ellen Orsburne, 608/267-7939Technical: Randy Zirk, 608/266-8532Policy: Rita Hallett, 608/267-0938


Mark GajewskiAccount DirectorEDS6406 Bridge Rd.Madison, WI 53713608/221-9326




Jodie Mender, ChiefDepartment of Health and Family ServicesDivision of Health and Family ServicesBureau of Managed Health Care Programs1 W. WilsonMadison, WI 53701T: 608/261-6763F: 608/261-7792E-mail: [email protected]


Richard Carr, M.D.608/266-0957

Health and Family Services Department Officials

Joe LeannSecretaryDepartment of Health and Family ServicesState Office BuildingOne West Wilson StreetMadison, WI 53701

John ChapinAdministratorDivision of Health

Peggy L. BartelsDirectorDivision of Health Care Financing, Medicaid


State Medical Society of WisconsinJohn Patchett, J.D.Executive Vice President330 East Lakeside, Box 1109Madison, WI 53701-1109608/257-6781

Wisconsin Pharmacists AssociationChristopher DeckerExecutive Director202 Price PlaceMadison, WI 53705608/238-5515

Wisconsin Association of Osteopathic Physicians &SurgeonsRobert J. Finnegan, CAEExecutive Director34615 Road E.Oconomowoc, WI 53066414/567-0520

State Board of PharmacyPatrick BraatzDirectorBureau of Health ProfessionsP.O. Box 89351400 E. Washington Ave.Madison, WI 53708608/266-2812

Wisconsin Hospital AssociationRobert C. TaylorPresident, CEO5721 Odana RoadMadison, WI 53719-1289608/274-1820


National Pharmaceutical Council Wyoming-1

WYOMING




Prescribed Drugs





Physician Services




RECEIVING CASH ASSISTANCE, TOTAL $6,318,738 8,945Aged $857,467 762Blind / Disabled $4,943,472 3,760AFDC-Child $290,311 1,836AFDC-Adult $227,486 587AFDC-Unemployed-Children $0 0AFDC-Unemployed-Adult $0 0


POVERTY RELATED, TOTAL $1,304,484 9,570Aged $29,388 43Blind / Disabled $191,789 148AFDC-Child $803,303 6,569AFDC-Adult $280,024 2,810

OTHER, TOTAL $9,496,162 15,946


C. ADMINISTRATION

Department of Health, Division of Health Care Financing.


2-Wyoming National Pharmaceutical Council


Benefit Design

Drug Benefit Product Coverage: Products covered:prescribed insulin, syringe combinations, disposableneedles for insulin; cosmetics (Retin A not covered overage 21); blood glucose test strips; urine ketone test strips;total parenteral nutrition; and interdialytic parenteralnutrition (covered under DME programs). Products notcovered: fertility drugs; and experimental drugs.

Over-the-Counter Product Coverage: Products covered:allergy, asthma, and sinus products (some); analgesics;cough and cold preparations; digestive products (H2antagonists); feminine products; some topical products;antidiarrheals; antitussives; hyperglycemics; laxatives;pediatric and prenatal vitamins; sodium chloride fornebulizer; topical antifungals; vaginal antifungals.Covered OTC drugs are reimbursed at 150% of AWP. Products not covered: digestive products (non-H2antagonists); and smoking deterrent products. Uponapproval, additional OTC drugs may be covered if theyare alternatives to more expensive therapy or they areunavailable by prescription order.

Therapeutic Category Coverage: Therapeutic categoriescovered: analgesics, antipyretics, NSAIDs; antibiotics;anticoagulants; anticonvulsants; anti-depressants;antidiabetic agents; antihistamine drugs; antilipemicagents; anti-psychotics; anxiolytics, sedatives, andhypnotics; cardiac drugs; chemotherapy agents; prescribedcold medications; contraceptives; ENT anti-inflammatoryagents; estrogens; growth hormones (covered under CHSprogram); hypotensive agents; misc. GI drugs;sympathominetics (adrenergic); and thyroid agents.Therapeutic categories not covered: anabolic steroids;anorectics; and prescribed smoking deterrents.


Vaccines: Vaccines reimbursable at AWP plus a $7.00injection fee as part of the EPSDT service.



Formulary: Open formulary. General exclusions includeanorexants, except amphetamines and derivatives whichare used for narcolepsy and hyperkinetic states; productsto stimulate hair growth.

Prior Authorization: No prior authorization procedure.


Quantity Limit: No more than a maximum quantity of a90-day supply may be dispensed for a maintenance drugor any drug used in a chronic manner as defined. Oralcontraceptives -- a 3-month supply may be dispensed atone time. A maximum quantity to be dispensed for aprescription drug for all other conditions shall be a one-month supply.


PRODUR system implemented in October 1995. Statecurrently has a DUR Board with 13 members.




Prescription Charge Formula: Payments shall be thelowest of:

1. The Estimated Acquisition Cost (AWP - 4%) of theingredient, plus a dispensing fee.

2. Usual and customary charge.3. The upper limit established by the Health Care

Financing Administration (HCFA) for multiple sourcedrugs.

Maximum Allowable Cost: State imposes Federal UpperLimits on generic drugs. Override requires “BrandMedically Necessary” or “Brand Necessary.”


Patient Cost Sharing: Copayment is $2.00. The followingrecipients or products are exempt from the copayment:

− Pregnant women− Foster care children− Home and community based waiver recipients− Eligible recipients under age 21− Patients residing in nursing homes− Family planning products






F. STATE CONTACTS


Roxanne Homar, R.Ph.Deputy AdministratorCommunity and Family Health DivisionPrimary Case Services2300 Capital Ave.Hathaway Building, 1st Fl.Cheyenne, WY 82002T: 307/777-6032F: 307/777-6964Internet Agency Address: http://www.state.wy.us

Shannon Whalen, R.Ph.Pharmacy Program Manager2300 Capital Ave.Hathaway Building, 1st Fl.Cheyenne, WY 82002T: 307/777-6016F: 307/777-6964E-mail: [email protected]


Garry McKee, Ph.D., M.P.H.DirectorDepartment of Health117 Hathaway BuildingCheyenne, WY 82002-0710T: 307/777-7656

Roxanne Homar, R.Ph.Deputy AdministratorCommunity and Family Health DivisionPrimary Case Services2300 Capital Ave.Hathaway Building, 1st Fl.Cheyenne, WY 82002T: 307/777-6032F: 307/777-6964

DUR Contact

Debra Devereaux, R.Ph.DUR CoordinatorUniversity of Wyoming School of PharmacyP.O. Box 3375Laramie, WY 82071-3375T: 307/766-6750

DUR Board

Debra Devereaux, R.Ph.DUR CoordinatorUniversity of Wyoming School of PharmacyP.O. Box 3375Laramie, WY 82071-3375307/766-6750E-mail: [email protected]

Ed Baker, R.Ph.Smith’s Pharmacy2531 Foothill Blvd.Rock Springs, WY 82901307/362-1841

Dawn Ford, R.Ph.2022 Reagan AvenueRock Springs, WY 82901307/382-5437

Roxanne Homar, R.Ph.Deputy AdministratorCommunity and Family Health DirectorPrimary Care Services2300 Capital Ave.Hathaway Building, 1st Fl.Cheyenne, WY 82002307/777-6032

Kathryn Kohler, M.D.204 McCollum DriveLaramie, WY 82070307/745-8991

Leonard Kosirog, R.Ph.3095 GallowayRiverton, WY 82501307/856-6993

Jay Swedberg, M.D.1020 S. ConwellCasper, WY 82609307/577-5100

George Zaharas, R.Ph.Town and Country Pharmacy514 S. GreeleyCheyenne, WY 82009307/634-6662

Stephen Brown, M.D.2521 E. 15th St.Casper, WY 82609307/234-3638


4-Wyoming National Pharmaceutical Council

Michael Carpenter, PA-C1121 Washington Blvd.Newcastle, WY 82701307/746-3582

William Harrison, M.D.MedPed Primary Care Clinic903-A South Greeley Highway, Ste ACheyenne, WY 82007307/634-8800

Linda G. Martin, R.Ph.University of WyomingSchool of PharmacyP.O. Box 3375Laramie, WY 82071-3375307/766-6128

Shannon Whalen, R.Ph.Community & Family Health Div.2300 Capital Avenue154 Hathaway BuildingCheyenne, WY 82002307/777-6016


First Data BankT: 800/633-3453F: 650/872-4510


Technical: Renee Greenmeyer, 307/777-5500Policy: Shannon Whalen, R.Ph., 307/777-6016Audits: Shannon Whalen, R.Ph., 307/777-6016


Jennifer DillingerAccount ManagerConsultec, Inc.P.O. Box 667Cheyenne, WY 82003307/777-5500E-mail: [email protected]


Shannon Whalen, R.Ph.307/777-6016






Wyoming State Medical SocietyWendy CurranExecutive Director1920 EvansP.O. Box 4009Cheyenne, WY 82003-4009307/635-2424

Wyoming Pharmacists AssociationRobert E. Smith, R.Ph.Executive DirectorGlenrock, WY 82432307/436-8001

Wyoming Association of Osteopathic Physicians &SurgeonsShirley CarpenterExecutive Director625 Albany AvenueTorrington, WY 82240307/532-2107

State Board of PharmacyJim CarderExecutive Director1720 S. Poplar Street, Ste. 5Casper, WY 82601307/234-0294

Wyoming Hospital AssociationDan PerduePresident2005 Warren AvenueCheyenne, WY 82001307/632-9344




National Pharmaceutical Council A-1

Appendix A:State and FederalMedicaid Contacts


A-2 National Pharmaceutical Council



STATE MEDICAID DRUG PROGRAM ADMINISTRATORS, 2000

ALABAMALouise F. JonesPharmacy Program ManagerAlabama Medicaid Agency501 Dexter AvenueP.O. Box 5624Montgomery, AL 36103-5624P: 334/242-5039F: 334/353-7014E-mail: [email protected] Internet Address: www.medicaid.state.al.us

ALASKADave Campana, R.Ph.Pharmacy Program ManagerDivision of Medical Assistance4501 Business Park Blvd., Suite 24Anchorage, AK 99503P: 907/273-3224F: 907/561-1684E-mail: [email protected]

ARIZONAJuman Abujbara, M.D.DirectorArizona Health Care Containment System801 E. Jefferson StreetPhoenix, AZ 85034P: 602/417-4241F: 602/254-1769

ARKANSASSuzette Bridges, P.D.Department of Human ServicesDivision of Medical ServicesPharmacy ProgramP.O. Box 1437, Slot 4105Little Rock, AR 72203P: 501/324-9141F: 501/324-9140E-mail: [email protected]

CALIFORNIAJ. Kevin Gorospe, Pharm.D.Chief, Pharmaceutical UnitMedi-Cal Policy Division714 P Street, Room 1540Sacramento, CA 95814P: 916/657-4213F: 916/654-0513E-mail: [email protected] Internet Address: http://www.dhs.ca.gov

COLORADOAllen ChapmanDepartment of Health Care Policy & Financing1575 Sherman Street, 5th FloorDenver, CO 80203P: 303/866-3176F: 303/866-2573

CONNECTICUTElizabeth A. GearyHealth Program SupervisorDepartment of Social Services25 Sigourney StreetHartford, CT 06106P: 860/424-5150F: 860/951-9544E-mail: [email protected] Internet Address: http://www.dss.state.ct.us

DELAWAREPhile SouléMedicaid Pharmacy DirectorDelaware Health and Social Services1901 N. Dupont HighwayNew Castle, DE 19720P: 302/577-4900F: 302/577-4405



DISTRICT OF COLUMBIADonna Bovell, R.Ph.Pharmacist ConsultantCommission on Health Care Finance2100 M.L. King Jr. Ave. SE, Suite 302Washington, DC 20023P: 202/698-2043F: 202/610-3209E-mail: [email protected]

FLORIDAJerry WellsAgency for Healthcare Administration Services2727 Mahan Drive, Building 1, Room 170Tallahassee, FL 32308P: 850/922-0681F: 850/922-0685E-mail: [email protected] Internet Address: www.fdhc.state.fl.us

GEORGIAEtta L. Hawkins, R.Ph.Department of Community Health-Medical Division2 Peachtree Street, 37th FloorAtlanta, GA 30303-3159P: 404/657-7239F: 404/656-8366E-mail: [email protected] Internet Address: www.state.ga.us/dch

HAWAIILynn Donovan, R.Ph.Medicaid Pharmacy ConsultantMed-Quest DivisionP.O. Box 339Honolulu, HI 96809-0339P: 808/692-8116F: 808/692-8131

IDAHOGary Duerr, R.Ph.Medicaid PolicyAmericana Terrace, Suite 140P.O. Box 83720Boise, ID 83720-0036P: 208/364-1829F: 208/364-1846E-mail: [email protected]

ILLINOISMarvin L. HazelwoodIllinois Department of Public AidDivision of Medical Assistance1001 N. Walnut St.Springfield, IL 62702P: 217/524-7112F: 217/524-7194E-mail: [email protected] Internet Address: www.state.il.us/dpa/

INDIANAMarc Shirley, R.Ph.Pharmacy Program Director-Indiana MedicaidOffice of Medicaid Policy and PlanningIndiana State Government Center South-Rm. W382402 W. Washington StreetIndianapolis, IN 46204-2739P: 317/232-4343F: 317/232-7382E-mail: [email protected]

IOWARonald J. Mahrenholz, R.Ph.Pharmacist ConsultantDivision of Medical ServicesDepartment of Human ServicesHoover State Office Bldg.Des Moines, IA 50319P: 515/281-6199F: 515/281-6230E-mail: [email protected]



KANSASKaren Braman, R.Ph., M.S.Health Care Policy DivisionKansas Department of Social and RehabilitationServices915 SW Harrison, Room 651-South DSOBTopeka, KS 66612-1570P: 785/296-6968F: 785/296-4813E-mail: [email protected] Internet Address: www.ink.org/public/srs

KENTUCKYDebra Bahr, R.Ph.Pharmacy Services Program MangerDepartment for Medicaid ServicesCHR Building, 6th Floor275 East Main StreetFrankfort, KY 40621P: 502/564-6511F: 502/564-3852E-mail: [email protected]

LOUISIANAM.J. Terrebonne, P.D.Pharmacy Program DirectorDepartment of Health and HospitalsP.O. Box 91030Baton Rouge, LA 70821P: 225/342-9479F: 225/342-3893E-mail: [email protected]

MAINEChristine GeeDirector of Pharmacy ProgramsDepartment of Health ServicesBureau of Medical ServicesPharmacy ProgramsBuilding 205, 3rd Fl.11 State House StationAugusta, ME 04333P: 207/287-4018F: 207/287-8601E-mail: [email protected]

MARYLANDFrank TetkoskiPharmacy Services ManagerDivision of Pharmacy and Clinic Services201 West Preston StreetBaltimore, MD 21201P: 410/767-1455F: 410/333-7049E-mail: [email protected] Internet Address: www.dhmh.state.md.us

MASSACHUSETTSGary P. Gilmore, R.Ph.Division of Medical Assistance600 Washington StreetBoston, MA 02111P: 617/210-5593F: 617/210/5597E-mail: [email protected]

MICHIGANJames Kenyon, R.Ph.Pharmacist ConsultantMDCH/ Medical Services Administration400 South Pine StreetLansing, MI 48933P: 517/335-5265F: 517/335-5294E-mail: [email protected] Internet Address: www.mdch.state.mi.us

MINNESOTACody Wiberg, Pharm.D., R.Ph.Acting Pharmacy Program ManagerMinnesota Department of Human Services444 Lafayette RoadSt. Paul, MN 55155-3853P: 651/296-8515F: 651/282-6744E-mail: [email protected]



MISSISSIPPIJames G. (Jack) Lee, R.Ph.Division of Medicaid, Office of the GovernorRobert E. Lee Building239 North Lamar Street, Suite 801Jackson, MS 39201-1399P: 601/359-6296F: 601/359-4185E-mail: [email protected]

MISSOURISusan McCann, R.Ph.Pharmaceutical ConsultantDivision of Medical Services615 Howerton CourtP.O. Box 6500Jefferson City, MO 65102-6500P: 573/751-6963F: 573/526-4650E-mail: [email protected]

MONTANADorothy D. PoulsenPharmacy Program OfficerDepartment of Public Health and Human ServicesMedicaid Services BureauP.O. Box 2029511400 BroadwayHelena, MT 59620-2951P: 406/444-2738F: 406/444-1861E-mail: [email protected]

NEBRASKAGary J. Cheloha M.B.A., R.Ph.Department of Health and Human ServicesFinance and Support, Medicaid DivisionP.O. Box 95026301 Centennial Mall S., 5th Fl.Lincoln, NE 68509P: 402/471-9379F: 402/471-9092E-mail: [email protected] Internet Address: www.hhs.state.ne.us

NEVADALaurie Squartsoff, R.Ph.Pharmaceutical ConsultantNevada Medicaid Office2527 N. Carson Street, Capitol ComplexCarson City, NV 89710P: 702/687-4869F: 702/687-8724E-mail: [email protected]

NEW HAMPSHIRELisè Farrand, R.Ph.Pharmaceutical Services SpecialistMedicaid Administration Bureau6 Hazen DriveConcord, NH 03301-6521T: 603/271-4419F: 603/271-4376E-mail: [email protected]

NEW JERSEYCarl D. Tepper, R.Ph.Department of Human ServicesDivision of Medical Assistance and Health ServicesP.O. Box 712, Room 202Trenton, NJ 08625-0712P: 609/588-2724F: 609/588-3889E-mail: [email protected]

NEW MEXICONeil SolomonMedicaid Assistance DivisionP. O. Box 2348Santa Fe, NM 87504P: 505/827-3174F: 505/827-3185



NEW YORKMark-Richard Butt, M.S., R.Ph.NYS Department of HealthPharmacy Policy and OperationsOffice of Medicaid Management99 Washington Ave., Room 606Albany, NY 12210P: 518/486-3209F: 518/473-5508E-mail: [email protected] Internet Address: www.health.state.ny.us

NORTH CAROLINAC. Benny Ridout, R.Ph.NC Division of Medical Assistance1985 Umstead Drive2511 Mail Service CenterRaleigh, NC 27699-2511P: 919/733-4034F: 919/733-2796E-mail: [email protected]

NORTH DAKOTACindy FrolickDepartment of Human ServicesState Capital, 600 East BoulevardDepartment 325Bismarck, ND 58505-0250P: 701/328-4023F: 701/328-1544E-mail: [email protected]

OHIORobert P. Reid, R.Ph.Administrator, Pharmacy Services UnitDepartment of Human Services30 East Broad St., 31st FloorColumbus, OH 43266-0423P: 614/466-6420F: 614/466-2908E-mail: [email protected]

OKLAHOMAJohn Crumly, MHA., R.Ph.Oklahoma Health Care Authority4545 N. Lincoln Boulevard, Suite 124Oklahoma City, OK 73105-9901P: 405/522-7300F: 405/522-7378E-mail: [email protected]

OREGONJesse AndersonDepartment of Human ResourcesOffice of Medical Assistance Programs500 Summer Street, NESalem, OR 97310-1014P: 503/945-6492F: 503/373-7689E-mail: [email protected]

PENNSYLVANIAJoseph E. Concino, R.Ph.Chief, Pharmacy ServicesOffice of Medical Assistance ProgramsP.O. Box 8046Harrisburg, PA 17105P: 717/772-6341F: 717/772-6366

RHODE ISLANDPaula J. Avarista, R.Ph.Chief of PharmacyDepartment of Human Services600 New London AvenueCranston, RI 02920P: 401/462-2183F: 401/462-2185

SOUTH CAROLINAJames M. Assey, R.Ph.Division DirectorS.C. Department of Health & Human ServicesP.O. Box 8206Columbia, SC 29202-8206P: 803/898-2876F: 803/898-4517E-mail: [email protected]



SOUTH DAKOTAMark Petersen, R.Ph.Department of Social Services700 Governors DrivePierre, SD 57501P: 605/773-3498F: 605/773-5246E-mail: [email protected]

TENNESSEEJeff Stockard, D.Ph.Director of PharmacyBureau of TennCare729 Church Street, 1st FloorNashville, TN 37247-6501P: 615/532-3107F: 615/741-0882Agency Internet Address:www.state.tn.us/health/tenncare/

TEXASRobert P. HarrissDirector, TX Department of HealthVendor Drug Program1100 W. 49th StreetAustin, TX 78756-3174P: 512/338-6961F: 512/338-6910E-mail: [email protected]

UTAHRaeDell Ashley, R.Ph.Pharmacy DirectorDivision of Health Care FinancingUtah Department of Health288 N. 1460 West, P.O. Box 143102Salt Lake City, UT 84114-2905P: 801/538-6495F: 801/538-6099E-mail: [email protected]

VERMONTPaul Wallace-BrodeurOffice of Vermont Health Access103 South Main StreetWaterbury, VT 05671-1201P: 802/241-2156F: 802/241-2974E-mail: [email protected]

VIRGINIADavid B. Shepherd, R.Ph.Department of Medical Assistance Services600 East Broad Street, Ste 1300Richmond, VA 23219P: 804/225-2773F: 804/786-0414E-mail: [email protected]

WASHINGTONSiri A. Childs, Pharm D.Pharmacy Research SpecialistMedical Assistance Administration, DSHS805 Plum Street, SEP.O. Box 45506Olympia, WA 98504-5506P: 360/725-1564F: 360/664-3884E-mail: [email protected]

WEST VIRGINIAPeggy A. King, R.Ph.Pharmaceutical CoordinatorWV Department of Human Services350 Capitol St., Room 251Charleston, WV 25301-3707P: 304/558-1753F: 304/558-1542E-mail: [email protected]



WISCONSINRoma Rowlands, R.Ph.Division of Health Care FinancingDepartment of Health and Family ServicesOne West Wilson StreetP.O. Box 309Madison, WI 53701-0309P: 608/266-3753F: 608/266-1096E-mail: [email protected] Internet Address:www.dhfs.state.wi.us/medicaid

WYOMINGRoxanne Homar, R.Ph.Deputy AdministratorShannon Whalen, Medicaid PharmacistCommunity and Family Health DivisionPrimary Care Services2300 Capital AvenueHathaway Building, 1st FloorCheyenne, WY 82002P: 307/777-6016F: 307/777-6964E-mail: [email protected]





DUR CONTACT INFORMATION, 2000

ALABAMAContracted DUR

State ContactLouise F. JonesAlabama Medicaid Agency501 Dexter AvenueP.O. Box 5624Montgomery, AL 36103-5624P: 334/242-5039F: 334/353-7014E-mail: [email protected]

ContractorAlabama Quality AssuranceFoundation1 Perimeter Park South, Suite 200NBirmingham, AL 35243P: 205/970-1600

ALASKAIn-House andcontracted DUR

State ContactDave Campana, R.PhPharmacy Program ManagerDivision of Medical Assistance4501 Business Park Blvd., Ste. 24Anchorage, AK 99503P: 907/273-3224F: 907/561-1684E-mail: [email protected]

ContractorNot Available

ARIZONADUR is conducted atthe plan level.

Within Federal and State guidelines,individual managed care and pharmacybenefit management organizations makeformulary/drug decisions.

ARKANSASContracted DUR

State ContactSuzette Bridges, P.D.AdministratorArkansas Department of Human ServicesDivision of Medical ServicesP.O. Box 1437, Slot 4105Little Rock, AR 72203P: 501/324-9141F: 501/324-9140E-mail: [email protected]

ContractorCraig Atkins, Pharm D.Director, Retro Spective DURHealth Information Design1550 Pumphrey AvenueAuburn, AL 36832P: 205/402-9530F: 205/402-9531

CALIFORNIAIn-House DUR

State ContactVic Walker, R.Ph. B.C.P.P.Sr. Pharmaceutical ConsultantMedi-Cal Policy Division714 P Street, Rm. 1540Sacramento, CA 95814P: 916/657-0785F: 916/654-0513E-mail: [email protected]



COLORADOContracted DUR

State ContactAllen ChapmanPharmacistDeptartment of Health Care Policy andFinancing1575 Sherman St., 5th FloorDenver, CO 80203P: 303/866-3176F: 303/866-2573

ContractorNot Available

CONNECTICUTContracted DUR

State ContactElizabeth Geary, R.Ph.Health Program SupervisorDepartment of Social Services25 Sigourney StreetHartford, CT 06106P: 860/424-5150F: 860/951-9544E-mail: [email protected]

ContractorMichelle Lester-BradleyAccount ManagerHealth Information Designs1550 Pumphrey Ave.Auburn, AL 35832P: 334/502-3262 x21F: 334/821-6589E-mail: [email protected]

DELAWAREContracted DUR

State ContactCynthia DenemarkPharmacist ConsultantEDS248 Chapman Road, Suite 200Newark, DE 197029720P: 302/453-8453F: 302/454-7603E-mail: [email protected]

ContractorCynthia DenemarkPharmacist ConsultantEDS

DISTRICT OFCOLUMBIAIn-House DUR

State ContactChrisopher Keeyes, Pharm.D.PresidentClinical Pharmacy Administration11710 Beltsville Drive, Ste. 510Calberton, MD 20705P: 301/572-1616

FLORIDAIn-house andContracted DUR

State ContactMarie Donnelly-StephensSenior Healthcare Program AnalystAHCA2727 Mahan Drive, mail stop 38Tallahassee, FL 32308P: 850/487-4441F: 850/922-0685

ContractorGaylen Fruit, R.Ph.DUR CoordinatorFlorida Pharmacy Association610 N. Adams St.Tallahassee, FL 32301P: 850/222-2400



GEORGIAIn-house DUR

State ContactJean B. Cox, R.Ph.DUR CoordinatorGA Dept. of Community Health2 Peachtree St. NWAtlanta, GA 30303P: 404/657-7241F: 404/656-8366E-mail: [email protected]

HAWAIIIn-House DUR

State ContactKathleen Kang-KaulupaliPharmacy ConsultantMed-Quest DivisionPO Bopx 339Honolulu, HI 96809-0339P: 808/692-8115F: 808/692-8131

IDAHOContracted DUR

State ContactGary Duerr, R.Ph.Medicaid PolicyAmericana Terrace, Suite 140PO Box 83720Boise, ID 83720-0036P: 208/364-1829F: 203/364-1846E-mail: [email protected]

ContractorVaughn Culbertson, Pharm.D.DUR CoordinatorIdaho State U. - College of PharmacyCampus Box 8356Pocatello, ID 83209-8356P: 208/236-4385F: 208/236-4482E-mail: [email protected]

ILLINOISIn-House DUR

State ContactStarlin Haydon Greatting, R.Ph.Pharmacist ConsultantDUR CoordinatorIllinois Department of Public Aid1001 N. Walnut St.Springfield, IL 62702P: 217/524-7112F: 217/524-7194

INDIANAContracted DUR

State ContactMs. Karen BaerDUR Board SecretaryOffice of Medicaid Policy and PlanningP: 317/232-4391F: 317/232-7382E-mail: [email protected]

ContractorPharmacy ServicesEDS950 N. Meridian St., 11th FloorIndianapolis, IN 46204P: 317/488-5000



IOWAContracted DUR

State ContactCheryl Clarke, R.Ph.DUR CoordinatorIowa Pharmacy Association8515 Douglas, Ste. 16Des Moines, IA 50322P: 515/270-0713F: 515/270-2979E-mail: [email protected]

ContractorCheryl Clarke, R.Ph.DUR CoordinatorIowa Pharmacy Association

KANSASContracted DUR

State ContactGlenn McNeese, R.Ph., M.S., BCPSDUR Program DirectorKansas University School of Pharmacy6052 Malott HallLawrence, KS 66045-2500P: 785/864-3264F: 785/864-5849E-mail: [email protected]

ContractorGlenn McNeese, R.Ph., M.S., BCPSDUR Program DirectorKansas University School of Pharmacy

KENTUCKYContracted DUR

State ContactDebra Bahr, R.Ph.Pharmacy Services Program MangerDepartment for Medicaid ServicesCHR Building, 6th Floor275 East Main StreetFrankfort, KY 40621P: 502/564-6511F: 502/564-3852E-mail: [email protected]

ContractorKim Moore, R.Ph.UnisysPO Box 2100Frankfort, KY 40602P: 502/226-1867F: 502/266-1860

LOUISIANAContracted DUR

State ContactMelwyn WendtPharmaceutical ConsultanDepartment of Health and HospitalsPO Box 91030Baton Rouge, LA 70821P: 225/219-4154F: 225/342-3893E-mail: [email protected]

ContractorDan SchollPharmacy DirectorUnisysPO Box 3396Baton Rouge, LA 70809P: 225/237-3208F: 225/924-6179E-mail: [email protected]

MAINEContracted DUR

State ContactChristine GeeDirector of Pharmacy ProgramsDHS – Bureau of Medical ServiesBldg 205, 3rd Fl.11 State House StationAugusta, ME 04333-0011P: 207/287-2674F: 207/287-8601

ContractorDennis G. Lyons, R.Ph.Retrospective DUR DirectorPharmaceutical Strategies Inc.255 Bennhill Rd.Waltham, MA 02451P: 781/830-3435



MARYLANDContracted DUR

State ContactJudy GeislerPharmacist ConsultantDHMH-Office of Health ServicesDivision of Pharmacy and Clinical Services201 W. Preston St., Rm. 208ABaltimore, MD 21201P: 410/787-1728F: 410/333-7049E-mail: [email protected]

ContractorContact Judy GeislerPharmacist Consultant

MASSACHUSETTSContracted DUR

State ContactAnna Morin, Pharm.D.DUR Program DirectorUMASS Medical school11 Midstate HwyAuburn, MA 01501-1863P: 508/721-7104F: 508/721-7138E-mail: [email protected]

ContractorAnna Morin, Pharm.D.DUR Program DirectorUMASS Medical schoolmailto:[email protected]

MICHIGANContracted DUR

State ContactMary Sandusky, R.Ph.Pharmacist ConsultantMDCH/Medical Services Administration400 S. Pine StreetLansing, MI 48933P: 517/335-5280F: 517/335-7813E-mail: [email protected]

ContractorFirst Health Services Corp.4300 Cox Rd.Glen Allen, VA 23060

MINNESOTAIn-House DUR

State ContactMary Beth Reinke, Pharm.D.DUR CoordinatorMinnesota Dept. of Human Services444 Lafayette Rd.St. Paul, MN 55155-3853P: 651/215-1239F: 651/282-6744E-mail: [email protected]

MISSISSIPPIContracted DUR

State ContactJack Lee, R.Ph.Pharmacy Program AdministratorDiv. Of Medicaid, Office of the Governor239 North Lamar St., Ste. 801Jackson, MS 39201-1399P: 601/359-6296F: 601/369-4185E-mail: [email protected]

ContractorCliff OshonHeritage Information System, Inc.2618 A. Southerland Dr.Jackson, MS 39216P: 601/362-3388F: 601/982-0143



MISSOURIContracted DUR

State ContactJayne ZemmerDUR CoordinatorDiv. Of Medical ServicesPO Box 6500Jefferson City, MO 65102-6500P: 573/751-6963F: 573526-4650E-mail:[email protected]

ContractorProVantage retro DUR)1300 N. 17th St., Ste. 1350Arlington, VA 22209P: 703/243-9571F: 703/528-5869

MONTANAContracted DUR

State ContactMark Eichler, R.Ph.DUR CoordinatorMountain-Pacific Quality Health Foundation3404 Cooney DriveHelena, MT 59602P: 406/443-4020F: 406/443-4585E-mail: [email protected]

ContractorMark Eichler, R.Ph.Mountain-Pacific Quality HealthFoundation

NEBRASKAContracted DUR

State ContactAllison Jorgensen, Pharm.D., R.Ph.DUR DirectorNebraska Pharmacists Association6221 South 58th, Ste. ALincoln, NE 68516P: 402/420-1500F: 402/420-1406E-mail: [email protected]

ContractorAllison Jorgensen, Pharm.D., R.Ph.DUR DirectorNebraska Pharmacists Association6221 South 58th, Ste. ALincoln, NE 68516P: 402/420-1500F: 402/420-1406E-mail: [email protected]

NEVADAIn-House DUR

State ContactLaurie Squartsoff, R.Ph.Pharmacy Services ConsultantNevada Medicaid2527 N. Carson St., Capitol ComplexCarson City, NV 89710P: 702/687-4869F: 702/687-8724

NEW HAMPSHIREContracted DUR

State ContactLisè Ferrand, R.Ph.Pharmaceutical Services SpecialistMedicaid Administration Bureau6 Hazen DriveConcord, NH 03301P: 603/271-4359F: 603/271-4376E-mail: [email protected]

ContractorJulie Simpson, R.Ph.Pharmacy ConsultantEDS Federal Corp.7 Eagle SquareConcord, NH 03301P: 603/225-4899



NEW JERSEYIn-House DUR

State ContactEdward Vaccaro, R.Ph.Assistant Director, OHSADivision of Medical Assistance and HealthServicesOffice of Health Service Administration, P.O.Box 712Trenton, NJ 08625-0712P: 609/588-2721F: 609/588-3889E-mail: [email protected]

NEW MEXICOContracted DUR

State ContactNeil SolomonP: 505/827-3174

ContractorUNM College of Pharmacy

NEW YORKIn-House DUR

State ContactMichael ZegarelliDUR Manager, Office of MedicaidManagementNYS Dept. of Health99 Washington Ave, Suite 601Albany, NY 12210P: 518/474-6866F: 518/473-5332E-mail: [email protected]

NORTH CAROLINAIn-House DUR

State ContactSharman LeinwandDUR CoordinatorN.C. Division of Medical Assistance2515 Mail Service CenterRaleigh, NC 27699-2515P: 919/733-3590F: 919/715-7706

NORTH DAKOTAIn-House DUR

State ContactPat KramerDirector, Utilization ManagementHuman Services600 E. Blvd., Dept. 325Bismarck, ND 58505-0250P: 701/328-4893F: 701/328-1544E-mail: [email protected]



OHIOContracted DUR

State ContactJan LawsonDUR CoordinatorDUR6S E. State, 4th FloorColumbus, OH 43215P: 614/466-7936

ContractorTheresa ShiremanUniversity of Cincinnati MedicalCenter3223 Eden AvenueCincinnati, Ohio 45267-0004P: 614/466-7936

OKLAHOMAContracted DUR

State ContactJohn Crumly, MHA, R.Ph.Medicaid Pharmacy DirectorOklahoma Health Care Authority4545 N. Lincoln Blvd. Ste 124Oklahoma City, OK 73105-9901P: 405/522-7300F: 405/522-7378E-mail: [email protected]

ContractorRon GrahamPharmacy Consultant ManagerCollege of PharmacyP.O.Box 26901Oklahoma City, OK 73190P: 405/271-9039F: 405/271-2615E-mail: [email protected]

OREGONContracted DUR

State ContactMariellen Rich, R.Ph.Pharmacist Account ManagerFirst Health Service Corporation565 Union St., NE, Suite 205Salem, OR 97310P:503/391-1980F: 503/391-1979E-mail: [email protected]

ContractorSame as state contact.

PENNSYLVANIAIn-House DUR

State ContactPRODUR – EDS/ RETRODUR – Universityof MarylandP.O. Box 8046Harrisburg, PA 17105

RHODE ISLANDContracted DUR

State ContactPaula AvaristaP: 401/462-2183

ContractorEDS -- Merck/Medco

SOUTH CAROLINAIn-House andContracted DUR

State ContactCaroline Y. Sojourner, R.Ph.Deptartment Head, Pharmacy ServicesS.C. Department of Health & HumanServicesP.O. Box 8206Columbia, SC 29202-8206P: 803/898-2876F: 803/898-4517E-mail: [email protected]

ContractorFirst Health Services Corporation4300 Cox RoadGlen Allen, VA 23060P: 800/884-2822F: 804/273-6961



SOUTH DAKOTAIn-House DUR

State ContactMichael Jockheck, R.Ph.Pharmacy ConsultantSD Department of Social Services700 Governors DrivePierre, SD 57501P: 605/773-6439E-mail: [email protected]

ContractorMichael Jockheck, R.Ph.Pharmacy ConsultantSD Department of Social Services

TENNESSEEDUR is conducted atthe plan level.

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

TEXASIn-House DUR

State ContactCurtis BurchDirectorDrug Utilization Review DivisionTexas Department of Health1100 West 49th StreetAustin, TX 78756-3174P: 512/338-6922F: 512/338-6910E-mail: [email protected]

UTAHIn-House DUR

State ContactDuane ParkeDUR CoordinatorHealth Care Financing288 N. 1460 West, P.O. Box 143102Salt Lake City, UT 84114-2905P: 801/538-6452F: 801/538-6099

VERMONTContracted DUR

State ContactGloria JacobsOperations AdministratorOffice of VT Health Access103 S. Main St.Waterbury, VT 05671P: 802/241-2763F: 802/241-2974E-mail: [email protected]

ContractorEDSFiscal Agent312 Hurrican Lane, Ste 101Williston, VT 05495P: 802/879-4450F: 802/878-3440

VIRGINIAContracted DUR

State ContactMarianne Rollins, R.Ph.DUR CoordinatorDeparment of Medical Asisstance Services600 East Broad Street, Suite 1300Richmond, VA 23112P: 804/225-4268

ContractorFirst Health ServicesGlen Allen, VA



WASHINGTONIn-House DUR

State ContactSiri A. Childs, Pharm D.Pharmacy Research SpecialistMedical Assistance Administration, DSHS805 Plum Street, SEP.O. Box 45506Olympia, WA 98504-5506P: 360/725-1564F: 360/664-3884E-mail: [email protected]

WEST VIRGINIAContracted DUR

State ContactPeggy A. KingPharmacy CoordinatoBureau for MedicalServices7012 MacCorkle Ave., SECharleston, WV 25304P: 304/926-1753F: 304/926-1993E-mail: [email protected]

ContractorMartha KophaziHealth Information Design11200 Waples Mill Road, Suite 360Fairfax, VA 22032P: 703/218-5800F: 703/218-5810E-mail: [email protected]

WISCONSINContracted DUR

State ContactMichael Mergener, R.Ph., Ph.D.Chief PharmacistMeridian Resource Corporation10 East Duty St., Suite 210Madison, WI 53703P: 608/258-3348F: 608/258-3359

ContractorSame as state contact

WYOMINGContracted DUR

State ContactDebra Devereaux, M.B.A., R.Ph.DUR Coordinator, WY-DURUniversity of Wyoming-School of PharmacyP.O. Box 3375Laramie, WY 82071-3375P: 307/766-6120

ContractorShannon WhalenPharmacy Program ManagerOffice of Primary Care-CAFHD2300 Capital Ave,154 Hathaway Bldg.Chyenne, WY 82002P: 307/777-3016F: 307/777-6964E-mail: [email protected]



CLAIMS SUBMISSION, 2000

ALABAMARicky PopeAccount Manager, EDS301 Technacenter Dr.Montgomery, AL 36117P: 334/215-0111

ALASKARose-Ellen HopePharmacistFirst Health565 Union St. NE #205Salem, OR 97301P: 503/391-0184

ARIZONAAHCCCS/DBF/CLMSLori Petre, Claims Administrator701 E. JeffersonPhoenix, AZ 85034P: 602/417-4547

ARKANSASJohn HerzogAccount ManagerEDS Federal Corp500 East Markham, Suite 400Little Rock, AR 72201P: 501/374-6608F: 501/372-2971E-mail: [email protected]

CALIFORNIADennis DwormanExecutive Program DirectorEDS-Medi-CalElectronic Data Systems3215 Prospect Park DriveRancho Cordova, CA 95670P: 916/636-1000F: 916/636-1000

COLORADOConsultec, Inc.600 17th StreetSuite 600 NorthDenver CO 80203P: 800/237-0757F: 303/534-0435

CONNECTICUTTwila SmithAccount ManagerEDS100 Stanley DriveNew Britain, CT 06053P: 860/832-5800

DELAWAREThomas IgnudoAccount ManagerEDS248 Chapman RdNewark, DE 19702

DISTRICT OF COLUMBIAContact not provided

FLORIDAMark SteckPBM DirectorConsultec, Inc.9040 Roswell Rd. Suite 700Atlanta, GA 30350P: 770/594-7799

GEORGIACheryl CollierAccount Manager, EDS736 Park North BlvdP.O. Box 736Clarkston, GA 30021P: 404/297-3700F: 404/298-1031



HAWAIILuukia AbbleySupervisor, MedicaidHMSA - Medicaid Claims ServiceP.O. Box 860Honolulu, HI 96808P: 808/948-5361

IDAHOEDSP.O. Box 1168Boise, ID 83701P: 208/395-2000

ILLINOISSelf-administered

INDIANAEDS950 North Meridan Street, 11th FloorIndianapolis, IN 46204P: 317/488-5000

IOWAKristi SheakleyAccount ManagerConsultec, Inc.P.O. Box 14422Des Moines, IA 50306-3422P: 515/327-0950 x1108F: 515/327-0945

KANSASBlue Cross Blue Shield of KansasP.O. Box 3571Topeka, KS 66611P: 800/933-6593

KENTUCKYUnisys-Provider ServicesP.O. Box 2100Frankfort, KY 40602P: 502/226-1140F: 502/226-1860

LOUISIANADepartment of Health and HospitalsSusan Taskin, Chief, MMISP.O. Box 91030Baton Rouge, LA 70821P: 225/342-9494

MAINEMarcia PykareGoold Health Systems12 Stone StreetAugusta, ME 04332P: 207/622-7153

MARYLANDCharlotte Krueger, ChiefFirst Health Services CorporationDivision of Claims Processing201 W. Preston St.Baltimore, MD 21201P: 401/767-5347F: 410/333-7186

MASSACHUSETTSUnisysP.O. Box 9101Somerville, MA 02145P: 617/576-4451

MICHIGANFirst Health Services Corp.4300 Cox Rd.Glen Allen, VA 23060

MINNESOTAMinnesota Dept. of Human ServicesP: 415/588-5454

MISSISSIPPITerry ChildressDirector of Systems239 North Lamar St.Jackson, MS 39201-1399P: 601/359-6050E-mail: [email protected]



MISSOURIGTE Data ServicesJim Judge905 Weathered Rock Rd.Jefferson City, MO 65101P: 573/635-2434

MONTANAConsultec, Inc.Brett Jakovac, Account Manager34 N. Last Chance Gulch, Ste. 200Helena, MT 59601P: 406/442-1837

NEBRASKAFirst Health Services Corp.Janice Jones, R.Ph., Clinical Pharmacy Manager4300 Cox Rd.Glen Allen, VA 23060P: 804/965-7517F: 804/273-6961E-mail: [email protected]

NEVADAAnthem/ Blue Cross Blue ShieldP.O. Box 12127Reno, NV 89510-2127P: 775/448-4020

NEW HAMPHSHIREEDSGary Patenaude, Account Manager7 Eagle SquareConcord, NJ 03301P: 603/225-4899E-mail: [email protected]

NEW JERSEYUnisysP.Ringel, Chief Architect3705 Quakerbridge Rd., Suite 101Trenton, NJ 08619P: 609/588-6000F: 609/584-8270E-mail: [email protected]

NEW MEXICONeil SolomonP: 505/827-3174

NEW YORKComputer Sciences Corporation800 North Pearl StreetAlbany, NY 12204P: 518/447-9200

NORTH CAROLINAEDSSharon Greeson, R.Ph., Pharmacist Consultant4905 Waters Edge Dr.Raleigh, NC 27606P: 919/233-6829F: 919/859-9703E-mail: [email protected]

NORTH DAKOTACindy FrolerDepartment of Human ServicesState Capital, 600 East BoulevardDepartment 325Bismarck, ND 58505-0250P: 701/328-4023F: 701/328-1544E-mail: [email protected]

OHIOFirst Health Services Corp.4300 Cox Rd.Glen Allen, VA 23060P: 800/884-2822F: 800/884-7682

OKLAHOMALaura Dickey-HottelDP Analyst/Planning Specialist IIIOklahoma Health Care Authority4545 N. Lincoln Blvd, Suite 124Oklahoma City, OK 73105-9901P: 405/522-7228F: 405/522-7378E-mail: [email protected]



OREGONMariellen Rich, R.Ph.Director, Pharmacist Account ManagerFirst Health Service, Corporation565 Union St., NE, Suite 205Salem, OR 97310P: 503/391-1980F: 503/391-1979E-mail: [email protected]

PENNSYLVANIAEDS

RHODE ISLANDContact not provided.

SOUTH CAROLINARod DavisBureau Chief, Bureau of Information SystemsS.C. Department of Health & Human ServicesP.O. Box 8206Columbia, SC 29202-8206P: 803/898-2610E-mail: [email protected]

SOUTH DAKOTAMeredith HeermanSD Dept. of Social ServicesClaims Processing Supervisor700 Governors Dr.Pierre, SD 57501P: 605/773-3495E-mail: [email protected]

TENNESSEEContact not provided

TEXASTexas Dept. of HealthPatsy McElroy, Director, Electronic ClaimsManagement1100 West 49th StreetAustin, TX 78756P: 512/338-6909E-mail: [email protected]

UTAHBrenda Bryant (In-House)Health Care Financing288 North 1460 WestSalt Lake City, UT 84114

VERMONTEDS312 Hurricane Lane, Ste 101Williston, VT 05495P: 802/879-4450F: 802/878-3440E-mail: [email protected]

VIRGINIAFirst Health ServicesGlen Allen, VA

WASHINGTONChris JohnsonClaims Processing ManagerMedical Assistance AdministratorP.O. Box 45560Olympia, WA 98504-5506P: 360/725-1067F: 360/586-4994E-mail: [email protected]

WEST VIRGINIAConsultec, Inc.Leslie Bratton, Account Manager9040 Roswell Road, Suite 700Atlanta, GA 30350P: 800/358-2381F: 800/793-2305E-mail: [email protected]

WISCONSINMark GajewskiAccount DirectorEDS6406 Bridge RoadMadison, WI 53713P: 608/221-9326



WYOMINGConsultec, Inc.Jennifer Dillinger, Account ManagerP.O. Box 667Cheyenne, WY 82003P: 307/777-5500





PRESCRIPTION PRICE UPDATING CONTACTS, 2000

ALABAMAFirst DataBank1111 Bayhill Drive, Suite 350San Bruno, CA 94066P: 650/588-5454

ALASKADave Campana, R.PhPharmacy Program ManagerDivision of Medical Assistance4501 Business Park Blvd., Ste. 24Anchorage, AK 99503P: 907/273-3224F: 907/561-1684E-mail: [email protected]

ARIZONAJoan TerryDBF/CLMS/AHCCCS701 E. JeffersonPhoenix, AZ 85034P: 602/417-7927

ARKANSASFirst DataBank1111 Bayhill DriveSan Bruno, CA 94066P: 650/588-5454

CALIFORNIAEDSPO Box 13029Sacramento, CA 95813-4029P: 916/636-1000

COLORADOAllen ChapmanDepartment of Health Care Policy and Financing1575 Sherman St., 5th FloorDenver, CO 00008-0203P: 303/866-3176F: 303/866-2573

CONNECTICUTFirst DataBank1111 Bayhill DriveSan Bruno, CA 94066P: 650/588-5454

DELAWARECynthia DenemarkPharmacist ConsultantEDS248 Chapman Road, Suite 200Newark, DE 197029720P: 302/453-8453F: 302/454-7603E-mail: [email protected]

DISTRICT OF COLUMBIAFirst DataBank1111 Bayhill DriveSan Bruno, CA 94066P: 650/588-5454

FLORIDAFirst DataBank1111 Bayhill Drive, Suite 350San Bruno, CA 94066P: 650/588-5454

GEORGIAEtta L. Hawkins, R.Ph.Department of Community Health-Medical Division2 Peachtree Street, 37th FloorAtlanta, GA 30303-3159P: 404/657-7239F: 404/656-8366E-mail: [email protected]

HAWAIIFirst DataBank111 Bayhill Dr.San Bruno, CA 94066P: 800/633-3453



IDAHOGary Duerr, R.Ph.Pharmacy Services SpecialistIdaho Medicaid PolicyAmericana Terrace, Suite 140PO Box 83720Boise, ID 83720-0036P: 208/364-1829F: 203/364-1846

ILLINOISFirst Data Bank1111 Bay Hill DriveSan Bruno, CA 94066P: 650/588-5454

INDIANAFirst DataBank1111 Bay Hill DriveSan Bruno, CA 94066P: 650/588-5454

IOWASherey SwansonDeputy Account ManagerConsultec, Inc.P.O. Box 14422Des Moines, IA 50306-3422P: 515/327-0950 x1107F: 515/327-0945

KANSASKaren Braman, R.Ph., M.S.Health Care Policy DivisionKansas Department of Social and RehabilitationServices915 SW Harrison, Room 651-South DSOBTopeka, KS 66612-1570P: 785/296-3981

KENTUCKYUnisys-Provider ServicesP.O. Box 2100Frankfort, KY 40602P: 502/226-1140

LOUISIANAMaggie VickUnisysPO Box 3396Baton Rouge, LA 70809P: 225/219-3251F: 225/219-4164E-mail: [email protected]

MAINEKathy ChadwickFirst DataBank1111 Bay Hill DriveSan Bruno, CA 94066P: 800/633-3453E-mail: [email protected]

MARYLANDFirst DataBank1111 Bayhill Drive, Suite 350San Bruno, CA 94066P: 650/588-5454

MASSACHUSETTSChristopher BurkePharmacy Program AnalystDivision of Medical Assistance600 Washington StreetBoston, MA 02111P: 617/210-5592F: 617-210-5597

MICHIGANFirst DataBank1111 Bayhill Drive, Suite 350San Bruno, CA 94066P: 650/588-5454F: 650/827-4578



MINNESOTAFirst DataBank1111 Bay Hill DriveSan Bruno, CA 94066P: 650/588-5454F: 650/827-4578

MISSISSIPPIJack Lee, R.Ph.Pharmacy Program AdministratorDiv. Of Medicaid, Office of the Governor239 North Lamar St., Ste. 801Jackson, MS 39201-1399P: 601/359-6296F: 601/369-4185

MISSOURIFirst DataBank1111 Bayhill Drive, Suite 350San Bruno, CA 94066P: 650/588-5454F: 650/827-4578

MONTANAFirst DataBank1111 Bayhill Drive, Suite 350San Bruno, CA 94066P: 650/588-5454F: 650/827-4578

NEBRASKAFirst DataBank1111 Bayhill Drive, Suite 350San Bruno, CA 94066P: 650/588-5454F: 650/827-4578

NEVADAFirst DataBank1111 Bayhill Drive, Suite 350San Bruno, CA 94066P: 650/588-5454F: 650/827-4578

NEW HAMPSHIREFirst DataBank1111 Bay Hill DriveSan Bruno, CA 94066P: 650/588-5454F: 650/827-4578

NEW JERSEYFirst DataBank, Inc.1111 Bayhill DriveSan Bruno, CA 94066P: 650/588-5454F: 650/827-4578

NEW MEXICONeil SolomonMedicaid Assistance DivisionP. O. Box 2348Santa Fe, NM 87504P: 505/827-3174

NEW YORKCarl CioppaPharmacy Program SpecialistPharmacy Policy and OperationsOffice of Medicaid ManagementNYS Dept. of Health99 Washington Ave., Suite 606Albany, NY 12210P: 518/486-3209F: 518/473-55008E-mail: [email protected]

NORTH CAROLINAC. Benny Ridout, R.Ph.Pharmacist DirectorNC Division of Medical Assistance1985 Umstead Drive2511 Mail Service CenterRaleigh, NC 27699-2511P: 919/857-4034F: 919/733-2796E-mail: [email protected]



NORTH DAKOTAFirst DataBank, Inc.1111 Bayhill DriveSan Bruno, CA 94066P: 800/633-3453

OHIOFirst DataBank1111 Bayhill Drive, Suite 350San Bruno, CA 94066P: 650/588-5454F: 650/827-4578

OKLAHOMAAngela ThomassonPharmacy Claims SpecialistOklahoma Health Care Authority4545 N. Lincoln Blvd., Suite 124Oklahoma City, OK 73105-9901P: 405/522-7307F: 405/522-7378E-mail: [email protected]

OREGONKathy FrankilnCustomer Support DepartmentFirst DataBank, Inc.1111 Bayhill DriveSan Bruno, CA 94066P: 650/588-5454F: 650/588-4003

PENNSYLVANIAFirst DataBank, Inc.1111 Bayhill DriveSan Bruno, CA 94066P: 800/633-3453

RHODE ISLANDPaula J. Avarista, R.Ph.Department of Human Services600 New London AvenueCranston, RI 02920P: 401/462-2183F: 401/462-2185

SOUTH CAROLINAFirst DataBank, Inc.1111 Bayhill DriveSan Bruno, CA 94066P: 650/588-5454F: 650/588-4003

SOUTH DAKOTAMark Petersen, R.Ph.Department of Social Services700 Governors DrivePierre, SD 57501P: 605/773-3498F: 605/773-5246E-mail: [email protected]

TENNESSEEContact Not Provided

TEXASMartha McNeillDirector, Product Enrollment DivisionTexas Department of Health1100 West 49th StreetAustin, TX 78756-3174P: 512/338-6965F: 512/338-6462

UTAHRaeDell AshleyPharmacy DirectorHealth Care Financing288 N. 1460 West, P.O. Box 143102Salt Lake City, UT 84114-2905P: 801/538-6495F: 801/538-6099

VERMONTChristine DapkiewiczDrug Rebate CoordinatorEDS312 Hurricane LaneWilliston, VT 05495P: 802/879-4450F: 802/878-3440



VIRGINIADavid B. Shepherd, R.Ph.Pharmacy ConsultantDepartment of Medical Asisstance Services600 East Broad Street, Suite 1300Richmond, VA 23112P: 804/786-8057F: 804/786-0414

WASHINGTONMarilyn MuellerPharmacy Program ManagerMedical Assistance Administration--DSHSP.O. Box 45506Olympia, WA 98504-5506P: 360/725-1569E-mail: [email protected]

WEST VIRGINIALeslie BrattonAccount ManagerConsultec, Inc.9040 Roswell Road, Suite 700Atlanta, GA 30350P: 800/358-2381F: 800/793-2305E-mail: [email protected]

WISCONSINFirst DataBank1111 Bayhill Drive, Suite 350San Bruno, CA 94066P: 650/588-5454F: 650/827-4578

WYOMINGFirst DataBank1111 Bayhill DriveSan Bruno, CA 94066P: 800/633-3453





MEDICAID DRUG REBATE, 2000

ALABAMAJim MorrisonAlabama Medicaid Agency501 Dexter AvenueMontgomery, AL 36103-5624334/242-2323E-mail: [email protected]

ALASKADave Campana, R.PhPharmacy Program ManagerDivision of Medical Assistance4501 Business Park Blvd., Ste. 24Anchorage, AK 99503P: 907/273-3224F: 907/561-1684

ARIZONAAHCCCS/DBF/CLMSLori Petre, Claims Administrator701 E. JeffersonPhoenix, AZ 85034P: 602/417-4547

ARKANSASSuzette Bridges, P.D.Department of Human ServicesDivision of Medical ServicesPharmacy ProgramP.O. Box 1437, Slot 4105Little Rock, AR 72203P: 501/324-9141

CALIFORNIACraig MillerChief, Contracting UnitMedi-Cal Policy Division714 P Street, Room 1540Sacramento, CA 95814P: 916/654-0532F: 916/654-0513E-mail: [email protected]

COLORADOVince SherryDepartment of Health Care Policy and Financing1575 Sherman St., 5th FloorDenver, CO 00008-0203P: 303/866-5408F: 303/866-2573

CONNECTICUTEllen Arce, R.Ph.Pharmacy Team LeadEDS100 Stanley DriveNew Britain, CT 06053P: 860/832-5885F: 860/832-5832

DELAWAREChristine WhitlockRebate AnalystEDS248 Chapman RoadNewark, DE 19702P: 302/454-7622F: 302/454-7603E-mail: [email protected]

DISTRICT OF COLUMBIAContact not provided

FLORIDAGreg BrackoRebate CoordinatorAHCA2727 Mahan Dr.Tallahassee, FL 32308P: 850/488-9193E-mail: [email protected]



GEORGIASusan OhDrug Rebate CoordinatorDepartment of Community Health2 Peachtree St. 37th FloorAtlanta, GA 30303P: 404/657-9181F: 404/656-8366E-mail: [email protected]

HAWAIIBrian PangFinance OfficerDepartment of Human ServicesMed QUEST DivisionP.O. Box 339Honolulu, HI 96809-0339P: 808/692-7956F: 808/692-7989

IDAHODavid MendozaMedicaid ProgramsP.O.Box 83720Boise, ID 83720-0036P: 208/364-1838F: 208/364-1846E-mail: [email protected]

ILLINOISAlberta LevanSupervisorIllinois Department of Public Aid110 West LawrenceSpringfield, IL 62763P: 217/524-7161F: 217/524-5176

INDIANAEDS950 North Meridan Street, 11th FloorIndianapolis, IN 46204P: 317/488-5000

IOWARocco RussoThird Party Liability ManagerConsultec, Inc.P.O. Box 14422Des Moines, IA 50306-3422P: 515/327-0950 x1114

KANSASKaren Braman, R.Ph., M.S.Health Care Policy DivisionKS Dept of Social and Rehabilitation Services915 SW Harrison, Room 651-South DSOBTopeka, KS 66612-1570P: 785/296-3981

KENTUCKYMarie CouchDepartment for Medicaid Services275 E. Main St.Frankfort, KY 40621P: 502/564-3476F: 502/564-3852

LOUISIANASusan Taskin, Chief, MMISDepartment of Health and HospitalsP.O. Box 91030Baton Rouge, LA 70821P: 225/342-9494

MAINERossi RoweTPL ManagerDHS/BMSBuilding 205, 2nd Fl.Augusta, ME 04333-0011P: 207/287-1838F: 207/287-1788E-mail: [email protected]



MARYLANDKenneth SmootDeputy DirectorOffice of Management and Finance201 W. Preston St.Baltimore, MD 21201P: 401/767-5186F: 410/333-5409

MASSACHUSETTSPaula McAreeDrug Rebate SpecialistDivision of Medical Assistance600 Washington St.Boston, MA 02111P: 617/210-5594F: 617/210-5597E-mail: [email protected]

MICHIGANDawn Parsons, R.Ph.MDCH/Medical Services Administration400 S. Pine St.Lansing, MI 48933P: 517/335-5078E-mail: [email protected]

MINNESOTAJarvis Jackson, R.Ph.Drug Rebate CoordinatorDept. of Human Services444 Lafayette Rd.St. Paul, MN 55155-3849P: 651/282-5881F: 651/282-6744E-mail: [email protected]

MISSISSIPPIGlenda GrantRebate CoordinatorDivision of Medicaid, Office of the Governor239 North Lamar St., Ste 801Jackson, MS 39201P: 601/359-6050F: 601/359-6712E-mail: [email protected]

MISSOURILynn HebenheimerPharmacy Rebate ManagerDivision of Medical ServicesP.O. Box 6500Jefferson City, MO 65102P: 573/751-2005F: 573/526-2045E:mail:[email protected]

MONTANABetty DeVaneyDrug Rebate CoordinatorDept. of Public Health and Human ServicesP.O. Box 202951Helena, MT 59620-2951P: 406/444-3457F: 406/[email protected]

NEBRASKAArlene RogersFiscal Project AnalystHHSS-Finance and SupportNSOB, 5th FloorLincoln, NE 68509P: 402/471-9159F: 7402/471-7783E-mail: [email protected]

NEVADALaurie Squartsoff, R.Ph.Pharmacy Services ConsultantNevada Medicaid2527 N. Carson St. Capitol ComplexCarson City, NV 89710P: 775/687-4869F: 775/[email protected]



NEW HAMPHSHIREJulie Simpson, R.Ph.EDS Federal Corp.7 Eagle SquareConcord, NH 03301P: 603/224-1747 ext. 3016E-mail: [email protected]

NEW JERSEYCarl Tepper, R.Ph.Chief, Pharmaceutical ServicesDepartment of Human ServicesDivision of Medical Assistance and Health ServicesP.O. Box 712, Bldg 11-ATrenton, NJ 08625P: 609/588-2724F: 609/588-3889E-mail: [email protected]

NEW MEXICONeil SolomonP: 505/827-3174

NEW YORKMark-Richard Butt, M.S., R.Ph.Director, Pharmacy Policy and OperationsNYS Department of HealthOffice of Medicaid Management99 Washington Ave., Room 606Albany, NY 12210P: 518/486-3209F: 518/473-5508

NORTH CAROLINASharon Greeson, R.Ph.Pharmacist ConsultantEDS4905 Waters Edge Dr.Raleigh, NC 27606P: 919/233-6829F: 919/859-9703E-mail: [email protected]

NORTH DAKOTACindy FrolickDepartment of Human ServicesState Capital, 600 East BoulevardDepartment 325Bismarck, ND 58505-0250P: 701/328-4023F: 701/328-1544E-mail: [email protected]

OHIOProgram Administrator

OKLAHOMATom SimonsonDrug Rebate ManagerOklahoma Health Care Authority4545 N. Lincoln Blvd, Suite 124Oklahoma City, OK 73105-9901P: 405/522-7327F: 405/522-7472E-mail: [email protected]

OREGONBecky SmithRebate AnalystFirst Health Services Corporation565 Union St. NE, Suite 205Salem, OR 97301P: 503/391-1981F: 503/391-1979E-mail: [email protected]

PENNSYLVANIAEDS

RHODE ISLANDContact not provided.



SOUTH CAROLINAKathy BassDepartment HeadS.C. Department of Health & Human ServicesP.O. Box 8206Columbia, SC 29202-8206P: 803/898-2974E-mail: [email protected]

SOUTH DAKOTAHelen RokusekRebate CoordinatorSD Dept. of Social Services700 Governors Dr.Pierre, SD 57501P: 605/773-3653

TENNESSEEContact not provided

TEXASTexas Dept. of HealthPatsy McElroy, Director, Electronic ClaimsManagement1100 West 49th StreetAustin, TX 78756P: 512/338-6909E-mail: [email protected]

UTAHBrenda Bryant (In-House)Health Care Financing288 North 1460 WestSalt Lake City, UT 84114

VERMONTChristine DapkiewiczDrug Rebate CoordinatorEDS312 Hurricane LaneWilliston, VT 05495P: 802/879-4450F: 802/878-3440

VIRGINIAFirst Health ServicesGlen Allen, VA

WASHINGTONSue HiltonDrug Rebate ManagerMedical Assistance AdministrationP.O. Box 45503Olympia, WA 98504-5503P: 360/725-1251F: 360/586-2373E-mail: [email protected]

WEST VIRGINIAGail Goodnight, R.Ph.Rebate CoordinatorDHHR, Bureau for Medical Services350 Capitol Street, Room 251Charleston, WV 25301-3707P: 304/558-1700F: 304/[email protected]

WISCONSINEllen OrsborneDivision of Health Care FinancingDepartment of Health and Family ServicesOne West Wilson Street, Rm 472P.O. Box 309Madison, WI 53701-0309P: 608/267-7939F: 608/266-1096

WYOMINGShannon WhalenPharmacy Program ManagerOffice of Primary Care-CAFHD2300 Capital Ave, 154 Hathaway Bldg.Cheyenne, WY 82002P: 307/777-6016F: 307/[email protected]





STATE OFFICIALS, 2000

ALABAMAGovernorHonorable Don SiegelmanState Capitol600 Dexter AvenueMontgomery, AL 36103334/242-7100Single State Agency DirectorMr. W. Dale WalleyActing Commissioner, Alabama Medicaid Agency501 Dexter AvenueP.O. Box 5624Montgomery, AL 36103-5624334/242-5010Medicaid DirectorMr. W. Dale WalleyActing Commissioner, Alabama Medicaid Agency501 Dexter AvenueP.O. Box 5624Montgomery, AL 36103-5624334/242-5600F: 334/242-5097E-mail – [email protected]

ALASKAGovernorHonorable Tony KnowlesP.O. Box 110001Juneau, AK 99811-0001907/465-3500Single State Agency DirectorMs. Karen PerdueCommissionerDepartment of Health and Social ServicesP.O. Box 110601Juneau, AK 99811-0601907/465-3030Medicaid DirectorMr. Bob LabbeDirectorDivision of Medical AssistanceDepartment of Health and Social ServicesP.O. Box 110660Juneau, AK 99811-0660907/465-3355F: 907/465-2204E-mail – [email protected]

ARIZONAGovernorHonorable Jane Dee HullState Capitol1700 W. WashingtonPhoenix, AZ 85007602/542-4331Single State Agency DirectorMs. Phyllis Beidess, DirectorArizona Health Care Cost Containment System80l East Jefferson StreetPhoenix, AZ 85034602/417-4680F: 602/252-6536E-mail – [email protected] DirectorMs. Phyllis Beidess, DirectorArizona Health Care Cost Containment System801 East Jefferson StreetPhoenix, AZ 85034602/417-4680F: 602/252-6536E-mail – [email protected]

ARKANSASGovernorHonorable Mike HuckabeeState Capitol BuildingLittle Rock, AR 72201501/682-2345Single State Agency DirectorMr. Kurt Knickrehm, DirectorDepartment of Human ServicesP.O. Box 1437, Slot 329Little Rock, AR 72203-1437501/682-8650Fax 501/682-6836E-mail – [email protected] DirectorMr. Ray Hanley, DirectorDivision of Medical Services Dept. of Human ServicesP.O. Box 1437, Slot 1100Little Rock, AR 72203-143750l/682-8292F: 501/682-1197E-mail – [email protected]



CALIFORNIAGovernorHonorable Gray DavisState Capitol, First FloorSacramento, CA 958l4916/445-2841F: 916/445-4633Single State Agency DirectorMs. Diana M. Bonta, Director714 P Street, Room 1253Sacramento, CA 95814916/657-1425Medicaid DirectorMs. Gail M. Margolis, Deputy DirectorMedical Care ServicesDepartment of Health Services714 P Street, Room 1253Sacramento, CA 95814916/654-0391F: 916/657-1156E-mail – [email protected]

COLORADOGovernorHonorable Bill OwensState CapitolRoom 136Denver, CO 80203303/866-2471F: 303/866-2003Single State Agency DirectorMr. James T. RizzutoExecutive DirectorDepartment of Human Servicesl575 Sherman StreetDenver, CO 80203-1714303/866-5096F: 303/866-4740E-mail – [email protected] DirectorMr. Richard AllenExecutive DirectorDepartment of Health Care Policy and Financingl575 Sherman StreetDenver, CO 80203-1714303/866-5401F: 303/866-2803TDD 303/866-3883E-mail – [email protected]

CONNECTICUTGovernorHonorable John G. RowlandState Capitol, Room 202Hartford, CT 06l06860/566-4840Single State Agency DirectorMs. Patricia Wilson-Coker, CommissionerDepartment of Social Services25 Sigourney StreetHartford, CT 06106-5033860/424-5008Medicaid DirectorMr. David Parella, Deputy CommissionerDepartment of Social Services25 Sigourney StreetHartford, CT 06106-5116860/424-5116F: 860/424-5114E-mail – [email protected]

DELAWAREGovernorHonorable Thomas R. CarperTatnall BuildingWilliam Penn StreetDover, DE 19901302/739-4101Single State Agency DirectorMr. Greg SylvesterSecretaryDepartment of Health and Social Services1901 North DuPont HighwayNew Castle, DE l9720302/421-6705Medicaid DirectorMr. Philip Soulé, Sr.DirectorMedical Assistance ProgramDepartment of Health and Social ServicesP.O. Box 906, Lewis Building1901 North DuPont HighwayNew Castle, DE 19720302/577-4901F: 302/577-4577E-mail – [email protected]



DISTRICT OF COLUMBIAMayorHonorable Anthony A. WilliamsDistrict of Columbia441 4th Street, NWSuite 1100Washington, DC 20001202/727-2980Single State Agency DirectorIvan C. A. Walks, MD, DirectorDepartment of Health825 North Capitol S., NEFourth FloorWashington, DC 20002202/442-5999F: 202/442-4788Medicaid DirectorMr. Herbert H. Weldon, Jr., Deputy DirectorMedical Assistance AdministrationDepartment of Health825 North Capitol S., NEFifth FloorWashington, DC 20002202/442-9090

FLORIDAGovernorHonorable Jeb BushState CapitolPlaza 05Tallahassee, FL 32399-0001904/488-2272Single State Agency DirectorMr. Ruben King-Shaw, DirectorAgency for Health Care Administration325 John Knox RoadSuite 301 AtriumTallahassee, FL 32303904/922-5527Medicaid DirectorMr. Gary Crayton, Director of MedicaidAgency for Health Care Administration2727 Mahan Drive, Bldg. 3Tallahassee, FL 32308850/922-6463F: 850/488-3560E-mail – [email protected]

GEORGIAGovernorHonorable Roy Barnes203 State CapitolAtlanta, GA 30334404/656-l776Single State Agency DirectorRuss Toal, CommissionerDepartment of Community of Health2 Peachtree Street, NWSuite 4043Atlanta, GA 30303-3159404/656-4479Medicaid DirectorGary B. Redding, DirectorDepartment of Community Health2 Peachtree Street, NWSuite 4043Atlanta, GA 30303-3159404/656-4479F: 404/651-6880E-mail – [email protected]

GUAMGovernorHonorable Carl T. C. GutierrezAdelup ComplexP.O. Box 2950Agana, GU 96932671/472-8931F: 671/472-4926Single State Agency DirectorDennis Rodriguez, DirectorDept. of Public Health and Social ServicesP.O. Box 2816Agana, GU 96910671/734-7123F: 671/734-5910Medicaid DirectorMs. Ma Theresa Arcangel, Acting AdministratorBureau of Health Care FinancingDepartment of Public Health and Social ServicesP.O. Box 28l6Agana, GU 96910671/735-7269F: 671/734-5910



HAWAIIGovernorHonorable Carl Benjamin J. CayetanoState CapitolHonolulu, HI 968l3808/586-0034Single State Agency DirectorMs. Susan M. Chandler, DirectorDepartment of Human ServicesP.O. Box 339Honolulu, HI 96809-0339808/586-4997Medicaid DirectorMr. Chuck C. Duarte, AdministratorMed-Quest DivisionDepartment of Human ServicesP.O. Box 399Honolulu, HI 96809-0339808/692-8056F: 808/692-8173E-mail – [email protected]

IDAHOGovernorHonorable Dirk KempthorneP.O. Box 83720Boise, ID 83720-0034208/334-2100Single State Agency DirectorMr. Karl Kurtz, DirectorDepartment of Health and Welfare450 West State StreetBoise, ID 83720-0036208/334-5500F: 208/334-6558Medicaid DirectorMr. Joe Brunson, AdministratorDivision of MedicaidDepartment of Health and WelfareAmericana BuildingP.O. Box 83720Boise, ID 83720-0036208/364-1802F: 208/334-1811E-mail: [email protected]

ILLINOISGovernorHonorable George H. Ryan207 Capitol BuildingState CapitolSpringfield, IL 627062l7/782-6830Single State Agency DirectorMs. Ann Patla, Dr.HL, DirectorDepartment of Public Aid201 South Grand Avenue, East, Third FloorSpringfield, IL 62763-00012l7/782-6717F: 217/524-7979Medicaid DirectorMr. Matt Powers, AdministratorDepartment of Public Aid20l South Grand Avenue, East, Third FloorSpringfield, IL 62763-00012l7/782-2570F: 217/524-7979E-mail – [email protected]

INDIANAGovernorHonorable Frank O’BannonState House, Room 206Indianapolis, IN 462043l7/232-4567Single State Agency DirectorMr. Peter Sybinsky, SecretaryFamily and Social Services AdministrationRoom 461, Mail Stop 25P.O. Box 7083402 W. Washington StreetIndianapolis, IN 46207-7083317/233-4452E-Mail: [email protected] DirectorMs. Kathleen D. Gifford, Assistant SecretaryMedicaid Policy and PlanningFamily and Social Services Administration402 W. Washington Street, Room W382Indianapolis, IN 46204-2739317/233-4455F: 317/232-7382E-Mail: [email protected]



IOWAGovernorHonorable Thomas J. VilsackState Capitol BuildingDes Moines, IA 503l95l5/28l-5211F: 515/281-6611Single State Agency DirectorJessie K. Rasmussen, DirectorDepartment of Human ServicesHoover State Office BuildingFifth FloorDes Moines, IA 503l9-01145l5/28l-5452F: 515/281-4597Medicaid DirectorDennis Headlee, AdministratorDivision of Medical ServicesDepartment of Human ServicesHoover State Office BuildingFifth FloorDes Moines, IA 503l9-01145l5/281-8621F: 515/281-7791

KANSASGovernorHonorable Bill Graves2nd FloorState Capitol BuildingTopeka, KS 66612-1590785/296-3232F: 785/296-7973Single State Agency DirectorMs. Janet Schalansky, SecretaryKansas Department of Social and Rehabilitation ServicesState Office BuildingTopeka, KS 66612785/296-3271F: 785/296-4685E-mail – [email protected] DirectorMr. Robert Day, CommissionerAdult and Medical ServicesDepartment of Social and Rehabilitation ServicesDocking State Office Building915 Harrison StreetTopeka, KS 66612785/296-8904F: 785/296-4813E-mail – [email protected]

KENTUCKYGovernorHonorable Paul E. PattonState Capitol Building700 Capitol AvenueFrankfort, KY 4060l502/564-2611Single State Agency DirectorMr. Jimmy D. Helton, CommissionerDepartment for Medicaid ServicesThird Floor275 East Main StreetFrankfort, KY 40621502/564-4321Medicaid DirectorMr. Dennis Boyd, CommissionerDepartment for Medicaid ServicesThird Floor275 East Main StreetFrankfort, KY 40621502/564-4321F: 502/564-0509E-mail- [email protected]

LOUISIANAGovernorHonorable M. J. “Mike” FosterState CapitolP.O. Box 94004Baton Rouge, LA 70804504/342-7015F: 504/342-7099Single State Agency DirectorMr. David W. Hood, SecretaryDepartment of Health and HospitalsP.O. Box 629, Bin #2Baton Rouge, LA 70821-0629504/342-9500F: 504/342-5568Medicaid DirectorMr. Thomas D. Collins, DirectorBureau of Health Services FinancingDepartment of Health and HospitalsP.O. Box 91030Baton Rouge, LA 70821-9030504/342-3891F: 504/342-9508E-mail – [email protected]



MAINEGovernorHonorable Angus S. King, Jr.1 State House StationAugusta, Maine 04333-0001207/287-3531Single State Agency DirectorMr. Kevin Concannon, CommissionerDepartment of Human ServicesState House Station 11Augusta, ME 04333-0011207/287-2736Medicaid DirectorMr. Francis T. Finnegan, Jr., DirectorBureau of Medical ServicesDepartment of Human ServicesState House Station 11Augusta, ME 04333-0011207/287-2093F: 207/287-2675E-mail: [email protected]

MARYLANDGovernorHonorable Parris N. GlendeningState HouseAnnapolis, MD 21401410/974-3901Single State Agency DirectorGeorges Benjamin, M.D.SecretaryDepartment of Health & Mental HygieneHerbert R. O'Connor Building201 West Preston StreetFifth FloorBaltimore, MD 21201410/225-6535Medicaid DirectorDebbie ChangDeputy Secretary for Health Care FinancingDepartment of Health & Mental Hygiene201 West Preston StreetBaltimore, MD 21201410/767-4664F: 410/333-7687E-mail – [email protected]

MASSACHUSETTSGovernorHonorable Argeo Paul CellucciExecutive Office, State HouseRoom 360Boston, MA 02133617/727-9173Single State Agency DirectorMr. Bruce Bullen, CommissionerDivision of Medical AssistanceMedicaid Division600 Washington StreetBoston, MA 02111617/210-5690Medicaid DirectorMr. Bruce Bullen, CommissionerDivision of Medical Assistance600 Washington StreetBoston, MA 02111617/210-5690F: 617/210-5697E-mail: [email protected]

MICHIGANGovernorHonorable John EnglerP.O. Box 30013Lansing, MI 489095l7/373-3400Single State Agency DirectorMr. James K. Haveman, Jr., DirectorMichigan Department of Community HealthLewis Cass Building320 South Walnut StreetLansing, MI 48913517/335-0267Medicaid DirectorMr. Robert M. Smedes, Chief Executive OfficerMedical Services AdministrationMichigan Department of Community Health400 S. Pine StreetLansing, MI 48909517/335-5001F: 517/335-5007E-mail – [email protected]



MINNESOTAGovernorHonorable Jesse Ventura130 State CapitolSt. Paul, MN 55155-1099651/296-3391Single State Agency DirectorMr. Michael O’Keefe, CommissionerMinnesota Department of Human Services444 Lafayette Road NorthSt. Paul, MN 55155-3815651/296-2701F: 651/297-3230E-mail – [email protected] DirectorMs. Mary B. Kennedy, Medicaid DirectorAssistant Commissioner Health CareMinnesota Department of Human Services444 Lafayette RoadSt. Paul, MN 55l55-3852651/282-9921F: 651/297-3230E-mail – [email protected]

MISSISSIPPIGovernorHonorable Kirk FordiceState CapitolP.O. Box 139Jackson, MS 3920560l/359-3150Single State Agency DirectorMs. Helen Wetherbee, Executive DirectorDivision of MedicaidOffice of the GovernorSuite 801, Robert E. Lee Building239 North Lamar StreetJackson, MS 39201-1399601/359-6050Medicaid DirectorMs. Helen Wetherbee, Executive DirectorDivision of MedicaidOffice of the GovernorSuite 801, Robert E. Lee Building239 North Lamar StreetJackson, MS 39201-1399601/359-6050F: 601/359-6048E-mail – [email protected]

MISSOURIGovernorHonorable Mel CarnahanState Capitol BuildingP.O. Box 720Jefferson City, MO 65101573/751-3222F: 573/751-1495Single State Agency DirectorMr. Gary J. Stangler, DirectorDepartment of Social ServicesP.O. Box 1527Jefferson City, MO 65102573/751-4815F: 573/751-3203Medicaid DirectorMr. Gregory A. VadnerDivision of Medical ServicesDepartment of Social Services615 Howerton CourtP.O. Box 6500Jefferson City, MO 65102-6500573/751-6922F: 573/751-6564E-mail – [email protected]

MONTANAGovernorHonorable Marc RacicotCapitol StationHelena, MT 59620-0801406/444-3111Single State Agency DirectorMs. Laurie Ekanger, DirectorDepartment of Public Health and Human ServicesP.O. Box 4210111 N. SandersHelena, MT 59604-4210406/444-5622Medicaid DirectorMs. Nancy Ellery, AdministratorDivision of Health Policy and ServicesDepartment of Public Health and Human Services1400 BroadwayHelena, MT 59601406/444-4141F: 406/444-1861E-mail – [email protected]



NEBRASKAGovernorHonorable Mike JohannsP.O. Box 94848Lincoln, NE 68509-4848402/471-2244F: 402/471-6031Single State Agency DirectorJeff Elliot, DirectorNebraska Department of Health and Human ServicesFinance and SupportP.O. Box 95026Lincoln, NE 68509-5026402/471-8533F: 402/471-9449Medicaid DirectorBob Seiffert, AdministratorMedicaid DivisionNebraska Department of HHS Finance and SupportP.O. Box 95026Lincoln, NE 68509-5026402/471-9506F: 402/471-9092

NEVADAGovernorHonorable Kenny C. GuinnState CapitolCarson City, NV 89710702/687-5670Single State Agency DirectorMs. Charlotte Crawford, DirectorDepartment of Human Resources505 East King Street, Room 600Carson City, NV 89710775/684-4000F: 775/684-4010Medicaid DirectorMr. Mike Willden, AdministratorNevada State Welfare Division2527 North Carson StreetCarson City, NV 89706775/687-4128F: 775/687-5080Mr. Chuck Duarte, AdministratorDivision of Health Care Financing and Policy1100 East William Street, Suite 116Carson City, NV 89701775/687-4176 ext. 251F: 775/684-8792E-mail – [email protected]

NEW HAMPSHIREGovernorHonorable Jeanne ShaheenRoom 208Concord, NH 03301-4990603/271-2121Single State Agency DirectorMr. Donald L. Shumway, CommissionerDepartment of Health and Human Services129 Pleasant StreetConcord, NH 03301-3857603/271-4331F: 603/271-4912Medicaid DirectorCarol EarlyMedicaid DirectorMedicaid Administration BureauDepartment of Health and Human Services6 Hazen DriveConcord, NH 03301-6521603/271-8887F: 603/271-4376

NEW JERSEYGovernorHonorable Christine Todd Whitman125 West State StreetState House CN-001Trenton, NJ 08625609/292-6000Single State Agency DirectorMs. Michele Guhl, CommissionerDepartment of Human ServicesCapitol Place One CN-700, Fifth Floor222 South Warren StreetTrenton, NJ 08625609/292-3717Medicaid DirectorMs. Margaret A. Murray, DirectorDivision of Medical Assistance and Health ServicesDepartment of Human ServicesP.O. Box 712Trenton, NJ 08625-0712609/588-2600F: 609/588-3583



NEW MEXICOGovernorHonorable Gary E. JohnsonState CapitolSuite 400Santa Fe, NM 87503505/827-3000Single State Agency DirectorMr. William H. Johnson Jr., SecretaryNew Mexico Human Services DepartmentP.O. Box 2348Santa Fe, NM 87504-2348505/827-7750800/432-6217F: 505/827-6286Medicaid DirectorMr. Charles J. Milligan, DirectorMedical Assistance DivisionNew Mexico Human Services DepartmentP.O. Box 2348Santa Fe, NM 87504-2348505/827-3106888/997-2583 Toll free client infoF: 505/827-3185E-mail: [email protected]

NEW YORKGovernorHonorable George E. PatakiExecutive ChamberState CapitolAlbany, NY 122245l8/474-1041Single State Agency DirectorAntonio C. Novello, M.D., M.P.H., CommissionerNYS Department of HealthESP, Corning Tower BuildingAlbany, NY 12237518/474-2011Medicaid DirectorKathryn Kuhmerker, Deputy CommissionerNYS Department of HealthOffice of Medicaid ManagementEmpire State PlazaRoom 1466, Corning Tower BuildingAlbany, NY 12237518/474-3018F: 518/486-6652E-mail – [email protected]

NORTH CAROLINAGovernorHonorable James B. Hunt, Jr.116 West Jones StreetRaleigh, NC 27603-8001919/733-4240Single State Agency DirectorDavid Bruton, M.D., SecretaryDepartment of Human and Human ServicesP.O. Box 29526101 Blair Drive, Adams BuildingRaleigh, NC 27626-0526919/733-4534Medicaid DirectorMr. Paul R. Perruzzi, DirectorDivision of Medical AssistanceDepartment of Health and Human Services1985 Umstead DriveP.O. Box 29529Raleigh, NC 27626-0529919/857-4011F: 919/733-6608E-mail – [email protected]

NORTH DAKOTAGovernorHonorable Edward T. Schafer600 East Boulevard AvenueBismarck, ND 58505-0001701/328-2200Single State Agency DirectorMs. Carol Olson, Executive DirectorDepartment of Human Services600 East Boulevard AvenueBismarck, ND 58505-0250701/328-2310Medicaid DirectorMr. David J. Zentner, DirectorDivision of Medical AssistanceDepartment of Human Services600 East Boulevard AvenueBismarck, ND 58505-0261701/328-3194F: 701/328-1544E-mail – [email protected]



NORTHERN MARIANA ISLANDSGovernorHonorable Froilan C. TenorioCommonwealth of the Northern Mariana IslandsCapitol HillSaipan, MP 96950670/322-5091Single State Agency DirectorMr. Joseph K.P. VillagomezSecretary for Health ServicesDepartment of Public Health and Environmental ServicesCommonwealth of the Northern Mariana IslandsP.O. Box 409 CKSaipan, MP 96950670/234-6225Medicaid DirectorMs. Maria A.V. Leon Guerrero, Medical AdministratorDepartment of Public Health and Environmental ServicesCommonwealth of the Northern Mariana IslandsP.O. Box 409 CKSaipan, MP 96950670/234-8931

OHIOGovernorHonorable Bob Taft77 South High Street, 30th FloorColumbus, OH 43266-0601614/466-3555Single State Agency DirectorMs. Jacqueline Romer-Sensky, DirectorDepartment of Human Services30 East Broad Street, 32nd FloorColumbus, OH 43266-0423614/466-6282Medicaid DirectorMs. Barbara Edwards, Deputy DirectorOffice of MedicaidDepartment of Human Services30 East Broad Street, 31st FloorColumbus, OH 43266-0423614/644-0140F: 614/752-3986E-mail – [email protected]

OKLAHOMAGovernorHonorable Frank Keating212 State CapitolOklahoma City, OK 73105405/521-2342Single State Agency DirectorGarth L. Splinter, M.D.Chief Executive OfficerOklahoma Health Care Authority4545 North Lincoln BoulevardSuite 124Oklahoma City, OK 73105405/522-7439F: 405/530-3471Medicaid DirectorMr. Michael Fogarty, State Medicaid DirectorOklahoma Health Care Authority4545 North Lincoln BoulevardSuite 124Oklahoma City, OK 73105405/522-7373F: 405/530-3478E-mail – [email protected]

OREGONGovernorHonorable John A. KitzhaberState CapitolSalem, OR 97310503/378-3111Single State Agency DirectorMs. Gary Weeks, DirectorDepartment of Human Resources500 Summer Street, NEHuman Resources BuildingSalem, OR 97310-1012503/945-5944Medicaid DirectorMr. Hersh Crawford, DirectorSenior and Disabled Services DivisionDepartment of Human Resources500 Summer Street, NE 2nd FloorHuman Resources Building, Third FloorSalem, OR 97310-1015503/945-5767F: 503/373-7689E-mail – [email protected]



PENNSYLVANIAGovernorHonorable Thomas J. Ridge25 Main Capitol BuildingHarrisburg, PA 17120717/787-2500Single State Agency DirectorMs. Feather O. Houstoun, SecretaryDepartment of Public WelfareHealth and Welfare BuildingP.O. Box 2675Harrisburg, PA 17120717/787-2600Medicaid DirectorMargaret J. Dierkers, Ph.D.Deputy SecretaryMedical Assistance ProgramsDepartment of Public WelfareHealth and Welfare Building, Room 515Harrisburg, PA 17120717/787-1870F: 717/787-4639E-mail – [email protected]

PUERTO RICOGovernorHonorable Pedro RosselloLa FortalezaP.O. Box 82San Juan, PR 00901809/721-7000Single State Agency DirectorCarmen Feliciano-DeMelecio, M.D.SecretaryDepartment of HealthG.P.O. Box 70184San Juan, PR 00936809/765-1230Medicaid DirectorMs. Margarita Latorre, Medicaid DirectorOffice of Economic Assistance to the Medically IndigentDepartment of HealthG.P.O. Box 70184San Juan, PR 00936809/765-1230F: 809/250-0990

RHODE ISLANDGovernorHonorable Lincoln C. AlmondState HouseRoom 143Providence, RI 02903401/222-2080Single State Agency DirectorMs. Christine C. Ferguson, DirectorDepartment of Human Services600 New London AvenueCranston, RI 02920401/462-2121Medicaid DirectorMr. John Young, C.P.M.Associate DirectorDivision of Medical ServicesDepartment of Human Services600 New London AvenueCranston, RI 02920401/462-3113F: 401/462-6338E-mail – [email protected]

SOUTH CAROLINAGovernorHonorable Jim HodgesP.O. Box 11369Columbia, SC 29211803/734-9818Single State Agency DirectorDr. J. Samuel Griswold, DirectorDepartment of Health and Human ServicesP.O. Box 8206Columbia, SC 29202-8206803/253-6100Medicaid DirectorDr. J. Samuel Griswold, DirectorDepartment of Health and Human ServicesP.O. Box 8206Columbia, SC 29202-8206803/898-2504F: 803/898-4515E-mail – [email protected]



SOUTH DAKOTAGovernorHonorable William J. Janklow500 East CapitolPierre, SD 57501605/773-3212Single State Agency DirectorMr. James W. Ellenbecker, SecretaryDepartment of Social ServicesRichard F. Kneip Building700 Governors DrivePierre, SD 57501-2291605/773-3165Medicaid DirectorMr. David M. ChristensenProgram Administrator Medical ServicesDepartment of Social ServicesRichard F. Kneip Building700 Governors DrivePierre, SD 57501-2291605/773-3495F: 605/773-5246E-mail – [email protected]

TENNESSEEGovernorHonorable Don SundquistState CapitolFirst FloorNashville, TN 37243-0001615/741-2001Single State Agency DirectorMr. John Ferguson, CommissionerDepartment of Finance and Administration1st Floor, State CapitolNashville, TN 37219615/741-2401Medicaid DirectorMr. John TigheDeputy CommissionerDepartment of Finance and Administration729 Church StreetNashville, TN 37247-6501615/741-0213F: 615/741-0882E-mail – [email protected]

TEXASGovernorHonorable George W. BushState CapitolP.O. Box 12428Austin, TX 787115l2/463-2000Single State Agency DirectorDon Gilbert, CommissionerHealth and Human Services CommissionP.O. Box 13247Austin, TX 787115l2/424-6502F: 512/424-6586E-mail [email protected] DirectorMs. Linda K. WertzState Medicaid DirectorHealth and Human Services CommissionP.O. Box 13247Austin, TX 78711512/424-6549F: 512/424-6547E-mail – [email protected]

UTAHGovernorHonorable Michael O. Leavitt210 State CapitolSalt Lake City, UT 84114801/538-1000Single State Agency DirectorMr. Rod Betit, Executive DirectorDepartment of HealthP.O. Box 141000Salt Lake City, UT 84114-1000801/538-6111Medicaid DirectorMr. Rod Betit, Executive DirectorDepartment of HealthDivision of Health Care FinancingP.O. Box 14100Salt Lake City, UT 84114-1000801/538-6111F: 801/538-6306



VERMONTGovernorHonorable Howard Dean, M.D.109 State StreetMontpelier, VT 05609802/828-3333Single State Agency DirectorMr. Cornelius D. Hogan, SecretaryAgency of Human Services103 South Main StreetWaterbury, VT 05671-0201802/241-2220Medicaid DirectorMr. Paul Wallace-Brodeur, DirectorOffice of Health AccessDepartment of Social Welfare103 South Main StreetWaterbury, VT 05676802/241-3985F: 802/241-2974E-mail – [email protected]

VIRGINIAGovernorHonorable James S. Gilmore IIIState Capitol Building, Third FloorRichmond, VA 232l9804/786-2211Single State Agency DirectorMr. Dennis G. Smith, DirectorDepartment of Medical Assistance Services600 East Broad StreetSuite 1300Richmond, VA 23219804/786-7933Medicaid DirectorMr. Dennis G. Smith, DirectorDepartment of Medical Assistance Services600 East Broad StreetSuite 1300Richmond, VA 23219804/786-8099F: 804/371-4981E-mail – [email protected]

VIRGIN ISLANDSGovernorHonorable Roy L. SchneiderGovernment House21-22 Kongens GadaCharlotte AmalieSt. Thomas, VI 00802809/774-0001Single State Agency DirectorJose F. Poblete, M.D.Commissioner of HealthVirgin Island Department of HealthCharles Harwood Hospital3500 RichmondChristenstead, St. Croix, VI 00820-4370809/774-0117Medicaid DirectorMs. Priscilla Berry-Quetel, DirectorBureau of Health Insurance and Medical AssistanceDepartment of Health210-3A Altona, Suite 302 Frostco CenterCharlotte Amalie, VI 00802809/774-4624F: 809/774-4918

WASHINGTONGovernorHonorable Gary LockeLegislative BuildingOlympia, WA 98504-0002360/753-6780Single State Agency DirectorMr. Lyle Quasim, SecretaryDepartment of Social and Health ServicesP.O. Box 45010Olympia, WA 98504-5010360/902-7800F: 360/902-7848Medicaid DirectorMr. Tom Bedell, Acting Assistant SecretaryMedical Assistance AdministrationP.O. Box 45080Olympia, WA 98504-5080360/902-7807F: 360/902-7855E-mail – [email protected]



WEST VIRGINIAGovernorHonorable Cecil UnderwoodState CapitolCharleston, WV 25305-0370304/558-2000Single State Agency DirectorMs. Joan Ohl, SecretaryDepartment of Health and Human ResourcesBuilding 3, State Capitol ComplexRoom 206Charleston, WV 25305304/348-0627Medicaid DirectorMs. Elizabeth Lawton, CommissionerBureau for Medical ServicesDepartment of Health and Human Resources7012 MacCorkle Avenue, SECharleston, WV 25304304/926-1703 ask for Ms. Lawton’s Secty)F: 304/926-1833E-mail: [email protected]

WISCONSINGovernorHonorable Tommy G. ThompsonState CapitolP.O. Box 7863Madison, WI 53707608/266-1212Single State Agency DirectorMr. Joe Leean, SecretaryDepartment of Health and Social ServicesRoom 650One West Wilson StreetMadison, WI 53701608/266-9622Medicaid DirectorMs. Peggy Bartels, AdministratorDivision of Health Care FinancingDepartment of Health and Social ServicesOne West Wilson Street, Room 350Madison, WI 53701608/266-8922F: 608/266-1096E-mail – [email protected]

WYOMINGGovernorHonorable Jim GeringerState Capitol, Room 124Cheyenne, WY 82002307/777-7434Single State Agency DirectorMr. Garry KcKee, DirectorDepartment of Health2300 Capital AvenueHathaway Building, Room 117Cheyenne, WY 82002307/777-7656Medicaid DirectorMr. Daniel G. Stackis, AdministratorHealth Care Access and Resource DivisionDepartment of HealthHathaway Building, Suite 1542300 Capitol AvenueCheyenne, WY 82002307/777-7531F: 307/777-6964E-mail – [email protected]



REGIONAL ADMINISTRATIVE OFFICESHEALTH AND HUMAN SERVICES

HEALTH CARE FINANCING ADMINISTRATION

Region IBoston Regional Office

John F. Kennedy Federal Bldg.Government Center, Room 2325Boston, MA 02203-0003617/565-1223

Connecticut, Maine, Massachusetts,New Hampshire, Rhode Island,Vermont

Region IINew York Regional Office

26 Federal PlazaRoom 3811New York, NY 10278-0063212/264-2058

New Jersey, New York, Puerto Rico,Virgin Islands

Region IIIPhiladelphia Regional Office

Suite 216, The Public Ledger Building150 South Independence Mall WestPhiladelphia, PA 19106215/861-4263

Delaware, District of Columbia,Maryland, Pennsylvania, Virginia,West Virginia

Region IVAtlanta Regional Office

Atlanta Federal Center61 Forsyth Street, S.W., Suite 4T20Atlanta, GA 30303-8909404/562-7400

Alabama, Florida, Georgia, Kentucky,Mississippi, North Carolina, SouthCarolina, Tennessee

Region VChicago Regional Office

233 North Michigan AvenueSuite 600Chicago, IL 60601-5519312/353-9805

Illinois, Indiana, Michigan,Minnesota, Ohio, Wisconsin

Region VIDallas Regional Office

1301 Young Street, Room 714Dallas, TX 75202214/767-6301

Arkansas, Louisiana, New Mexico,Oklahoma, Texas

Region VIIKansas City Regional Office

Richard Bolling Federal Building601 East 12th Street, Room 235Kansas City, MO 64106-2808816/426-5925

Iowa, Kansas, Missouri, Nebraska

Region VIIIDenver Regional Office

Colorado State Bank Building1600 Broadway, Suite 700Denver, CO 80202-4367303/844-1977

Colorado, Montana, North Dakota,South Dakota, Utah, Wyoming

Region IXSan Francisco Regional Office

75 Hawthorne Street, 4th & 5th FloorsSan Francisco, CA 94105-3901415/744-3568

Arizona, California, Hawaii, GuamNevada, and Pacific Islands

Region XSeattle Regional Office

2201 6th AvenueMail Stop RX-40Seattle, WA 98121-2500206/615-2313

Alaska, Idaho, Oregon, Washington



HEALTH CARE FINANCING ADMINISTRATION (HCFA)CENTER FOR MEDICAID AND STATE OPERATIONS

7500 Security BoulevardBaltimore, MD 21244-1850

410/786-3000

DirectorTim Westmoreland

410/786-3870

Deputy DirectorRachel Block410/786-3230

Appeals and GrievancesNicole Martin410/786-1068

Assignment of Rights to BenefitsBob Nakielny410/786-4466

Beneficiary ServicesLindsey Cometa410/786-8201

Budget Information for State AgenciesMiles McDermott

410/786-3722

Child Health InsuranceCindy Shirk

410/786-6614

Coordination of BenefitsDave Witt

410/786-5600

Data InquiriesMarilyn McMillan

410/786-4623

Department Appeals Board DecisionsEd Davis

410/786-3280

Drugs(Coverage, Payment & Rebate Program Issues)

Larry Reed410/786-3325

Drug Rebate Agreement/DataJudy Allison

410/786-3330

Drug Utilization ReviewChristina Lyon410/786-3332

EligibilityMarty Svolos410/786-4582

Investigational/Experimental DrugsTami Bruce

410/786-1519

HCFA 2082 Statistical ReportRoger Buchanan

410/786-0780

Managed Care Enrollment ReportCarolyn Lawson410/786-0704

Program ReviewsMary Jean Duckett

410/786-3294

Pharmacy Issues/Pharmacy ReimbursementSue Gaston

410/786-6918

Statistical Information SystemRoger Buchanan

410/786-0780


National Pharmaceutical Council B-1

Appendix B:Medicaid Program Statistics --HCFA-2082 Report


B-2 National Pharmaceutical Council



Medicaid Program Statistics -- HCFA-2082 Report

The HCFA-2082 is an annual report designed to collect state-reported statisticalsummary data on eligibles, recipients, services, and expenditures during aFederal fiscal year (i.e., October l through September 30). The data reported fora given year represent recipients of service and the amount of payments forclaims adjudicated during the year. The data reflect bills adjudicated during theyear rather than the services used during the year.

Historically, States summarized and reported the data processed through theirMedicaid claims processing and payment operations unless they opted toparticipate in the Medicaid Statistical Information System (MSIS) project. Priorto Federal fiscal year 1999, MSIS was a voluntary program and those Statesparticipating in the MSIS project provide data tapes from their claims processingsystems to HCFA in lieu of the 2082 tables. However, in accordance with theBalanced Budget Act of 1997, all claims processed on or after January 1, 1999,must be submitted electronically in the MSIS format.

The Federal Fiscal Year 1998 (October 1997-September 1998) HCFA-2082 datatables are based on information reported to HCFA on an annual basis by the 50States, the District of Columbia, Puerto Rico, and the Virgin Islands. Thesetables reflect fiscal year 1998 data submitted by the States through September1999. When using the data, note the following caveats and data limitations.

GENERAL

• The 1998 reports include managed care capitation payments on the MedicaidMedical Vendor Payments tables and managed care recipients are nowincluded on the Medicaid Recipient tables. Managed care utilization andpayments are also broken out in the Type of Service tables. Tables 33through 48 are specifically managed care tables.

STATE-SPECIFIC

• Alabama submitted totals only for their Prepaid Health Care and PCCMrecipients and payments. This data is reported as Unknown. The total Childeligible population went up 25%. This was the result of the new programcalled ARKIDSFIRST.

• Arizona submitted reported capitation payments (Prepaid Health Care data)but no recipients were reported to correspond with these payments. The PHCcount for recipients was taken from the Medicaid Managed Care EnrollmentReport -1998

• Hawaii's recipient, eligible and vendor payment data are a result ofcombining their fee-for-service and Quest data. The Quest data consists ofmainly Prepaid Health Care/Poverty Related data. This combined data wasreported in Sections A, B, C, D (1), D (2), D (3), G, H and Sections K (1)and M.

FY 1998 HCFA-2082CAVEATS AND DATALIMITATIONS*



• The total Child eligible population went up 37% and adults went down 29%.This data agrees with Louisiana's 1996 data. Louisiana's FFY 1997 dataappears to include a misallocation of eligibles between the adult and childcategories.

• The total Child eligible population went up 67%. Maryland's FFY 1997data counted some children as adults; the FFY 1998 data is correct. Theyalso implemented the Maryland Children Health Program in July of 1998.

• The total Child eligible population went up 32%. Massachusetts made a lotof corrections to their data in FFY 1998 causing the counts to go up. HealthCare Reform also increased the eligible population for Children.

• Nebraska submitted data for Sections A, B, C and D only.

• New York's PCCM payments and eligibles in Section K (2) (Table 33) arenot correct. These counts include Targeted Case Management data. The totaladult eligible population went up 56%. The increase was due to New York'snew Medicaid Managed Care Waiver - Home and Community Basedprogram. The increase in this area was about 400K adults.

• Oklahoma submitted total recipients, eligibles and vendor payments only.Their data is reported as Unknown. The total Child eligible populationdecreased 34% from 97 due to a misallocation of Children in the 97 datacounts.

• Puerto Rico submitted a total recipient count only. The vendor paymentamount was taken from the HCFA-64. Their data is reported as Unknown.

• The total adult eligible population went up 25%. South Carolina alwaysused the midpoint of the FFY (03/31) to determine age, under MSIS they use09/30 as the date.

• The total adult eligible population went up 17%. This was due to Vermont'sexpansion of Medicaid population. More adults are now eligible forMedicaid and more services are provided to these adults.

• Total adult eligible population decreased by 17%. When the WisconsinWork Not Welfare (W2) initiative was implemented a lot of recipients lostMedicaid eligibility. Wisconsin then conducted an outreach campaign thatbrought a number of these individuals back to Medicaid.

*Readers of the book should be cautioned that discrepancies in the 2082 datacan extend beyond these caveats and data limitations presented by HCFA.


Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.


Table 1. Medicaid Recipients by Maintenance Assistance Status and by State: FY 1998

State NameTotal

RecipientsReceiving

Cash PaymentsMedically

NeedyPovertyRelated Other

MASUnknown

National Total 40,649,482 17,556,201 4,368,961 9,202,219 6,347,817 3,174,284Alabama 527,078 231,997 - 219,029 74,385 1,667Alaska 74,508 48,821 - 14,556 9,315 1,816Arizona 507,668 171,977 - 175,730 159,961 -Arkansas 424,727 157,450 33,542 162,638 63,045 8,052California 7,082,175 3,595,292 1,647,992 287,622 1,113,380 437,889Colorado 344,916 120,745 - 84,801 135,255 4,115Connecticut 381,208 151,939 41,568 52,394 135,307 -Delaware 101,436 36,876 - 46,928 15,291 2,341District of Columbia 166,146 87,261 17,242 7,753 4,108 49,782Florida 1,904,591 1,100,787 41,070 498,267 249,348 15,119Georgia 1,221,978 473,537 841 536,420 179,778 31,402Hawaii 184,614 109,151 4,751 58,953 4,006 7,753Idaho 123,176 13,767 - 34,793 56,599 18,017Illinois 1,363,856 608,119 286,438 248,864 220,435 -Indiana 607,293 231,768 - 181,086 172,542 21,897Iowa 314,936 129,836 12,299 63,159 107,262 2,380Kansas 241,933 90,083 32,802 79,787 33,327 5,934Kentucky 644,482 346,507 50,532 184,829 53,190 9,424Louisiana 720,615 372,578 8,629 190,227 149,181 -Maine 170,456 73,907 2,396 47,447 42,843 3,863Maryland 561,085 274,117 49,892 142,031 69,419 25,626Massachusetts 908,238 445,998 224,414 191,690 46,136 -Michigan 1,362,890 660,669 323,778 252,770 46,477 79,196Minnesota 538,413 239,835 15,263 69,756 204,665 8,894Mississippi 485,767 235,016 231 200,645 38,716 11,159Missouri 734,015 206,175 - 259,920 251,738 16,182Montana 100,760 47,965 7,586 15,922 23,572 5,715Nebraska 211,188 104,483 436 71,025 35,244 -Nevada 128,144 61,123 - 5,534 54,947 6,540New Hampshire 93,970 28,219 9,734 33,005 21,900 1,112New Jersey 813,251 418,784 6,296 167,133 213,615 7,423New Mexico 329,418 144,046 - 167,569 15,579 2,224New York 3,073,241 1,679,561 1,009,659 302,265 81,756 -North Carolina 1,167,988 594,269 122,027 389,458 62,234 -North Dakota 62,280 22,462 15,711 12,196 9,618 2,293Ohio 1,290,776 515,191 - 730,667 44,918 -Oklahoma 342,475 - - - - 342,475Oregon 511,171 139,766 6,843 222,907 121,234 20,421Pennsylvania 1,523,120 718,234 119,253 361,594 322,065 1,974Puerto Rico 964,015 - - - - 964,015Rhode Island 153,130 92,176 9,437 21,172 22,610 7,735South Carolina 594,962 190,767 - 225,889 155,498 22,808South Dakota 89,537 36,920 - 31,169 21,448 -Tennessee 1,843,661 449,326 139,188 628,086 221,416 405,645Texas 2,324,810 917,603 38,247 903,813 465,147 -Utah 215,801 54,561 5,080 27,564 97,612 30,984Vermont 123,992 38,507 9,057 56,418 18,082 1,928Virgin Islands 19,764 6,316 11,991 - 1,457 -Virginia 653,236 285,976 17,884 245,429 103,947 -Washington 1,413,208 397,055 12,333 183,766 265,814 554,240West Virginia 342,668 172,278 3,895 29,197 111,592 25,706Wisconsin 518,595 216,998 30,624 63,944 199,063 7,966Wyoming 46,121 9,407 - 14,402 21,740 572




Table 2. Medicaid Recipients by Basis of Eligibility and by State: FY 1998

State NameTotal

RecipientsAge 65

And OlderBlind/

Disabled ChildrenNational Total 40,649,482 3,964,223 6,637,980 18,309,145Alabama 527,078 64,651 145,892 262,547Alaska 74,508 5,306 8,912 37,429Arizona 507,668 27,473 78,121 282,256Arkansas 424,727 50,746 96,507 179,405California 7,082,175 587,326 926,252 3,345,491Colorado 344,916 43,264 62,492 154,206Connecticut 381,208 51,741 51,586 189,083Delaware 101,436 6,652 13,726 49,425District of Columbia 166,146 7,979 22,551 58,488Florida 1,904,591 186,566 383,978 944,280Georgia 1,221,978 89,197 226,263 666,385Hawaii 184,614 17,022 16,913 75,329Idaho 123,176 12,210 17,395 57,056Illinois 1,363,856 108,132 262,773 620,251Indiana 607,293 72,880 91,514 313,972Iowa 314,936 39,847 51,219 138,633Kansas 241,933 27,388 43,388 120,383Kentucky 644,482 65,739 178,672 273,114Louisiana 720,615 93,838 160,544 345,723Maine 170,456 22,669 37,064 74,213Maryland 561,085 44,502 104,461 264,965Massachusetts 908,238 113,876 197,426 409,962Michigan 1,362,890 91,663 259,243 616,825Minnesota 538,413 58,701 73,913 293,632Mississippi 485,767 60,567 131,439 218,491Missouri 734,015 88,776 113,652 384,773Montana 100,760 9,130 16,378 45,686Nebraska 211,188 25,162 27,724 106,023Nevada 128,144 12,320 19,320 65,349New Hampshire 93,970 12,291 12,124 51,166New Jersey 813,251 94,244 151,050 372,807New Mexico 329,418 19,601 44,824 209,014New York 3,073,241 393,567 592,598 1,315,777North Carolina 1,167,988 158,676 198,254 609,190North Dakota 62,280 10,376 8,953 27,779Ohio 1,290,776 168,246 232,986 586,546Oklahoma 342,475 - - -Oregon 511,171 39,401 97,889 129,409Pennsylvania 1,523,120 222,458 272,083 745,977Puerto Rico 964,015 - - -Rhode Island 153,130 17,540 28,524 64,882South Carolina 594,962 72,074 102,904 269,751South Dakota 89,537 9,496 15,767 48,794Tennessee 1,843,661 88,948 302,470 554,235Texas 2,324,810 301,368 288,293 1,327,276Utah 215,801 9,716 20,093 106,259Vermont 123,992 14,101 15,258 53,842Virgin Islands 19,764 1,516 1,208 11,424Virginia 653,236 86,550 121,112 333,370Washington 1,413,208 61,996 112,306 489,005West Virginia 342,668 29,157 73,037 153,021Wisconsin 518,595 63,432 120,136 231,607Wyoming 46,121 4,146 6,793 24,639




Table 2. Medicaid Recipients by Basis of Eligibility and by State: FY 1998 (Con’t)

State Name AdultsFoster Care

ChildrenOther/

UnknownNational Total 7,907,935 654,684 3,175,515Alabama 48,049 4,038 1,901Alaska 19,990 1,055 1,816Arizona 114,360 5,458 -Arkansas 85,023 4,994 8,052California 1,646,576 138,609 437,921Colorado 66,485 14,354 4,115Connecticut 81,613 7,185 -Delaware 28,831 461 2,341District of Columbia 25,682 1,664 49,782Florida 354,337 20,311 15,119Georgia 202,223 6,508 31,402Hawaii 64,575 3,022 7,753Idaho 17,147 1,351 18,017Illinois 293,879 78,821 -Indiana 101,228 5,802 21,897Iowa 78,021 4,836 2,380Kansas 40,811 4,029 5,934Kentucky 111,161 6,369 9,427Louisiana 120,369 141 -Maine 30,487 2,160 3,863Maryland 106,312 15,219 25,626Massachusetts 186,362 612 -Michigan 287,617 28,346 79,196Minnesota 96,443 6,476 9,248Mississippi 61,217 2,894 11,159Missouri 115,773 14,859 16,182Montana 20,665 3,186 5,715Nebraska 42,199 10,080 -Nevada 21,460 3,155 6,540New Hampshire 14,838 2,434 1,117New Jersey 172,122 15,605 7,423New Mexico 52,197 1,558 2,224New York 689,543 81,756 -North Carolina 189,692 12,176 -North Dakota 11,398 1,481 2,293Ohio 278,603 24,395 -Oklahoma - - 342,475Oregon 210,350 13,701 20,421Pennsylvania 257,602 23,026 1,974Puerto Rico - - 964,015Rhode Island 30,866 3,583 7,735South Carolina 121,013 6,412 22,808South Dakota 14,154 1,326 -Tennessee 479,727 12,130 406,151Texas 391,786 16,087 -Utah 44,966 3,783 30,984Vermont 36,814 1,952 2,025Virgin Islands 5,616 - -Virginia 107,944 4,260 -Washington 181,319 14,342 554,240West Virginia 56,682 5,065 25,706Wisconsin 82,360 13,094 7,966Wyoming 9,448 523 572




Table 3. Medicaid Recipients by Type of Service and by State: FY 1998

State NameTotal

Recipients

InpatientGeneralHospital

InpatientMental

Hospital

Nursing FacilityServices

ICF MentallyRetarded

National Total 40,649,482 4,272,878 135,284 1,645,728 126,490Alabama 527,078 28,911 1,329 23,844 750Alaska 74,508 11,084 627 887 8Arizona 507,668 94,153 710 14,670 209Arkansas 424,727 72,883 3,146 21,486 1,867California 7,082,175 495,143 463 123,270 9,885Colorado 344,916 24,250 361 18,928 500Connecticut 381,208 26,198 398 28,791 1,556Delaware 101,436 3,781 531 3,256 342District of Columbia 166,146 17,487 162 4,217 821Florida 1,904,591 241,668 253 73,030 3,567Georgia 1,221,978 161,694 - 40,390 1,728Hawaii 184,614 3,221 - 37,583 146Idaho 123,176 17,056 39 5,297 1,012Illinois 1,363,856 176,928 3,768 79,751 12,081Indiana 607,293 91,414 2,134 44,524 6,035Iowa 314,936 32,182 958 25,115 2,338Kansas 241,933 27,435 333 16,802 1,441Kentucky 644,482 93,875 4,338 27,439 1,240Louisiana 720,615 153,081 2,847 34,403 6,014Maine 170,456 18,009 705 9,278 361Maryland 561,085 43,196 1,827 27,834 627Massachusetts 908,238 91,546 952 72,342 1,949Michigan 1,362,890 128,694 2,334 44,678 1,322Minnesota 538,413 42,969 249 37,580 4,273Mississippi 485,767 111,615 2,334 19,552 2,490Missouri 734,015 72,848 9 37,226 1,442Montana 100,760 12,315 14 5,316 149Nebraska 211,188 24,577 418 16,528 685Nevada 128,144 19,926 686 3,747 293New Hampshire 93,970 10,832 200 7,700 33New Jersey 813,251 70,725 1,899 48,552 4,514New Mexico 329,418 54,968 468 8,170 362New York 3,073,241 462,705 45,770 135,450 11,928North Carolina 1,167,988 171,477 2,387 41,683 4,853North Dakota 62,280 8,480 145 5,506 637Ohio 1,290,776 165,016 783 86,236 8,162Oklahoma 342,475 - - - -Oregon 511,171 3,014 761 11,960 373Pennsylvania 1,523,120 116,765 8,512 76,592 5,757Puerto Rico 964,015 - - - -Rhode Island 153,130 11,993 341 11,128 100South Carolina 594,962 137,289 1,531 17,352 2,856South Dakota 89,537 15,126 51 6,095 337Tennessee 1,843,661 58 - 86,763 -Texas 2,324,810 444,750 - 88,522 13,935Utah 215,801 16,934 2 5,433 867Vermont 123,992 6,235 133 3,804 17Virgin Islands 19,764 1,056 - 67 -Virginia 653,236 98,015 36,689 28,053 2,126Washington 1,413,208 42,082 28 23,949 156West Virginia 342,668 43,213 1,564 11,677 609Wisconsin 518,595 45,591 2,087 40,715 3,600Wyoming 46,121 8,415 8 2,557 137




Table 3. Medicaid Recipients by Type of Service and by State: FY 1998 (Con’t)

State NamePhysician

ServicesOutpatient

HospitalEPSDT

Screening ServicesPrescribed

DrugsDental

ServicesNational Total 18,554,746 12,157,729 6,174,628 19,337,543 4,965,202Alabama 393,194 221,538 121,122 395,290 68,485Alaska 50,070 37,166 1,074 43,734 20,498Arizona 237,544 192,365 360,994 56,796 91,734Arkansas 271,538 160,321 100,589 262,907 37,433California 2,621,178 1,466,203 680,220 2,644,430 76,020Colorado 150,497 84,807 37,337 147,033 52,131Connecticut 103,264 79,692 5,176 108,331 42,588Delaware 16,453 9,203 1,495 69,027 8,065District of Columbia 42,789 50,346 848 57,733 12,682Florida 754,818 644,876 256,591 1,014,372 374,202Georgia 872,557 540,218 287,928 805,923 229,794Hawaii 34,412 16,154 341 32,222 3,475Idaho 88,192 45,261 22,688 86,775 31,969Illinois 902,308 647,402 482,495 959,472 2,086Indiana 345,017 218,100 125,592 323,811 105,402Iowa 197,337 120,492 60,276 215,173 95,466Kansas 142,424 79,508 75,475 155,875 34,083Kentucky 438,403 292,864 38,422 429,102 131,560Louisiana 598,546 355,568 279,309 552,481 128,341Maine 92,879 38,361 50,661 137,816 28,593Maryland 203,528 105,346 45,814 176,403 8,725Massachusetts 497,694 411,868 33,551 613,186 288,682Michigan 544,576 372,791 155,631 589,818 331,316Minnesota 215,960 133,447 16,844 203,220 86,274Mississippi 365,280 177,966 143,184 368,609 24,282Missouri 259,688 246,492 71,161 353,902 85,188Montana 61,621 32,775 10,866 58,641 20,635Nebraska 133,342 77,751 32,513 145,408 63,484Nevada 60,344 46,068 27,822 50,903 22,372New Hampshire 61,209 42,768 16,155 70,339 25,024New Jersey 275,224 220,552 12,317 309,849 93,991New Mexico 125,982 77,898 17,983 96,637 19,263New York 1,486,182 1,302,949 503,968 1,803,428 847,717North Carolina 805,816 459,214 387,904 764,886 212,697North Dakota 37,865 25,740 42 37,675 16,598Ohio 729,550 548,785 124,921 702,143 238,685Oklahoma - - - - -Oregon 71,294 48,058 - 148,258 3,018Pennsylvania 522,594 386,011 163,797 580,749 174,702Puerto Rico - - - - -Rhode Island 34,577 36,740 3,953 44,852 51,266South Carolina 418,331 233,585 108,591 401,611 130,360South Dakota 51,049 39,419 13,837 46,588 45Tennessee 220,657 - - 1 -Texas 1,783,470 1,011,359 1,046,345 1,894,447 7,026Utah 67,664 40,234 5,142 126,953 48,521Vermont 46,583 30,432 19,735 58,037 44,187Virgin Islands 79 2,070 347 12,938 1,788Virginia 438,974 267,436 85,641 383,880 76,341Washington 286,442 147,633 36,564 274,463 275,281West Virginia 242,889 166,885 61,956 267,398 81,557Wisconsin 115,612 146,281 31,200 221,508 102,194Wyoming 37,250 18,731 8,211 32,510 9,376





State NameOther

PractitionerClinic

ServicesLab &X-Ray

FamilyPlanning

HomeHealth

National Total 4,341,915 5,285,415 9,380,689 2,011,124 1,224,714Alabama 72,649 111,804 157,551 35,953 43,277Alaska 10,699 15,352 31,121 1,710 583Arizona 25,836 59,496 156,286 30,092 15,650Arkansas 77,588 80,534 120,126 50,089 9,966California 693,399 801,776 1,692,841 248,680 60,918Colorado 19,792 70,266 64,421 9,321 19,626Connecticut 63,038 24,389 29,134 4,183 18,372Delaware 22,641 3,050 5,549 4,821 2,113District of Columbia 8,837 7,339 19,585 4,316 2,914Florida 121,191 169,145 463,748 137 33,507Georgia 132,412 60,632 167,860 107,417 84,820Hawaii 6,974 2,592 21,327 233 698Idaho 22,693 16,147 38,057 6,188 1,869Illinois 73,268 200,455 581,922 92,355 17,259Indiana 141,790 94,541 211,802 20,754 10,243Iowa 71,169 41,158 29,810 22,447 14,628Kansas 30,572 72,021 71,632 15,530 6,395Kentucky 95,907 144,896 238,713 34,698 67,405Louisiana 71,230 69,912 432,781 60,975 41,705Maine 33,625 29,225 62,810 8,570 6,825Maryland 19,151 39,897 50,211 19,141 8,114Massachusetts 115,654 120,551 114,014 80,262 39,534Michigan 110,247 298,371 328,030 65,390 10,823Minnesota 83,294 45,304 138,016 18,684 71,770Mississippi 9,598 134,967 74,063 - 10,879Missouri 84,827 293,062 118,223 23,557 24,954Montana 10,391 7,420 26,931 3,695 -Nebraska 51,858 6,698 52,194 13,268 3,512Nevada 11,224 7,463 17,716 2,632 1,445New Hampshire 20,508 29,049 12,930 7,861 2,359New Jersey 93,388 88,631 192,194 40,837 17,611New Mexico 25,720 60,811 16,603 5,401 2,026New York 433,693 616,595 933,858 262,810 230,195North Carolina 159,902 182,633 594,307 73,849 62,187North Dakota 11,748 17,361 25,018 3,757 678Ohio 237,356 108,729 110,324 16,802 29,654Oklahoma - - - - -Oregon 24,468 25,546 38,933 8,442 7,298Pennsylvania 137,692 122,534 282,362 45,743 14,398Puerto Rico - - - - -Rhode Island 10,880 11,113 23,188 1,926 11,794South Carolina 87,212 224,554 150,252 112,341 10,331South Dakota 10,826 17,975 23,615 4,579 530Tennessee 1 31 - - 13Texas 478,837 267,969 815,014 181,434 116,552Utah 14,449 16,087 37,823 7,554 922Vermont 16,716 18,629 22,021 9,919 2,600Virgin Islands - 10,912 91 1,496 -Virginia 70,449 95,786 180,726 23,655 7,470Washington 91,089 56,459 152,580 166,048 3,997West Virginia 62,112 98,672 78,244 25,549 21,797Wisconsin 57,506 182,191 151,585 22,174 48,247Wyoming 5,809 4,685 22,547 3,849 4,251





State NamePersonal Care

Support ServicesHome/Community

Based ServicesOtherCare

PrepaidHealthcare

PCCMServices

National Total 3,108,432 467,451 6,975,027 20,202,887 4,066,440Alabama 52,098 4,112 75,170 344,907 151,910Alaska 9,482 1,741 24,510 - -Arizona 18,635 3,567 152,121 368,344 -Arkansas 30,524 9,369 100,502 244,768 243,266California 497,531 36,286 1,722,936 6,022,536 54,471Colorado 3,335 9,267 51,060 316,060 48,907Connecticut 20,376 12,262 52,881 271,411 -Delaware 4,353 1,442 14,266 85,239 -District of Columbia 6,641 - 23,241 100,867 8,623Florida 199,651 - 275,172 791,752 841,304Georgia 194,528 15,251 137,889 78,463 879,554Hawaii - - 11,940 144,744 -Idaho 17,888 787 29,513 - 50,665Illinois 39,760 88,727 312,616 142,429 16,414Indiana 70,735 4,523 129,439 271,005 242,844Iowa 13,974 7,751 70,781 246,582 80,428Kansas 8,579 15,406 47,549 44,003 123,902Kentucky 27,589 13,125 208,539 194,164 -Louisiana 67,602 2,751 142,350 - -Maine 24,933 3,245 57,423 9,324 -Maryland 63,467 3,820 44,395 449,825 -Massachusetts 4,661 13,452 309,835 768,831 264,035Michigan 141,167 12,147 175,146 758,185 53,733Minnesota 61,532 18,048 93,767 318,854 -Mississippi 4,430 - 63,361 17,628 -Missouri 75,373 104 92,017 336,057 -Montana 18,270 - 19,901 96,701 59,578Nebraska 1,056 1,781 31,651 159,614 27,577Nevada 16,328 1,647 15,756 55,923 28,638New Hampshire 5,973 3,828 16,940 11,176 -New Jersey 41,062 12,995 109,463 545,380 -New Mexico 8,636 - 41,592 263,256 103,867New York 349,647 31,868 681,519 884,443 804North Carolina 356,450 14,421 165,210 220,700 591,740North Dakota 5,096 4,265 17,115 1,549 32,566Ohio 29,241 28,640 335,039 453,265 -Oklahoma - - - - -Oregon 78,965 26,753 39,196 481,498 11,163Pennsylvania 51,201 1,888 177,888 902,896 -Puerto Rico - - - - -Rhode Island 13,129 1,627 27,042 96,178 -South Carolina 61,734 14,675 113,086 17,195 -South Dakota 13,841 2,024 15,852 83,998 39,858Tennessee 4,337 - 2 1,764,279 -Texas 209,980 25,762 186,423 - -Utah 15,280 3,247 16,230 170,319 -Vermont 6,333 2,734 34,118 69,682 -Virgin Islands - - 2,268 - -Virginia 31,984 4,589 100,122 159,392 110,559Washington 16,623 - 234,814 1,146,180 -West Virginia 60,409 5,437 36,243 52 -Wisconsin 45,441 - 135,974 293,233 34Wyoming 8,572 2,087 3,164 - -




Table 4. Medicaid Recipients Who Receive Cash Payments by Basis of Eligibility and by State: FY 1998

State NameTotal

RecipientsAge 65

And OlderBlind/

Disabled Children AdultsOther/

UnknownNational Total 17,556,201 1,663,402 4,938,095 7,518,095 3,436,434 175Alabama 231,997 33,782 133,568 47,498 17,149 -Alaska 48,821 4,707 8,439 22,130 13,545 -Arizona 171,977 11,050 62,484 62,968 35,475 -Arkansas 157,450 19,810 79,422 40,822 17,396 -California 3,595,292 366,023 791,034 1,690,580 747,655 -Colorado 120,745 19,733 10,839 61,544 28,629 -Connecticut 151,939 7,743 20,673 82,351 41,172 -Delaware 36,876 2,208 10,415 17,496 6,757 -District of Columbia 87,261 2,889 17,408 46,490 20,474 -Florida 1,100,787 94,402 305,121 486,777 214,487 -Georgia 473,537 42,268 181,366 182,592 67,311 -Hawaii 109,151 15,367 16,471 49,699 27,614 -Idaho 13,767 1,597 7,174 3,225 1,771 -Illinois 608,119 24,430 173,098 283,637 126,954 -Indiana 231,768 21,814 59,055 97,242 53,657 -Iowa 129,836 9,088 40,438 50,912 29,398 -Kansas 90,083 5,115 32,803 34,049 18,116 -Kentucky 346,507 26,791 162,095 105,190 52,431 -Louisiana 372,578 51,275 143,060 128,630 49,613 -Maine 73,907 3,862 24,631 29,368 16,046 -Maryland 274,117 17,585 83,990 124,733 47,809 -Massachusetts 445,998 44,593 148,246 173,428 79,731 -Michigan 660,669 22,413 191,253 290,969 156,034 -Minnesota 239,835 16,395 51,453 117,548 54,288 151Mississippi 235,016 29,516 116,291 62,653 26,556 -Missouri 206,175 4,697 9,476 132,426 59,576 -Montana 47,965 1,995 13,072 21,795 11,103 -Nebraska 104,483 9,475 25,281 38,101 31,626 -Nevada 61,123 6,409 16,060 26,717 11,937 -New Hampshire 28,219 1,619 6,119 13,912 6,569 -New Jersey 418,784 33,922 120,029 175,742 89,091 -New Mexico 144,046 9,522 40,594 61,327 32,603 -New York 1,679,561 179,121 469,035 726,236 305,169 -North Carolina 594,269 83,182 126,773 254,658 129,656 -North Dakota 22,462 3,820 6,365 8,470 3,807 -Ohio 515,191 1,218 10,443 352,125 151,405 -Oklahoma - - - - - -Oregon 139,766 8,805 42,068 51,743 37,150 -Pennsylvania 718,234 69,084 208,952 316,699 123,499 -Puerto Rico - - - - - -Rhode Island 92,176 4,867 22,199 42,872 22,238 -South Carolina 190,767 35,808 78,065 55,126 21,768 -South Dakota 36,920 2,658 13,886 13,865 6,511 -Tennessee 449,326 40,467 241,337 117,476 50,022 24Texas 917,603 164,663 251,266 350,262 151,412 -Utah 54,561 3,039 12,257 24,936 14,329 -Vermont 38,507 2,339 10,635 17,305 8,228 -Virgin Islands 6,316 429 583 3,627 1,677 -Virginia 285,976 38,986 97,404 103,548 46,038 -Washington 397,055 22,597 88,491 183,623 102,344 -West Virginia 172,278 22,828 57,955 57,225 34,270 -Wisconsin 216,998 16,484 94,396 72,808 33,310 -Wyoming 9,407 912 4,527 2,940 1,028 -




Table 5. Medically Needy Medicaid Recipients by Basis of Eligibility and by State: FY 1998

State NameTotal

RecipientsAge 65

And OlderBlind/


UnknownNational Total 4,368,961 791,880 553,524 1,980,201 1,042,805 551Alabama - - - - - -Alaska - - - - - -Arizona - - - - - -Arkansas 33,542 356 6,210 16,132 10,844 -California 1,647,992 193,514 116,129 977,396 360,953 -Colorado - - - - - -Connecticut 41,568 14,001 18,741 4,822 4,004 -Delaware - - - - - -District of Columbia 17,242 3,554 3,674 6,503 3,511 -Florida 41,070 23 11,243 12,031 17,773 -Georgia 841 99 682 58 2 -Hawaii 4,751 1,597 442 1,447 1,265 -Idaho - - - - - -Illinois 286,438 63,711 51,144 88,849 82,734 -Indiana - - - - - -Iowa 12,299 3,898 3,304 1,468 3,629 -Kansas 32,802 21,739 9,265 1,631 167 -Kentucky 50,532 5,363 3,754 25,574 15,841 -Louisiana 8,629 1,315 1,989 1,199 4,126 -Maine 2,396 816 538 652 390 -Maryland 49,892 20,476 15,532 8,832 5,052 -Massachusetts 224,414 31,375 6,593 109,840 76,606 -Michigan 323,778 66,766 65,436 104,792 86,784 -Minnesota 15,263 6,644 6,728 1,243 577 71Mississippi 231 211 20 - - -Missouri - - - - - -Montana 7,586 5,461 2,112 3 10 -Nebraska 436 135 211 23 67 -Nevada - - - - - -New Hampshire 9,734 4,565 2,604 1,297 1,267 1New Jersey 6,296 3,340 1,117 1,837 2 -New Mexico - - - - - -New York 1,009,659 214,446 123,563 474,192 197,458 -North Carolina 122,027 46,527 55,200 6,974 13,326 -North Dakota 15,711 6,520 2,559 3,632 3,000 -Ohio - - - - - -Oklahoma - - - - - -Oregon 6,843 2,317 4,526 - - -Pennsylvania 119,253 23,357 4,068 50,761 41,067 -Puerto Rico - - - - - -Rhode Island 9,437 5,811 2,085 68 1,473 -South Carolina - - - - - -South Dakota - - - - - -Tennessee 139,188 18,667 10,989 39,504 69,549 479Texas 38,247 - - 9,164 29,083 -Utah 5,080 550 806 1,890 1,834 -Vermont 9,057 881 1,363 3,583 3,230 -Virgin Islands 11,991 1,087 625 7,345 2,934 -Virginia 17,884 9,792 6,504 1,308 280 -Washington 12,333 6,092 6,127 76 38 -West Virginia 3,895 355 2,401 106 1,033 -Wisconsin 30,624 6,519 5,240 15,969 2,896 -Wyoming - - - - - -




Table 6. Poverty Related Medicaid Recipients by Basis of Eligibility and by State: FY 1998

State NameTotal

RecipientsAge 65

And OlderBlind/


UnknownNational Total 9,202,219 600,117 571,132 6,116,866 1,914,007 97Alabama 219,029 11,413 5,906 184,459 17,251 -Alaska 14,556 4 4 10,231 4,317 -Arizona 175,730 142 653 147,738 27,197 -Arkansas 162,638 7,398 4,881 103,574 46,785 -California 287,622 2,544 5,076 234,783 45,219 -Colorado 84,801 1,477 2,275 56,902 24,147 -Connecticut 52,394 1,025 508 45,200 5,661 -Delaware 46,928 1,267 692 26,499 18,470 -District of Columbia 7,753 1,535 1,469 4,127 622 -Florida 498,267 54,232 51,193 303,233 89,609 -Georgia 536,420 20,439 12,492 407,203 96,286 -Hawaii 58,953 58 - 23,532 35,363 -Idaho 34,793 10,613 9,610 9,864 4,706 -Illinois 248,864 17,300 25,510 167,005 39,049 -Indiana 181,086 4,666 6,153 151,004 19,263 -Iowa 63,159 3,920 2,677 43,854 12,708 -Kansas 79,787 407 354 66,183 12,843 -Kentucky 184,829 11,124 7,692 131,909 34,103 1Louisiana 190,227 12,317 5,102 134,775 38,033 -Maine 47,447 8,539 6,213 28,633 4,062 -Maryland 142,031 6,423 3,644 96,672 35,292 -Massachusetts 191,690 37,908 40,053 105,030 8,699 -Michigan 252,770 2,225 2,478 206,938 41,129 -Minnesota 69,756 2,190 1,538 64,120 1,816 92Mississippi 200,645 16,531 12,352 147,744 24,018 -Missouri 259,920 6,146 4,950 211,830 36,994 -Montana 15,922 186 60 11,492 4,184 -Nebraska 71,025 3,646 996 66,383 - -Nevada 5,534 2,060 2,121 903 450 -New Hampshire 33,005 286 151 29,507 3,057 4New Jersey 167,133 17,386 15,700 107,203 26,844 -New Mexico 167,569 115 546 147,314 19,594 -New York 302,265 - - 115,349 186,916 -North Carolina 389,458 - - 346,302 43,156 -North Dakota 12,196 29 29 10,405 1,733 -Ohio 730,667 167,028 222,543 224,508 116,588 -Oklahoma - - - - - -Oregon 222,907 614 7,768 60,676 153,849 -Pennsylvania 361,594 84,483 1,379 248,475 27,257 -Puerto Rico - - - - - -Rhode Island 21,172 20 17 15,856 5,279 -South Carolina 225,889 21,738 18,248 155,544 30,359 -South Dakota 31,169 682 316 25,094 5,077 -Tennessee 628,086 4 44,431 290,466 293,185 -Texas 903,813 26,121 11,642 729,443 136,607 -Utah 27,564 2,281 3,713 5,965 15,605 -Vermont 56,418 7,502 2,530 23,797 22,589 -Virgin Islands - - - - - -Virginia 245,429 14,215 10,117 176,514 44,583 -Washington 183,766 1,947 2,206 157,526 22,087 -West Virginia 29,197 5,883 12,681 774 9,859 -Wisconsin 63,944 1,579 - 45,021 17,344 -Wyoming 14,402 469 463 9,307 4,163 -




Table 7. Medicaid Recipients of Other Coverage Groups by Basis of Eligibility and by State: FY 1998

State NameTotal

RecipientsAge 65

And OlderBlind/

Disabled Children AdultsFoster

ChildrenOther/

UnknownNational Total 6,347,817 908,824 575,229 2,693,983 1,514,689 654,684 408Alabama 74,385 19,456 6,418 30,590 13,649 4,038 234Alaska 9,315 595 469 5,068 2,128 1,055 -Arizona 159,961 16,281 14,984 71,550 51,688 5,458 -Arkansas 63,045 23,182 5,994 18,877 9,998 4,994 -California 1,113,380 25,245 14,013 442,732 492,749 138,609 32Colorado 135,255 22,054 49,378 35,760 13,709 14,354 -Connecticut 135,307 28,972 11,664 56,710 30,776 7,185 -Delaware 15,291 3,177 2,619 5,430 3,604 461 -District of Columbia 4,108 1 - 1,368 1,075 1,664 -Florida 249,348 37,909 16,421 142,239 32,468 20,311 -Georgia 179,778 26,391 31,723 76,532 38,624 6,508 -Hawaii 4,006 - - 651 333 3,022 -Idaho 56,599 - 611 43,967 10,670 1,351 -Illinois 220,435 2,691 13,021 80,760 45,142 78,821 -Indiana 172,542 46,400 26,306 65,726 28,308 5,802 -Iowa 107,262 22,941 4,800 42,399 32,286 4,836 -Kansas 33,327 127 966 18,520 9,685 4,029 -Kentucky 53,190 22,461 5,131 10,441 8,786 6,369 2Louisiana 149,181 28,931 10,393 81,119 28,597 141 -Maine 42,843 9,452 5,682 15,560 9,989 2,160 -Maryland 69,419 18 1,295 34,728 18,159 15,219 -Massachusetts 46,136 - 2,534 21,664 21,326 612 -Michigan 46,477 259 76 14,126 3,670 28,346 -Minnesota 204,665 33,472 14,194 110,721 39,762 6,476 40Mississippi 38,716 14,309 2,776 8,094 10,643 2,894 -Missouri 251,738 77,933 99,226 40,517 19,203 14,859 -Montana 23,572 1,488 1,134 12,396 5,368 3,186 -Nebraska 35,244 11,906 1,236 1,516 10,506 10,080 -Nevada 54,947 3,851 1,139 37,729 9,073 3,155 -New Hampshire 21,900 5,821 3,250 6,450 3,945 2,434 -New Jersey 213,615 39,596 14,204 88,025 56,185 15,605 -New Mexico 15,579 9,964 3,684 373 - 1,558 -New York 81,756 - - - - 81,756 -North Carolina 62,234 28,967 16,281 1,256 3,554 12,176 -North Dakota 9,618 7 - 5,272 2,858 1,481 -Ohio 44,918 - - 9,913 10,610 24,395 -Oklahoma - - - - - - -Oregon 121,234 27,665 43,527 16,990 19,351 13,701 -Pennsylvania 322,065 45,534 57,684 130,042 65,779 23,026 -Puerto Rico - - - - - - -Rhode Island 22,610 6,842 4,223 6,086 1,876 3,583 -South Carolina 155,498 14,528 6,591 59,081 68,886 6,412 -South Dakota 21,448 6,156 1,565 9,835 2,566 1,326 -Tennessee 221,416 29,810 5,713 106,789 66,971 12,130 3Texas 465,147 110,584 25,385 238,407 74,684 16,087 -Utah 97,612 3,846 3,317 73,468 13,198 3,783 -Vermont 18,082 3,379 730 9,157 2,767 1,952 97Virgin Islands 1,457 - - 452 1,005 - -Virginia 103,947 23,557 7,087 52,000 17,043 4,260 -Washington 265,814 31,360 15,482 147,780 56,850 14,342 -West Virginia 111,592 91 - 94,916 11,520 5,065 -Wisconsin 199,063 38,850 20,500 97,809 28,810 13,094 -Wyoming 21,740 2,765 1,803 12,392 4,257 523 -




Table 8. Medicaid Medical Vendor Payments by Maintenance Assistance Status of Recipientand by State: FY 1998

State NameTotal

PaymentsReceiving



MASUnknown

National Total $142,317,903,795 $63,034,798,342 $25,138,863,775 $19,758,455,422 $30,686,156,426 $3,699,629,829Alabama 1,902,300,047 602,742,522 - 176,216,348 607,749,253 515,591,924Alaska 330,378,398 213,828,341 - 43,610,989 71,856,764 1,082,304Arizona 1,643,966,305 712,364,833 - 238,491,706 693,109,765 -Arkansas 1,375,797,421 713,252,376 79,146,711 223,104,306 596,207,736 (235,913,708)California 14,236,592,915 8,647,488,244 3,879,870,004 295,066,192 1,262,422,388 151,746,087Colorado 1,439,366,499 304,817,936 - 129,898,201 960,589,934 44,060,428Connecticut 2,420,791,474 563,107,925 331,270,561 90,114,928 1,436,298,060 -Delaware 419,732,143 183,870,881 - 79,747,325 152,583,054 3,530,883District of Columbia 731,292,552 361,750,299 233,651,729 27,498,854 21,665,816 86,725,854Florida 5,686,844,862 2,950,414,878 126,182,907 1,348,334,446 1,236,568,867 25,343,764Georgia 3,012,346,312 1,377,872,299 3,794,773 689,569,489 889,614,162 51,495,589Hawaii 507,433,146 349,140,826 58,350,850 81,498,940 7,972,123 10,470,407Idaho 424,512,387 77,400,112 - 236,140,479 70,620,282 40,351,514Illinois 6,172,865,261 2,639,261,770 2,449,228,109 415,474,024 668,901,358 -Indiana 2,564,005,047 954,525,663 - 220,277,390 1,370,926,082 18,275,912Iowa 1,288,770,390 522,779,438 43,959,500 80,855,385 637,601,466 3,574,601Kansas 916,323,608 374,101,538 385,066,257 90,102,609 52,944,805 14,108,399Kentucky 2,425,288,141 1,376,672,479 174,912,771 275,954,959 588,092,271 9,655,661Louisiana 2,383,508,985 1,227,251,177 35,159,084 227,270,626 893,828,098 -Maine 747,027,618 289,878,332 11,059,685 101,617,050 332,465,141 12,007,410Maryland 2,489,280,148 1,233,921,421 798,379,206 231,634,487 189,104,492 36,240,542Massachusetts 4,609,360,933 2,143,677,179 856,606,399 1,482,929,991 126,147,364 -Michigan 4,345,007,824 2,009,893,152 1,613,885,806 272,152,987 70,708,537 378,367,342Minnesota 2,924,447,719 1,209,395,516 138,072,538 64,387,956 1,494,649,325 17,942,384Mississippi 1,442,373,276 714,491,940 29,257 306,914,267 417,485,900 3,451,912Missouri 2,569,646,129 340,186,310 - 274,104,538 1,942,734,440 12,620,841Montana 361,238,668 141,690,577 104,383,328 20,793,093 88,089,349 6,282,321Nebraska 753,162,904 430,209,028 2,974,236 82,582,317 237,397,323 -Nevada 462,087,777 222,245,177 - 4,622,406 211,394,224 23,825,970New Hampshire 606,004,232 170,615,173 121,049,747 52,614,350 260,382,807 1,342,155New Jersey 4,218,822,993 1,963,153,334 57,860,478 458,183,790 1,725,703,499 13,921,892New Mexico 862,144,872 437,218,245 - 241,810,168 177,322,949 5,793,510New York 24,298,610,635 12,312,300,018 10,634,644,651 984,445,331 367,220,635 -North Carolina 4,013,996,742 2,080,692,247 1,266,350,628 558,638,298 108,315,569 -North Dakota 341,015,420 121,167,482 179,804,840 14,402,609 22,843,885 2,796,604Ohio 6,120,967,557 824,053,633 - 5,180,692,237 116,221,687 -Oklahoma 1,177,853,941 - - - - 1,177,853,941Oregon 1,377,514,740 392,064,018 19,562,289 613,603,111 335,137,219 17,148,103Pennsylvania 6,080,191,710 2,471,881,538 696,874,020 821,478,988 2,087,655,250 2,301,914Puerto Rico 250,000,000 - - - - 250,000,000Rhode Island 919,353,410 430,262,938 140,267,792 27,623,971 308,397,218 12,801,491South Carolina 2,018,620,428 751,927,407 - 448,329,281 558,650,582 259,713,158South Dakota 355,833,902 156,736,607 - 31,265,704 167,831,591 -Tennessee 3,167,188,993 988,402,868 162,210,873 693,524,367 923,383,603 399,667,282Texas 7,139,928,843 3,164,249,057 125,836,860 1,024,387,837 2,825,455,089 -Utah 618,675,433 150,439,909 17,227,134 67,272,642 311,792,358 71,943,390Vermont 351,341,290 143,568,188 21,108,255 70,329,475 115,229,024 1,106,348Virgin Islands 10,097,973 3,007,722 6,056,113 - 1,034,138 -Virginia 2,118,202,866 1,013,741,200 163,396,812 276,531,633 664,533,221 -Washington 2,044,234,831 845,368,582 80,835,552 155,230,925 830,670,996 132,128,776West Virginia 1,243,150,526 830,135,721 24,132,569 121,766,318 144,277,023 122,838,895Wisconsin 2,206,398,750 859,392,921 95,661,451 84,267,682 1,170,245,392 (3,168,696)Wyoming 192,004,819 36,187,365 - 21,090,417 134,124,312 602,725




Table 9. Medicaid Medical Vendor Payments by Basis of Eligibility of Recipient and by State: FY 1998

State NameTotal

PaymentsAge 65

And OlderBlind/

Disabled ChildrenNational Total $142,317,903,795 $40,602,116,833 $60,375,123,225 $20,459,140,959Alabama 1,902,300,047 550,365,257 597,810,766 186,782,542Alaska 330,378,398 57,121,304 115,136,373 85,965,470Arizona 1,643,966,305 324,219,550 609,672,915 405,457,935Arkansas 1,375,797,421 430,018,281 791,182,772 262,322,716California 14,236,592,915 2,877,789,089 6,143,133,891 2,665,260,487Colorado 1,439,366,499 437,704,252 581,915,898 149,568,323Connecticut 2,420,791,474 1,048,144,688 890,332,880 289,118,311Delaware 419,732,143 95,287,226 196,514,572 67,829,755District of Columbia 731,292,552 150,809,511 346,252,423 78,395,395Florida 5,686,844,862 1,555,193,567 2,659,251,017 846,258,629Georgia 3,012,346,312 493,367,044 1,402,741,189 582,740,389Hawaii 507,433,146 157,256,534 128,342,971 117,090,747Idaho 424,512,387 124,484,856 167,695,747 51,677,781Illinois 6,172,865,261 1,104,777,674 3,262,390,656 786,450,294Indiana 2,564,005,047 863,879,770 1,083,989,118 399,777,342Iowa 1,288,770,390 463,839,101 489,399,669 179,317,603Kansas 916,323,608 253,024,983 450,243,800 131,960,635Kentucky 2,425,288,141 583,123,078 1,162,378,389 386,980,809Louisiana 2,383,508,985 672,322,724 1,101,257,511 371,500,804Maine 747,027,618 239,292,715 329,088,855 96,498,432Maryland 2,489,280,148 603,934,490 1,183,637,666 386,698,407Massachusetts 4,609,360,933 1,475,161,716 2,174,271,507 561,432,617Michigan 4,345,007,824 940,257,050 1,944,525,068 515,623,409Minnesota 2,924,447,719 993,413,008 1,223,393,074 455,098,154Mississippi 1,442,373,276 415,324,517 665,398,149 225,920,481Missouri 2,569,646,129 927,285,221 1,016,081,357 410,373,527Montana 361,238,668 114,977,600 138,852,060 56,626,017Nebraska 753,162,904 264,480,513 278,110,955 107,639,405Nevada 462,087,777 91,651,233 174,129,939 79,001,535New Hampshire 606,004,232 226,786,873 221,210,838 98,665,958New Jersey 4,218,822,993 1,325,345,586 1,977,873,602 433,771,126New Mexico 862,144,872 145,828,469 310,111,561 269,533,249New York 24,298,610,635 7,871,285,862 11,645,320,828 2,324,009,772North Carolina 4,013,996,742 1,193,291,589 1,663,065,550 716,185,408North Dakota 341,015,420 131,361,999 140,167,178 33,676,323Ohio 6,120,967,557 2,245,207,690 2,544,856,524 705,040,424Oklahoma 1,177,853,941 - - -Oregon 1,377,514,740 112,980,883 267,864,281 366,507,811Pennsylvania 6,080,191,710 2,510,003,519 1,988,012,614 1,024,778,811Puerto Rico 250,000,000 - - -Rhode Island 919,353,410 298,102,394 454,553,955 81,377,077South Carolina 2,018,620,428 477,950,896 762,312,898 305,302,576South Dakota 355,833,902 107,444,635 160,719,294 57,057,240Tennessee 3,167,188,993 674,937,423 990,880,890 410,584,137Texas 7,139,928,843 2,341,889,852 2,484,970,969 1,397,377,640Utah 618,675,433 90,122,694 226,841,136 120,451,826Vermont 351,341,290 97,201,440 135,753,840 54,910,386Virgin Islands 10,097,973 2,490,221 1,767,095 3,125,020Virginia 2,118,202,866 638,501,136 933,333,485 336,321,911Washington 2,044,234,831 572,572,467 622,897,992 340,856,081West Virginia 1,243,150,526 359,268,463 473,514,655 153,582,113Wisconsin 2,206,398,750 816,986,679 978,356,783 256,202,612Wyoming 192,004,819 54,049,511 83,606,070 30,455,507




Table 9. Medicaid Medical Vendor Payments by Basis of Eligibility of Recipientand by State: FY 1998 (Con’t)

State Name AdultsFoster

ChildrenOther/

UnknownNational Total $14,833,097,385 $2,346,800,698 $3,701,624,687Alabama 33,684,838 17,825,019 515,831,625Alaska 61,419,264 9,653,683 1,082,304Arizona 296,765,130 7,850,767 -Arkansas 99,324,540 28,862,820 (235,913,708)California 2,149,128,619 249,516,816 151,764,013Colorado 124,900,958 101,216,640 44,060,428Connecticut 175,979,323 17,216,272 -Delaware 54,956,394 1,613,313 3,530,883District of Columbia 53,304,930 15,804,439 86,725,854Florida 549,341,749 51,456,136 25,343,764Georgia 458,044,573 23,957,528 51,495,589Hawaii 88,877,805 5,394,682 10,470,407Idaho 37,809,908 2,492,581 40,351,514Illinois 686,289,405 332,957,232 -Indiana 175,348,016 22,734,889 18,275,912Iowa 134,057,212 18,582,204 3,574,601Kansas 59,588,457 7,397,334 14,108,399Kentucky 239,916,610 43,231,020 9,658,235Louisiana 238,273,512 154,433 -Maine 43,739,741 26,400,465 12,007,410Maryland 238,767,249 40,001,794 36,240,542Massachusetts 397,513,145 981,948 -Michigan 514,607,970 51,626,985 378,367,342Minnesota 196,885,958 36,699,762 18,957,763Mississippi 119,880,832 12,397,385 3,451,912Missouri 156,676,911 46,608,272 12,620,841Montana 38,484,670 6,016,000 6,282,321Nebraska 66,708,154 36,223,877 -Nevada 52,414,904 41,064,196 23,825,970New Hampshire 33,867,455 24,126,996 1,346,112New Jersey 370,456,043 97,454,744 13,921,892New Mexico 104,703,118 26,174,965 5,793,510New York 2,090,773,539 367,220,635 -North Carolina 396,970,898 44,483,297 -North Dakota 22,899,991 10,113,325 2,796,604Ohio 554,468,305 71,394,614 -Oklahoma - - 1,177,853,941Oregon 576,396,640 36,617,022 17,148,103Pennsylvania 457,250,934 97,843,918 2,301,914Puerto Rico - - 250,000,000Rhode Island 59,149,256 13,369,237 12,801,491South Carolina 162,109,475 51,231,425 259,713,158South Dakota 26,827,646 3,785,087 -Tennessee 632,709,631 57,825,355 400,251,557Texas 871,515,674 44,174,708 -Utah 79,480,227 29,836,160 71,943,390Vermont 46,777,227 15,461,003 1,237,394Virgin Islands 2,715,637 - -Virginia 200,657,760 9,388,574 -Washington 353,872,825 21,906,690 132,128,776West Virginia 101,663,671 32,282,729 122,838,895Wisconsin 123,315,198 34,706,174 (3,168,696)Wyoming 21,825,458 1,465,548 602,725




Table 10. Medicaid Medical Vendor Payments by Type of Service and by State: FY 1998

State NameTotal

PaymentsInpatient General

Hospital

InpatientMental

Hospital

Nursing FacilityServices

ICF MentallyRetarded

National Total $142,317,903,795 $21,498,719,619 $2,800,541,598 $31,892,064,551 $9,481,723,907Alabama 1,902,300,047 42,908,107 26,475,030 522,825,844 55,663,840Alaska 330,378,398 55,725,816 13,764,917 45,782,809 293,827Arizona 1,643,966,305 75,903,069 20,966 16,458,558 -Arkansas 1,375,797,421 178,532,888 54,470,602 300,012,732 108,852,817California 14,236,592,915 2,539,212,053 7,648,556 2,158,053,360 559,948,974Colorado 1,439,366,499 186,830,191 5,955,144 333,591,591 26,124,204Connecticut 2,420,791,474 166,380,038 23,576,663 858,713,862 203,094,688Delaware 419,732,143 15,358,566 10,648,377 83,062,656 32,687,748District of Columbia 731,292,552 198,380,143 2,498,290 155,399,067 71,613,329Florida 5,686,844,862 1,038,563,277 14,638,423 1,340,608,163 255,636,949Georgia 3,012,346,312 668,075,530 - 603,835,584 107,450,025Hawaii 507,433,146 36,301,298 - 144,973,700 10,066,595Idaho 424,512,387 68,827,832 770,647 90,878,627 44,777,200Illinois 6,172,865,261 1,690,971,723 355,291,866 1,268,060,053 661,728,014Indiana 2,564,005,047 411,039,286 19,825,621 699,667,232 314,681,105Iowa 1,288,770,390 144,960,334 18,447,053 318,547,045 179,085,736Kansas 916,323,608 115,383,465 5,935,917 189,319,221 73,011,007Kentucky 2,425,288,141 277,720,828 42,689,470 491,196,404 79,305,645Louisiana 2,383,508,985 527,916,078 15,963,066 490,677,315 322,468,549Maine 747,027,618 47,116,426 19,950,621 169,130,251 27,011,643Maryland 2,489,280,148 324,719,290 56,546,963 546,941,004 55,095,149Massachusetts 4,609,360,933 546,768,099 30,800,067 1,276,236,770 250,951,685Michigan 4,345,007,824 792,887,794 39,700,896 898,994,947 92,056,064Minnesota 2,924,447,719 252,541,378 16,286,663 843,536,749 234,768,692Mississippi 1,442,373,276 324,944,298 15,483,002 313,037,056 125,503,877Missouri 2,569,646,129 313,541,971 248,998 677,899,462 101,104,939Montana 361,238,668 48,271,464 308,414 95,255,260 16,269,810Nebraska 753,162,904 97,977,946 5,651,820 234,516,077 42,963,860Nevada 462,087,777 106,004,413 11,508,517 72,595,501 28,894,383New Hampshire 606,004,232 34,844,009 1,904,281 195,434,499 1,519,278New Jersey 4,218,822,993 402,674,879 72,438,654 1,154,707,872 347,217,754New Mexico 862,144,872 90,148,335 2,077,546 138,825,024 16,317,149New York 24,298,610,635 3,972,442,080 1,525,566,813 5,032,111,363 2,196,796,587North Carolina 4,013,996,742 692,184,068 26,557,229 760,826,548 361,838,061North Dakota 341,015,420 30,884,006 3,918,724 111,162,630 44,567,046Ohio 6,120,967,557 870,502,764 4,452,888 1,911,111,609 537,681,556Oklahoma 1,177,853,941 - - - -Oregon 1,377,514,740 12,124,512 35,339,858 188,522,343 77,395,292Pennsylvania 6,080,191,710 539,676,985 85,078,979 1,961,739,776 442,232,151Puerto Rico 250,000,000 - - - -Rhode Island 919,353,410 178,178,042 12,260,928 234,578,181 4,930,618South Carolina 2,018,620,428 522,891,024 47,960,982 302,667,749 167,959,347South Dakota 355,833,902 67,004,925 2,818,786 101,120,652 19,582,925Tennessee 3,167,188,993 76,296 - 1,066,992,955 -Texas 7,139,928,843 1,643,167,234 - 1,384,415,773 728,574,336Utah 618,675,433 90,973,076 218 90,411,547 43,954,818Vermont 351,341,290 19,306,558 1,219,044 74,038,926 1,031,673Virgin Islands 10,097,973 3,739,587 - 1,194,261 -Virginia 2,118,202,866 334,376,705 101,470,932 394,719,042 143,102,604Washington 2,044,234,831 265,579,863 101,471 496,372,294 8,999,877West Virginia 1,243,150,526 194,479,017 24,905,723 256,580,323 47,738,110Wisconsin 2,206,398,750 210,485,418 37,293,417 748,856,930 198,693,920Wyoming 192,004,819 29,216,635 68,556 45,867,354 10,480,451




Table 10. Medicaid Medical Vendor Payments by Type of Service and by State: FY 1998 (Con’t)

State NamePhysician

ServicesOutpatient

HospitalEPSDT

ScreeningPrescribed

DrugsDental

ServicesNational Total $6,070,022,680 $5,758,982,745 $1,334,828,107 $13,521,707,689 $901,385,043Alabama 115,683,384 55,232,113 14,722,820 236,674,147 9,698,164Alaska 36,742,125 22,710,772 125,107 32,887,828 8,420,013Arizona 24,742,477 8,377,604 4,361,822 1,442,917 2,518,958Arkansas 120,802,774 37,099,507 55,748,372 150,891,615 7,789,946California 744,150,459 332,585,224 46,051,880 1,553,598,462 17,764,417Colorado 55,434,596 48,863,284 3,011,047 110,159,725 9,477,271Connecticut 43,027,135 63,273,506 400,479 186,593,992 7,461,733Delaware 5,689,663 3,309,098 99,029 41,350,537 1,752,407District of Columbia 15,832,207 40,597,949 238,707 41,254,973 1,367,185Florida 201,410,207 322,884,138 28,486,368 933,782,041 79,571,073Georgia 367,096,683 266,142,731 25,513,441 370,562,935 32,076,080Hawaii 32,883,850 12,656,332 38,941 39,623,380 342,042Idaho 30,240,179 16,952,114 4,114,029 54,971,097 9,262,516Illinois 242,774,121 202,113,879 64,468,090 583,239,675 215,457Indiana 116,841,929 83,721,391 7,082,193 325,712,348 25,616,874Iowa 67,672,741 59,171,793 5,485,072 147,115,884 17,727,507Kansas 37,813,417 12,667,886 8,874,886 118,825,316 8,611,769Kentucky 164,972,078 211,965,422 61,282,505 319,983,951 23,876,778Louisiana 196,895,190 146,755,783 43,497,715 352,784,785 18,204,824Maine 21,137,156 17,436,520 3,421,839 121,771,298 4,500,980Maryland 46,541,325 53,105,201 73,840,753 148,532,940 354,031Massachusetts 197,750,106 231,764,549 2,388,137 497,146,531 53,661,108Michigan 130,599,586 149,872,689 13,622,196 374,145,567 33,412,598Minnesota 84,806,776 50,953,215 2,935,735 173,602,492 13,553,739Mississippi 177,155,371 68,541,350 21,663,630 231,735,360 2,746,014Missouri 51,276,977 154,379,218 40,121,136 382,512,566 9,726,354Montana 27,356,355 16,184,168 1,610,004 42,368,399 5,062,200Nebraska 49,001,395 31,187,108 3,281,729 92,558,539 9,742,058Nevada 39,449,916 25,062,559 3,914,920 34,518,901 12,458,638New Hampshire 18,962,156 26,598,507 983,291 55,374,478 4,589,120New Jersey 72,855,718 282,697,673 735,125 426,075,488 13,016,134New Mexico 35,207,392 34,276,483 1,921,546 41,507,229 3,947,881New York 327,039,971 1,145,218,581 109,536,163 1,368,451,273 182,756,864North Carolina 335,106,875 209,392,736 30,846,296 466,528,812 42,821,503North Dakota 14,780,039 20,795,249 211,991 27,619,684 4,451,231Ohio 271,665,208 244,422,218 13,012,653 645,118,962 33,705,390Oklahoma - - - - -Oregon 15,646,781 17,909,248 - 87,805,350 424,893Pennsylvania 115,538,851 112,286,027 182,678,258 525,261,211 20,591,630Puerto Rico - - - - -Rhode Island 7,051,133 19,380,312 211,727 61,401,958 9,372,139South Carolina 150,905,913 52,518,262 7,942,631 224,962,203 18,640,048South Dakota 20,495,792 27,514,589 5,817,668 31,106,511 17,126Tennessee 112,908,373 - - 36 -Texas 661,475,584 446,493,015 416,748,794 817,591,112 2,165,089Utah 20,149,326 19,162,944 307,155 68,827,853 10,531,291Vermont 9,490,861 11,029,031 1,819,403 43,445,887 7,965,583Virgin Islands 195,307 303,353 28,550 2,796,833 88,095Virginia 187,632,422 120,861,960 8,139,341 284,578,558 10,991,454Washington 91,489,892 89,625,083 2,388,569 244,478,658 75,222,685West Virginia 111,149,189 61,622,445 7,642,253 148,962,081 18,553,850Wisconsin 26,755,558 65,575,950 2,482,161 232,326,359 12,373,895Wyoming 17,740,161 5,731,976 971,950 17,138,952 2,186,408





State NameOther

PractitionerClinic

ServicesLab &X-Ray

FamilyPlanning

HomeHealth

National Total $587,137,593 $3,921,167,731 $938,700,266 $449,136,397 $2,701,512,000Alabama 4,502,485 62,372,094 9,563,557 6,639,031 22,844,852Alaska 1,122,830 41,247,912 5,947,523 1,022,171 1,098,932Arizona 154,063 17,310,281 1,379,779 884,686 1,015,977Arkansas 7,022,549 128,802,658 11,348,972 8,389,414 13,985,570California 84,350,296 427,958,908 259,080,646 32,791,127 82,965,929Colorado 4,054,732 34,940,819 6,240,321 2,893,789 168,003,075Connecticut 27,819,279 19,702,620 4,409,946 976,553 101,980,227Delaware 8,839,087 20,037,258 294,317 656,579 7,437,812District of Columbia 8,567,475 12,113,259 2,128,643 821,195 15,216,416Florida 37,239,783 103,185,250 36,231,750 81,663 75,237,726Georgia 18,735,368 114,306,637 12,445,037 27,091,933 42,656,324Hawaii 1,164,072 766,029 2,826,800 25,718 1,767,751Idaho 2,193,545 4,467,987 3,391,858 836,858 3,013,366Illinois 24,532,236 68,143,140 46,360,141 17,568,951 27,167,763Indiana 44,540,516 21,354,616 19,574,422 2,486,445 47,073,916Iowa 6,178,733 9,897,420 1,441,968 5,191,063 39,364,761Kansas 2,871,248 35,264,649 3,843,169 3,733,061 13,271,790Kentucky 8,865,468 98,656,658 26,978,851 8,543,697 96,406,052Louisiana 4,492,336 33,718,060 42,386,889 11,599,544 41,600,791Maine 3,660,348 7,483,979 4,583,536 1,509,167 13,702,291Maryland 1,016,724 6,643,345 3,137,857 4,613,117 48,456,286Massachusetts 7,732,818 110,221,454 9,377,844 20,222,721 178,727,342Michigan 5,349,653 331,384,716 24,631,759 9,163,934 30,029,536Minnesota 22,306,688 12,456,913 15,517,890 3,713,564 51,998,745Mississippi 522,487 72,866,687 5,643,549 - 11,727,240Missouri 4,862,991 68,809,727 6,568,226 5,124,562 46,793,370Montana 2,795,476 1,469,660 5,460,753 1,162,644 -Nebraska 8,861,275 3,127,968 5,773,091 3,250,360 15,357,587Nevada 2,506,707 2,307,097 1,231,397 1,096,613 4,806,532New Hampshire 3,277,888 88,397,728 873,180 2,043,842 4,044,940New Jersey 7,891,739 117,799,809 18,202,916 5,446,420 84,239,565New Mexico 3,792,233 20,484,797 1,204,963 999,819 3,621,004New York 28,371,373 1,220,723,903 49,239,115 68,785,044 805,659,216North Carolina 10,405,963 47,713,966 69,535,830 22,561,251 98,708,726North Dakota 1,033,246 15,462,744 2,552,182 954,964 1,671,089Ohio 22,152,879 44,383,797 9,581,841 13,237,826 97,338,109Oklahoma - - - - -Oregon 13,049,696 7,404,707 2,644,788 1,154,298 5,451,650Pennsylvania 16,378,048 68,910,361 20,529,415 14,783,309 36,365,790Puerto Rico - - - - -Rhode Island 1,188,997 3,386,680 1,800,816 479,444 147,013,312South Carolina 6,023,393 138,424,592 12,185,658 34,421,428 15,473,934South Dakota 1,749,501 6,329,164 2,100,717 783,923 813,135Tennessee 18 1,196 - - 4,524Texas 70,751,154 52,613,251 94,105,855 40,544,183 98,543,994Utah 1,571,558 31,508,963 2,011,687 700,045 2,586,721Vermont 4,557,773 5,429,887 1,523,301 1,729,559 3,726,368Virgin Islands - 1,191,919 47,288 120,767 -Virginia 7,747,728 44,638,403 12,882,270 2,750,996 8,156,865Washington 5,664,924 34,712,064 34,356,590 49,005,157 6,274,767West Virginia 10,060,720 46,008,114 5,844,856 2,458,392 17,894,521Wisconsin 13,966,929 51,528,358 17,001,830 3,357,816 56,048,763Wyoming 640,565 3,095,527 2,674,677 727,754 4,167,048





State NamePersonal Care

Support ServicesHome/Community

Based ServicesOtherCare

PrepaidHealthcare

PCCMServices

National Total $8,221,956,899 $6,708,703,006 $4,386,176,341 $19,296,223,487 $134,367,179Alabama 71,655,382 83,614,761 8,421,214 288,972,436 3,830,786Alaska 12,168,162 31,646,356 19,671,298 - -Arizona 1,565,498 206,027 56,205,118 1,431,418,497 -Arkansas 84,465,101 43,604,265 53,900,984 4,359,975 5,488,182California 1,461,040,635 477,040,219 577,661,831 2,867,713,795 6,976,144Colorado 13,191,011 91,982,851 88,225,223 238,585,930 1,801,695Connecticut 13,155,907 284,893,048 38,118,905 377,212,893 -Delaware 23,982,676 30,242,559 12,234,800 122,048,974 -District of Columbia 9,016,714 - 56,988,647 98,238,002 1,020,351Florida 391,136,226 - 108,796,297 701,322,837 18,032,691Georgia 101,836,605 146,234,294 27,214,508 57,871,451 23,190,993Hawaii - - 10,384,058 213,612,580 -Idaho 41,189,565 10,096,183 35,553,198 - 1,440,856Illinois 37,604,578 418,523,830 222,113,084 241,278,075 710,585Indiana 119,419,033 54,880,354 77,567,573 167,977,207 4,942,986Iowa 16,554,369 74,697,885 69,039,766 107,189,198 1,002,062Kansas 7,034,122 196,664,037 51,817,279 17,201,600 24,173,083Kentucky 23,492,967 84,874,155 82,951,173 311,526,039 -Louisiana 30,413,215 62,765,878 41,368,966 - -Maine 27,570,385 85,600,648 167,202,572 4,237,958 -Maryland 79,099,039 154,029,172 28,357,568 851,988,946 -Massachusetts 28,926,115 363,334,110 316,130,351 477,932,296 9,288,830Michigan 238,876,125 270,956,190 77,138,062 823,728,725 9,402,768Minnesota 206,010,480 390,376,183 65,853,806 483,228,011 -Mississippi 15,345,300 - 30,018,167 22,152,325 -Missouri 360,789,849 679,049 67,554,180 277,652,554 -Montana 32,546,074 - 10,049,415 53,600,495 1,468,077Nebraska 4,836,944 50,040,956 21,637,799 72,980,602 415,790Nevada 55,204,326 12,290,773 10,688,468 32,332,069 4,463,574New Hampshire 18,486,793 111,506,824 25,034,883 12,128,535 -New Jersey 243,903,851 249,988,289 101,339,785 617,591,322 -New Mexico 5,320,387 (38) 88,194,680 372,647,285 760,878New York 2,690,464,403 1,439,637,872 497,301,640 1,638,382,814 125,558North Carolina 452,804,716 275,215,305 12,764,633 85,665,363 12,518,863North Dakota 7,820,124 43,749,691 7,421,835 1,319,356 477,330Ohio 64,907,670 262,590,804 580,256,144 494,845,239 -Oklahoma - - - - -Oregon 88,633,858 144,321,876 13,466,470 665,872,224 237,107Pennsylvania 43,550,833 20,558,811 72,947,073 1,801,084,202 -Puerto Rico - - - - -Rhode Island 57,280,255 10,108,166 55,859,821 114,870,881 -South Carolina 73,310,778 123,052,297 102,108,042 17,172,147 -South Dakota 14,637,149 43,004,042 6,250,599 3,797,234 889,464Tennessee 128,077,009 - 141 1,859,127,110 -Texas 425,887,768 203,678,629 53,173,072 - -Utah 11,019,128 62,895,077 11,930,762 147,730,653 -Vermont 5,761,603 58,670,584 46,416,750 53,890,106 -Virgin Islands - - 392,013 - -Virginia 117,734,230 95,785,869 54,680,560 186,255,441 1,697,486Washington 7,262,046 - 103,678,034 529,020,076 -West Virginia 125,929,361 100,995,995 35,751,670 26,573,906 -Wisconsin 124,375,147 - 83,379,136 321,886,123 11,040Wyoming 6,663,387 43,669,130 964,288 - -




Table 11. Medicaid Medical Vendor Payments for Recipients Who Receive Cash Paymentsby State: FY 1998

State NameTotal

PaymentsAge 65

And OlderBlind/


UnknownNational Total $63,034,798,342 $9,175,983,172 $39,127,774,287 $8,426,821,440 $6,303,780,773 $438,668Alabama 602,742,522 104,513,657 460,513,836 23,431,818 14,283,211 -Alaska 213,828,341 28,824,334 104,037,418 40,331,657 40,634,932 -Arizona 712,364,833 60,299,301 427,209,144 129,156,438 95,699,947 -Arkansas 713,252,376 78,232,338 561,683,616 51,077,268 22,259,154 -California 8,647,488,244 1,183,408,519 4,898,110,390 1,566,802,910 999,166,425 -Colorado 304,817,936 95,573,584 117,920,331 49,219,528 42,104,493 -Connecticut 563,107,925 61,520,290 303,954,741 118,266,090 79,366,804 -Delaware 183,870,881 15,106,185 135,771,374 20,307,696 12,685,626 -District of Columbia 361,750,299 30,859,174 240,493,617 55,783,946 34,613,562 -Florida 2,950,414,878 380,519,516 1,889,065,482 395,519,106 285,310,774 -Georgia 1,377,872,299 124,735,711 976,265,813 142,562,950 134,307,825 -Hawaii 349,140,826 109,396,032 120,996,571 79,337,837 39,410,386 -Idaho 77,400,112 7,069,411 62,698,923 3,049,437 4,582,341 -Illinois 2,639,261,770 147,427,072 1,774,490,199 379,801,069 337,543,430 -Indiana 954,525,663 161,282,234 627,460,798 80,491,333 85,291,298 -Iowa 522,779,438 102,697,086 298,890,407 61,776,293 59,415,652 -Kansas 374,101,538 33,019,252 285,871,129 28,883,787 26,327,370 -Kentucky 1,376,672,479 110,247,544 1,002,698,813 151,768,704 111,957,418 -Louisiana 1,227,251,177 215,325,121 810,905,188 112,404,628 88,616,240 -Maine 289,878,332 17,692,847 212,676,163 33,849,947 25,659,375 -Maryland 1,233,921,421 113,592,984 847,041,712 164,445,071 108,841,654 -Massachusetts 2,143,677,179 283,296,710 1,441,171,460 252,210,899 166,998,110 -Michigan 2,009,893,152 88,206,689 1,383,209,822 240,629,880 297,846,761 -Minnesota 1,209,395,516 148,585,822 786,938,538 167,173,525 106,291,166 406,465Mississippi 714,491,940 87,312,336 532,502,217 53,103,913 41,573,474 -Missouri 340,186,310 32,253,899 93,216,860 126,878,239 87,837,312 -Montana 141,690,577 8,823,262 89,382,721 26,473,390 17,011,204 -Nebraska 430,209,028 87,384,446 250,552,885 37,251,060 55,020,637 -Nevada 222,245,177 22,880,467 143,320,397 29,687,911 26,356,402 -New Hampshire 170,615,173 14,723,622 119,048,938 22,536,517 14,306,096 -New Jersey 1,963,153,334 240,196,251 1,319,415,872 198,115,568 205,425,643 -New Mexico 437,218,245 26,126,120 275,434,457 78,809,778 56,847,890 -New York 12,312,300,018 2,402,931,691 7,879,465,179 1,224,804,368 805,098,781 -North Carolina 2,080,692,247 470,658,696 1,124,566,917 256,353,163 229,113,471 -North Dakota 121,167,482 21,885,774 79,622,252 10,919,712 8,739,744 -Ohio 824,053,633 6,171,893 91,779,316 409,565,263 316,537,161 -Oklahoma - - - - - -Oregon 392,064,018 24,160,952 115,461,551 148,441,395 104,000,120 -Pennsylvania 2,471,881,538 335,201,626 1,387,383,538 501,658,445 247,637,929 -Puerto Rico - - - - - -Rhode Island 430,262,938 35,312,486 297,800,358 55,240,146 41,909,948 -South Carolina 751,927,407 142,977,503 511,725,270 54,700,129 42,524,505 -South Dakota 156,736,607 8,344,318 120,166,195 16,370,593 11,855,501 -Tennessee 988,402,868 72,855,779 747,284,126 97,873,612 70,357,148 32,203Texas 3,164,249,057 707,491,516 1,850,133,604 317,008,004 289,615,933 -Utah 150,439,909 14,138,243 89,019,591 23,313,210 23,968,865 -Vermont 143,568,188 11,988,914 96,369,883 22,275,596 12,933,795 -Virgin Islands 3,007,722 584,050 843,603 808,469 771,600 -Virginia 1,013,741,200 187,012,654 657,646,370 83,879,652 85,202,524 -Washington 845,368,582 85,138,908 447,814,652 127,587,258 184,827,764 -West Virginia 830,135,721 347,814,749 364,958,698 61,493,372 55,868,902 -Wisconsin 859,392,921 76,092,968 646,903,131 89,542,075 46,854,747 -Wyoming 36,187,365 4,088,636 25,880,221 3,848,785 2,369,723 -




Table 12. Medicaid Medical Vendor Payments for Medically Needy Recipients by Basis of Eligibilityand by State: FY 1998

State NameTotal

PaymentsAge 65

And OlderBlind/


UnknownNational Total $25,138,863,775 $12,361,168,832 $8,641,051,903 $2,331,098,475 $1,804,846,335 $698,230Alabama - - - - - -Alaska - - - - - -Arizona - - - - - -Arkansas 79,146,711 889,336 28,079,512 31,136,043 19,041,820 -California 3,879,870,004 1,595,406,804 1,167,100,970 696,180,314 421,181,916 -Colorado - - - - - -Connecticut 331,270,561 147,497,845 168,260,256 5,899,211 9,613,249 -Delaware - - - - - -District of Columbia 233,651,729 112,690,243 94,486,741 14,958,863 11,515,882 -Florida 126,182,907 142,479 63,383,911 23,775,531 38,880,986 -Georgia 3,794,773 274,620 3,294,913 218,759 6,481 -Hawaii 58,350,850 47,795,992 7,346,400 1,936,738 1,271,720 -Idaho - - - - - -Illinois 2,449,228,109 922,432,463 1,224,045,905 134,088,989 168,660,752 -Indiana - - - - - -Iowa 43,959,500 12,328,729 20,664,061 2,622,330 8,344,380 -Kansas 385,066,257 217,683,097 151,238,434 15,885,521 259,205 -Kentucky 174,912,771 63,709,718 29,040,575 49,473,823 32,688,655 -Louisiana 35,159,084 7,320,083 14,507,817 2,160,074 11,171,110 -Maine 11,059,685 5,627,121 3,939,097 884,762 608,705 -Maryland 798,379,206 478,833,202 258,830,120 46,878,973 13,836,911 -Massachusetts 856,606,399 516,067,558 51,767,956 141,434,516 147,336,369 -Michigan 1,613,885,806 846,891,239 548,453,540 83,731,109 134,809,918 -Minnesota 138,072,538 47,477,188 86,927,932 2,099,126 1,382,476 185,816Mississippi 29,257 9,007 20,250 - - -Missouri - - - - - -Montana 104,383,328 79,096,557 25,259,060 4,406 23,305 -Nebraska 2,974,236 454,382 1,992,544 39,387 487,923 -Nevada - - - - - -New Hampshire 121,049,747 82,549,114 32,542,469 2,603,896 3,352,838 1,430New Jersey 57,860,478 48,038,072 8,474,784 1,341,987 5,635 -New Mexico - - - - - -New York 10,634,644,651 5,468,354,171 3,765,855,649 903,888,146 496,546,685 -North Carolina 1,266,350,628 690,787,251 518,926,928 13,025,286 43,611,163 -North Dakota 179,804,840 109,085,655 60,517,580 5,344,257 4,857,348 -Ohio - - - - - -Oklahoma - - - - - -Oregon 19,562,289 6,359,110 13,203,179 - - -Pennsylvania 696,874,020 514,843,643 77,812,475 60,870,018 43,347,884 -Puerto Rico - - - - - -Rhode Island 140,267,792 107,253,067 30,407,052 47,936 2,559,737 -South Carolina - - - - - -South Dakota - - - - - -Tennessee 162,210,873 37,060,800 17,988,219 31,768,343 74,882,527 510,984Texas 125,836,860 - - 32,745,054 93,091,806 -Utah 17,227,134 4,231,409 6,269,066 1,394,817 5,331,842 -Vermont 21,108,255 2,542,982 9,408,181 4,929,981 4,227,111 -Virgin Islands 6,056,113 1,906,171 923,492 1,995,822 1,230,628 -Virginia 163,396,812 94,787,897 64,724,212 3,177,468 707,235 -Washington 80,835,552 43,965,735 36,604,049 209,664 56,104 -West Virginia 24,132,569 1,741,056 17,996,886 236,658 4,157,969 -Wisconsin 95,661,451 45,035,036 30,757,688 14,110,667 5,758,060 -Wyoming - - - - - -




Table 13. Medicaid Medical Vendor Payments for Poverty Related Medicaid Recipients by Basis ofEligibility and by State: FY 1998

State NameTotal

PaymentsAge 65

And OlderBlind/


UnknownNational Total $19,758,455,422 $4,565,969,420 $4,431,978,829 $6,296,469,645 $4,463,769,119 $268,406Alabama 176,216,348 12,379,712 4,578,243 148,833,492 10,424,901 -Alaska 43,610,989 2,984 3,141 26,956,105 16,648,759 -Arizona 238,491,706 1,383,449 739,781 133,971,943 102,396,531 -Arkansas 223,104,306 8,836,616 8,389,023 158,065,059 47,813,608 -California 295,066,192 3,278,901 4,788,110 175,714,435 111,284,746 -Colorado 129,898,201 855,228 1,384,318 71,584,652 56,074,003 -Connecticut 90,114,928 587,386 287,908 80,331,280 8,908,354 -Delaware 79,747,325 1,898,151 1,167,617 41,444,435 35,237,122 -District of Columbia 27,498,854 7,257,139 11,272,065 6,602,416 2,367,234 -Florida 1,348,334,446 538,400,521 416,393,147 207,172,320 186,368,458 -Georgia 689,569,489 24,402,577 17,226,614 373,943,804 273,996,494 -Hawaii 81,498,940 64,510 - 34,025,915 47,408,515 -Idaho 236,140,479 117,415,445 99,271,406 9,242,077 10,211,551 -Illinois 415,474,024 18,585,853 100,582,572 189,301,093 107,004,506 -Indiana 220,277,390 5,904,962 5,607,387 166,541,286 42,223,755 -Iowa 80,855,385 5,750,901 4,912,988 44,468,194 25,723,302 -Kansas 90,102,609 1,349,170 1,221,289 62,739,078 24,793,072 -Kentucky 275,954,959 12,243,055 7,742,277 173,170,114 82,799,390 123Louisiana 227,270,626 15,429,415 7,872,775 104,679,240 99,289,195 -Maine 101,617,050 36,484,851 30,699,381 28,345,737 6,087,081 -Maryland 231,634,487 11,300,440 9,036,644 133,240,135 78,057,268 -Massachusetts 1,482,929,991 675,797,448 646,071,584 142,670,344 18,390,615 -Michigan 272,152,987 4,231,452 12,000,170 176,674,586 79,246,779 -Minnesota 64,387,956 3,841,613 2,541,512 50,624,013 7,115,062 265,756Mississippi 306,914,267 41,728,923 46,127,432 162,687,404 56,370,508 -Missouri 274,104,538 7,880,747 15,766,902 201,943,031 48,513,858 -Montana 20,793,093 149,405 25,393 9,564,948 11,053,347 -Nebraska 82,582,317 8,625,874 4,815,086 69,141,357 - -Nevada 4,622,406 1,307,106 1,774,635 985,534 555,131 -New Hampshire 52,614,350 248,498 111,491 45,002,089 7,249,745 2,527New Jersey 458,183,790 122,437,688 127,461,536 134,127,028 74,157,538 -New Mexico 241,810,168 409,905 2,933,380 190,611,655 47,855,228 -New York 984,445,331 - - 195,317,258 789,128,073 -North Carolina 558,638,298 - - 443,414,536 115,223,762 -North Dakota 14,402,609 23,652 27,346 10,139,180 4,212,431 -Ohio 5,180,692,237 2,239,035,797 2,453,077,208 270,502,570 218,076,662 -Oklahoma - - - - - -Oregon 613,603,111 5,869,388 17,772,507 167,589,287 422,371,929 -Pennsylvania 821,478,988 483,338,647 1,809,929 266,014,217 70,316,195 -Puerto Rico - - - - - -Rhode Island 27,623,971 7,630 12,152 17,331,267 10,272,922 -South Carolina 448,329,281 70,953,823 103,443,171 192,671,226 81,261,061 -South Dakota 31,265,704 477,516 316,454 19,967,569 10,504,165 -Tennessee 693,524,367 1,924 97,708,390 198,841,784 396,972,269 -Texas 1,024,387,837 28,285,148 20,500,823 627,565,322 348,036,544 -Utah 67,272,642 6,507,397 26,072,325 6,849,931 27,842,989 -Vermont 70,329,475 11,458,758 12,725,211 19,728,749 26,416,757 -Virgin Islands - - - - - -Virginia 276,531,633 17,338,208 12,330,125 156,019,733 90,843,567 -Washington 155,230,925 1,780,234 2,067,486 96,667,404 54,715,801 -West Virginia 121,766,318 8,086,718 90,559,071 436,882 22,683,647 -Wisconsin 84,267,682 1,899,043 - 45,577,401 36,791,238 -Wyoming 21,090,417 435,612 750,824 7,430,530 12,473,451 -




Table 14. Medicaid Medical Vendor Payment for Recipients of Other Coverage Groups by Basis of Eligibilityand by State: FY 1998

State NameTotal

PaymentsAge 65

And OlderBlind/

Disabled ChildrenNational Total $30,686,156,426 $14,498,995,409 $8,174,318,206 $3,404,751,399Alabama 607,749,253 433,471,888 132,718,687 14,517,232Alaska 71,856,764 28,293,986 11,095,814 18,677,708Arizona 693,109,765 262,536,800 181,723,990 142,329,554Arkansas 596,207,736 342,059,991 193,030,621 22,044,346California 1,262,422,388 95,694,865 73,134,421 226,562,828Colorado 960,589,934 341,275,440 462,611,249 28,764,143Connecticut 1,436,298,060 838,539,167 417,829,975 84,621,730Delaware 152,583,054 78,282,890 59,575,581 6,077,624District of Columbia 21,665,816 2,955 - 1,050,170Florida 1,236,568,867 636,131,051 290,408,477 219,791,672Georgia 889,614,162 343,954,136 405,953,849 66,014,876Hawaii 7,972,123 - - 1,790,257Idaho 70,620,282 - 5,725,418 39,386,267Illinois 668,901,358 16,332,286 163,271,980 83,259,143Indiana 1,370,926,082 696,692,574 450,920,933 152,744,723Iowa 637,601,466 343,062,385 164,932,213 70,450,786Kansas 52,944,805 973,464 11,912,948 24,452,249Kentucky 588,092,271 396,922,761 122,896,724 12,568,168Louisiana 893,828,098 434,248,105 267,971,731 152,256,862Maine 332,465,141 179,487,896 81,774,214 33,417,986Maryland 189,104,492 207,864 68,729,190 42,134,228Massachusetts 126,147,364 - 35,260,507 25,116,858Michigan 70,708,537 927,670 861,536 14,587,834Minnesota 1,494,649,325 793,508,385 346,985,092 235,201,490Mississippi 417,485,900 286,274,251 86,748,250 10,129,164Missouri 1,942,734,440 887,150,575 907,097,595 81,552,257Montana 88,089,349 26,908,376 24,184,886 20,583,273Nebraska 237,397,323 168,015,811 20,750,440 1,207,601Nevada 211,394,224 67,463,660 29,034,907 48,328,090New Hampshire 260,382,807 129,265,639 69,507,940 28,523,456New Jersey 1,725,703,499 914,673,575 522,521,410 100,186,543New Mexico 177,322,949 119,292,444 31,743,724 111,816New York 367,220,635 - - -North Carolina 108,315,569 31,845,642 19,571,705 3,392,423North Dakota 22,843,885 366,918 - 7,273,174Ohio 116,221,687 - - 24,972,591Oklahoma - - - -Oregon 335,137,219 76,591,433 121,427,044 50,477,129Pennsylvania 2,087,655,250 1,176,619,603 521,006,672 196,236,131Puerto Rico - - - -Rhode Island 308,397,218 155,529,211 126,334,393 8,757,728South Carolina 558,650,582 264,019,570 147,144,457 57,931,221South Dakota 167,831,591 98,622,801 40,236,645 20,719,078Tennessee 923,383,603 565,018,920 127,900,155 82,100,398Texas 2,825,455,089 1,606,113,188 614,336,542 420,059,260Utah 311,792,358 65,245,645 105,480,154 88,893,868Vermont 115,229,024 71,210,786 17,250,565 7,976,060Virgin Islands 664,533,221 339,362,377 198,632,778 93,245,058Virginia 1,034,138 - - 320,729Washington 830,670,996 441,687,590 136,411,805 116,391,755West Virginia 144,277,023 1,625,940 - 91,415,201Wisconsin 1,170,245,392 693,959,632 300,695,964 106,972,469Wyoming 134,124,312 49,525,263 56,975,025 19,176,192




Table 14. Medicaid Medical Vendor Payment for Recipients of Other Coverage Groups by Basis of Eligibilityand by State: FY 1998 (Con’t)


ChildrenOther/

UnknownNational Total $2,260,701,158 $2,346,800,698 $589,554Alabama 8,976,726 17,825,019 239,701Alaska 4,135,573 9,653,683 -Arizona 98,668,652 7,850,767 -Arkansas 10,209,958 28,862,820 -California 617,495,532 249,516,816 17,926Colorado 26,722,462 101,216,640 -Connecticut 78,090,916 17,216,272 -Delaware 7,033,646 1,613,313 -District of Columbia 4,808,252 15,804,439 -Florida 38,781,531 51,456,136 -Georgia 49,733,773 23,957,528 -Hawaii 787,184 5,394,682 -Idaho 23,016,016 2,492,581 -Illinois 73,080,717 332,957,232 -Indiana 47,832,963 22,734,889 -Iowa 40,573,878 18,582,204 -Kansas 8,208,810 7,397,334 -Kentucky 12,471,147 43,231,020 2,451Louisiana 39,196,967 154,433 -Maine 11,384,580 26,400,465 -Maryland 38,031,416 40,001,794 -Massachusetts 64,788,051 981,948 -Michigan 2,704,512 51,626,985 -Minnesota 82,097,254 36,699,762 157,342Mississippi 21,936,850 12,397,385 -Missouri 20,325,741 46,608,272 -Montana 10,396,814 6,016,000 -Nebraska 11,199,594 36,223,877 -Nevada 25,503,371 41,064,196 -New Hampshire 8,958,776 24,126,996 -New Jersey 90,867,227 97,454,744 -New Mexico - 26,174,965 -New York - 367,220,635 -North Carolina 9,022,502 44,483,297 -North Dakota 5,090,468 10,113,325 -Ohio 19,854,482 71,394,614 -Oklahoma - - -Oregon 50,024,591 36,617,022 -Pennsylvania 95,948,926 97,843,918 -Puerto Rico - - -Rhode Island 4,406,649 13,369,237 -South Carolina 38,323,909 51,231,425 -South Dakota 4,467,980 3,785,087 -Tennessee 90,497,687 57,825,355 41,088Texas 140,771,391 44,174,708 -Utah 22,336,531 29,836,160 -Vermont 3,199,564 15,461,003 131,046Virgin Islands 23,904,434 9,388,574 -Virginia 713,409 - -Washington 114,273,156 21,906,690 -West Virginia 18,953,153 32,282,729 -Wisconsin 33,911,153 34,706,174 -Wyoming 6,982,284 1,465,548 -




Table 15. Medicaid Eligibles by Full-Year, Partial Year and Months Covered and by State: FY 1998

State NameTotal

EligiblesFull-YearEligibles

Partial YearEligibles

Partial YearMonths

National Total 41,361,532 22,997,728 17,399,787 104,387,484Alabama 628,220 352,365 275,855 1,749,290Alaska 87,873 32,278 55,595 367,248Arizona 649,302 272,640 376,662 2,218,598Arkansas 426,080 206,010 220,070 1,385,264California 6,191,269 3,809,289 2,381,980 13,906,720Colorado 346,928 166,055 180,873 1,045,628Connecticut 402,547 270,305 132,242 819,511Delaware 105,153 54,703 50,450 316,264District of Columbia 138,722 94,137 44,585 284,704Florida 2,040,541 923,737 1,116,804 6,501,745Georgia 1,223,439 663,324 560,115 3,440,181Hawaii 182,460 97,128 85,332 443,464Idaho 116,718 43,432 73,286 446,038Illinois 1,784,159 1,169,262 614,897 3,714,135Indiana 610,146 286,792 323,354 1,892,603Iowa 321,119 201,636 119,483 669,249Kansas 246,598 113,754 132,844 754,482Kentucky 653,553 388,599 264,954 1,650,057Louisiana 723,864 403,647 320,217 1,962,179Maine 195,839 111,951 83,888 494,830Maryland 603,562 328,051 275,511 1,654,875Massachusetts 953,469 750,084 203,385 1,282,741Michigan 1,354,718 805,792 548,926 3,347,918Minnesota 557,232 330,691 226,541 1,403,157Mississippi 526,604 273,040 253,564 1,536,116Missouri 772,622 453,274 319,348 1,935,404Montana 93,298 40,760 52,538 304,464Nebraska 210,261 110,520 99,741 560,457Nevada 130,662 52,898 77,764 437,856New Hampshire 98,340 53,810 44,530 270,721New Jersey 857,898 504,335 353,563 2,155,234New Mexico 339,527 172,211 167,316 1,008,741New York 3,500,292 2,168,626 1,331,666 8,149,801North Carolina 1,201,681 625,528 576,153 3,453,468North Dakota 62,115 27,989 34,126 202,387Ohio 1,402,364 740,166 662,198 3,921,544Oklahoma 459,570 185,342 274,226 1,653,167Oregon 537,465 215,517 321,948 1,894,454Pennsylvania 1,720,000 1,104,850 615,150 3,650,919Puerto Rico 964,015 - - -Rhode Island 148,797 93,981 54,816 348,167South Carolina 656,263 402,532 253,731 1,698,420South Dakota 83,111 40,588 42,523 252,649Tennessee 1,454,799 1,076,031 378,768 2,330,633Texas 2,680,583 1,202,113 1,478,470 8,842,892Utah 198,730 73,365 125,365 687,551Vermont 131,639 80,720 50,919 333,252Virgin Islands 19,914 14,093 5,821 -Virginia 689,571 385,302 304,269 1,856,445Washington 915,214 517,249 397,965 2,464,506West Virginia 373,090 196,127 176,963 1,057,767Wisconsin 538,229 292,355 245,874 1,442,518Wyoming 51,367 18,744 32,623 187,070




Table 16. Medicaid Eligibles by Maintenance Assistance Status and by State: FY 1998

State NameTotal

EligiblesReceiving



MASUnknown

National Total 41,361,532 17,663,099 4,239,284 10,568,471 7,458,731 1,431,947Alabama 628,220 260,614 - 263,587 104,019 -Alaska 87,873 56,288 - 16,695 14,890 -Arizona 649,302 263,593 - 206,776 178,933 -Arkansas 426,080 74,087 108,750 195,128 47,801 314California 6,191,269 3,202,001 1,361,944 369,005 1,258,319 -Colorado 346,928 102,264 - 88,123 156,541 -Connecticut 402,547 157,719 45,477 59,334 140,017 -Delaware 105,153 34,034 - 53,788 17,331 -District of Columbia 138,722 98,892 21,796 10,068 6,318 1,648Florida 2,040,541 1,181,859 56,251 569,091 233,339 1Georgia 1,223,439 423,014 813 560,476 239,131 5Hawaii 182,460 112,219 5,234 58,966 4,177 1,864Idaho 116,718 12,725 - 37,162 66,831 -Illinois 1,784,159 783,543 386,883 307,813 305,920 -Indiana 610,146 238,360 - 205,636 166,150 -Iowa 321,119 61,219 10,050 68,437 181,254 159Kansas 246,598 84,965 36,572 87,505 37,556 -Kentucky 653,553 333,376 53,842 197,815 68,520 -Louisiana 723,864 389,032 8,030 186,270 137,265 3,267Maine 195,839 74,747 2,019 50,959 68,114 -Maryland 603,562 267,549 57,874 187,404 90,735 -Massachusetts 953,469 451,577 244,709 199,301 57,882 -Michigan 1,354,718 597,873 193,142 301,489 261,563 651Minnesota 557,232 251,261 13,859 78,289 213,704 119Mississippi 526,604 239,078 - 245,413 42,110 3Missouri 772,622 190,147 - 296,853 285,622 -Montana 93,298 43,590 7,275 16,618 25,749 66Nebraska 210,261 93,822 27,657 74,285 14,497 -Nevada 130,662 59,177 - 7,822 63,650 13New Hampshire 98,340 28,041 9,811 36,535 23,945 8New Jersey 857,898 410,748 6,302 196,530 244,318 -New Mexico 339,527 141,399 - 163,968 34,160 -New York 3,500,292 1,902,380 998,432 512,355 87,125 -North Carolina 1,201,681 603,766 121,444 395,637 80,834 -North Dakota 62,115 22,121 16,672 11,382 11,940 -Ohio 1,402,364 535,575 - 807,506 59,283 -Oklahoma 459,570 - - - - 459,570Oregon 537,465 132,633 6,941 253,977 143,805 109Pennsylvania 1,720,000 707,783 150,126 476,668 385,423 -Puerto Rico 964,015 - - - - 964,015Rhode Island 148,797 92,523 8,757 24,195 23,322 -South Carolina 656,263 191,752 - 235,549 228,942 20South Dakota 83,111 35,345 - 28,078 19,688 -Tennessee 1,454,799 446,713 135,724 663,204 209,148 10Texas 2,680,583 1,049,611 47,805 1,067,067 516,100 -Utah 198,730 54,394 6,376 28,677 109,189 94Vermont 131,639 34,988 10,057 64,994 21,598 2Virgin Islands 19,914 6,345 12,092 - 1,477 -Virginia 689,571 299,904 16,597 269,519 103,551 -Washington 915,214 382,328 11,863 221,528 299,492 3West Virginia 373,090 200,222 4,372 29,004 139,492 -Wisconsin 538,229 236,456 33,736 64,972 203,062 3Wyoming 51,367 9,447 - 17,018 24,899 3




Table 17. Medicaid Eligibles by Basis of Eligibility and by State: FY 1998

State NameTotal

EligiblesAge 65

And OlderBlind/

Disabled ChildrenNational Total 41,361,532 4,078,149 6,960,124 19,434,290Alabama 628,220 76,756 165,972 326,400Alaska 87,873 5,722 9,586 47,257Arizona 649,302 32,752 89,642 359,687Arkansas 426,080 50,770 102,277 185,051California 6,191,269 557,436 892,277 3,093,098Colorado 346,928 42,052 64,153 158,182Connecticut 402,547 55,244 54,602 198,388Delaware 105,153 7,565 14,958 51,057District of Columbia 138,722 10,020 28,890 65,697Florida 2,040,541 202,885 412,175 1,002,737Georgia 1,223,439 92,211 226,999 680,791Hawaii 182,460 19,079 18,420 75,329Idaho 116,718 12,848 18,468 65,776Illinois 1,784,159 122,317 289,618 821,594Indiana 610,146 70,806 93,879 337,737Iowa 321,119 40,233 52,681 142,100Kansas 246,598 29,238 46,314 124,514Kentucky 653,553 69,450 187,148 282,190Louisiana 723,864 93,353 164,758 350,492Maine 195,839 24,463 40,114 86,689Maryland 603,562 53,714 113,836 295,549Massachusetts 953,469 101,133 198,747 463,804Michigan 1,354,718 97,752 273,214 567,854Minnesota 557,232 61,018 76,989 308,613Mississippi 526,604 64,709 142,423 255,614Missouri 772,622 92,655 119,232 421,830Montana 93,298 9,204 16,262 44,416Nebraska 210,261 21,508 27,483 120,392Nevada 130,662 14,685 21,799 69,281New Hampshire 98,340 11,690 11,980 56,064New Jersey 857,898 108,805 165,497 394,443New Mexico 339,527 21,105 46,502 221,490New York 3,500,292 373,295 625,643 1,488,919North Carolina 1,201,681 168,788 210,064 621,126North Dakota 62,115 10,728 9,219 28,972Ohio 1,402,364 147,520 231,324 652,630Oklahoma 459,570 - - -Oregon 537,465 41,337 112,407 141,508Pennsylvania 1,720,000 246,811 299,438 799,439Puerto Rico 964,015 - - -Rhode Island 148,797 17,747 30,002 65,263South Carolina 656,263 76,772 110,839 310,020South Dakota 83,111 8,575 14,899 45,742Tennessee 1,454,799 88,326 306,344 546,545Texas 2,680,583 338,535 320,882 1,547,176Utah 198,730 10,145 21,507 115,434Vermont 131,639 15,610 16,350 57,405Virgin Islands 19,914 1,526 1,240 11,489Virginia 689,571 91,088 127,524 360,013Washington 915,214 64,925 120,040 515,912West Virginia 373,090 32,612 81,681 182,281Wisconsin 538,229 66,223 126,166 242,255Wyoming 51,367 4,408 7,660 28,045




Table 17. Medicaid Eligibles by Basis of Eligibility and by State: FY 1998 (Con’t)


ChildrenOther/

UnknownNational Total 8,712,861 743,588 1,432,520Alabama 54,419 4,673 -Alaska 23,946 1,362 -Arizona 160,345 6,876 -Arkansas 82,815 4,853 314California 1,511,094 137,334 30Colorado 67,095 15,446 -Connecticut 85,395 8,918 -Delaware 30,964 609 -District of Columbia 30,139 2,328 1,648Florida 400,324 22,419 1Georgia 209,091 14,342 5Hawaii 64,575 3,193 1,864Idaho 17,936 1,690 -Illinois 417,213 133,417 -Indiana 101,308 6,416 -Iowa 80,997 4,949 159Kansas 41,714 4,818 -Kentucky 107,045 7,717 3Louisiana 111,937 57 3,267Maine 42,014 2,559 -Maryland 124,162 16,301 -Massachusetts 189,180 605 -Michigan 413,701 1,546 651Minnesota 102,477 7,925 210Mississippi 60,329 3,526 3Missouri 122,206 16,699 -Montana 19,930 3,420 66Nebraska 30,255 10,623 -Nevada 21,207 3,677 13New Hampshire 16,029 2,569 8New Jersey 170,873 18,280 -New Mexico 48,867 1,563 -New York 925,310 87,125 -North Carolina 189,333 12,370 -North Dakota 11,649 1,547 -Ohio 335,747 35,143 -Oklahoma - - 459,570Oregon 229,567 12,537 109Pennsylvania 347,440 26,872 -Puerto Rico - - 964,015Rhode Island 31,162 4,623 -South Carolina 151,444 7,168 20South Dakota 12,618 1,277 -Tennessee 501,663 11,545 376Texas 455,759 18,231 -Utah 47,504 4,046 94Vermont 40,026 2,163 85Virgin Islands 5,659 - -Virginia 106,021 4,925 -Washington 194,023 20,311 3West Virginia 70,294 6,222 -Wisconsin 87,424 16,158 3Wyoming 10,636 615 3




Table 18. Medicaid Eligibles Who Receive Cash Payments by Basis of Eligibility and by State: FY 1998

State NameTotal

EligiblesAge 65

And OlderBlind/


UnknownNational Total 17,663,099 1,697,350 5,074,095 7,380,074 3,511,525 55Alabama 260,614 34,599 146,339 58,099 21,577 -Alaska 56,288 5,135 9,087 26,406 15,660 -Arizona 263,593 14,136 71,501 125,158 52,798 -Arkansas 74,087 18,961 5,738 35,349 14,039 -California 3,202,001 354,618 770,362 1,460,553 616,468 -Colorado 102,264 19,544 9,109 49,983 23,628 -Connecticut 157,719 8,194 21,526 84,977 43,022 -Delaware 34,034 2,339 11,068 14,951 5,676 -District of Columbia 98,892 3,998 23,291 49,055 22,548 -Florida 1,181,859 107,990 321,282 501,407 251,180 -Georgia 423,014 41,123 180,781 147,966 53,144 -Hawaii 112,219 17,079 17,827 49,699 27,614 -Idaho 12,725 1,636 7,501 2,462 1,126 -Illinois 783,543 26,301 186,029 396,812 174,401 -Indiana 238,360 17,408 60,345 101,145 59,462 -Iowa 61,219 8,976 39,776 6,608 5,859 -Kansas 84,965 5,293 33,270 28,443 17,959 -Kentucky 333,376 25,974 167,550 94,384 45,468 -Louisiana 389,032 52,649 147,904 137,157 51,322 -Maine 74,747 4,017 27,026 28,750 14,954 -Maryland 267,549 20,677 89,630 112,532 44,710 -Massachusetts 451,577 41,702 148,876 178,824 82,175 -Michigan 597,873 23,550 199,337 125,416 249,570 -Minnesota 251,261 16,775 53,894 122,778 57,782 32Mississippi 239,078 29,653 125,030 57,967 26,428 -Missouri 190,147 4,280 9,317 125,418 51,132 -Montana 43,590 1,981 13,036 19,022 9,551 -Nebraska 93,822 8,242 23,874 41,879 19,827 -Nevada 59,177 6,818 16,970 24,646 10,743 -New Hampshire 28,041 1,629 5,953 13,975 6,484 -New Jersey 410,748 35,717 128,411 161,921 84,699 -New Mexico 141,399 10,204 41,826 59,091 30,278 -New York 1,902,380 181,284 508,219 861,044 351,833 -North Carolina 603,766 83,239 132,599 257,439 130,489 -North Dakota 22,121 3,968 6,505 8,203 3,445 -Ohio 535,575 1,209 7,801 383,866 142,699 -Oklahoma - - - - - -Oregon 132,633 8,496 47,811 43,925 32,401 -Pennsylvania 707,783 74,525 227,384 283,999 121,875 -Puerto Rico - - - - - -Rhode Island 92,523 5,133 23,474 41,930 21,986 -South Carolina 191,752 37,766 85,148 47,284 21,554 -South Dakota 35,345 2,565 13,275 13,421 6,084 -Tennessee 446,713 40,534 242,903 114,145 49,108 23Texas 1,049,611 177,775 275,960 409,182 186,694 -Utah 54,394 3,238 12,728 24,982 13,446 -Vermont 34,988 2,382 11,468 14,523 6,615 -Virgin Islands 6,345 430 595 3,630 1,690 -Virginia 299,904 38,864 100,317 112,615 48,108 -Washington 382,328 22,416 93,848 169,471 96,593 -West Virginia 200,222 24,570 65,892 63,063 46,697 -Wisconsin 236,456 16,766 99,623 81,974 38,093 -Wyoming 9,447 992 5,079 2,545 831 -




Table 19. Medically Needy Medicaid Eligibles by State: FY 1998

State NameTotal

EligiblesAge 65

And OlderBlind/


UnknownNational Total 4,239,284 759,191 618,236 1,807,779 1,053,709 369Alabama - - - - - -Alaska - - - - - -Arizona - - - - - -Arkansas 108,750 299 79,925 17,867 10,659 -California 1,361,944 170,805 98,679 787,798 304,662 -Colorado - - - - - -Connecticut 45,477 14,868 19,776 6,007 4,826 -Delaware - - - - - -District of Columbia 21,796 4,103 3,816 8,785 5,092 -Florida 56,251 16 11,387 16,020 28,828 -Georgia 813 110 638 62 3 -Hawaii 5,234 1,929 593 1,447 1,265 -Idaho - - - - - -Illinois 386,883 67,720 57,657 116,304 145,202 -Indiana - - - - - -Iowa 10,050 3,188 2,615 980 3,267 -Kansas 36,572 22,601 10,949 2,766 256 -Kentucky 53,842 4,044 3,085 28,767 17,946 -Louisiana 8,030 1,312 1,907 1,848 2,963 -Maine 2,019 702 531 494 292 -Maryland 57,874 23,337 17,356 10,185 6,996 -Massachusetts 244,709 29,480 7,538 132,622 75,069 -Michigan 193,142 66,936 67,212 7,924 51,070 -Minnesota 13,859 6,309 6,813 516 194 27Mississippi - - - - - -Missouri - - - - - -Montana 7,275 5,286 1,978 3 8 -Nebraska 27,657 9,049 1,828 8,315 8,465 -Nevada - - - - - -New Hampshire 9,811 4,220 2,502 1,550 1,539 -New Jersey 6,302 3,123 1,125 2,052 2 -New Mexico - - - - - -New York 998,432 192,011 117,424 501,513 187,484 -North Carolina 121,444 43,491 55,713 8,238 14,002 -North Dakota 16,672 6,613 2,710 4,591 2,758 -Ohio - - - - - -Oklahoma - - - - - -Oregon 6,941 1,935 5,006 - - -Pennsylvania 150,126 28,438 5,172 57,730 58,786 -Puerto Rico - - - - - -Rhode Island 8,757 5,348 1,847 22 1,540 -South Carolina - - - - - -South Dakota - - - - - -Tennessee 135,724 18,084 9,878 37,089 70,331 342Texas 47,805 - - 11,327 36,478 -Utah 6,376 648 1,091 2,309 2,328 -Vermont 10,057 787 1,050 4,031 4,189 -Virgin Islands 12,092 1,096 645 7,397 2,954 -Virginia 16,597 8,866 6,030 1,423 278 -Washington 11,863 5,754 5,852 114 143 -West Virginia 4,372 342 2,719 143 1,168 -Wisconsin 33,736 6,341 5,189 19,540 2,666 -Wyoming - - - - - -




Table 20. Poverty Related Medicaid Eligibles by Basis of Eligibility and by State: FY 1998

State NameTotal

EligiblesAge 65

And OlderBlind/


UnknownNational Total 10,568,471 704,722 670,007 6,940,283 2,253,438 21Alabama 263,587 22,302 10,433 218,890 11,962 -Alaska 16,695 19 16 12,611 4,049 -Arizona 206,776 3,745 3,472 152,854 46,705 -Arkansas 195,128 9,053 10,282 123,756 52,037 -California 369,005 3,206 8,833 302,891 54,075 -Colorado 88,123 2,170 3,135 59,866 22,952 -Connecticut 59,334 2,247 925 49,822 6,340 -Delaware 53,788 2,017 1,174 29,604 20,993 -District of Columbia 10,068 1,918 1,783 5,629 738 -Florida 569,091 58,571 62,472 363,123 84,925 -Georgia 560,476 22,220 15,131 424,270 98,855 -Hawaii 58,966 71 - 23,532 35,363 -Idaho 37,162 11,212 10,336 10,398 5,216 -Illinois 307,813 25,414 32,493 208,992 40,914 -Indiana 205,636 4,966 6,420 180,069 14,181 -Iowa 68,437 5,708 4,386 46,120 12,223 -Kansas 87,505 1,224 939 73,598 11,744 -Kentucky 197,815 16,458 11,124 140,600 29,632 1Louisiana 186,270 13,503 5,593 136,655 30,519 -Maine 50,959 9,806 6,887 30,485 3,781 -Maryland 187,404 9,680 5,589 127,220 44,915 -Massachusetts 199,301 29,951 39,813 121,318 8,219 -Michigan 301,489 6,272 6,565 250,290 38,362 -Minnesota 78,289 4,319 2,629 69,276 2,045 20Mississippi 245,413 20,664 14,585 188,366 21,798 -Missouri 296,853 9,887 6,918 245,522 34,526 -Montana 16,618 437 146 12,378 3,657 -Nebraska 74,285 3,784 1,565 68,936 - -Nevada 7,822 4,115 3,558 143 6 -New Hampshire 36,535 361 232 33,071 2,871 -New Jersey 196,530 32,613 21,341 113,631 28,945 -New Mexico 163,968 110 547 144,722 18,589 -New York 512,355 - - 126,362 385,993 -North Carolina 395,637 - - 354,150 41,487 -North Dakota 11,382 142 4 9,740 1,496 -Ohio 807,506 146,311 223,523 258,422 179,250 -Oklahoma - - - - - -Oregon 253,977 727 9,014 75,462 168,774 -Pennsylvania 476,668 99,249 13,772 303,037 60,610 -Puerto Rico - - - - - -Rhode Island 24,195 745 338 17,080 6,032 -South Carolina 235,549 22,679 18,943 174,006 19,921 -South Dakota 28,078 407 147 23,344 4,180 -Tennessee 663,204 2 47,521 300,411 315,270 -Texas 1,067,067 45,654 18,140 858,646 144,627 -Utah 28,677 2,408 4,103 5,968 16,198 -Vermont 64,994 9,054 2,912 27,364 25,664 -Virgin Islands - - - - - -Virginia 269,519 22,496 14,473 192,116 40,434 -Washington 221,528 4,136 4,092 189,001 24,299 -West Virginia 29,004 7,590 13,070 1,018 7,326 -Wisconsin 64,972 4,336 1 43,703 16,932 -Wyoming 17,018 763 632 11,815 3,808 -




Table 21. Medicaid Eligibles of Other Coverage Groups by Basis of Eligibility and by State: FY 1998

State NameTotal

EligiblesAge 65

And OlderBlind/

Disabled ChildrenNational Total 7,458,731 916,886 597,786 3,306,154Alabama 104,019 19,855 9,200 49,411Alaska 14,890 568 483 8,240Arizona 178,933 14,871 14,669 81,675Arkansas 47,801 22,457 6,332 8,079California 1,258,319 28,807 14,403 541,856Colorado 156,541 20,338 51,909 48,333Connecticut 140,017 29,935 12,375 57,582Delaware 17,331 3,209 2,716 6,502District of Columbia 6,318 1 - 2,228Florida 233,339 36,308 17,034 122,187Georgia 239,131 28,758 30,449 108,493Hawaii 4,177 - - 651Idaho 66,831 - 631 52,916Illinois 305,920 2,882 13,439 99,486Indiana 166,150 48,432 27,114 56,523Iowa 181,254 22,361 5,904 88,392Kansas 37,556 120 1,156 19,707Kentucky 68,520 22,974 5,389 18,439Louisiana 137,265 25,889 9,354 74,832Maine 68,114 9,938 5,670 26,960Maryland 90,735 20 1,261 45,612Massachusetts 57,882 - 2,520 31,040Michigan 261,563 994 100 184,224Minnesota 213,704 33,615 13,653 116,043Mississippi 42,110 14,392 2,808 9,281Missouri 285,622 78,488 102,997 50,890Montana 25,749 1,500 1,102 13,013Nebraska 14,497 433 216 1,262Nevada 63,650 3,752 1,271 44,492New Hampshire 23,945 5,480 3,293 7,468New Jersey 244,318 37,352 14,620 116,839New Mexico 34,160 10,791 4,129 17,677New York 87,125 - - -North Carolina 80,834 42,058 21,752 1,299North Dakota 11,940 5 - 6,438Ohio 59,283 - - 10,342Oklahoma - - - -Oregon 143,805 30,179 50,576 22,121Pennsylvania 385,423 44,599 53,110 154,673Puerto Rico - - - -Rhode Island 23,322 6,521 4,343 6,231South Carolina 228,942 16,327 6,748 88,730South Dakota 19,688 5,603 1,477 8,977Tennessee 209,148 29,706 6,042 94,900Texas 516,100 115,106 26,782 268,021Utah 109,189 3,851 3,585 82,175Vermont 21,598 3,387 920 11,487Virgin Islands 1,477 - - 462Virginia 103,551 20,862 6,704 53,859Washington 299,492 32,619 16,248 157,326West Virginia 139,492 110 - 118,057Wisconsin 203,062 38,780 21,353 97,038Wyoming 24,899 2,653 1,949 13,685




Table 21. Medicaid Eligibles of Other Coverage Groups by Basis of Eligibility and by State: FY 1998 (Con’t)


ChildrenOther/

UnknownNational Total 1,894,189 743,588 128Alabama 20,880 4,673 -Alaska 4,237 1,362 -Arizona 60,842 6,876 -Arkansas 6,080 4,853 -California 535,889 137,334 30Colorado 20,515 15,446 -Connecticut 31,207 8,918 -Delaware 4,295 609 -District of Columbia 1,761 2,328 -Florida 35,391 22,419 -Georgia 57,089 14,342 -Hawaii 333 3,193 -Idaho 11,594 1,690 -Illinois 56,696 133,417 -Indiana 27,665 6,416 -Iowa 59,648 4,949 -Kansas 11,755 4,818 -Kentucky 13,999 7,717 2Louisiana 27,133 57 -Maine 22,987 2,559 -Maryland 27,541 16,301 -Massachusetts 23,717 605 -Michigan 74,699 1,546 -Minnesota 42,456 7,925 12Mississippi 12,103 3,526 -Missouri 36,548 16,699 -Montana 6,714 3,420 -Nebraska 1,963 10,623 -Nevada 10,458 3,677 -New Hampshire 5,135 2,569 -New Jersey 57,227 18,280 -New Mexico - 1,563 -New York - 87,125 -North Carolina 3,355 12,370 -North Dakota 3,950 1,547 -Ohio 13,798 35,143 -Oklahoma - - -Oregon 28,392 12,537 -Pennsylvania 106,169 26,872 -Puerto Rico - - -Rhode Island 1,604 4,623 -South Carolina 109,969 7,168 -South Dakota 2,354 1,277 -Tennessee 66,954 11,545 1Texas 87,960 18,231 -Utah 15,532 4,046 -Vermont 3,558 2,163 83Virgin Islands 1,015 - -Virginia 17,201 4,925 -Washington 72,988 20,311 -West Virginia 15,103 6,222 -Wisconsin 29,733 16,158 -Wyoming 5,997 615 -




Table 22. Medicaid Recipients of Medical Care by Age and by State: FY 1998

State NameTotal

RecipientsAges

Under 1From Ages

1 to 5From Ages

6 to 14From Ages

15 to 20From Ages

21 to 44National Total 40,649,482 1,558,643 6,933,058 8,552,786 3,770,295 8,835,632Alabama 527,078 27,969 111,576 111,380 43,098 93,433Alaska 74,508 3,402 13,768 17,224 7,395 20,429Arizona 507,668 46,561 110,446 119,360 43,213 122,185Arkansas 424,727 16,248 77,228 93,906 48,658 88,600California 7,082,175 138,898 1,206,917 1,534,178 753,019 1,694,033Colorado 344,916 17,393 70,592 76,847 30,328 75,406Connecticut 381,208 11,337 61,527 91,304 38,712 94,144Delaware 101,436 3,611 18,017 24,015 10,825 28,552District of Columbia 166,146 3,164 23,730 28,842 10,957 28,937Florida 1,904,591 72,385 360,477 457,266 175,370 424,619Georgia 1,221,978 64,474 255,052 280,857 129,665 225,920Hawaii 184,614 10,481 26,262 34,392 16,114 48,768Idaho 123,176 5,313 26,308 26,804 10,351 25,513Illinois 1,363,856 89,743 260,125 302,023 125,509 327,306Indiana 607,293 27,842 125,480 137,858 55,705 126,370Iowa 314,936 11,800 55,265 66,549 32,200 84,025Kansas 241,933 10,427 47,237 54,610 26,317 51,939Kentucky 644,482 22,487 108,103 136,877 56,460 153,490Louisiana 720,615 57,639 144,132 158,730 64,869 139,767Maine 170,456 4,257 22,420 36,703 18,827 42,537Maryland 561,085 23,208 102,693 133,175 50,928 128,022Massachusetts 908,238 36,321 126,727 178,469 79,006 245,415Michigan 1,362,890 44,555 236,433 317,589 128,690 336,515Minnesota 538,413 17,157 93,654 136,544 66,890 121,112Mississippi 485,767 26,367 90,526 96,034 42,668 95,579Missouri 734,015 27,330 142,186 181,373 81,044 147,058Montana 100,760 3,530 17,888 22,870 9,490 25,881Nebraska 211,188 17,290 39,175 49,790 22,657 43,831Nevada 128,144 7,618 29,865 30,159 9,140 24,882New Hampshire 93,970 2,499 16,657 24,433 9,903 20,093New Jersey 813,251 26,256 149,651 181,330 73,879 195,093New Mexico 329,418 12,877 70,445 97,061 42,995 58,552New York 3,073,241 101,784 503,121 616,071 285,914 771,013North Carolina 1,167,988 79,785 213,089 250,288 117,711 243,112North Dakota 62,280 2,060 10,456 13,214 5,921 13,706Ohio 1,290,776 91,067 220,394 276,683 123,728 307,773Oklahoma 342,475 - - - - -Oregon 511,171 14,102 80,111 94,824 47,731 164,643Pennsylvania 1,523,120 43,654 248,534 360,366 160,445 374,254Puerto Rico 964,015 - - - - -Rhode Island 153,130 4,288 25,004 34,289 13,617 37,367South Carolina 594,962 27,168 100,788 130,359 64,024 131,514South Dakota 89,537 6,767 18,085 21,985 9,632 16,246Tennessee 1,843,661 33,132 191,472 284,213 152,278 410,025Texas 2,324,810 144,065 558,876 574,293 179,470 417,767Utah 215,801 13,992 46,317 40,620 19,690 46,322Vermont 123,992 2,410 15,757 26,550 12,569 35,932Virgin Islands 19,764 840 4,553 4,168 2,103 5,059Virginia 653,236 41,524 123,243 152,702 66,403 125,801Washington 1,413,208 25,861 167,150 235,062 107,258 197,921West Virginia 342,668 12,093 56,474 73,311 35,841 76,345Wisconsin 518,595 20,872 98,851 114,714 46,662 112,151Wyoming 46,121 2,740 10,221 10,522 4,416 10,675




Table 22. Medicaid Recipients of Medical Care by Age and by State: FY 1998 (Con’t)

State NameFrom Ages

45 to 64From Ages

65 to 74From Ages

75 to 84From Ages

85 and Over UnknownNational Total 3,329,608 1,806,516 1,577,798 1,271,386 3,013,760Alabama 51,573 31,817 30,249 25,309 674Alaska 5,439 2,991 2,018 741 1,101Arizona 30,740 14,001 11,580 9,582 -Arkansas 34,820 21,708 22,996 19,644 919California 573,977 357,113 261,022 141,650 421,368Colorado 26,732 16,807 14,897 13,748 2,166Connecticut 32,065 16,290 17,759 18,070 -Delaware 8,598 2,934 2,607 2,127 150District of Columbia 11,323 5,038 4,058 2,388 47,709Florida 150,693 100,119 85,574 65,924 12,164Georgia 87,177 53,477 49,912 68,219 7,225Hawaii 13,035 8,509 6,629 3,809 16,615Idaho 9,084 4,212 4,077 3,873 7,641Illinois 116,503 55,375 47,224 39,126 922Indiana 45,457 26,414 26,052 25,780 10,335Iowa 23,148 11,145 13,760 15,829 1,215Kansas 19,175 8,927 9,813 11,298 2,190Kentucky 75,170 35,195 30,128 22,252 4,320Louisiana 59,953 36,578 33,406 25,404 137Maine 18,530 9,387 8,784 7,287 1,724Maryland 44,058 23,068 19,948 14,168 21,817Massachusetts 104,051 42,822 44,504 50,923 -Michigan 109,172 45,213 38,461 33,254 73,008Minnesota 34,707 17,342 20,595 25,156 5,256Mississippi 47,702 30,780 28,555 22,461 5,095Missouri 58,750 32,984 32,949 29,374 967Montana 8,332 3,582 3,659 3,594 1,934Nebraska 13,038 7,140 8,327 9,940 -Nevada 8,841 5,610 4,477 2,789 4,763New Hampshire 6,988 3,490 4,253 5,151 503New Jersey 60,994 43,824 41,617 36,436 4,171New Mexico 19,573 11,319 8,569 6,708 1,319New York 324,892 181,044 155,864 133,538 -North Carolina 102,889 62,261 59,626 39,227 -North Dakota 4,618 2,677 3,661 4,500 1,467Ohio 114,741 54,935 54,832 46,623 -Oklahoma - - - - 342,475Oregon 62,059 14,678 12,961 9,942 10,120Pennsylvania 155,593 66,800 60,712 51,748 1,014Puerto Rico - - - - 964,015Rhode Island 13,343 6,887 7,528 8,109 2,698South Carolina 46,949 29,380 27,507 17,408 19,865South Dakota 5,714 3,090 3,661 4,340 17Tennessee 222,467 68,911 45,752 31,923 403,488Texas 148,914 122,019 103,321 76,084 1Utah 10,243 4,361 3,589 3,120 27,547Vermont 13,359 5,897 5,905 3,954 1,659Virgin Islands 1,381 839 619 202 -Virginia 52,956 36,481 32,497 21,629 -Washington 60,366 25,297 22,437 18,886 552,970West Virginia 35,696 12,697 10,569 7,838 21,804Wisconsin 41,219 21,719 26,802 28,800 6,805Wyoming 2,811 1,332 1,496 1,501 407




Table 23. Medicaid Recipients of Medical Care by Sex and by State: FY 1998

State NameTotal

Recipients Male Female UnknownNational Total 40,649,482 14,733,230 22,376,441 3,539,811Alabama 527,078 196,812 322,644 7,622Alaska 74,508 29,343 44,064 1,101Arizona 507,668 - - 507,668Arkansas 424,727 157,095 266,608 1,024California 7,082,175 2,755,161 3,905,643 421,371Colorado 344,916 134,691 208,059 2,166Connecticut 381,208 147,258 233,950 -Delaware 101,436 40,392 60,894 150District of Columbia 166,146 45,453 72,968 47,725Florida 1,904,591 747,611 1,144,816 12,164Georgia 1,221,978 466,356 748,398 7,224Hawaii 184,614 74,800 93,280 16,534Idaho 123,176 45,716 69,818 7,642Illinois 1,363,856 531,086 831,848 922Indiana 607,293 230,233 366,725 10,335Iowa 314,936 124,286 189,435 1,215Kansas 241,933 95,628 144,097 2,208Kentucky 644,482 253,917 386,239 4,326Louisiana 720,615 278,337 442,067 211Maine 170,456 66,832 101,902 1,722Maryland 561,085 209,354 329,915 21,816Massachusetts 908,238 361,068 547,170 -Michigan 1,362,890 514,653 775,234 73,003Minnesota 538,413 219,165 313,992 5,256Mississippi 485,767 176,349 304,322 5,096Missouri 734,015 288,756 444,292 967Montana 100,760 41,104 57,722 1,934Nebraska 211,188 81,843 122,002 7,343Nevada 128,144 48,510 74,729 4,905New Hampshire 93,970 36,484 56,954 532New Jersey 813,251 297,939 511,141 4,171New Mexico 329,418 137,842 190,255 1,321New York 3,073,241 1,201,561 1,871,645 35North Carolina 1,167,988 443,966 724,022 -North Dakota 62,280 23,579 37,224 1,477Ohio 1,290,776 497,750 793,007 19Oklahoma 342,475 - - 342,475Oregon 511,171 219,412 281,633 10,126Pennsylvania 1,523,120 602,675 919,434 1,011Puerto Rico 964,015 - - 964,015Rhode Island 153,130 57,293 93,137 2,700South Carolina 594,962 205,046 369,944 19,972South Dakota 89,537 35,541 51,522 2,474Tennessee 1,843,661 603,827 836,338 403,496Texas 2,324,810 910,233 1,414,555 22Utah 215,801 75,205 112,713 27,883Vermont 123,992 52,636 69,697 1,659Virgin Islands 19,764 6,652 13,112 -Virginia 653,236 253,854 399,382 -Washington 1,413,208 355,421 504,765 553,022West Virginia 342,668 132,574 187,552 22,542Wisconsin 518,595 204,135 307,665 6,795Wyoming 46,121 17,796 27,911 414




Table 24. Medicaid Recipients of Medical Care by Race/Ethnicity and by State: FY 1998

State NameTotal

RecipientsWhite

Not HispanicBlack

Not HispanicHispanic

National Total 40,649,482 16,771,976 9,847,580 6,353,196Alabama 527,078 238,107 260,790 4,483Alaska 74,508 34,485 4,797 2,671Arizona 507,668 - - -Arkansas 424,727 257,363 141,972 5,396California 7,082,175 2,028,789 876,628 2,598,598Colorado 344,916 176,003 27,613 110,326Connecticut 381,208 170,175 95,626 109,224Delaware 101,436 42,152 46,817 7,817District of Columbia 166,146 1,840 106,929 3,999Florida 1,904,591 759,097 663,851 305,827Georgia 1,221,978 443,904 647,000 40,754Hawaii 184,614 24,871 1,817 6,427Idaho 123,176 99,097 552 12,954Illinois 1,363,856 554,463 567,071 208,620Indiana 607,293 421,513 145,694 23,288Iowa 314,936 271,369 25,612 11,179Kansas 241,933 166,353 44,774 19,046Kentucky 644,482 525,911 82,799 5,070Louisiana 720,615 238,916 431,382 -Maine 170,456 - - -Maryland 561,085 184,348 307,223 19,120Massachusetts 908,238 533,292 102,428 136,456Michigan 1,362,890 682,290 488,168 49,697Minnesota 538,413 343,748 80,703 28,932Mississippi 485,767 151,798 298,883 1,319Missouri 734,015 506,398 226,649 -Montana 100,760 74,115 640 1,872Nebraska 211,188 148,160 29,859 20,346Nevada 128,144 71,199 23,871 22,083New Hampshire 93,970 90,345 876 1,447New Jersey 813,251 252,882 296,751 182,860New Mexico 329,418 89,343 8,850 168,019New York 3,073,241 859,517 688,544 649,517North Carolina 1,167,988 511,841 515,303 43,585North Dakota 62,280 44,676 1,008 1,508Ohio 1,290,776 813,089 426,783 31,086Oklahoma 342,475 - - -Oregon 511,171 401,228 21,658 50,838Pennsylvania 1,523,120 896,151 458,668 123,070Puerto Rico 964,015 - - -Rhode Island 153,130 87,594 15,172 26,785South Carolina 594,962 220,674 326,308 4,108South Dakota 89,537 52,126 185 130Tennessee 1,843,661 952,473 414,173 12,588Texas 2,324,810 645,978 458,055 1,119,760Utah 215,801 140,036 3,966 26,951Vermont 123,992 120,771 705 183Virgin Islands 19,764 173 15,493 3,991Virginia 653,236 300,535 311,541 24,123Washington 1,413,208 629,997 57,659 102,737West Virginia 342,668 296,447 14,776 497Wisconsin 518,595 180,361 80,023 19,779Wyoming 46,121 35,983 935 4,130




Table 24. Medicaid Recipients of Medical Care by Race/Ethnicity and by State: FY 1998 (Con’t)

State NameAsian or

Pacific IslandsAmerican Indian/

Alaskan Native UnknownNational Total 1,022,077 335,582 6,319,071Alabama 1,510 1,049 21,139Alaska 3,888 25,929 2,738Arizona - - 507,668Arkansas 912 837 18,247California 512,660 30,983 1,034,517Colorado 3,744 2,301 24,929Connecticut 5,525 582 76Delaware 401 248 4,001District of Columbia 779 16 52,583Florida 8,633 926 166,257Georgia 10,620 622 79,078Hawaii 74,931 99 76,469Idaho 332 2,600 7,641Illinois 30,252 2,237 1,213Indiana 1,455 398 14,945Iowa 3,786 1,775 1,215Kansas 6,490 3,080 2,190Kentucky 1,286 208 29,208Louisiana - - 50,317Maine - - 170,456Maryland 11,551 1,039 37,804Massachusetts 30,441 2,469 103,152Michigan 17,568 5,843 119,324Minnesota 40,133 25,640 19,257Mississippi 1,698 1,813 30,256Missouri - 1 967Montana 430 21,752 1,951Nebraska 2,355 8,539 1,929Nevada 2,912 2,577 5,502New Hampshire 776 21 505New Jersey 8,979 1,891 69,888New Mexico 1,617 51,500 10,089New York 57,224 7,092 811,347North Carolina 10,659 20,124 66,476North Dakota 321 13,278 1,489Ohio 4,819 1,314 13,685Oklahoma - - 342,475Oregon 14,412 9,425 13,610Pennsylvania 26,676 1,285 17,270Puerto Rico - - 964,015Rhode Island 4,615 248 18,716South Carolina 892 667 42,313South Dakota 61 31,510 5,525Tennessee 7,366 3,420 453,641Texas 23,253 6,280 71,484Utah 6,439 9,092 29,317Vermont 434 240 1,659Virgin Islands 78 11 18Virginia 14,973 748 1,316Washington 46,052 23,794 552,969West Virginia 325 - 30,623Wisconsin 17,679 6,233 214,520Wyoming 135 3,846 1,092




Table 25. Medicaid Vendor Payments of Medical Care by Age and by State: FY 1998

State NameTotal

PaymentsAges

Under 1From Ages

1 to 5From Ages

6 to 14From Ages

15 to 20From Ages

21 to 44National Total $142,317,903,795 $4,181,702,420 $8,603,546,258 $11,154,216,158 $8,423,079,186 $35,470,454,641Alabama 1,902,300,047 22,820,090 67,146,126 137,864,651 45,748,090 204,929,306Alaska 330,378,398 18,512,179 26,147,375 46,203,751 32,941,090 98,122,887Arizona 1,643,966,305 150,504,669 164,096,117 209,815,378 137,883,403 420,953,820Arkansas 1,375,797,421 69,985,612 170,587,004 157,649,124 121,005,431 350,725,626California 14,236,592,915 159,027,699 1,099,696,397 1,488,518,619 961,974,962 4,035,630,454Colorado 1,439,366,499 37,548,894 91,164,647 122,067,919 114,342,985 347,447,472Connecticut 2,420,791,474 37,449,638 105,518,904 119,339,122 81,403,500 585,828,450Delaware 419,732,143 9,896,557 29,854,591 50,307,997 35,039,968 117,558,642District of Columbia 731,292,552 14,424,526 46,265,668 41,119,366 39,854,823 177,387,401Florida 5,686,844,862 207,214,109 426,888,964 428,913,238 295,567,125 1,379,641,858Georgia 3,012,346,312 130,274,039 256,674,945 228,998,832 229,873,552 737,273,945Hawaii 507,433,146 13,215,325 37,860,256 42,742,017 21,814,656 101,708,497Idaho 424,512,387 14,402,838 27,319,923 30,021,260 28,677,864 120,915,949Illinois 6,172,865,261 369,710,789 297,236,608 394,413,854 529,742,708 1,861,505,117Indiana 2,564,005,047 86,166,403 149,572,250 165,692,398 129,727,953 638,727,347Iowa 1,288,770,390 31,010,044 73,834,267 115,849,468 108,926,139 347,901,735Kansas 916,323,608 31,073,118 43,044,576 65,465,347 63,337,713 262,174,644Kentucky 2,425,288,141 39,767,195 182,568,410 257,295,529 170,759,041 571,166,507Louisiana 2,383,508,985 168,716,699 139,107,477 164,913,424 157,908,697 611,395,836Maine 747,027,618 7,245,901 31,281,848 77,280,919 59,429,808 193,621,824Maryland 2,489,280,148 59,865,791 176,722,191 242,862,808 154,004,636 641,599,245Massachusetts 4,609,360,933 122,380,919 198,016,371 288,877,243 192,799,760 1,220,375,985Michigan 4,345,007,824 103,768,590 242,082,971 287,871,822 210,654,465 1,177,273,480Minnesota 2,924,447,719 61,200,048 208,440,363 232,135,456 170,201,289 746,278,109Mississippi 1,442,373,276 55,834,210 96,211,119 111,359,490 104,913,877 310,382,434Missouri 2,569,646,129 72,341,660 163,428,780 176,213,721 140,570,168 589,861,158Montana 361,238,668 9,996,360 18,294,856 33,302,058 29,089,839 83,126,095Nebraska 753,162,904 41,094,566 38,081,715 60,523,842 46,255,062 177,550,894Nevada 462,087,777 20,897,202 44,967,398 56,851,800 42,129,982 112,883,176New Hampshire 606,004,232 5,371,744 23,485,035 62,338,125 37,075,477 147,223,561New Jersey 4,218,822,993 62,638,007 242,197,724 282,906,145 209,346,536 1,046,385,654New Mexico 862,144,872 31,342,287 91,463,467 143,247,036 118,582,902 173,657,451New York 24,298,610,635 465,752,704 1,098,859,279 1,573,592,359 1,031,876,055 6,368,540,586North Carolina 4,013,996,742 219,104,317 233,057,550 335,643,471 294,081,459 991,888,410North Dakota 341,015,420 5,421,612 13,258,687 20,678,612 19,985,618 86,326,115Ohio 6,120,967,557 312,960,286 219,216,802 360,697,356 306,294,127 1,501,817,268Oklahoma 1,177,853,941 - - - - -Oregon 1,377,514,740 15,545,694 98,235,110 162,365,217 101,366,690 393,343,003Pennsylvania 6,080,191,710 82,817,865 357,914,294 666,490,834 421,800,531 1,287,454,674Puerto Rico 250,000,000 - - - - -Rhode Island 919,353,410 12,399,211 48,529,981 59,308,455 38,847,474 224,855,093South Carolina 2,018,620,428 79,118,760 117,683,342 163,537,315 146,855,007 426,843,487South Dakota 355,833,902 22,685,147 19,035,793 29,797,699 27,517,415 85,332,923Tennessee 3,167,188,993 30,739,369 139,001,982 237,099,354 253,428,307 763,980,092Texas 7,139,928,843 428,826,197 681,906,816 523,617,923 410,885,398 1,602,967,227Utah 618,675,433 32,591,866 53,961,059 52,186,345 56,276,177 183,641,866Vermont 351,341,290 4,365,501 15,573,132 37,715,946 30,298,880 94,383,464Virgin Islands 10,097,973 551,923 1,032,869 827,904 781,957 2,812,008Virginia 2,118,202,866 114,024,927 126,666,594 147,224,727 122,588,008 552,938,255Washington 2,044,234,831 35,769,579 154,415,362 166,326,790 124,864,608 521,145,517West Virginia 1,243,150,526 17,099,015 59,891,308 92,021,543 87,059,121 279,277,299Wisconsin 2,206,398,750 28,368,530 142,851,338 187,435,648 114,819,943 453,779,746Wyoming 192,004,819 7,862,209 13,196,617 14,686,901 11,868,910 57,913,049




Table 25. Medicaid Vendor Payments of Medical Care by Age and by State: FY 1998 (Con’t)

State NameFrom Ages

45 to 64From Ages

65 to 74From Ages

75 to 84From Ages

85 and Over UnknownNational Total $25,428,205,744 $11,816,786,953 $15,787,654,578 $17,987,033,024 $3,465,224,822Alabama 222,430,043 138,331,051 233,804,983 315,442,465 513,783,242Alaska 48,111,274 21,079,241 22,794,123 16,180,644 285,834Arizona 183,783,798 104,866,008 134,376,262 137,686,845 -Arkansas 239,447,900 117,089,152 181,078,028 213,433,778 (245,204,234)California 2,605,396,220 1,267,911,644 1,321,426,945 1,160,443,354 136,566,621Colorado 235,123,077 101,694,946 153,088,046 194,124,581 42,763,932Connecticut 439,438,023 211,019,689 351,701,578 489,092,570 -Delaware 71,005,891 27,780,252 37,139,549 40,650,854 497,842District of Columbia 161,332,148 58,421,889 66,322,438 59,170,120 66,994,173Florida 948,473,963 492,763,811 672,651,882 814,255,757 20,474,155Georgia 507,321,902 225,627,074 302,572,083 372,731,195 20,998,745Hawaii 76,018,112 38,360,172 58,062,894 73,841,565 43,809,654Idaho 71,893,153 26,739,298 40,002,588 51,931,442 12,608,072Illinois 1,246,416,786 453,682,260 504,674,065 515,442,795 40,279Indiana 501,374,204 226,730,761 305,021,585 352,618,604 8,373,542Iowa 206,413,954 80,224,074 132,264,291 189,837,627 2,508,791Kansas 175,770,453 66,162,248 87,292,819 117,594,529 4,408,161Kentucky 492,554,678 183,342,077 250,195,634 271,845,644 5,793,426Louisiana 465,816,270 195,457,195 240,901,709 239,184,115 107,564Maine 134,278,978 57,972,838 81,036,079 101,971,621 2,907,802Maryland 472,837,550 201,989,548 245,346,175 266,497,836 27,554,368Massachusetts 909,101,419 361,200,739 564,592,348 752,016,149 -Michigan 852,441,315 261,404,363 371,361,023 466,060,921 372,088,874Minnesota 450,072,629 201,316,637 328,016,607 518,294,261 8,492,320Mississippi 257,489,521 127,851,781 168,177,532 208,776,837 1,376,475Missouri 465,882,450 228,326,459 325,826,357 406,569,598 625,778Montana 61,098,168 23,253,794 42,424,696 59,096,081 1,556,721Nebraska 122,546,774 56,085,965 85,095,618 125,928,469 -Nevada 69,765,335 26,730,084 33,091,340 35,548,384 19,223,076New Hampshire 97,365,677 44,633,623 75,165,683 112,644,970 700,337New Jersey 719,076,240 396,093,554 566,277,295 686,390,687 7,511,151New Mexico 116,690,103 48,756,597 60,110,922 72,980,615 5,313,492New York 4,829,113,896 2,546,546,564 3,107,820,036 3,276,509,156 -North Carolina 730,963,532 312,081,536 462,921,843 434,254,624 -North Dakota 58,928,321 27,136,683 42,074,930 66,020,835 1,184,007Ohio 1,212,619,311 551,295,117 815,224,323 840,842,962 -Oklahoma - - - - 1,177,853,941Oregon 252,153,490 92,448,859 127,029,299 128,852,296 6,175,082Pennsylvania 963,973,632 497,082,758 796,964,252 1,004,040,138 1,652,732Puerto Rico - - - - 250,000,000Rhode Island 179,527,633 80,422,597 119,175,726 152,158,672 4,128,568South Carolina 338,951,033 137,571,468 179,507,553 173,537,576 255,014,887South Dakota 52,355,727 22,329,101 36,988,783 59,783,196 8,118Tennessee 536,687,431 187,217,995 281,906,447 340,325,499 396,802,517Texas 1,149,707,374 620,704,247 810,913,913 910,398,749 997Utah 88,516,271 29,376,390 34,475,544 40,405,737 47,244,178Vermont 63,400,831 25,835,031 35,828,585 43,230,554 709,366Virgin Islands 1,357,835 1,158,325 1,072,172 502,980 -Virginia 390,567,507 198,282,074 244,845,675 221,065,096 -Washington 319,502,360 135,937,153 201,754,089 253,203,632 131,315,741West Virginia 249,943,764 85,512,581 117,549,030 140,540,957 114,255,908Wisconsin 352,207,086 180,113,687 311,428,280 439,100,543 (3,706,051)Wyoming 30,960,702 12,835,963 18,280,921 23,974,909 424,638




Table 26. Medicaid Vendor Payments of Medical Care by Sex and by State: FY 1998

State NameTotal

Payments Male Female UnknownNational Total $142,317,903,795 $54,505,135,169 $84,263,344,977 $3,549,423,630Alabama 1,902,300,047 428,934,012 901,448,396 571,917,639Alaska 330,378,398 143,251,512 186,841,052 285,834Arizona 1,643,966,305 611,103,276 1,032,863,023 -Arkansas 1,375,797,421 670,651,186 950,004,425 (244,858,190)California 14,236,592,915 5,684,321,859 8,415,698,843 136,572,213Colorado 1,439,366,499 568,161,269 828,441,298 42,763,932Connecticut 2,420,791,474 909,770,244 1,511,021,230 -Delaware 419,732,143 176,105,564 243,128,737 497,842District of Columbia 731,292,552 290,532,181 373,738,633 67,021,738Florida 5,686,844,862 2,186,073,956 3,480,296,751 20,474,155Georgia 3,012,346,312 1,024,630,832 1,966,718,337 20,997,143Hawaii 507,433,146 205,541,343 258,176,979 43,714,824Idaho 424,512,387 161,041,265 250,861,633 12,609,489Illinois 6,172,865,261 2,683,512,469 3,489,312,513 40,279Indiana 2,564,005,047 996,709,219 1,558,922,286 8,373,542Iowa 1,288,770,390 524,987,594 761,274,005 2,508,791Kansas 916,323,608 370,328,914 541,562,987 4,431,707Kentucky 2,425,288,141 908,938,450 1,510,527,921 5,821,770Louisiana 2,383,508,985 917,846,494 1,465,177,548 484,942Maine 747,027,618 308,154,135 435,970,254 2,903,229Maryland 2,489,280,148 1,003,696,022 1,458,030,690 27,553,436Massachusetts 4,609,360,933 1,775,376,600 2,833,984,333 -Michigan 4,345,007,824 1,536,838,141 2,436,083,617 372,086,066Minnesota 2,924,447,719 1,199,637,751 1,716,317,648 8,492,320Mississippi 1,442,373,276 495,820,726 945,154,295 1,398,255Missouri 2,569,646,129 969,602,591 1,599,417,760 625,778Montana 361,238,668 137,459,729 222,222,218 1,556,721Nebraska 753,162,904 277,327,336 465,517,769 10,317,800Nevada 462,087,777 187,811,985 254,846,778 19,429,014New Hampshire 606,004,232 233,111,156 372,103,000 790,076New Jersey 4,218,822,993 1,514,612,537 2,696,699,305 7,511,151New Mexico 862,144,872 354,666,166 502,159,764 5,318,942New York 24,298,610,635 10,246,955,529 14,050,848,812 806,292North Carolina 4,013,996,742 1,537,982,121 2,476,014,620 -North Dakota 341,015,420 138,869,223 200,950,010 1,196,187Ohio 6,120,967,557 2,219,780,890 3,891,587,868 9,598,794Oklahoma 1,177,853,941 - - 1,177,853,941Oregon 1,377,514,740 560,534,420 810,785,923 6,194,397Pennsylvania 6,080,191,710 2,244,847,299 3,833,695,224 1,649,187Puerto Rico 250,000,000 - - 250,000,000Rhode Island 919,353,410 367,807,751 547,415,973 4,129,686South Carolina 2,018,620,428 691,382,912 1,072,190,466 255,047,050South Dakota 355,833,902 144,940,742 209,534,188 1,358,972Tennessee 3,167,188,993 1,050,449,413 1,719,918,660 396,820,920Texas 7,139,928,843 2,628,419,621 4,511,436,002 73,218Utah 618,675,433 248,855,565 322,010,723 47,809,145Vermont 351,341,290 141,585,986 209,045,938 709,366Virgin Islands 10,097,973 2,708,355 7,389,618 -Virginia 2,118,202,866 802,007,954 1,316,194,909 -Washington 2,044,234,831 662,728,122 1,250,021,549 131,485,160West Virginia 1,243,150,526 431,380,707 695,486,096 116,283,723Wisconsin 2,206,398,750 853,584,729 1,356,526,399 (3,712,378)Wyoming 192,004,819 73,757,316 117,767,971 479,532




Table 27. Medicaid Vendor Payments of Medical Care by Race/Ethnicity and by State: FY 1998

State NameTotal

PaymentsWhite

Not HispanicBlack

Not Hispanic HispanicNational Total $142,317,903,795 $77,308,255,958 $27,924,916,921 $11,701,697,152Alabama 1,902,300,047 827,952,829 438,900,267 3,315,366Alaska 330,378,398 174,019,260 14,417,242 7,940,171Arizona 1,643,966,305 807,626,871 94,508,661 471,119,023Arkansas 1,375,797,421 1,073,552,240 425,077,863 9,412,021California 14,236,592,915 6,166,204,632 1,876,614,170 2,889,656,926Colorado 1,439,366,499 919,883,912 71,612,726 281,989,029Connecticut 2,420,791,474 1,764,041,602 346,434,628 289,165,417Delaware 419,732,143 222,835,727 146,959,824 19,433,350District of Columbia 731,292,552 40,491,720 546,117,413 14,241,198Florida 5,686,844,862 2,882,195,485 1,489,923,156 486,938,537Georgia 3,012,346,312 1,449,477,236 1,239,615,206 48,382,042Hawaii 507,433,146 82,883,964 4,340,418 15,687,138Idaho 424,512,387 383,043,599 1,286,656 19,683,988Illinois 6,172,865,261 3,144,842,530 2,366,092,290 550,384,662Indiana 2,564,005,047 2,092,496,250 396,194,656 47,183,688Iowa 1,288,770,390 1,196,460,179 60,119,039 18,178,910Kansas 916,323,608 749,842,750 108,914,987 32,226,321Kentucky 2,425,288,141 1,993,823,547 266,183,359 12,665,231Louisiana 2,383,508,985 1,099,777,803 1,065,218,687 -Maine 747,027,618 - - -Maryland 2,489,280,148 1,131,688,380 1,174,483,476 45,768,784Massachusetts 4,609,360,933 3,532,575,981 328,298,442 252,985,739Michigan 4,345,007,824 2,488,989,444 1,090,315,294 68,841,694Minnesota 2,924,447,719 2,377,783,348 250,351,425 68,520,048Mississippi 1,442,373,276 632,011,633 678,234,773 2,338,315Missouri 2,569,646,129 1,996,030,667 572,989,632 -Montana 361,238,668 300,075,153 1,673,278 4,103,634Nebraska 753,162,904 620,174,553 69,028,503 33,978,627Nevada 462,087,777 310,748,421 64,283,449 46,021,153New Hampshire 606,004,232 597,538,126 2,998,753 3,358,173New Jersey 4,218,822,993 2,306,563,061 1,081,590,761 351,049,969New Mexico 862,144,872 334,362,382 24,062,597 328,367,182New York 24,298,610,635 8,526,521,151 3,317,705,424 2,128,810,934North Carolina 4,013,996,742 2,108,139,775 1,388,709,316 62,993,852North Dakota 341,015,420 295,976,110 1,985,205 2,124,462Ohio 6,120,967,557 4,523,992,068 1,444,982,894 77,540,662Oklahoma 1,177,853,941 - - -Oregon 1,377,514,740 1,174,610,986 57,050,374 66,963,540Pennsylvania 6,080,191,710 4,168,714,616 1,435,448,567 312,794,476Puerto Rico 250,000,000 - - -Rhode Island 919,353,410 722,585,451 48,070,593 58,620,869South Carolina 2,018,620,428 823,140,050 819,207,631 4,653,034South Dakota 355,833,902 265,096,471 476,867 461,142Tennessee 3,167,188,993 1,948,698,449 688,986,766 10,801,097Texas 7,139,928,843 3,237,522,829 1,265,091,320 2,267,459,706Utah 618,675,433 471,999,810 7,957,899 53,862,180Vermont 351,341,290 347,145,661 1,481,137 498,532Virgin Islands 10,097,973 158,015 8,196,959 1,686,823Virginia 2,118,202,866 1,185,068,839 848,667,684 42,863,490Washington 2,044,234,831 1,520,911,231 107,831,858 147,560,588West Virginia 1,243,150,526 1,050,971,933 43,439,640 1,216,634Wisconsin 2,206,398,750 1,072,860,297 139,997,459 28,153,946Wyoming 192,004,819 164,148,931 2,787,697 9,694,849




Table 27. Medicaid Vendor Payments of Medical Care by Race/Ethnicity and by State: FY 1998 (Con’t)

State NameAsian or


Alaskan Native UnknownNational Total $1,966,402,451 $1,106,464,681 $22,310,166,621Alabama 1,654,070 1,076,069 629,401,446Alaska 12,240,077 114,087,825 7,673,823Arizona 14,159,234 223,441,777 33,110,736Arkansas 2,948,804 2,006,208 (137,199,715)California 628,002,960 38,373,365 2,637,740,862Colorado 9,908,033 5,693,343 150,279,456Connecticut 17,312,049 3,385,027 452,751Delaware 1,105,200 1,238,666 28,159,376District of Columbia 2,680,052 120,284 127,641,885Florida 11,254,474 1,353,164 815,180,046Georgia 13,872,906 1,141,307 259,857,615Hawaii 290,493,960 144,750 113,882,916Idaho 751,185 7,138,887 12,608,072Illinois 101,700,238 9,535,747 309,794Indiana 4,841,617 1,036,794 22,252,042Iowa 7,513,271 3,990,200 2,508,791Kansas 14,513,033 6,418,356 4,408,161Kentucky 2,464,396 395,633 149,755,975Louisiana - - 218,512,495Maine - - 747,027,618Maryland 44,293,674 4,034,803 89,011,031Massachusetts 48,043,679 14,419,906 433,037,186Michigan 37,945,112 13,049,032 645,867,248Minnesota 95,240,916 90,141,150 42,410,832Mississippi 2,822,491 5,546,935 121,419,129Missouri - 52 625,778Montana 889,994 52,781,368 1,715,241Nebraska 4,719,794 16,738,730 8,522,698Nevada 8,741,149 8,923,139 23,370,466New Hampshire 1,244,444 121,244 743,492New Jersey 19,945,359 10,874,552 448,799,291New Mexico 3,698,818 124,608,852 47,045,041New York 209,885,774 23,977,462 10,091,709,891North Carolina 16,512,917 49,156,977 388,483,905North Dakota 892,876 38,824,907 1,211,860Ohio 12,862,937 4,743,094 56,845,897Oklahoma - - 1,177,853,941Oregon 36,008,771 22,672,988 20,208,081Pennsylvania 70,377,689 4,353,009 88,503,353Puerto Rico - - 250,000,000Rhode Island 10,763,133 566,136 78,747,228South Carolina 1,161,374 1,154,481 369,303,858South Dakota 215,280 83,251,611 6,332,531Tennessee 7,597,700 3,973,350 507,131,631Texas 41,302,705 16,224,173 312,328,108Utah 11,642,604 19,437,596 53,775,344Vermont 1,070,663 435,931 709,366Virgin Islands 37,888 1,569 16,719Virginia 36,992,590 1,703,034 2,907,226Washington 82,984,768 53,631,256 131,315,130West Virginia 791,928 - 146,730,391Wisconsin 19,944,179 10,808,831 934,634,038Wyoming 355,686 9,731,111 5,286,545




Table 28. Medicaid Eligibles of Medical Care by Age and by State: FY 1998

State NameTotal

EligiblesAges

Under 1From Ages

1 to 5From Ages

6 to 14From Ages

15 to 20From Ages

21 to 44National Total 41,361,532 2,014,962 7,205,401 9,131,328 3,979,331 9,305,563Alabama 628,220 33,381 131,578 147,209 52,664 104,960Alaska 87,873 3,974 16,913 22,459 9,082 23,394Arizona 649,302 60,354 133,626 161,127 57,260 158,158Arkansas 426,080 17,345 74,684 94,746 49,952 88,040California 6,191,269 208,178 1,103,640 1,452,046 674,192 1,519,166Colorado 346,928 20,123 70,573 79,258 30,454 76,396Connecticut 402,547 13,284 63,646 95,206 41,559 99,390Delaware 105,153 4,017 18,666 24,597 11,233 29,434District of Columbia 138,722 3,743 25,888 33,624 13,270 34,185Florida 2,040,541 84,616 373,694 484,949 194,122 468,339Georgia 1,223,439 70,643 254,844 288,518 132,840 224,595Hawaii 182,460 10,481 26,262 34,392 16,114 48,768Idaho 116,718 6,340 27,952 29,758 10,539 23,646Illinois 1,784,159 122,734 354,562 402,627 165,950 446,101Indiana 610,146 33,629 129,822 147,188 61,334 121,762Iowa 321,119 13,467 56,116 69,327 33,328 84,648Kansas 246,598 11,944 48,477 57,433 26,869 51,149Kentucky 653,553 24,325 110,623 143,371 57,300 151,955Louisiana 723,864 56,922 139,567 167,148 66,428 140,092Maine 195,839 5,469 25,250 42,943 22,027 52,479Maryland 603,562 27,373 109,740 143,818 57,635 151,227Massachusetts 953,469 231,669 123,853 149,432 59,606 198,095Michigan 1,354,718 55,629 246,010 340,091 139,279 338,950Minnesota 557,232 19,738 98,267 144,380 70,801 125,605Mississippi 526,604 29,728 100,482 120,046 48,018 94,316Missouri 772,622 32,650 148,577 198,866 87,406 149,716Montana 93,298 4,200 16,669 21,898 8,699 23,703Nebraska 210,261 20,971 38,945 49,960 22,187 43,716Nevada 130,662 9,005 29,982 32,428 9,332 24,927New Hampshire 98,340 3,012 18,259 27,046 10,544 20,723New Jersey 857,898 30,492 154,605 193,382 81,961 198,073New Mexico 339,527 15,914 70,406 100,440 44,618 60,024New York 3,500,292 124,586 524,368 656,138 316,777 940,604North Carolina 1,201,681 88,252 211,122 255,365 119,267 248,009North Dakota 62,115 2,174 10,539 13,859 6,085 13,805Ohio 1,402,364 58,716 253,059 335,401 148,880 337,620Oklahoma 459,570 - - - - -Oregon 537,465 19,886 83,913 100,302 51,793 175,945Pennsylvania 1,720,000 54,408 261,002 386,151 181,316 457,350Puerto Rico 964,015 - - - - -Rhode Island 148,797 4,717 24,666 34,432 13,936 36,881South Carolina 656,263 30,163 112,674 152,085 75,061 158,586South Dakota 83,111 6,417 17,077 20,752 8,679 14,791Tennessee 1,454,799 35,630 192,922 286,070 154,441 416,376Texas 2,680,583 162,406 627,209 680,891 219,455 485,901Utah 198,730 15,377 46,724 43,188 21,001 47,592Vermont 131,639 2,840 16,871 28,804 13,767 38,585Virgin Islands 19,914 - - - - -Virginia 689,571 46,016 128,645 168,243 69,331 126,533Washington 915,214 33,407 175,278 249,653 114,589 211,109West Virginia 373,090 15,738 64,968 85,709 42,926 90,418Wisconsin 538,229 25,868 100,815 122,134 50,547 117,638Wyoming 51,367 3,011 11,371 12,438 4,877 12,088




Table 28. Medicaid Eligibles of Medical Care by Age and by State: FY 1998 (Con’t)

State NameFrom Ages

45 to 64From Ages

65 to 74From Ages

75 to 84From Ages

85 and Over UnknownNational Total 3,489,125 1,934,986 1,597,608 1,172,148 1,531,080Alabama 58,130 38,632 34,564 25,855 1,247Alaska 6,028 3,285 2,040 698 -Arizona 36,519 19,059 13,742 9,457 -Arkansas 35,305 23,647 23,809 18,543 9California 523,390 350,410 242,507 117,730 10Colorado 27,455 16,972 14,185 11,511 1Connecticut 33,795 17,914 19,039 18,714 -Delaware 8,872 3,410 2,820 2,104 -District of Columbia 13,962 6,354 4,856 2,836 4Florida 159,809 117,026 93,111 64,875 -Georgia 85,260 53,551 48,141 65,040 7Hawaii 13,035 9,517 7,168 4,030 12,693Idaho 7,943 3,781 3,466 3,290 3Illinois 134,941 66,024 52,430 38,790 -Indiana 45,305 25,595 24,149 21,362 -Iowa 23,260 12,100 14,072 14,801 -Kansas 19,192 10,174 10,467 10,893 -Kentucky 76,449 37,918 30,904 20,662 46Louisiana 60,726 37,753 32,477 22,749 2Maine 21,263 10,218 9,018 7,111 61Maryland 48,096 26,858 22,938 15,862 15Massachusetts 84,509 41,166 36,769 28,370 -Michigan 112,038 49,403 40,828 32,410 80Minnesota 35,377 18,398 20,885 23,781 -Mississippi 49,635 33,460 29,697 21,222 -Missouri 59,689 34,298 33,194 28,224 2Montana 7,935 3,449 3,476 3,269 -Nebraska 12,931 6,996 7,241 7,279 35Nevada 9,989 7,108 5,098 2,764 29New Hampshire 6,860 3,445 4,001 4,450 -New Jersey 64,994 51,802 47,118 35,454 17New Mexico 20,310 12,480 8,833 6,329 173New York 418,550 191,246 148,608 110,054 69,361North Carolina 108,682 69,688 63,564 37,732 -North Dakota 4,707 2,897 3,748 4,287 14Ohio 118,880 54,092 51,225 44,491 -Oklahoma - - - - 459,570Oregon 65,374 16,040 13,845 10,359 8Pennsylvania 183,119 76,914 66,694 53,037 9Puerto Rico - - - - 964,015Rhode Island 12,984 7,001 7,217 6,963 -South Carolina 49,981 31,189 28,603 17,872 49South Dakota 5,302 2,791 3,355 3,947 -Tennessee 224,016 68,903 45,332 31,109 -Texas 166,102 143,551 115,059 80,005 4Utah 10,474 4,477 3,506 2,710 3,681Vermont 13,931 6,525 6,319 3,997 -Virgin Islands - - - - 19,914Virginia 55,936 41,004 33,939 19,924 -Washington 62,567 27,129 23,173 18,304 5West Virginia 39,413 14,282 11,412 8,224 -Wisconsin 42,962 23,516 27,463 27,271 15Wyoming 3,143 1,538 1,503 1,397 1




Table 29. Medicaid Eligibles of Medical Care by Sex and by State: FY 1998

State NameTotal

Eligibles Male Female UnknownNational Total 41,361,532 16,061,565 23,757,344 1,542,623Alabama 628,220 246,111 373,496 8,613Alaska 87,873 37,351 50,522 -Arizona 649,302 254,985 394,317 -Arkansas 426,080 158,087 267,867 126California 6,191,269 2,549,535 3,641,730 4Colorado 346,928 137,075 209,853 -Connecticut 402,547 156,951 245,596 -Delaware 105,153 42,157 62,996 -District of Columbia 138,722 54,592 83,970 160Florida 2,040,541 813,906 1,226,635 -Georgia 1,223,439 472,711 750,722 6Hawaii 182,460 75,609 94,239 12,612Idaho 116,718 47,979 68,733 6Illinois 1,784,159 734,788 1,049,370 1Indiana 610,146 240,536 369,610 -Iowa 321,119 128,417 192,702 -Kansas 246,598 99,884 146,688 26Kentucky 653,553 265,594 387,906 53Louisiana 723,864 286,802 436,987 75Maine 195,839 81,408 114,382 49Maryland 603,562 230,580 372,969 13Massachusetts 953,469 387,651 565,818 -Michigan 1,354,718 553,462 801,256 -Minnesota 557,232 231,848 325,384 -Mississippi 526,604 204,935 321,668 1Missouri 772,622 311,009 461,612 1Montana 93,298 39,042 54,256 -Nebraska 210,261 84,200 121,169 4,892Nevada 130,662 52,910 77,583 169New Hampshire 98,340 39,193 59,112 35New Jersey 857,898 322,247 535,634 17New Mexico 339,527 144,024 195,499 4New York 3,500,292 1,405,012 2,025,906 69,374North Carolina 1,201,681 462,274 739,407 -North Dakota 62,115 24,403 37,687 25Ohio 1,402,364 557,553 844,807 4Oklahoma 459,570 - - 459,570Oregon 537,465 236,268 301,187 10Pennsylvania 1,720,000 688,234 1,031,766 -Puerto Rico 964,015 - - 964,015Rhode Island 148,797 57,441 91,354 2South Carolina 656,263 233,707 422,372 184South Dakota 83,111 34,135 48,961 15Tennessee 1,454,799 610,842 843,949 8Texas 2,680,583 1,075,529 1,605,019 35Utah 198,730 79,772 117,584 1,374Vermont 131,639 57,749 73,890 -Virgin Islands 19,914 - - 19,914Virginia 689,571 274,850 414,721 -Washington 915,214 381,162 533,998 54West Virginia 373,090 158,690 213,237 1,163Wisconsin 538,229 217,485 320,744 -Wyoming 51,367 20,880 30,474 13




Table 30. Medicaid Eligibles of Medical Care by Race/Ethnicity and by State: FY 1998

State NameTotal

EligiblesWhite

Not HispanicBlack

Not Hispanic HispanicNational Total 41,361,532 17,838,846 10,646,780 6,924,815Alabama 628,220 273,245 322,829 5,575Alaska 87,873 37,940 5,477 2,946Arizona 649,302 250,559 42,748 246,508Arkansas 426,080 258,183 143,381 5,349California 6,191,269 1,806,631 804,451 2,515,612Colorado 346,928 172,252 27,617 115,446Connecticut 402,547 180,483 99,614 114,419Delaware 105,153 43,908 48,219 8,202District of Columbia 138,722 2,666 123,675 4,765Florida 2,040,541 824,278 704,220 336,323Georgia 1,223,439 441,075 654,613 42,039Hawaii 182,460 25,039 1,822 6,513Idaho 116,718 99,797 550 13,680Illinois 1,784,159 713,454 763,561 265,041Indiana 610,146 426,177 151,049 25,813Iowa 321,119 277,085 26,527 11,600Kansas 246,598 170,132 46,234 20,212Kentucky 653,553 537,100 84,798 5,097Louisiana 723,864 231,218 441,877 -Maine 195,839 - - -Maryland 603,562 210,449 335,488 23,554Massachusetts 953,469 532,005 105,065 136,792Michigan 1,354,718 718,380 502,143 58,319Minnesota 557,232 355,580 85,478 32,231Mississippi 526,604 160,692 334,520 1,600Missouri 772,622 537,215 235,406 -Montana 93,298 69,648 604 1,712Nebraska 210,261 146,079 30,199 21,085Nevada 130,662 75,951 25,025 22,998New Hampshire 98,340 94,836 969 1,629New Jersey 857,898 259,995 307,264 189,885New Mexico 339,527 92,276 9,236 173,187New York 3,500,292 975,344 819,724 759,184North Carolina 1,201,681 526,527 529,550 45,537North Dakota 62,115 45,043 1,011 1,640Ohio 1,402,364 883,444 460,334 1,407Oklahoma 459,570 - - -Oregon 537,465 428,563 23,122 55,968Pennsylvania 1,720,000 1,036,265 496,909 136,041Puerto Rico 964,015 - - -Rhode Island 148,797 85,136 15,128 26,695South Carolina 656,263 251,122 373,442 5,110South Dakota 83,111 49,424 178 126Tennessee 1,454,799 963,006 417,128 12,947Texas 2,680,583 739,597 543,971 1,280,864Utah 198,730 146,326 4,253 28,724Vermont 131,639 129,962 761 206Virgin Islands 19,914 - - -Virginia 689,571 314,040 332,198 25,396Washington 915,214 670,018 61,404 109,817West Virginia 373,090 343,131 18,218 699Wisconsin 538,229 187,321 83,707 21,540Wyoming 51,367 40,249 1,083 4,782




Table 30. Medicaid Eligibles of Medical Care by Race/Ethnicity and by State: FY 1998 (Con’t)

State NameAsian or


Alaskan Native UnknownNational Total 1,028,316 482,594 4,440,181Alabama 2,477 1,304 22,790Alaska 4,640 34,922 1,948Arizona 4,796 92,322 12,369Arkansas 932 826 17,409California 465,987 27,731 570,857Colorado 3,793 2,268 25,552Connecticut 6,030 642 1,359Delaware 423 257 4,144District of Columbia 954 21 6,641Florida 9,319 1,022 165,379Georgia 10,774 625 74,313Hawaii 76,438 101 72,547Idaho 342 2,346 3Illinois 38,551 2,968 584Indiana 1,556 423 5,128Iowa 4,061 1,846 -Kansas 6,690 3,330 -Kentucky 1,283 219 25,056Louisiana - - 50,769Maine - - 195,839Maryland 13,757 1,139 19,175Massachusetts 30,943 2,254 146,410Michigan 18,724 6,304 50,848Minnesota 42,220 27,012 14,711Mississippi 1,981 1,825 25,986Missouri - - 1Montana 400 20,920 14Nebraska 2,418 8,578 1,902Nevada 3,101 2,818 769New Hampshire 877 23 6New Jersey 9,528 2,105 89,121New Mexico 1,682 54,191 8,955New York 71,262 8,351 866,427North Carolina 11,269 20,514 68,284North Dakota 321 14,061 39Ohio 5,547 36,703 14,929Oklahoma - - 459,570Oregon 15,287 10,537 3,988Pennsylvania 29,882 1,521 19,382Puerto Rico - - 964,015Rhode Island 4,670 241 16,927South Carolina 1,186 799 24,604South Dakota 60 30,455 2,868Tennessee 7,517 3,470 50,731Texas 26,005 7,477 82,669Utah 6,827 10,604 1,996Vermont 464 246 -Virgin Islands - - 19,914Virginia 15,763 809 1,365Washington 48,392 25,583 -West Virginia 432 - 10,610Wisconsin 18,593 6,608 220,460Wyoming 162 4,273 818




Table 31. Medicaid Inpatient Hospital Recipients, Discharges, and Days of Care by State: FY 1998

State NameTotal Recipients

DischargedTotal

DischargesTotal

Days of CareNational Total 2,792,656 3,970,901 19,091,219Alabama 2,184 3,017 27,025Alaska 8,699 10,898 51,128Arizona 91,418 110,981 378,392Arkansas 48,588 61,879 251,944California 349,987 516,785 1,895,493Colorado 23,568 30,787 147,863Connecticut 10,151 16,123 96,982Delaware 1,753 2,089 11,809District of Columbia 12,923 22,231 156,197Florida 156,364 215,213 989,643Georgia 110,240 138,776 657,879Hawaii - - -Idaho 13,518 16,891 56,223Illinois 164,377 248,036 1,301,729Indiana 19,787 84,102 442,636Iowa 20,817 27,951 148,066Kansas 22,537 28,945 120,568Kentucky 53,780 81,507 300,124Louisiana 82,645 114,480 570,417Maine 5,197 10,155 25,177Maryland 27,632 38,140 214,760Massachusetts 37,350 54,197 720,322Michigan 98,367 135,295 623,300Minnesota 27,707 37,805 197,166Mississippi 52,051 70,459 315,262Missouri 53,387 77,868 381,867Montana 9,587 13,669 47,170Nebraska - - -Nevada 17,933 23,758 139,834New Hampshire 7,476 10,053 46,515New Jersey 37,687 71,577 501,729New Mexico 16,619 20,742 80,280New York 290,616 412,783 2,744,476North Carolina 102,240 137,791 692,093North Dakota 6,071 7,993 34,456Ohio 109,549 164,813 758,676Oklahoma - - -Oregon 2,710 24,786 8,969Pennsylvania 82,768 113,654 658,135Puerto Rico - - -Rhode Island 5,451 10,267 98,741South Carolina 75,007 99,277 438,550South Dakota 9,221 12,562 89,503Tennessee - - -Texas 346,148 414,685 1,581,584Utah 13,643 15,481 56,280Vermont 3,352 4,786 22,098Virgin Islands 997 1,138 5,281Virginia 69,536 92,857 332,835Washington 26,544 43,755 285,966West Virginia 31,996 51,277 170,226Wisconsin 25,346 59,522 184,578Wyoming 7,132 9,065 31,272




Table 32. Medicaid Long-Term Care Recipients and Days of Care by State: FY 1998

Inpatient Mental Health Nursing Facility ICF/MR

State NameTotal

RecipientsDays of

CareTotal

RecipientsDays of

CareTotal

RecipientsDays of

CareNational Total 125,632 6,514,273 1,555,329 384,548,919 123,658 50,635,779Alabama 1,329 44,840 23,844 6,217,003 750 259,415Alaska 627 41,468 887 203,831 8 526Arizona 14 53 1,426 187,124 - -Arkansas 3,146 166,910 21,486 6,464,116 1,867 1,273,503California 463 15,224 123,270 25,166,839 9,885 3,234,774Colorado 361 19,105 18,928 3,944,425 500 114,696Connecticut 370 39,951 28,167 7,731,433 1,530 475,573Delaware 531 23,033 3,256 1,083,374 342 120,187District of Columbia 162 8,059 4,217 1,245,685 821 389,879Florida 253 41,000 73,030 17,028,588 3,567 1,256,138Georgia - - 40,390 14,236,601 1,728 643,772Hawaii - - 4,420 1,065,390 146 44,281Idaho 39 2,656 5,297 937 1,012 15,878Illinois 3,768 73,442 79,751 21,499,940 12,081 5,464,459Indiana 2,134 115,547 44,524 23,443,019 6,035 3,478,807Iowa 958 137,683 25,115 5,878,668 2,338 780,929Kansas 333 18,910 16,802 3,222,044 1,441 385,049Kentucky 4,338 117,198 27,439 6,301,308 1,240 423,694Louisiana 6,043 45,597 34,403 9,315,664 6,014 2,086,796Maine 705 29,868 9,278 1,238,844 361 137,353Maryland 1,827 214,908 27,834 5,950,791 627 218,311Massachusetts 830 48,586 46,875 8,836,620 43 5,504Michigan 2,334 107,850 44,678 10,964,698 1,322 280,090Minnesota 249 27,079 37,580 9,863,220 4,273 1,241,279Mississippi 2,334 39,556 19,552 4,725,887 2,490 837,052Missouri 9 2,663 37,226 9,507,778 1,442 490,620Montana 14 1,298 5,316 1,375,288 149 56,237Nebraska - - - - - -Nevada 686 36,007 3,747 943,285 293 115,832New Hampshire 200 3,687 7,700 2,149,243 33 8,509New Jersey 1,899 239,445 48,552 11,730,568 4,514 7,866,245New Mexico 468 6,384 8,170 1,759,296 362 97,381New York 36,713 2,246,241 135,450 33,887,907 11,928 4,017,960North Carolina 2,377 101,370 41,218 9,872,937 4,853 1,670,529North Dakota 145 165,060 5,506 1,291,824 637 147,873Ohio 783 10,591 86,236 21,082,183 8,162 2,879,008Oklahoma - - - - - -Oregon 761 146,234 11,960 2,683,606 373 128,121Pennsylvania 8,512 229,355 76,592 19,505,418 5,757 1,886,153Puerto Rico - - - - - -Rhode Island 341 23,123 11,128 4,184,505 100 113,887South Carolina 1,531 134,357 17,352 4,313,445 2,856 914,241South Dakota 51 11,887 6,095 1,618,401 337 108,007Tennessee - - 86,763 10,679,610 - -Texas - - 88,522 23,558,778 13,935 4,757,721Utah 2 8 5,433 1,347,951 867 295,499Vermont 133 2,035 3,804 910,719 17 2,830Virgin Islands - - 67 9,824 - -Virginia 34,172 1,621,453 27,145 6,800,731 2,120 722,853Washington 28 236 23,949 8,797,689 156 48,794West Virginia 1,564 65,907 11,677 - 609 -Wisconsin 2,087 88,239 40,715 10,113,439 3,600 1,092,081Wyoming 8 170 2,557 608,445 137 47,453




Table 33. Medicaid Eligibles and Premium Payments for Capitation Plans and PCCM by State:FY 1998

HMO/HIO Plans Prepaid PlansState Name Eligibles Payments Eligibles PaymentsNational Total 14,722,177 $16,213,910,471 8,382,884 $1,790,303,756Alabama 38,523 62,473,486 306,384 226,498,950Alaska - - - -Arizona 655,571 1,289,163,211 596,131 142,255,286Arkansas - - 244,596 4,360,523California 2,799,369 2,142,428,098 4,862,797 586,587,065Colorado 112,705 131,714,033 297,604 101,006,921Connecticut 271,411 377,212,893 - -Delaware 85,147 121,932,232 - -District of Columbia 60,710 45,298,685 1 21Florida 722,113 684,011,686 88,872 16,860,657Georgia 78,418 57,848,295 - -Hawaii 144,744 213,612,580 - -Idaho - - - -Illinois 270,106 241,278,075 - -Indiana 268,410 165,505,151 - -Iowa 97,517 53,304,564 245,703 53,870,893Kansas 43,887 17,149,248 - -Kentucky 193,864 311,260,601 - -Louisiana - - - -Maine 9,268 4,098,201 - -Maryland 447,701 803,474,501 47 779,269Massachusetts 247,767 305,723,630 621,146 172,208,666Michigan 631,599 707,677,964 147,765 102,308,349Minnesota 317,914 482,903,353 - -Mississippi 17,621 22,134,623 - -Missouri 330,539 277,251,576 - -Montana 3,574 3,189,285 88,837 49,392,200Nebraska 19,506 - 110,606 -Nevada 21,382 16,811,739 33,691 14,343,694New Hampshire 11,097 12,100,995 - -New Jersey 501,456 610,251,739 40,890 6,770,772New Mexico 262,506 372,264,074 - -New York 813,694 990,708,190 68,771 78,893,290North Carolina 221,886 85,667,708 31 61,505North Dakota 1,555 1,316,917 - -Ohio 452,447 494,153,710 64 691,529Oklahoma 82,973 - - -Oregon 437,914 501,525,712 477,139 163,273,360Pennsylvania 891,093 1,800,415,624 - -Puerto Rico - - - -Rhode Island 94,562 112,545,918 - -South Carolina 8,202 4,345,686 9,027 12,827,431South Dakota 13,734 6,420,420 - -Tennessee 1,414,683 1,670,212,023 - -Texas 284,226 - - -Utah 92,951 73,991,642 141,226 33,112,909Vermont 69,440 53,763,059 - -Virgin Islands - - - -Virginia 159,392 186,255,441 112 1,528,628Washington 604,315 403,713,433 - -West Virginia 131,349 - - -Wisconsin 283,336 296,800,470 1,444 22,671,838Wyoming - - - -




Table 33. Medicaid Eligibles and Premium Payments for Capitation Plans and PCCM by State:FY 1998 (Con’t)

PCCM UnduplicatedState Name Eligibles Payments Enrolled EligiblesNational Total 4,569,691 $18,007,746 21,813,135Alabama 151,910 3,830,786 362,272Alaska - - -Arizona - - 655,571Arkansas 229,092 5,405,229 318,625California 52,402 6,943,824 5,044,803Colorado - - 308,035Connecticut - - 271,411Delaware - - 85,147District of Columbia 8,403 1,003,654 66,873Florida 835,207 17,980,527 1,411,107Georgia 877,799 21,797,455 906,717Hawaii - - 131,761Idaho 45,745 1,389,468 45,745Illinois 16,414 710,585 286,520Indiana 241,557 4,936,728 477,480Iowa 80,287 1,001,800 247,483Kansas 118,281 1,618,536 152,288Kentucky - - 194,314Louisiana 40,729 - 40,729Maine - - 9,345Maryland - - 451,757Massachusetts 621,146 9,288,830 720,576Michigan - - 747,895Minnesota - - 318,088Mississippi - - 17,654Missouri - - 333,096Montana 57,957 1,460,907 88,872Nebraska 17,466 - 110,606Nevada 26,047 4,009,342 55,886New Hampshire - - 11,097New Jersey - - 542,826New Mexico 101,119 754,694 272,499New York 51,530 20,295,994 920,302North Carolina 617,827 13,163,095 697,376North Dakota 32,099 476,322 32,525Ohio - - 452,511Oklahoma 71,297 - 154,270Oregon 11,112 231,444 481,050Pennsylvania - - 897,853Puerto Rico - - -Rhode Island - - 94,563South Carolina - - 17,186South Dakota - - -Tennessee - - 1,436,197Texas 153,672 - 437,898Utah - - 144,199Vermont - - 69,440Virgin Islands - - -Virginia 110,559 1,697,486 259,808Washington - - 613,060West Virginia - - 131,349Wisconsin 34 11,040 286,470Wyoming - - -




Table 34. Prepaid Health Care Medicaid Recipients by Maintenance Assistance Status and by State:FY 1998

State NameTotal

RecipientsReceiving



MASUnknown

National Total 20,202,887 9,662,017 2,401,288 3,514,045 2,894,690 2,045,872Alabama 344,907 - - - - 344,907Alaska - - - - - -Arizona 368,344 - - - - 368,344Arkansas 244,768 118,180 23,121 83,383 18,446 1,638California 6,022,536 3,511,431 1,498,574 128,401 876,362 7,768Colorado 316,060 115,659 - 77,144 121,401 316,881Connecticut 271,411 122,049 7,488 48,312 93,562 -Delaware 85,239 30,911 - 43,189 9,544 1,595District of Columbia 100,867 49,614 6,378 3,150 1,374 40,351Florida 791,752 530,364 5,948 175,007 79,139 1,294Georgia 78,463 45,792 - 18,770 13,694 207Hawaii 144,744 77,313 2,712 58,895 3,960 1,864Idaho - - - - - -Illinois 142,429 107,279 8,436 13,065 13,649 -Indiana 271,005 104,184 - 73,873 91,135 1,813Iowa 246,582 114,478 3,992 50,841 77,015 256Kansas 44,003 15,078 88 22,564 6,173 100Kentucky 194,164 114,814 12,905 56,743 9,059 643Louisiana - - - - - -Maine 9,324 4,149 22 2,930 2,198 25Maryland 449,825 240,158 22,856 117,274 65,366 4,171Massachusetts 768,831 373,918 204,450 136,205 54,258 -Michigan 758,185 469,222 141,355 123,737 21,719 2,152Minnesota 318,854 144,319 1,497 65,421 106,102 1,515Mississippi 17,628 8,939 - 7,681 980 28Missouri 336,057 140,788 - 141,948 45,772 7,549Montana 96,701 46,928 7,230 15,133 22,534 4,876Nebraska 159,614 81,317 19 60,609 17,669 -Nevada 55,923 25,874 - 258 27,944 1,847New Hampshire 11,176 4,079 166 5,172 1,758 1New Jersey 545,380 264,886 2,757 120,979 156,167 591New Mexico 263,256 111,939 - 148,937 1,993 387New York 884,443 575,752 228,890 76,179 3,622 -North Carolina 220,700 102,128 2,311 111,834 4,427 -North Dakota 1,549 467 202 460 416 4Ohio 453,265 305,146 - 140,278 7,841 -Oklahoma - - - - - -Oregon 481,498 133,858 6,564 213,327 116,095 11,654Pennsylvania 902,896 509,692 51,371 170,453 171,186 194Puerto Rico - - - - - -Rhode Island 96,178 64,623 1,214 20,334 7,933 2,074South Carolina 17,195 5,666 - 7,999 3,494 36South Dakota 83,998 35,519 - 28,556 19,923 -Tennessee 1,764,279 439,299 136,153 623,307 216,494 349,026Texas - - - - - -Utah 170,319 36,839 4,000 18,888 82,028 28,564Vermont 69,682 21,104 4,602 34,184 9,547 245Virgin Islands - - - - - -Virginia 159,392 81,488 289 56,163 21,452 -Washington 1,146,180 271,871 148 160,350 177,195 536,616West Virginia 52 - - - - 52Wisconsin 293,233 104,903 15,550 52,112 114,064 6,604Wyoming - - - - - -




Table 35. Prepaid Health Care Medicaid Recipients by Basis of Eligibility and by State: FY 1998

State NameTotal

RecipientsAge 65

And OlderBlind/


UnknownNational Total 20,202,887 997,266 2,351,991 10,356,858 4,493,559 2,003,213Alabama 344,907 - - - - 344,907Alaska - - - - - -Arizona 368,344 - - - - 368,344Arkansas 244,768 22,617 70,690 110,674 35,766 5,021California 6,022,536 548,137 894,674 3,053,189 1,390,107 136,429Colorado 316,060 37,302 58,614 148,339 56,531 15,274Connecticut 271,411 13 919 185,624 77,905 6,950Delaware 85,239 259 8,145 47,228 27,610 1,997District of Columbia 100,867 - 1,896 43,292 15,317 40,362Florida 791,752 17,332 110,154 507,475 149,399 7,392Georgia 78,463 672 8,271 53,596 15,677 247Hawaii 144,744 - - 75,329 64,575 4,840Idaho - - - - - -Illinois 142,429 86 1,338 101,088 38,686 1,231Indiana 271,005 59,343 42,171 127,846 38,790 2,855Iowa 246,582 817 41,618 130,634 68,540 4,973Kansas 44,003 1 53 34,092 9,645 212Kentucky 194,164 9,288 50,936 97,791 35,142 1,007Louisiana - - - - - -Maine 9,324 - 22 6,711 2,458 133Maryland 449,825 6,261 75,205 258,313 91,156 18,890Massachusetts 768,831 1,667 111,699 451,115 203,740 610Michigan 758,185 8,715 130,478 422,747 180,954 15,291Minnesota 318,854 27,611 2,607 222,262 64,298 2,076Mississippi 17,628 795 4,666 9,709 2,413 45Missouri 336,057 1 458 248,210 69,798 17,590Montana 96,701 8,617 15,812 44,510 19,757 8,005Nebraska 159,614 1,234 14,598 98,022 37,507 8,253Nevada 55,923 646 65 40,708 12,594 1,910New Hampshire 11,176 - 19 9,113 1,939 105New Jersey 545,380 35,542 16,460 353,264 138,754 1,360New Mexico 263,256 984 26,717 192,207 41,706 1,642New York 884,443 6,220 51,023 565,619 257,959 3,622North Carolina 220,700 - 12,346 194,263 9,761 4,330North Dakota 1,549 - 1 1,125 414 9Ohio 453,265 75 1,852 315,021 135,782 535Oklahoma - - - - - -Oregon 481,498 37,705 93,759 123,793 201,456 24,785Pennsylvania 902,896 63,018 144,515 505,598 178,596 11,169Puerto Rico - - - - - -Rhode Island 96,178 3 625 63,451 29,690 2,409South Carolina 17,195 399 1,586 13,553 1,519 138South Dakota 83,998 8,137 14,713 46,960 12,894 1,294Tennessee 1,764,279 84,154 293,570 552,654 472,496 361,405Texas - - - - - -Utah 170,319 6,552 11,325 92,508 29,359 30,575Vermont 69,682 33 1,082 36,706 31,477 384Virgin Islands - - - - - -Virginia 159,392 1,166 20,533 105,720 31,967 6Washington 1,146,180 1,569 10,651 455,401 141,869 536,690West Virginia 52 - - - - 52Wisconsin 293,233 295 6,125 211,398 67,556 7,859Wyoming - - - - - -




Table 36. PCCM Medicaid Recipients by Maintenance Assistance Status and by State: FY 1998

State NameTotal

RecipientsReceiving



MASUnknown

National Total 4,066,440 1,891,472 114,232 1,293,024 479,745 287,967Alabama 151,910 - - - - 151,910Alaska - - - - - -Arizona - - - - - -Arkansas 243,266 86,345 20,096 99,153 32,938 4,734California 54,471 35,894 7,902 470 8,730 1,475Colorado 48,907 - - - - 48,907Connecticut - - - - - -Delaware - - - - - -District of Columbia 8,623 7,325 547 250 233 268Florida 841,304 520,029 5,340 190,927 119,245 5,763Georgia 879,554 370,738 95 390,617 110,441 7,663Hawaii - - - - - -Idaho 50,665 6,018 - 11,983 26,587 6,077Illinois 16,414 244 48 43 16,079 -Indiana 242,844 92,311 - 101,825 47,301 1,407Iowa 80,428 35,092 281 21,937 23,103 15Kansas 123,902 53,718 1,202 48,543 17,387 3,052Kentucky - - - - - -Louisiana - - - - - -Maine - - - - - -Maryland - - - - - -Massachusetts 264,035 157,495 51,179 43,461 11,900 -Michigan 53,733 - - - - 53,733Minnesota - - - - - -Mississippi - - - - - -Missouri - - - - - -Montana 59,578 30,807 18 12,528 14,748 1,477Nebraska 27,577 15,431 - 9,799 2,347 -Nevada 28,638 14,751 - 116 13,259 512New Hampshire - - - - - -New Jersey - - - - - -New Mexico 103,867 56,583 - 47,230 46 8New York 804 599 168 15 22 -North Carolina 591,740 342,233 21,991 225,751 1,765 -North Dakota 32,566 9,701 5,058 10,289 6,653 865Ohio - - - - - -Oklahoma - - - - - -Oregon 11,163 3,203 162 4,947 2,750 101Pennsylvania - - - - - -Puerto Rico - - - - - -Rhode Island - - - - - -South Carolina - - - - - -South Dakota 39,858 13,963 - 19,322 6,573 -Tennessee - - - - - -Texas - - - - - -Utah - - - - - -Vermont - - - - - -Virgin Islands - - - - - -Virginia 110,559 38,962 144 53,818 17,635 -Washington - - - - - -West Virginia - - - - - -Wisconsin 34 30 1 - 3 -Wyoming - - - - - -




Table 37. PCCM Medicaid Recipients BY Basis OF Eligibility and by State: FY 1998

State NameTotal

RecipientsAge 65

And OlderBlind/


UnknownNational Total 4,066,440 44,327 548,443 2,509,468 629,893 334,309Alabama 151,910 - - - - 151,910Alaska - - - - - -Arizona - - - - - -Arkansas 243,266 554 38,988 151,321 43,778 8,625California 54,471 914 7,366 29,233 14,529 2,429Colorado 48,907 - - - - 48,907Connecticut - - - - -Delaware - - - - - -District of Columbia 8,623 1 34 5,937 2,378 273Florida 841,304 16,897 164,152 510,793 126,334 23,128Georgia 879,554 11,665 136,798 623,313 98,975 8,803Hawaii - - - - - -Idaho 50,665 2,422 7,186 29,932 4,646 6,479Illinois 16,414 - 13 310 34 16,057Indiana 242,844 15 8,755 186,089 45,530 2,455Iowa 80,428 1 180 54,447 25,593 207Kansas 123,902 878 19,661 77,791 22,151 3,421Kentucky - - - - - -Louisiana - - - - - -Maine - - - - - -Maryland - - - - - -Massachusetts 264,035 15 50,706 153,613 59,549 152Michigan 53,733 - - - - 53,733Minnesota - - - - - -Mississippi - - - - - -Missouri - - - - - -Montana 59,578 60 7,485 36,330 12,310 3,393Nebraska 27,577 193 1,434 17,862 7,223 865Nevada 28,638 643 40 21,985 5,432 538New Hampshire - - - - - -New Jersey - - - - - -New Mexico 103,867 404 14,481 74,914 14,020 48New York 804 - 96 685 1 22North Carolina 591,740 7,937 72,988 409,100 100,288 1,427North Dakota 32,566 2 98 22,956 8,489 1,021Ohio - - - - - -Oklahoma - - - - - -Oregon 11,163 959 2,178 2,948 4,668 410Pennsylvania - - - - - -Puerto Rico - - - - - -Rhode Island - - - - - -South Carolina - - - - - -South Dakota 39,858 2 4,615 27,754 7,486 1Tennessee - - - - - -Texas - - - - - -Utah - - - - - -Vermont - - - - - -Virgin Islands - - - - - -Virginia 110,559 765 11,156 72,154 26,479 5Washington - - - - - -West Virginia - - - - - -Wisconsin 34 - 33 1 - -Wyoming - - - - - -




Table 38. Prepaid Health Care Medicaid Recipients by Age and by State: FY 1998

State NameTotal

RecipientsAges

Under 1From Ages

1 to 5From Ages

6 to 14From Ages

15 to 20From Ages

21 to 44National Total 20,202,887 586,976 3,726,967 4,846,633 2,005,878 4,409,601Alabama 344,907 - - - - -Alaska - - - - - -Arizona 368,344 - - - - -Arkansas 244,768 13,179 48,721 59,642 21,325 46,099California 6,022,536 56,292 1,108,708 1,464,620 682,263 1,447,924Colorado 316,060 17,262 67,679 74,094 26,941 66,164Connecticut 271,411 10,871 60,801 89,814 36,608 67,780Delaware 85,239 3,444 17,309 22,468 9,761 25,181District of Columbia 100,867 2,641 19,421 18,281 5,993 13,089Florida 791,752 25,307 186,752 255,561 82,666 173,104Georgia 78,463 2,229 19,706 26,211 7,937 17,074Hawaii 144,744 - - - - -Idaho - - - - - -Illinois 142,429 10,484 40,833 43,205 14,486 31,492Indiana 271,005 12,142 48,975 55,463 21,345 50,822Iowa 246,582 11,271 51,530 63,471 28,943 72,874Kansas 44,003 3,404 13,485 13,873 5,066 7,758Kentucky 194,164 9,272 39,495 47,868 17,430 46,322Louisiana - - - - - -Maine 9,324 384 2,140 3,127 1,285 2,236Maryland 449,825 22,652 99,718 130,238 46,561 106,271Massachusetts 768,831 42,031 137,135 186,284 83,429 238,823Michigan 758,185 27,295 157,771 223,507 78,367 198,428Minnesota 318,854 12,140 66,172 98,887 46,762 60,530Mississippi 17,628 1,137 3,869 4,417 1,681 3,684Missouri 336,057 15,942 91,094 118,237 47,507 60,498Montana 96,701 3,460 17,369 22,449 9,091 24,731Nebraska 159,614 - - - - -Nevada 55,923 5,115 16,955 17,228 4,340 10,263New Hampshire 11,176 293 3,420 4,307 1,118 1,946New Jersey 545,380 23,743 135,270 157,051 52,252 121,812New Mexico 263,256 12,298 63,597 90,410 37,956 44,362New York 884,443 25,673 208,860 255,227 91,352 243,955North Carolina 220,700 27,921 72,570 84,209 24,303 10,149North Dakota 1,549 60 433 515 159 363Ohio 453,265 40,450 115,360 138,417 47,374 105,364Oklahoma - - - - - -Oregon 481,498 13,741 78,629 91,859 45,563 158,953Pennsylvania 902,896 26,835 167,058 245,379 98,823 236,745Puerto Rico - - - - - -Rhode Island 96,178 4,132 22,851 30,097 10,917 25,675South Carolina 17,195 1,385 5,695 6,140 1,265 1,734South Dakota 83,998 6,678 17,267 21,408 8,925 14,926Tennessee 1,764,279 33,019 190,961 282,970 149,889 402,126Texas - - - - - -Utah 170,319 12,991 43,238 32,720 12,441 29,518Vermont 69,682 1,451 10,400 17,383 7,553 25,745Virgin Islands - - - - - -Virginia 159,392 5,828 38,319 53,444 20,703 32,357Washington 1,146,180 23,579 152,663 207,568 86,439 123,579West Virginia 52 - - - - -Wisconsin 293,233 18,945 84,738 88,584 29,059 59,145Wyoming - - - - - -




Table 38. Prepaid Health Care Medicaid Recipients by Age and by State: FY 1998 (Con’t)

State NameFrom Ages

45 to 64From Ages

65 to 74From Ages

75 to 84From Ages

85 and Over UnknownNational Total 1,383,923 566,028 419,531 265,807 1,991,543Alabama - - - - 344,907Alaska - - - - -Arizona - - - - 368,344Arkansas 22,958 13,037 12,151 7,633 23California 543,134 332,520 248,647 132,446 5,982Colorado 24,520 15,269 12,901 10,560 670Connecticut 5,504 32 1 - -Delaware 6,437 467 131 34 7District of Columbia 1,267 15 4 - 40,156Florida 42,928 14,088 6,924 3,508 914Georgia 3,699 903 320 360 24Hawaii - - - - 144,744Idaho - - - - -Illinois 1,807 54 46 22 -Indiana 20,724 20,901 20,976 19,075 582Iowa 17,843 545 17 21 67Kansas 379 2 - - 36Kentucky 18,634 7,812 4,848 2,216 267Louisiana - - - - -Maine 148 1 - - 3Maryland 32,166 6,872 2,608 732 2,007Massachusetts 77,701 2,143 780 505 -Michigan 54,646 11,785 3,885 1,210 1,291Minnesota 4,958 8,882 9,317 10,736 470Mississippi 1,668 670 369 129 4Missouri 2,754 12 - - 13Montana 7,957 3,305 3,415 3,375 1,549Nebraska - - - - 159,614Nevada 430 301 276 72 943New Hampshire 92 - - - -New Jersey 14,722 5,922 13,186 20,992 430New Mexico 12,544 1,456 323 94 216New York 50,578 5,235 2,468 1,095 -North Carolina 1,544 3 - 1 -North Dakota 19 - - - -Ohio 6,224 30 26 20 -Oklahoma - - - - -Oregon 58,272 12,279 11,186 9,080 1,936Pennsylvania 82,368 26,999 13,982 4,653 54Puerto Rico - - - - -Rhode Island 2,108 13 2 1 382South Carolina 548 115 161 142 10South Dakota 5,204 2,636 3,108 3,840 6Tennessee 218,221 66,293 43,792 30,025 346,983Texas - - - - -Utah 5,776 2,808 2,418 2,196 26,213Vermont 6,765 146 8 1 230Virgin Islands - - - - -Virginia 7,133 1,209 343 56 -Washington 14,058 632 508 683 536,471West Virginia - - - - 52Wisconsin 5,485 636 404 294 5,943Wyoming - - - - -




Table 39. Prepaid Health Care Medicaid Recipients by Sex and by State: FY 1998

State NameTotal

Recipients Male Female UnknownNational Total 20,202,887 7,517,298 10,692,036 1,993,553Alabama 344,907 - - 344,907Alaska - - - -Arizona 368,344 - - 368,344Arkansas 244,768 97,329 147,370 69California 6,022,536 2,557,879 3,458,672 5,985Colorado 316,060 126,797 188,593 670Connecticut 271,411 106,677 164,734 -Delaware 85,239 34,763 50,469 7District of Columbia 100,867 24,161 36,541 40,165Florida 791,752 327,441 463,397 914Georgia 78,463 29,947 48,492 24Hawaii 144,744 - - 144,744Idaho - - - -Illinois 142,429 53,960 88,469 -Indiana 271,005 101,216 169,207 582Iowa 246,582 103,230 143,285 67Kansas 44,003 18,121 25,844 38Kentucky 194,164 77,712 116,183 269Louisiana - - - -Maine 9,324 3,703 5,618 3Maryland 449,825 182,425 265,394 2,006Massachusetts 768,831 318,398 450,433 -Michigan 758,185 309,665 447,232 1,288Minnesota 318,854 129,936 188,448 470Mississippi 17,628 6,847 10,777 4Missouri 336,057 136,846 199,198 13Montana 96,701 39,763 55,389 1,549Nebraska 159,614 - - 159,614Nevada 55,923 21,770 33,168 985New Hampshire 11,176 4,657 6,516 3New Jersey 545,380 201,674 343,276 430New Mexico 263,256 114,919 148,119 218New York 884,443 332,669 551,774 -North Carolina 220,700 105,782 114,918 -North Dakota 1,549 604 945 -Ohio 453,265 174,748 278,517 -Oklahoma - - - -Oregon 481,498 210,791 268,766 1,941Pennsylvania 902,896 358,234 544,610 52Puerto Rico - - - -Rhode Island 96,178 36,784 59,012 382South Carolina 17,195 7,733 9,452 10South Dakota 83,998 33,826 48,327 1,845Tennessee 1,764,279 596,030 821,259 346,990Texas - - - -Utah 170,319 61,485 82,572 26,262Vermont 69,682 30,965 38,487 230Virgin Islands - - - -Virginia 159,392 62,955 96,437 -Washington 1,146,180 260,243 349,451 536,486West Virginia 52 - - 52Wisconsin 293,233 114,613 172,685 5,935Wyoming - - - -




Table 40. Prepaid Health Care Medicaid Recipients by Race/Ethnicity and by State: FY 1998

State NameTotal

RecipientsWhite

Not HispanicBlack

Not Hispanic HispanicNational Total 20,202,887 7,683,322 4,888,675 3,645,975Alabama 344,907 - - -Alaska - - - -Arizona 368,344 - - -Arkansas 244,768 145,661 81,795 3,531California 6,022,536 1,904,341 849,639 2,176,630Colorado 316,060 162,596 25,982 100,816Connecticut 271,411 96,431 79,049 91,794Delaware 85,239 34,013 41,222 6,823District of Columbia 100,867 211 57,416 2,397Florida 791,752 248,119 362,279 133,084Georgia 78,463 7,310 65,908 1,958Hawaii 144,744 - - -Idaho - - - -Illinois 142,429 9,226 104,667 27,153Indiana 271,005 178,634 80,562 8,581Iowa 246,582 208,720 23,477 9,718Kansas 44,003 27,176 11,496 3,607Kentucky 194,164 130,145 52,200 2,377Louisiana - - - -Maine 9,324 - - -Maryland 449,825 136,929 272,690 15,441Massachusetts 768,831 392,392 101,038 147,030Michigan 758,185 291,087 404,497 25,069Minnesota 318,854 182,363 63,152 16,039Mississippi 17,628 5,689 10,736 81Missouri 336,057 168,003 168,041 -Montana 96,701 71,008 615 1,789Nebraska 159,614 - - -Nevada 55,923 25,833 13,674 13,317New Hampshire 11,176 10,402 228 466New Jersey 545,380 144,448 224,543 153,390New Mexico 263,256 63,342 7,369 145,092New York 884,443 224,257 334,160 228,503North Carolina 220,700 98,000 97,137 11,306North Dakota 1,549 1,171 54 86Ohio 453,265 168,223 261,557 14,515Oklahoma - - - -Oregon 481,498 384,633 21,039 48,341Pennsylvania 902,896 371,692 400,482 97,753Puerto Rico - - - -Rhode Island 96,178 47,782 11,197 22,063South Carolina 17,195 5,216 11,499 78South Dakota 83,998 48,531 177 126Tennessee 1,764,279 935,725 409,630 12,521Texas - - - -Utah 170,319 109,093 3,281 20,835Vermont 69,682 68,419 457 124Virgin Islands - - - -Virginia 159,392 35,429 118,100 3,178Washington 1,146,180 441,388 44,822 83,219West Virginia 52 - - -Wisconsin 293,233 99,684 72,808 17,144Wyoming - - - -




Table 40. Prepaid Health Care Medicaid Recipients by Race/Ethnicity and by State: FY 1998 (Con’t)

State NameAsian or


Alaskan Native UnknownNational Total 720,118 182,202 3,082,595Alabama - - 344,907Alaska - - -Arizona - - 368,344Arkansas 582 522 12,677California 481,230 28,708 581,988Colorado 3,519 2,166 20,981Connecticut 3,696 392 49Delaware 338 184 2,659District of Columbia 343 6 40,494Florida 3,285 380 44,605Georgia 495 25 2,767Hawaii - - 144,744Idaho - - -Illinois 1,183 195 5Indiana 584 156 2,488Iowa 2,993 1,607 67Kansas 1,013 675 36Kentucky 878 98 8,466Louisiana - - -Maine - - 9,324Maryland 8,347 892 15,526Massachusetts 30,562 2,154 95,655Michigan 12,236 2,530 22,766Minnesota 33,257 11,173 12,870Mississippi 271 17 834Missouri - - 13Montana 420 21,304 1,565Nebraska - - 159,614Nevada 1,459 574 1,066New Hampshire 80 - -New Jersey 7,019 764 15,216New Mexico 1,403 42,415 3,635New York 14,955 2,603 79,965North Carolina 3,195 1,841 9,221North Dakota 8 230 -Ohio 2,311 462 6,197Oklahoma - - -Oregon 14,145 8,078 5,262Pennsylvania 22,620 677 9,672Puerto Rico - - -Rhode Island 3,637 162 11,337South Carolina 10 4 388South Dakota 60 30,412 4,692Tennessee 7,313 3,400 395,690Texas - - -Utah 5,096 4,317 27,697Vermont 311 141 230Virgin Islands - - -Virginia 2,302 201 182Washington 32,008 8,272 536,471West Virginia - - 52Wisconsin 16,954 4,465 82,178Wyoming - - -




Table 41. PCCM Medicaid Recipients by Age and by State: FY 1998

State NameTotal

RecipientsAges

Under 1From Ages

1 to 5From Ages

6 to 14From Ages

15 to 20From Ages

21 to 44National Total 4,066,440 208,733 990,902 1,133,983 395,065 710,818Alabama 151,910 - - - - -Alaska - - - - - -Arizona - - - - - -Arkansas 243,266 10,847 67,949 79,230 29,061 42,828California 54,471 670 10,010 15,117 5,858 15,607Colorado 48,907 - - - - -Connecticut - - - - - -Delaware - - - - - -District of Columbia 8,623 2 2,425 2,926 742 1,992Florida 841,304 35,739 217,755 251,721 78,934 164,192Georgia 879,554 56,272 237,384 259,590 95,548 125,516Hawaii - - - - - -Idaho 50,665 2,123 15,103 14,634 3,906 8,231Illinois 16,414 250 4,741 8,802 2,581 40Indiana 242,844 16,216 75,121 80,552 27,026 40,561Iowa 80,428 3,173 21,332 25,611 8,366 20,645Kansas 123,902 5,434 31,823 36,226 14,274 25,934Kentucky - - - - - -Louisiana - - - - - -Maine - - - - - -Maryland - - - - - -Massachusetts 264,035 10,836 57,169 67,929 22,604 72,465Michigan 53,733 - - - - -Minnesota - - - - - -Mississippi - - - - - -Missouri - - - - - -Montana 59,578 2,789 14,733 17,575 6,471 14,161Nebraska 27,577 - - - - -Nevada 28,638 401 10,149 10,258 2,103 4,636New Hampshire - - - - - -New Jersey - - - - - -New Mexico 103,867 630 29,335 39,046 9,883 16,651New York 804 - 104 575 123 2North Carolina 591,740 55,325 143,750 169,050 62,918 116,133North Dakota 32,566 1,626 8,416 10,298 3,943 7,453Ohio - - - - - -Oklahoma - - - - - -Oregon 11,163 103 1,189 1,961 823 2,105Pennsylvania - - - - - -Puerto Rico - - - - - -Rhode Island - - - - - -South Carolina - - - - - -South Dakota 39,858 4,310 11,230 11,337 4,446 7,010Tennessee - - - - - -Texas - - - - - -Utah - - - - - -Vermont - - - - - -Virgin Islands - - - - - -Virginia 110,559 1,987 31,177 31,535 15,451 24,648Washington - - - - - -West Virginia - - - - - -Wisconsin 34 - 7 10 4 8Wyoming - - - - - -




Table 41. PCCM Medicaid Recipients by Age and by State: FY 1998 (Con’t)

State NameFrom Ages

45 to 64From Ages

65 to 74From Ages

75 to 84From Ages

85 and Over UnknownNational Total 238,041 41,889 18,300 36,817 291,892Alabama - - - - 151,910Alaska - - - - -Arizona - - - - -Arkansas 11,811 1,166 229 119 26California 4,537 760 452 212 1,248Colorado - - - - 48,907Connecticut - - - - -Delaware - - - - -District of Columbia 313 3 - - 220Florida 64,433 15,333 6,352 1,879 4,966Georgia 53,776 13,829 5,833 31,504 302Hawaii - - - - -Idaho 3,445 1,240 883 431 669Illinois - - - - -Indiana 2,437 26 - - 905Iowa 1,301 - - - -Kansas 8,278 722 308 228 675Kentucky - - - - -Louisiana - - - - -Maine - - - - -Maryland - - - - -Massachusetts 32,553 478 - 1 -Michigan - - - - 53,733Minnesota - - - - -Mississippi - - - - -Missouri - - - - -Montana 3,512 129 22 4 182Nebraska - - - - 27,577Nevada 224 292 278 73 224New Hampshire - - - - -New Jersey - - - - -New Mexico 7,242 933 121 25 1New York - - - - -North Carolina 36,085 5,297 2,318 864 -North Dakota 515 4 - - 311Ohio - - - - -Oklahoma - - - - -Oregon 1,507 715 1,297 1,427 36Pennsylvania - - - - -Puerto Rico - - - - -Rhode Island - - - - -South Carolina - - - - -South Dakota 1,462 56 6 1 -Tennessee - - - - -Texas - - - - -Utah - - - - -Vermont - - - - -Virgin Islands - - - - -Virginia 4,605 906 201 49 -Washington - - - - -West Virginia - - - - -Wisconsin 5 - - - -Wyoming - - - - -




Table 42. PCCM Medicaid Recipients by Sex and by State: FY 1998

State NameTotal

Recipients Male Female UnknownNational Total 4,066,440 1,608,714 2,165,338 292,388Alabama 151,910 - - 151,910Alaska - - - -Arizona - - - -Arkansas 243,266 102,544 140,652 70California 54,471 22,083 31,140 1,248Colorado 48,907 - 48,907Connecticut - - - -Delaware - - - -District of Columbia 8,623 3,026 5,377 220Florida 841,304 369,971 466,367 4,966Georgia 879,554 385,892 493,361 301Hawaii - - - -Idaho 50,665 21,294 28,702 669Illinois 16,414 8,198 8,216 -Indiana 242,844 100,600 141,339 905Iowa 80,428 32,228 48,200 -Kansas 123,902 51,985 71,238 679Kentucky - - - -Louisiana - - - -Maine - - - -Maryland - - - -Massachusetts 264,035 104,035 160,000 -Michigan 53,733 - - 53,733Minnesota - - - -Mississippi - - - -Missouri - - - -Montana 59,578 25,894 33,502 182Nebraska 27,577 - - 27,577Nevada 28,638 11,597 16,805 236New Hampshire - - - -New Jersey - - - -New Mexico 103,867 46,250 57,616 1New York 804 394 410 -North Carolina 591,740 244,990 346,750 -North Dakota 32,566 12,534 19,717 315Ohio - - - -Oklahoma - - - -Oregon 11,163 4,298 6,829 36Pennsylvania - - - -Puerto Rico - - - -Rhode Island - - - -South Carolina - - - -South Dakota 39,858 16,338 23,087 433Tennessee - - - -Texas - - - -Utah - - - -Vermont - - - -Virgin Islands - - - -Virginia 110,559 44,545 66,014 -Washington - - - -West Virginia - - - -Wisconsin 34 18 16 -Wyoming - - - -




Table 43. PCCM Medicaid Recipients by Race/Ethnicity and by State: FY 1998

State NameTotal

RecipientsWhite

Not HispanicBlack

Not Hispanic HispanicNational Total 4,066,440 1,715,126 1,379,717 382,938Alabama 151,910 - - -Alaska - - - -Arizona - - - -Arkansas 243,266 142,112 89,918 3,639California 54,471 30,244 4,942 12,201Colorado 48,907 - - -Connecticut - - - -Delaware - - - -District of Columbia 8,623 24 8,054 252Florida 841,304 320,189 289,775 153,504Georgia 879,554 283,721 505,355 31,783Hawaii - - - -Idaho 50,665 42,432 248 6,045Illinois 16,414 811 14,767 765Indiana 242,844 168,806 58,866 11,832Iowa 80,428 70,808 5,819 2,552Kansas 123,902 79,178 27,391 11,084Kentucky - - - -Louisiana - - - -Maine - - - -Maryland - - - -Massachusetts 264,035 141,491 29,800 55,751Michigan 53,733 - - -Minnesota - - - -Mississippi - - - -Missouri - - - -Montana 59,578 44,690 449 1,263Nebraska 27,577 - - -Nevada 28,638 12,024 8,437 6,945New Hampshire - - - -New Jersey - - - -New Mexico 103,867 22,610 2,674 54,959New York 804 157 502 49North Carolina 591,740 238,369 287,656 22,685North Dakota 32,566 22,259 554 991Ohio - - - -Oklahoma - - - -Oregon 11,163 10,379 122 326Pennsylvania - - - -Puerto Rico - - - -Rhode Island - - - -South Carolina - - - -South Dakota 39,858 27,959 59 36Tennessee - - - -Texas - - - -Utah - - - -Vermont - - - -Virgin Islands - - - -Virginia 110,559 56,862 44,328 6,276Washington - - - -West Virginia - - - -Wisconsin 34 1 1 -Wyoming - - - -




Table 43. PCCM Medicaid Recipients by Race/Ethnicity and by State: FY 1998 (Con’t)

State NameAsian or


Alaskan Native UnknownNational Total 47,143 68,305 473,211Alabama - - 151,910Alaska - - -Arizona - - -Arkansas 546 529 6,522California 2,491 932 3,661Colorado - - 48,907Connecticut - - -Delaware - - -District of Columbia 69 2 222Florida 4,864 446 72,526Georgia 8,058 454 50,183Hawaii - - -Idaho 145 1,126 669Illinois 69 2 -Indiana 422 161 2,757Iowa 859 390 -Kansas 3,920 1,654 675Kentucky - - -Louisiana - - -Maine - - -Maryland - - -Massachusetts 15,703 692 20,598Michigan - - 53,733Minnesota - - -Mississippi - - -Missouri - - -Montana 305 12,688 183Nebraska - - 27,577Nevada 726 222 284New Hampshire - - -New Jersey - - -New Mexico 165 21,368 2,091New York 6 10 80North Carolina 5,826 9,566 27,638North Dakota 171 8,263 328Ohio - - -Oklahoma - - -Oregon 70 122 144Pennsylvania - - -Puerto Rico - - -Rhode Island - - -South Carolina - - -South Dakota 19 9,540 2,245Tennessee - - -Texas - - -Utah - - -Vermont - - -Virgin Islands - - -Virginia 2,709 138 246Washington - - -West Virginia - - -Wisconsin - - 32Wyoming - - -




Table 44 Medicaid Medical Vendor Payments for Prepaid Health Care Medicaid Recipientsby Maintenance Assistance Status and by State: FY 1998

State NameTotal

PaymentsReceiving



MASUnknown

National Total $19,296,223,487 $11,115,495,025 $1,367,726,879 $3,147,537,749 $2,897,425,088 $768,038,747Alabama 288,972,436 - - - - 288,972,436Alaska - - - - - -Arizona 1,431,418,497 614,603,926 - 207,764,064 609,050,506 -Arkansas 4,359,975 2,521,205 323,118 1,153,249 342,098 20,305California 2,867,713,795 2,061,454,084 525,689,657 22,725,657 257,149,439 694,958Colorado 238,585,930 65,864,936 - 35,788,921 130,183,665 6,748,408Connecticut 377,212,893 175,591,675 7,832,085 59,283,808 134,505,325 -Delaware 122,048,974 66,198,863 - 42,075,482 12,418,295 1,356,334District of Columbia 98,238,002 39,248,549 3,729,742 1,608,362 584,193 53,067,156Florida 701,322,837 566,149,381 2,316,992 83,078,417 49,258,606 519,441Georgia 57,871,451 41,529,226 - 7,660,608 8,615,452 66,165Hawaii 213,612,580 118,748,223 3,208,458 81,434,430 7,649,821 2,571,648Idaho - - - - - -Illinois 241,278,075 199,373,324 7,760,840 6,195,840 27,948,071 -Indiana 167,977,207 68,108,993 - 37,036,720 62,255,871 575,623Iowa 107,189,198 64,336,134 712,597 16,390,556 25,717,235 32,676Kansas 17,201,600 4,815,387 18,507 10,247,585 2,080,091 40,030Kentucky 311,526,039 218,623,439 13,597,872 69,595,167 9,018,745 690,816Louisiana - - - - - -Maine 4,237,958 2,052,490 4,697 1,317,463 846,918 16,390Maryland 851,988,946 604,575,473 57,240,565 128,822,252 58,693,808 2,656,848Massachusetts 477,932,296 297,071,252 83,364,337 74,100,646 23,396,061 -Michigan 823,728,725 612,392,605 133,623,737 58,315,824 7,469,950 11,926,609Minnesota 483,228,011 210,302,771 1,806,770 53,545,476 216,531,078 1,041,916Mississippi 22,152,325 10,337,698 - 10,921,260 799,156 94,211Missouri 277,652,554 125,014,933 - 103,237,881 48,121,506 1,278,234Montana 53,600,495 33,796,563 3,533,417 3,767,984 11,584,313 918,218Nebraska 72,980,602 39,927,033 3,390 11,124,260 21,925,919 -Nevada 32,332,069 13,237,436 - 241,038 17,738,526 1,115,069New Hampshire 12,128,535 4,824,765 112,995 5,348,430 1,842,210 135New Jersey 617,591,322 331,952,834 403,857 143,310,698 141,522,476 401,457New Mexico 372,647,285 221,083,291 - 143,723,448 7,546,939 293,607New York 1,638,382,814 1,231,486,532 309,597,191 94,632,388 2,666,704 -North Carolina 85,665,363 43,721,752 959,689 38,967,044 2,016,879 -North Dakota 1,319,356 336,060 141,444 501,372 338,682 1,798Ohio 494,845,239 342,793,287 - 145,671,328 6,380,624 -Oklahoma - - - - - -Oregon 665,872,224 189,542,785 9,513,697 297,598,133 161,992,195 7,225,414Pennsylvania 1,801,084,202 1,240,064,684 49,689,569 221,148,782 290,298,862 (117,695)Puerto Rico - - - - - -Rhode Island 114,870,881 76,874,255 1,278,891 21,317,460 10,210,320 5,189,955South Carolina 17,172,147 6,807,312 - 4,788,444 5,567,623 8,768South Dakota 3,797,234 1,666,614 - 1,310,044 820,576 -Tennessee 1,859,127,110 649,322,117 129,917,182 686,664,190 204,999,975 188,223,646Texas - - - - - -Utah 147,730,653 42,275,707 3,090,652 15,338,023 45,224,158 41,802,113Vermont 53,890,106 17,733,240 3,861,771 26,244,877 5,921,444 128,774Virgin Islands - - - - - -Virginia 186,255,441 124,695,551 277,865 36,783,725 24,498,300 -Washington 529,020,076 200,698,542 70,098 82,034,437 124,357,212 121,859,787West Virginia 26,573,906 - - - - 26,573,906Wisconsin 321,886,123 133,740,098 14,045,197 54,721,976 117,335,261 2,043,591Wyoming - - - - - -




Table 45. Medicaid Medical Vendor Payments for Prepaid Health Care by Basis of Eligibility and by State:FY 1998

State NameTotal

PaymentsAge 65

And OlderBlind/


UnknownNational Total $19,007,251,051 $1,281,654,876 $5,061,114,370 $7,258,178,184 $4,716,575,575 $689,728,040Alabama 288,972,436 - - - - 288,972,436Alaska - - - - - -Arizona 1,431,418,497 305,894,109 538,339,506 348,626,397 230,958,895 7,599,583Arkansas 4,359,975 381,256 1,770,581 1,664,699 448,043 95,396California 2,867,713,795 243,415,639 502,135,327 1,461,163,668 626,989,806 34,009,355Colorado 238,585,930 18,269,296 91,997,892 62,949,574 26,218,634 39,150,534Connecticut 377,212,893 16,430 889,578 230,046,226 138,902,495 7,358,164Delaware 122,048,974 1,717,732 50,022,867 31,807,937 36,919,623 1,580,815District of Columbia 98,238,002 - 10,560,659 25,540,587 9,063,283 53,073,473Florida 701,322,837 71,539,620 279,151,654 223,804,129 121,764,996 5,062,438Georgia 57,871,451 760,211 18,236,400 22,359,579 16,442,094 73,167Hawaii 213,612,580 - - 117,090,747 88,877,805 7,644,028Idaho - - - - - -Illinois 241,278,075 1,441,713 1,348,803 135,309,792 102,496,767 681,000Indiana 167,977,207 33,281,397 22,104,213 75,113,583 36,352,314 1,125,700Iowa 107,189,198 248,652 26,584,004 41,528,601 37,918,466 909,475Kansas 17,201,600 188 7,484 11,334,679 5,798,449 60,800Kentucky 311,526,039 9,948,951 140,944,026 122,137,361 37,474,425 1,021,276Louisiana - - - - - -Maine 4,237,958 - 2,964 2,925,767 1,259,800 49,427Maryland 851,988,946 29,433,961 429,574,081 217,332,175 157,701,903 17,946,826Massachusetts 477,932,296 17,799,618 168,863,527 191,656,653 99,465,302 147,196Michigan 823,728,725 7,665,104 369,991,661 206,701,594 223,274,867 16,095,499Minnesota 483,228,011 99,224,132 3,660,788 273,466,276 105,537,325 1,339,490Mississippi 22,152,325 1,071,123 8,690,390 10,066,921 2,223,849 100,042Missouri 277,652,554 349 216,687 207,000,926 60,088,789 10,345,803Montana 53,600,495 4,081,792 21,674,024 18,234,121 5,883,408 3,727,150Nebraska 72,980,602 1,827,740 17,877,950 20,941,089 12,862,703 19,471,120Nevada 32,332,069 533,667 17,239 15,103,694 15,545,523 1,131,946New Hampshire 12,128,535 - 12,690 10,046,700 1,953,315 115,830New Jersey 617,591,322 8,007,536 37,308,372 338,914,552 232,546,221 814,641New Mexico 372,647,285 1,788,025 134,622,609 163,844,455 66,324,600 6,067,596New York 1,638,382,814 107,872,874 645,819,379 490,808,458 391,215,400 2,666,704North Carolina 85,665,363 - 8,859,180 65,478,146 9,322,127 2,005,910North Dakota 1,319,356 - 198 797,300 519,146 2,712Ohio 494,845,239 663,103 3,350,900 282,677,169 207,768,926 385,141Oklahoma - - - - - -Oregon 665,872,224 52,979,578 131,218,913 174,549,708 281,400,515 25,723,510Pennsylvania 1,801,084,202 177,836,994 663,224,362 652,028,654 290,803,023 17,191,169Puerto Rico - - - - - -Rhode Island 114,870,881 1,982 302,363 58,118,090 51,092,650 5,355,796South Carolina 17,172,147 10,258,041 2,606,790 3,160,340 1,119,935 27,041South Dakota 3,797,234 321,796 703,936 2,316,950 379,036 75,516Tennessee 1,859,127,110 61,216,442 571,127,838 396,513,777 630,339,991 199,929,062Texas - - - - - -Utah 147,730,653 4,469,049 35,856,760 45,468,041 19,196,670 42,740,133Vermont 53,890,106 47,299 2,325,308 21,361,006 29,920,465 236,028Virgin Islands - - - - - -Virginia 186,255,441 1,975,407 68,820,208 73,769,467 41,689,275 1,084Washington 529,020,076 858,720 6,971,922 211,108,633 188,203,019 121,877,782West Virginia 26,573,906 - - - - 26,573,906Wisconsin 321,886,123 4,805,350 43,320,337 193,309,963 72,311,697 8,138,776Wyoming - - - - - -




Table 46. Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Ageand by State: FY 1998

State NameTotal

PaymentsAges

Under 1From Ages

1 to 5From Ages

6 to 14From Ages

15 to 20From Ages

21 to 44National Total $19,296,223,487 $663,270,071 $2,571,271,634 $3,072,843,689 $1,713,753,844 $5,178,849,381Alabama 288,972,436 - - - - -Alaska - - - - - -Arizona 1,431,418,497 - - - - -Arkansas 4,359,975 165,478 956,290 884,160 305,391 957,597California 2,867,713,795 13,209,454 515,347,850 766,649,821 298,185,030 680,351,715Colorado 238,585,930 5,851,482 37,932,814 53,024,495 23,780,778 54,695,564Connecticut 377,212,893 27,836,189 84,970,120 83,856,221 50,253,265 119,608,032Delaware 122,048,974 7,444,938 14,473,261 18,190,902 12,883,886 45,342,960District of Columbia 98,238,002 3,743,655 18,013,512 10,816,349 3,944,788 8,037,555Florida 701,322,837 20,416,040 97,246,070 104,294,029 57,717,411 221,554,555Georgia 57,871,451 1,574,558 9,292,110 9,452,878 6,107,675 20,822,290Hawaii 213,612,580 - - - - -Idaho - - - - - -Illinois 241,278,075 19,435,778 62,557,061 36,908,645 24,814,153 89,640,324Indiana 167,977,207 11,690,185 31,209,886 25,648,505 14,574,725 40,060,244Iowa 107,189,198 3,540,487 17,655,792 21,208,108 14,551,222 40,819,219Kansas 17,201,600 3,358,384 4,260,169 1,694,930 3,159,391 4,504,848Kentucky 311,526,039 10,065,260 53,935,311 74,499,203 27,021,626 80,383,927Louisiana - - - - - -Maine 4,237,958 452,074 1,004,906 966,790 622,067 1,058,095Maryland 851,988,946 35,760,475 98,755,759 111,236,613 72,296,988 289,111,724Massachusetts 477,932,296 11,606,162 68,653,269 99,211,663 40,656,305 153,404,081Michigan 823,728,725 33,633,121 91,911,136 78,169,032 61,786,742 328,737,518Minnesota 483,228,011 31,205,609 119,766,946 76,326,241 51,642,893 92,932,142Mississippi 22,152,325 5,762,963 3,021,071 1,412,028 1,562,621 4,537,547Missouri 277,652,554 28,275,079 85,689,665 73,232,376 35,930,476 50,514,480Montana 53,600,495 123,307 1,051,688 17,091,288 14,450,375 12,081,374Nebraska 72,980,602 - - - - -Nevada 32,332,069 3,891,345 6,014,421 4,438,112 4,666,812 11,939,029New Hampshire 12,128,535 155,925 3,796,335 4,988,385 1,151,685 1,949,400New Jersey 617,591,322 47,468,930 149,390,573 107,664,770 65,997,142 206,213,047New Mexico 372,647,285 14,531,960 49,072,446 89,770,157 68,706,455 93,634,772New York 1,638,382,814 54,914,302 190,982,711 182,006,374 94,094,647 593,575,857North Carolina 85,665,363 9,640,707 12,397,979 32,014,625 19,230,997 9,976,490North Dakota 1,319,356 53,367 300,097 260,043 222,968 445,350Ohio 494,845,239 116,389,364 62,355,148 76,664,074 62,884,487 161,461,589Oklahoma - - - - - -Oregon 665,872,224 11,991,839 76,050,828 99,495,632 58,776,145 233,035,657Pennsylvania 1,801,084,202 33,729,565 221,515,046 366,521,522 190,539,526 549,111,806Puerto Rico - - - - - -Rhode Island 114,870,881 9,353,107 26,101,164 16,604,258 15,284,178 42,375,112South Carolina 17,172,147 569,572 1,495,569 1,188,910 509,547 1,359,628South Dakota 3,797,234 276,666 897,180 1,126,800 404,718 488,728Tennessee 1,859,127,110 30,658,983 132,596,542 204,177,921 193,056,223 587,144,169Texas - - - - - -Utah 147,730,653 10,553,967 18,670,383 16,976,877 7,198,759 34,292,229Vermont 53,890,106 1,725,324 6,337,145 7,320,476 5,831,121 21,520,117Virgin Islands - - - - - -Virginia 186,255,441 9,030,622 33,615,628 30,826,600 24,253,318 57,608,532Washington 529,020,076 22,773,492 84,295,694 75,975,889 48,454,641 162,010,235West Virginia 26,573,906 - - - - -Wisconsin 321,886,123 10,410,356 77,682,059 90,047,987 36,242,667 71,551,843Wyoming - - - - - -




Table 46. Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Ageand by State: FY 1998 (Con’t)

State NameFrom Ages

45 to 64From Ages

65 to 74From Ages

75 to 84From Ages

85 and Over UnknownNational Total $2,374,630,221 $615,929,994 $396,380,134 $247,911,989 $2,461,382,531Alabama - - - - 288,972,436Alaska - - - - -Arizona - - - - 1,431,418,497Arkansas 506,508 249,221 218,230 118,239 (1,139)California 268,402,826 141,526,857 109,225,777 74,335,881 478,584Colorado 36,903,487 9,149,216 6,190,210 4,568,995 6,488,889Connecticut 10,638,402 50,441 223 - -Delaware 20,868,858 1,909,646 750,768 181,267 2,488District of Columbia 724,949 13,507 4,391 - 52,939,296Florida 100,532,484 42,372,100 30,723,983 26,141,677 324,488Georgia 8,890,305 1,187,070 360,359 171,785 12,421Hawaii - - - - 213,612,580Idaho - - - - -Illinois 6,009,647 699,832 814,921 397,448 266Indiana 10,692,692 11,708,270 12,470,176 9,833,271 89,253Iowa 9,245,818 143,152 11,711 12,743 946Kansas 208,948 1,061 - - 13,869Kentucky 48,745,997 9,611,724 4,975,171 2,047,175 240,645Louisiana - - - - -Maine 132,090 585 - - 1,351Maryland 192,222,579 35,774,016 12,503,907 3,240,544 1,086,341Massachusetts 81,477,691 6,791,609 9,013,837 7,117,679 -Michigan 197,402,303 15,906,082 3,784,086 1,094,952 11,303,753Minnesota 8,198,704 38,022,997 35,119,240 29,804,940 208,299Mississippi 4,194,860 975,335 506,104 162,517 17,279Missouri 3,990,141 18,577 - - 1,760Montana 3,922,798 1,523,252 1,605,578 1,597,184 153,651Nebraska - - - - 72,980,602Nevada 330,509 242,073 235,394 59,846 514,528New Hampshire 86,805 - - - -New Jersey 30,104,674 3,709,895 3,217,016 3,558,916 266,359New Mexico 51,669,983 4,305,567 631,410 150,035 174,500New York 349,214,118 94,422,624 55,137,837 24,034,343 -North Carolina 2,403,413 995 - 158 -North Dakota 37,531 - - - -Ohio 14,442,636 292,370 259,985 95,586 -Oklahoma - - - - -Oregon 126,028,104 26,171,354 19,719,835 13,823,922 778,908Pennsylvania 304,636,648 83,293,815 39,684,751 12,208,206 (156,683)Puerto Rico - - - - -Rhode Island 3,344,627 17,865 2,112 492 1,787,966South Carolina 1,637,531 2,536,145 4,091,505 3,781,995 1,745South Dakota 215,384 113,116 125,624 148,922 96Tennessee 396,748,525 69,289,240 35,633,293 22,288,636 187,533,578Texas - - - - -Utah 14,335,028 3,503,988 1,563,614 635,734 40,000,074Vermont 10,850,404 164,873 14,885 1,776 123,985Virgin Islands - - - - -Virginia 27,282,895 2,950,538 601,164 86,145 -Washington 12,652,685 389,168 274,509 370,179 121,823,584West Virginia - - - - 26,573,906Wisconsin 14,696,634 6,891,818 6,908,528 5,840,801 1,613,430Wyoming - - - - -




Table 47. Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Sexand by State: FY 1998

State NameTotal

Payments Male Female UnknownNational Total $19,296,223,487 $6,371,960,186 $10,460,328,903 $2,463,934,398Alabama 288,972,436 - - 288,972,436Alaska - - - -Arizona 1,431,418,497 - - 1,431,418,497Arkansas 4,359,975 1,848,704 2,511,984 (713)California 2,867,713,795 1,188,412,224 1,678,818,709 482,862Colorado 238,585,930 98,538,857 133,558,184 6,488,889Connecticut 377,212,893 125,688,730 251,524,163 -Delaware 122,048,974 46,701,836 75,344,650 2,488District of Columbia 98,238,002 20,235,744 25,051,743 52,950,515Florida 701,322,837 256,733,902 444,264,447 324,488Georgia 57,871,451 16,504,588 41,354,442 12,421Hawaii 213,612,580 - - 213,612,580Idaho - - - -Illinois 241,278,075 71,473,133 169,804,676 266Indiana 167,977,207 56,394,499 111,493,455 89,253Iowa 107,189,198 38,730,632 68,457,620 946Kansas 17,201,600 5,294,188 11,892,866 14,546Kentucky 311,526,039 132,639,343 178,638,239 248,457Louisiana - - - -Maine 4,237,958 1,599,611 2,636,996 1,351Maryland 851,988,946 328,225,186 522,678,351 1,085,409Massachusetts 477,932,296 191,883,979 286,048,317 -Michigan 823,728,725 286,073,576 526,353,707 11,301,442Minnesota 483,228,011 177,115,708 305,904,004 208,299Mississippi 22,152,325 8,252,448 13,882,598 17,279Missouri 277,652,554 110,451,332 167,199,462 1,760Montana 53,600,495 25,061,257 28,385,587 153,651Nebraska 72,980,602 - - 72,980,602Nevada 32,332,069 8,159,170 23,625,902 546,997New Hampshire 12,128,535 5,147,550 6,978,285 2,700New Jersey 617,591,322 186,936,733 430,388,230 266,359New Mexico 372,647,285 154,292,150 218,178,420 176,715New York 1,638,382,814 626,743,732 1,011,639,074 9North Carolina 85,665,363 36,860,097 48,805,266 -North Dakota 1,319,356 343,129 976,227 -Ohio 494,845,239 145,797,261 346,632,905 2,415,072Oklahoma - - - -Oregon 665,872,224 270,264,196 394,817,726 790,302Pennsylvania 1,801,084,202 700,297,042 1,100,947,308 (160,148)Puerto Rico - - - -Rhode Island 114,870,881 32,405,762 80,677,153 1,787,966South Carolina 17,172,147 4,484,249 12,686,153 1,745South Dakota 3,797,234 1,640,282 2,117,756 39,196Tennessee 1,859,127,110 648,037,009 1,023,539,781 187,550,320Texas - - - -Utah 147,730,653 46,210,088 61,515,574 40,004,991Vermont 53,890,106 21,314,625 32,451,496 123,985Virgin Islands - - - -Virginia 186,255,441 62,219,339 124,036,102 -Washington 529,020,076 113,052,671 294,131,756 121,835,649West Virginia 26,573,906 - - 26,573,906Wisconsin 321,886,123 119,895,624 200,379,589 1,610,910Wyoming - - - -




Table 48. Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Race/Ethnicityand by State: FY 1998

State NameTotal

PaymentsWhite

Not HispanicBlack

Not Hispanic HispanicNational Total $19,296,223,487 $6,971,046,006 $5,424,759,152 $2,465,159,044Alabama 288,972,436 - - -Alaska - - - -Arizona 1,431,418,497 - - -Arkansas 4,359,975 2,384,384 1,614,896 48,468California 2,867,713,795 820,555,222 487,617,383 967,106,015Colorado 238,585,930 116,429,108 21,481,320 68,576,183Connecticut 377,212,893 133,015,461 111,183,457 127,462,428Delaware 122,048,974 51,811,375 55,384,205 9,308,431District of Columbia 98,238,002 175,177 41,711,203 1,697,604Florida 701,322,837 200,648,478 312,690,985 76,908,022Georgia 57,871,451 6,211,574 46,212,136 778,345Hawaii 213,612,580 - - -Idaho - - - -Illinois 241,278,075 17,977,074 190,654,668 30,831,653Indiana 167,977,207 107,009,316 53,251,599 5,584,848Iowa 107,189,198 88,529,917 13,074,920 3,499,999Kansas 17,201,600 11,237,535 3,772,419 1,538,532Kentucky 311,526,039 198,174,755 87,502,578 3,371,173Louisiana - - - -Maine 4,237,958 - - -Maryland 851,988,946 289,337,600 494,247,122 20,220,791Massachusetts 477,932,296 288,388,006 71,270,979 75,058,724Michigan 823,728,725 291,325,697 448,956,331 18,650,003Minnesota 483,228,011 284,480,133 89,825,022 25,909,085Mississippi 22,152,325 8,071,914 11,913,383 129,995Missouri 277,652,554 131,368,857 146,281,937 -Montana 53,600,495 40,733,062 378,343 953,078Nebraska 72,980,602 - - -Nevada 32,332,069 16,029,764 6,870,965 7,415,636New Hampshire 12,128,535 11,252,385 254,205 527,715New Jersey 617,591,322 132,285,603 272,103,646 182,477,490New Mexico 372,647,285 109,777,182 10,934,417 175,691,834New York 1,638,382,814 491,797,939 450,530,344 261,095,778North Carolina 85,665,363 33,406,093 43,866,121 3,263,231North Dakota 1,319,356 1,056,698 48,005 48,234Ohio 494,845,239 179,164,021 287,807,436 15,482,001Oklahoma - - - -Oregon 665,872,224 543,216,685 33,211,731 49,129,279Pennsylvania 1,801,084,202 637,775,454 873,410,484 210,736,115Puerto Rico - - - -Rhode Island 114,870,881 54,749,866 12,986,826 25,379,168South Carolina 17,172,147 4,236,183 11,916,431 16,070South Dakota 3,797,234 2,135,624 8,146 5,642Tennessee 1,859,127,110 1,098,535,007 475,376,234 9,936,111Texas - - - -Utah 147,730,653 82,460,377 2,741,398 14,009,607Vermont 53,890,106 52,965,970 310,809 88,135Virgin Islands - - - -Virginia 186,255,441 42,397,973 138,049,280 2,674,894Washington 529,020,076 294,984,443 31,790,969 52,830,212West Virginia 26,573,906 - - -Wisconsin 321,886,123 94,954,094 83,516,819 16,718,515Wyoming - - - -




Table 48. Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Race/Ethnicityand by State: FY 1998 (Con’t)

State NameAsian or


Alaskan Native UnknownNational Total $584,061,196 $134,704,727 $2,461,382,531Alabama - - 288,972,436Alaska - - -Arizona - - 1,431,418,497Arkansas 10,176 7,377 (1,139)California 294,236,703 8,640,240 478,584Colorado 2,103,149 1,439,083 6,488,889Connecticut 4,966,585 515,229 -Delaware 542,146 440,451 2,488District of Columbia 222,162 4,093 52,939,296Florida 1,854,574 175,145 324,488Georgia 346,375 12,683 12,421Hawaii - - 213,612,580Idaho - - -Illinois 1,510,807 292,853 266Indiana 665,533 75,529 89,253Iowa 1,446,729 636,687 946Kansas 375,410 263,835 13,869Kentucky 1,211,148 108,466 240,645Louisiana - - -Maine - - 1,351Maryland 22,909,496 2,040,903 1,086,341Massachusetts 10,950,049 1,173,993 -Michigan 12,516,835 1,994,247 11,303,753Minnesota 55,641,385 14,708,695 208,299Mississippi 377,365 26,934 17,279Missouri - - 1,760Montana 201,817 11,163,929 153,651Nebraska - - 72,980,602Nevada 1,053,602 365,238 514,528New Hampshire 94,230 - -New Jersey 8,524,702 944,911 266,359New Mexico 2,430,041 58,314,252 174,500New York 17,793,471 3,055,203 -North Carolina 1,432,851 611,227 -North Dakota 4,957 161,462 -Ohio 2,658,216 525,561 -Oklahoma - - -Oregon 25,783,520 9,034,978 778,908Pennsylvania 54,370,431 1,245,841 (156,683)Puerto Rico - - -Rhode Island 4,223,146 171,462 1,787,966South Carolina 2,236 640 1,745South Dakota 2,424 1,486,962 96Tennessee 6,829,155 3,770,117 187,533,578Texas - - -Utah 5,029,685 2,244,147 40,000,074Vermont 275,438 125,769 123,985Virgin Islands - - -Virginia 2,640,478 238,376 -Washington 22,213,553 5,377,315 121,823,584West Virginia - - 26,573,906Wisconsin 16,610,616 3,310,894 1,613,430Wyoming - - -





National Pharmaceutical Council C-1

Appendix C:Medicaid Rebate Law


C-2 National Pharmaceutical Council



42 USC Sec. 1396r-8 01/06/97

TITLE 42 - THE PUBLIC HEALTH AND WELFARECHAPTER 7 - SOCIAL SECURITYSUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCEPROGRAMS

Sec. 1396r-8. Payment for covered outpatient drugs

(a) Requirement for rebate agreement

(1) In generalIn order for payment to be available under section 1396b(a) of this title for covered outpatient drugs of amanufacturer, the manufacturer must have entered into and have in effect a rebate agreement described insubsection (b) of this section with the Secretary, on behalf of States (except that, the Secretary may authorize aState to enter directly into agreements with a manufacturer), and must meet the requirements of paragraph(5)(with respect to drugs purchased by a covered entity on or after the first day of the first month that begins afterNovember 4,1992) and paragraph (6). Any agreement between a State and a manufacturer prior to April 1, 1991,shall be deemed to have been entered into on January 1, 1991, and payment to such manufacturer shall beretroactively calculated as if the agreement between the manufacturer and the State had been entered into onJanuary 1,1991. If a manufacturer has not entered into such an agreement before March 1, 1991, such anagreement, subsequently entered into, shall not be effective until the first day of the calendar quarter that beginsmore than 60 days after the date the agreement is entered into.

(2) Effective dateParagraph (1) shall first apply to drugs dispensed under this subchapter on or after January 1, 1991.

(3) Authorizing payment for drugs not covered under rebate agreementsParagraph (1), and section 1396b(i)(10)(A) of this title, shall not apply to the dispensing of a single source drug orinnovator multiple source drug if (A)(i) the State has made a determination that the availability of the drug isessential to the health of beneficiaries under the State plan for medical assistance; (ii) such drug has been givena rating of 1-A by the Food and Drug Administration; and (iii)(I) the physician has obtained approval for use ofthe drug in advance of its dispensing in accordance with a prior authorization program described in subsection(d) of this section, or (II) the Secretary has reviewed and approved the State’s determination undersubparagraph (A); or (B) the Secretary determines that in the first calendar quarter of 1991, there wereextenuating circumstances.

(4) Effect on existing agreementsIn the case of a rebate agreement in effect between a State and a manufacturer on November 5, 1990, suchagreement, for the initial agreement period specified therein, shall be considered to be a rebate agreement incompliance with this section with respect to that State, if the State agrees to report to the Secretary any rebatespaid pursuant to the agreement and such agreement provides for a minimum aggregate rebate of 10 percent ofthe State’s total expenditures under the State plan for coverage of the manufacturer’s drugs under thissubchapter. If, after the initial agreement period, the State establishes to the satisfaction of the Secretary that anagreement in effect on November 5, 1990, provides for rebates that are at least as large as the rebates otherwiserequired under this section, and the State agrees to report any rebates under the agreement to the Secretary, theagreement shall be considered to be a rebate agreement in compliance with the section for the renewal periods ofsuch agreement.

(5) Limitation on prices of drugs purchased by covered entities

(A) Agreement with SecretaryA manufacturer meets the requirements of this paragraph if the manufacturer has entered into anagreement with the Secretary that meets the requirements of section 256b of this title with respect tocovered outpatient drugs purchased by a covered entity on or after the first day of the first month thatbegins after November 4, 1992.



(B) “Covered entity” definedIn this subsection, the term “covered entity” means an entity described in section 256b(a)(4) of this title.

(C) Establishment of alternative mechanism to ensure against duplicate discounts or rebatesIf the Secretary does not establish a mechanism under section 256b(a)(5)(A) of this title within 12 monthsof November 4, 1992, the following requirements shall apply:(i) EntitiesEach covered entity shall inform the single State agency under section 1396a(a)(5) of this title when it isseeking reimbursement from the State plan for medical assistance described in section 1396d(a)(12) ofthis title with respect to a unit of any covered outpatient drug which is subject to an agreement undersection 56b(a) of this title.(ii) State agencyEach such single State agency shall provide a means by which a covered entity shall indicate on anydrug reimbursement claims form (or format, where electronic claims management is used) that a unit ofthe drug that is the subject of the form is subject to an agreement under section 256b of this title, and notsubmit to any manufacturer a claim for a rebate payment under subsection (b) of this section with respectto such a drug.

(D) Effect of subsequent amendmentsIn determining whether an agreement under subparagraph (A) meets the requirements of section 256b ofthis title, the Secretary shall not take into account any amendments to such section that are enacted afterNovember 4, 1992.

(E) Determination of complianceA manufacturer is deemed to meet the requirements of this paragraph if the manufacturer establishes tothe satisfaction of the Secretary that the manufacturer would comply (and has offered to comply) with theprovisions of section 256b of this title (as in effect immediately after November 4, 1992) and would haveentered into an agreement under such section (as such section was in effect at such time), but for alegislative change in such section after November 4, 1992.

(6) Requirements relating to master agreements for drugs procured by Department of Veterans Affairs and certainother Federal agencies

(A) In generalA manufacturer meets the requirements of this paragraph if the manufacturer complies with the provisionsof section 8126 of title 38, including the requirement of entering into a master agreement with theSecretary of Veterans Affairs under such section.

(B) Effect of subsequent amendmentsIn determining whether a master agreement described in subparagraph (A) meets the requirements ofsection 8126 of title 38, the Secretary shall not take into account any amendments to such section thatare enacted after November 4, 1992.

(C) Determination of complianceA manufacturer is deemed to meet the requirements of this paragraph if the manufacturer establishes tothe satisfaction of the Secretary that the manufacturer would comply (and has offered to comply) with theprovisions of section 8126 of title 38, (as in effect immediately after November 4, 1992) and would haveentered into an agreement under such section (as such section was in effect at such time), but for alegislative change in such section after November 4, 1992.

(b) Terms of rebate agreement

(1) Periodic rebates

(A) In generalA rebate agreement under this subsection shall require the manufacturer to provide, to each State planapproved under this subchapter, a rebate for a rebate period in an amount specified in subsection (C) ofthis section for covered outpatient drugs of the manufacturer dispensed after December 31, 1990, for



which payment was made under the State plan for such period. Such rebate shall be paid by themanufacturer not later than 30 days after the date of receipt of the information described in paragraph (2)for the period involved.

(B) Offset against medical assistanceAmounts received by a State under this section (or under an agreement authorized by the Secretaryunder subsection (a)(1) of this section or an agreement described in subsection (a)(4) of this section) inany quarter shall be considered to be a reduction in the amount expended under the State plan in thequarter for medical assistance for purposes of section 1396b(a)(1) of this title.

(2) State provision of information

(A) State responsibilityEach State agency under this subchapter shall report to each manufacturer not later than 60 days afterthe end of each rebate period and in a form consistent with a standard reporting format established by theSecretary, information on the total number of units of each dosage form and strength and package size ofeach covered outpatient drug dispensed after December 31, 1990, for which payment was made underthe plan during the period, and shall promptly transmit a copy of such report to the Secretary.

(B) AuditsA manufacturer may audit the information provided (or required to be provided) under subparagraph (A).Adjustments to rebates shall be made to the extent that information indicates that utilization was greateror less than the amount previously specified.

(3) Manufacturer provision of price information

(A) In generalEach manufacturer with an agreement in effect under this section shall report to the Secretary - (i) notlater than 30 days after the last day of each rebate period under the agreement (beginning on or afterJanuary 1, 1991), on the average manufacturer price (as defined in subsection (k)(1) of this section) and,(for single source drugs and innovator multiple source drugs), the manufacturer’s best price (as defined insubsection (C)(2)(B) of this section) for covered outpatient drugs for the rebate period under theagreement, and (ii) not later than 30 days after the date of entering into an agreement under this sectionon the average manufacturer price (as defined in subsection (k)(1) of this section) as of October 1, 1990(FOOTNOTE 1) for each of the manufacturer’s covered outpatient drugs.(FOOTNOTE 1) So in original. Probably should be followed by a comma.

(B) Verification surveys of average manufacturer priceThe Secretary may survey wholesalers and manufacturers that directly distribute their covered outpatientdrugs, when necessary, to verify manufacturer prices reported under subparagraph (A). The Secretarymay impose a civil monetary penalty in an amount not to exceed $100,000 on a wholesaler,manufacturer, or direct seller, if the wholesaler, manufacturer, or direct seller of a covered outpatient drugrefuses a request for information about charges or prices by the Secretary in connection with a surveyunder this subparagraph or knowingly provides false information. The provisions of section 1320a-7a ofthis title (other than subsections (a) (with respect to amounts of penalties or additional assessments) and(b)) shall apply to a civil money penalty under this subparagraph in the same manner as such provisionsapply to a penalty or proceeding under section 1320a-7a(a) of this title.

(C) Penalties(i) Failure to provide timely informationIn the case of a manufacturer with an agreement under this section that fails to provide informationrequired under subparagraph (A) on a timely basis, the amount of the penalty shall be increased by$10,000 for each day in which such information has not been provided and such amount shall be paid tothe Treasury, and, if such information is not reported within 90 days of the deadline imposed, theagreement shall be suspended for services furnished after the end of such 90-day period and until thedate such information is reported (but in no case shall such suspension be for a period of less than 30days).



(ii) False informationAny manufacturer with an agreement under this section that knowingly provides false information issubject to a civil money penalty in an amount not to exceed $100,000 for each item of false information.Such civil money penalties are in addition to other penalties as may be prescribed by law. The provisionsof section 1320a-7a of this title (other than subsections (a) and (b)) shall apply to a civil money penaltyunder this subparagraph in the same manner as such provisions apply to a penalty or proceeding undersection 1320a-7a(a) of this title.

(D) Confidentiality of informationNotwithstanding any other provision of law, information disclosed by manufacturers or wholesalers underthis paragraph or under an agreement with the Secretary of Veterans Affairs described in subsection(a)(6)(A)(ii) of this section is confidential and shall not be disclosed by the Secretary or the Secretary ofVeterans Affairs or a State agency (or contractor therewith) in a form which discloses the identity of aspecific manufacturer or wholesaler, prices charged for drugs by such manufacturer or wholesaler,except-(i) as the Secretary determines to be necessary to carry out this section,(ii) to permit the Comptroller General to review the information provided, and(iii) to permit the Director of the Congressional Budget Office to review the information provided.

(4) Length of agreement

(A) In generalA rebate agreement shall be effective for an initial period of not less than 1 year and shall beautomatically renewed for a period of not less than one year unless terminated under subparagraph (B).

(B) Termination(i) By the SecretaryThe Secretary may provide for termination of a rebate agreement for violation of the requirements of theagreement or other good cause shown. Such termination shall not be effective earlier than 60 days afterthe date of notice of such termination. The Secretary shall provide, upon request, a manufacturer with ahearing concerning such a termination, but such hearing shall not delay the effective date of thetermination.(ii) By a manufacturerA manufacturer may terminate a rebate agreement under this section for any reason. Any suchtermination shall not be effective until the calendar quarter beginning at least 60 days after the date themanufacturer provides notice to the Secretary.(iii) Effectiveness of terminationAny termination under this subparagraph shall not affect rebates due under the agreement before theeffective date of its termination.(iv) Notice to StatesIn the case of a termination under this subparagraph, the Secretary shall provide notice of suchtermination to the States within not less than 30 days before the effective date of such termination.(v) Application to terminations of other agreementsThe provisions of this subparagraph shall apply to the terminations of agreements described in section256b(a)(1) of this title and master agreements described in section 8126(a) of title 38.

(C) Delay before reentryIn the case of any rebate agreement with a manufacturer under this section which is terminated, anothersuch agreement with the manufacturer (or a successor manufacturer) may not be entered into until aperiod of 1 calendar quarter has elapsed since the date of the termination, unless the Secretary findsgood cause for an earlier reinstatement of such an agreement.



(c) Determination of amount of rebate

(1) Basic rebate for single source drugs and innovator multiplesource drugs

(A) In generalExcept as provided in paragraph (2), the amount of the rebate specified in this subsection for a rebateperiod (as defined in subsection (k)(8) of this section) with respect to each dosage form and strength of asingle source drug or an innovator multiple source drug shall be equal to the product of -(i) the total number of units of each dosage form and strength paid for under the State plan in the rebateperiod (as reported by the State); and(ii) subject to subparagraph (B)(ii), the greater of -

(I) the difference between the average manufacturer price and the best price (as defined insubparagraph (C)) for the dosage form and strength of the drug, or(II) the minimum rebate percentage (specified in subparagraph (B)(i)) of such average manufacturerprice, for the rebate period.

(B) Range of rebates required(i) Minimum rebate percentageFor purposes of subparagraph (A)(ii)(II), the “minimum rebate percentage” for rebate periods beginning -

(I) after December 31, 1990, and before October 1, 1992, is 12.5 percent;(II) after September 30, 1992, and before January 1, 1994, is 15.7 percent;(III) after December 31, 1993, and before January 1, 1995, is 15.4 percent;(IV) after December 31, 1994, and before January 1, 1996, is 15.2 percent; and(V) after December 31, 1995, is 15.1 percent.

(ii) Temporary limitation on maximum rebate amountIn no case shall the amount applied under subparagraph (A)(ii) for a rebate period beginning -

(I) before January 1, 1992, exceed 25 percent of the average manufacturer price; or(II) after December 31, 1991, and before January 1, 1993, exceed 50 percent of the averagemanufacturer price.

(C) “Best price” definedFor purposes of this section -(i) In generalThe term “best price” means, with respect to a single source drug or innovator multiple source drug of amanufacturer, the lowest price available from the manufacturer during the rebate period to anywholesaler, retailer, provider, health maintenance organization, nonprofit entity, or governmental entitywithin the United States, excluding -

(I) any prices charged on or after October 1, 1992, to the Indian Health Service, the Department ofVeterans Affairs, a State home receiving funds under section 1741 of title 38, the Department ofDefense, the Public Health Service, or a covered entity described in subsection (a)(5)(B) of thissection;(II) any prices charged under the Federal Supply Schedule of the General Services Administration;(III) any prices used under a State pharmaceutical assistance program; and(IV) any depot prices and single award contract prices, as defined by the Secretary, of any agency ofthe Federal Government.

(ii) Special rulesThe term “best price” -

(I) shall be inclusive of cash discounts, free goods that are contingent on any purchase requirement,volume discounts, and rebates (other than rebates under this section);(II) shall be determined without regard to special packaging, labeling, or identifiers on the dosage formor product or package; and(III) shall not take into account prices that are merely nominal in amount.



(2) Additional rebate for single source and innovator multiple source drugs

(A) In generalThe amount of the rebate specified in this subsection for a rebate period, with respect to each dosageform and strength of a single source drug or an innovator multiple source drug, shall be increased by anamount equal to the product of -(i) the total number of units of such dosage form and strength dispensed after December 31, 1990, forwhich payment was made under the State plan for the rebate period; and(ii) the amount (if any) by which -

(I) the average manufacturer price for the dosage form and strength of the drug for the period, exceeds(II) the average manufacturer price for such dosage form and strength for the calendar quarterbeginning July 1, 1990 (without regard to whether or not the drug has been sold or transferred to anentity, including a division or subsidiary of the manufacturer, after the first day of such quarter),increased by the percentage by which the consumer price index for all urban consumers (United Statescity average) for the month before the month in which the rebate period begins exceeds such index forSeptember 1990

.(B) Treatment of subsequently approved drugsIn the case of a covered outpatient drug approved by the Food and Drug Administration after October 1,1990, clause (ii)(II) of subparagraph (A) shall be applied by substituting “the first full calendar quarter afterthe day on which the drug was first marketed” for “the calendar quarter beginning July 1, 1990” and “themonth prior to the first month of the first full calendar quarter after the day on which the drug was firstmarketed” for “September 1990”.

(3) Rebate for other drugs

(A) In generalThe amount of the rebate paid to a State for a rebate period with respect to each dosage form andstrength of covered outpatient drugs (other than single source drugs and innovator multiple source drugs)shall be equal to the product of -(i) the applicable percentage (as described in subparagraph (B)) of the average manufacturer price for thedosage form and strength for the rebate period, and(ii) the total number of units of such dosage form and strength dispensed after December 31, 1990, forwhich payment was made under the State plan for the rebate period.

(B) “Applicable percentage” definedFor purposes of subparagraph (A)(i), the “applicable percentage” for rebate periods beginning -(i) before January 1, 1994, is 10 percent, and(ii) after December 31, 1993, is 11 percent.

(d) Limitations on coverage of drugs

(1) Permissible restrictions

(A) A State may subject to prior authorization any covered outpatient drug. Any such prior authorizationprogram shall comply with the requirements of paragraph (5).

(B) A State may exclude or otherwise restrict coverage of a covered outpatient drug if -(i) the prescribed use is not for a medically accepted indication (as defined in subsection (k)(6) of thissection);(ii) the drug is contained in the list referred to in paragraph (2);(iii) the drug is subject to such restrictions pursuant to an agreement between a manufacturer and a Stateauthorized by the Secretary under subsection (a)(1) of this section or in effect pursuant to subsection(a)(4) of this section; or(iv) the State has excluded coverage of the drug from its formulary established in accordance withparagraph (4).



(2) List of drugs subject to restrictionThe following drugs or classes of drugs, or their medical uses, may be excluded from coverage or otherwiserestricted:

(A) Agents when used for anorexia, weight loss, or weight gain.(B) Agents when used to promote fertility.(C) Agents when used for cosmetic purposes or hair growth.(D) Agents when used for the symptomatic relief of cough and colds.(E) Agents when used to promote smoking cessation.(F) Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.(G) Nonprescription drugs.(H) Covered outpatient drugs which the manufacturer seeks to require as a condition of sale thatassociated tests or monitoring services be purchased exclusively from the manufacturer or its designee.(I) Barbiturates.(J) Benzodiazepines.

(3) Update of drug listingsThe Secretary shall, by regulation, periodically update the list of drugs or classes of drugs described in paragraph(2) or their medical uses, which the Secretary has determined, based on data collected by surveillance andutilization review programs of State medical assistance programs, to be subject to clinical abuse or inappropriateuse.

(4) Requirements for formulariesA State may establish a formulary if the formulary meets the following requirements:

(A) The formulary is developed by a committee consisting of physicians, pharmacists, and otherappropriate individuals appointed by the Governor of the State (or, at the option of the State, the State’sdrug use review board established under subsection (g)(3) of this section).

(B) Except as provided in subparagraph (C), the formulary includes the covered outpatient drugs of anymanufacturer which has entered into and complies with an agreement under subsection (a) of this section(other than any drug excluded from coverage or otherwise restricted under paragraph (2)).

(C) A covered outpatient drug may be excluded with respect to the treatment of a specific disease orcondition for an identified population (if any) only if, based on the drug’s labeling (or, in the case of a drugthe prescribed use of which is not approved under the Federal Food, Drug, and Cosmetic Act(21 U.S.C. 301 et seq.) but is a medically accepted indication, based on information from the appropriatecompendia described in subsection (k)(6) of this section), the excluded drug does not have a significant,clinically meaningful therapeutic advantage in terms of safety, effectiveness, or clinical outcome of suchtreatment for such population over other drugs included in the formulary and there is a written explanation(available to the public) of the basis for the exclusion.

(D) The State plan permits coverage of a drug excluded from the formulary (other than any drug excludedfrom coverage or otherwise restricted under paragraph (2)) pursuant to a prior authorization program thatis consistent with paragraph (5).

(E) The formulary meets such other requirements as the Secretary may impose in order to achieveprogram savings consistent with protecting the health of program beneficiaries. A prior authorizationprogram established by a State under paragraph (5) is not a formulary subject to the requirements of thisparagraph.

(5) Requirements of prior authorization programsA State plan under this subchapter may require, as a condition of coverage or payment for a covered outpatientdrug for which Federal financial participation is available in accordance with this section, with respect to drugsdispensed on or after July 1, 1991, the approval of the drug before its dispensing for any medically acceptedindication (as defined in subsection (k)(6) of this section) only if the system providing for such approval –

(A) provides response by telephone or other telecommunication device within 24 hours of a request forprior authorization; and



(B) except with respect to the drugs on the list referred to in paragraph (2), provides for the dispensing ofat least 72-hour supply of a covered outpatient prescription drug in an emergency situation (as defined bythe Secretary).

(6) Other permissible restrictionsA State may impose limitations, with respect to all such drugs in a therapeutic class, on the minimum or maximumquantities per prescription or on the number of refills, if such limitations are necessary to discourage waste, andmay address instances of fraud or abuse by individuals in any manner authorized under this chapter.

(e) Treatment of pharmacy reimbursement limits

(1) In generalDuring the period beginning on January 1, 1991, and ending onDecember 31, 1994 –

(A) a State may not reduce the payment limits established by regulation under this subchapter or anylimitation described in paragraph (3) with respect to the ingredient cost of a covered outpatient drug or thedispensing fee for such a drug below the limits in effect as of January 1, 1991, and

(B) except as provided in paragraph (2), the Secretary may not modify by regulation the formulaestablished under sections 447.331 through 447.334 of title 42, Code of Federal Regulations, in effect onNovember 5, 1990, to reduce the limits described in subparagraph (A).

(2) Special ruleIf a State is not in compliance with the regulations described in paragraph (1)(B), paragraph (1)(A) shall not applyto such State until such State is in compliance with such regulations.

(3) Effect on State maximum allowable cost limitationsThis section shall not supersede or affect provisions in effect prior to January 1, 1991, or after December 31,1994, relating to any maximum allowable cost limitation established by a State for payment by the State forcovered outpatient drugs, and rebates shall be made under this section without regard to whether or not paymentby the State for such drugs is subject to such a limitation or the amount of such a limitation.

((4)) (FOOTNOTE 2) Establishment of upper payment limits(FOOTNOTE 2) See 1993 Amendment note below.HCFA shall establish a Federal upper reimbursement limit for each multiple source drug for which the FDA hasrated three or more products therapeutically and pharmaceutically equivalent, regardless of whether all suchadditional formulations are rated as such and shall use only such formulations when determining any such upperlimit.

(f) Repealed and redesignated

(1) Repealed. Pub. L. 103-66, title XIII, Sec. 13602(a)(1), Aug. 10, 1993, 107 Stat. 613

(2) Redesignated (e)((4))

(g) Drug use review

(1) In general

(A) In order to meet the requirement of section 1396b(i)(10)(B) of this title, a State shall provide, by notlater than January 1, 1993, for a drug use review program described in paragraph (2) for coveredoutpatient drugs in order to assure that prescriptions (i) are appropriate, (ii) are medically necessary, and(iii) are not likely to result in adverse medical results. The program shall be designed to educatephysicians and pharmacists to identify and reduce the frequency of patterns of fraud, abuse, grossoveruse, or inappropriate or medically unnecessary care, among physicians, pharmacists, and patients,or associated with specific drugs or groups of drugs, as well as potential and actual severe adversereactions to drugs including education on therapeutic appropriateness, overutilization and underutilization,



appropriate use of generic products, therapeutic duplication, drug-disease contraindications, drug-druginteractions, incorrect drug dosage or duration of drug treatment, drug-allergy interactions, and clinicalabuse/misuse.

(B) The program shall assess data on drug use against predetermined standards, consistent with thefollowing:(i) compendia which shall consist of the following:

(I) American Hospital Formulary Service Drug Information;(II) United States Pharmacopeia-Drug Information; and(III) American Medical Association Drug Evaluations; and

(ii) the peer-reviewed medical literature.

(C) The Secretary, under the procedures established in section 1396b of this title, shall pay to each Statean amount equal to 75 per centum of so much of the sums expended by the State plan during calendaryears 1991 through 1993 as the Secretary determines is attributable to the statewide adoption of a druguse review program which conforms to the requirements of this subsection.

(D) States shall not be required to perform additional drug use reviews with respect to drugs dispensed toresidents of nursing facilities which are in compliance with the drug regimen review proceduresprescribed by the Secretary for such facilities in regulations implementing section 1396r of this title,currently at section 483.60 of title 42, Code of Federal Regulations.

(2) Description of programEach drug use review program shall meet the following requirements for covered outpatient drugs:

(A) Prospective drug review(i) The State plan shall provide for a review of drug therapy before each prescription is filled or deliveredto an individual receiving benefits under this subchapter, typically at the point-of-sale or point ofdistribution. The review shall include screening for potential drug therapy problems due to therapeuticduplication, drug-disease contraindications, drug-drug interactions (including serious interactions withnonprescription or over-the-counter drugs), incorrect drug dosage or duration of drug treatment, drug-allergy interactions, and clinical abuse/misuse. Each State shall use the compendia and literaturereferred to in paragraph (1)(B) as its source of standards for such review.(ii) As part of the State’s prospective drug use review program under this subparagraph applicable Statelaw shall establish standards for counseling of individuals receiving benefits under this subchapter bypharmacists which includes at least the following:

(I) The pharmacist must offer to discuss with each individual receiving benefits under this subchapteror caregiver of such individual (in person, whenever practicable, or through access to a telephoneservice which is toll-free for long-distance calls) who presents a prescription, matters which in theexercise of the pharmacist’s professional judgment (consistent with State law respecting the provisionof such information), the pharmacist deems significant including the following:

(aa) The name and description of the medication.(bb) The route, dosage form, dosage, route of administration, and duration of drug therapy.(cc) Special directions and precautions for preparation, administration and use by the patient.(dd) Common severe side or adverse effects or interactions and therapeutic contraindications thatmay be encountered, including their avoidance, and the action required if they occur.(ee) Techniques for self-monitoring drug therapy.(ff) Proper storage.(gg) Prescription refill information.(hh) Action to be taken in the event of a missed dose.

(II) A reasonable effort must be made by the pharmacist to obtain, record, and maintain at least thefollowing information regarding individuals receiving benefits under this subchapter:

(aa) Name, address, telephone number, date of birth (or age) and gender.(bb) Individual history where significant, including disease state or states, known allergies anddrug reactions, and a comprehensive list of medications and relevant devices.(cc) Pharmacist comments relevant to the individuals (FOOTNOTE 3) drug therapy.(FOOTNOTE 3) So in original. Probably should be “individual’s”.



Nothing in this clause shall be construed as requiring a pharmacist to provide consultation whenan individual receiving benefits under this subchapter or caregiver of such individual refuses suchconsultation.

(B) Retrospective drug use reviewThe program shall provide, through its mechanized drug claims processing and information retrievalsystems (approved by the Secretary under section 1396b® of this title) or otherwise, for the ongoingperiodic examination of claims data and other records in order to identify patterns of fraud, abuse, grossoveruse, or inappropriate or medically unnecessary care, among physicians, pharmacists and individualsreceiving benefits under this subchapter, or associated with specific drugs or groups of drugs.

(C) Application of standardsThe program shall, on an ongoing basis, assess data on drug use against explicit predeterminedstandards (using the compendia and literature referred to in subsection (FOOTNOTE 4) (1)(B) as thesource of standards for such assessment) including but not limited to monitoring for therapeuticappropriateness, overutilization and underutilization, appropriate use of generic products, therapeuticduplication, drug-disease contraindications, drug-drug interactions, incorrect drug dosage or duration ofdrug treatment, and clinical abuse/misuse and, as necessary, introduce remedial strategies, in order toimprove the quality of care and to conserve program funds or personal expenditures.(FOOTNOTE 4) So in original. Probably should be “paragraph”.

(D) Educational programThe program shall, through its State drug use review board established under paragraph (3), eitherdirectly or through contracts with accredited health care educational institutions, State medical societiesor State pharmacists associations/societies or other organizations as specified by the State, and usingdata provided by the State drug use review board on common drug therapy problems, provide for activeand ongoing educational outreach programs (including the activities described in paragraph (3)(C)(iii) ofthis subsection) to educate practitioners on common drug therapy problems with the aim of improvingprescribing or dispensing practices.

(3) State drug use review board

(A) EstablishmentEach State shall provide for the establishment of a drug use review board (hereinafter referred to as the“DUR Board”) either directly or through a contract with a private organization.

(B) MembershipThe membership of the DUR Board shall include health care professionals who have recognizedknowledge and expertise in one or more of the following:(i) The clinically appropriate prescribing of covered outpatient drugs.(ii) The clinically appropriate dispensing and monitoring of covered outpatient drugs.(iii) Drug use review, evaluation, and intervention.(iv) Medical quality assurance.The membership of the DUR Board shall be made up at least 1/3 but no more than 51 percent licensedand actively practicing physicians and at least 1/3 * * * (FOOTNOTE 5) licensed and actively practicingpharmacists.(FOOTNOTE 5) So in original.

(C) ActivitiesThe activities of the DUR Board shall include but not be limited to the following:(i) Retrospective DUR as defined in section (FOOTNOTE 6) (2)(B).(FOOTNOTE 6) So in original. Probably should be “paragraph”.(ii) Application of standards as defined in section (FOOTNOTE 6) (2)(C).(iii) Ongoing interventions for physicians and pharmacists, targeted toward therapy problems orindividuals identified in the course of retrospective drug use reviews performed under this subsection.Intervention programs shall include, in appropriate instances, at least:

(I) information dissemination sufficient to ensure the ready availability to physicians and pharmacists inthe State of information concerning its duties, powers, and basis for its standards;



(II) written, oral, or electronic reminders containing patient-specific or drug-specific (or both) informationand suggested changes in prescribing or dispensing practices, communicated in a manner designed toensure the privacy of patient-related information;(III) use of face-to-face discussions between health care professionals who are experts in rational drugtherapy and selected prescribers and pharmacists who have been targeted for educationalintervention, including discussion of optimal prescribing, dispensing, or pharmacy care practices, andfollow-up face-to-face discussions; and(IV) intensified review or monitoring of selected prescribers or dispensers. The Board shall re-evaluateinterventions after an appropriate period of time to determine if the intervention improved the quality ofdrug therapy, to evaluate the success of the interventions and make modifications as necessary.

(D) Annual reportEach State shall require the DUR Board to prepare a report on an annual basis. The State shall submit areport on an annual basis to the Secretary which shall include a description of the activities of the Board,including the nature and scope of the prospective and retrospective drug use review programs, asummary of the interventions used, an assessment of the impact of these educational interventions onquality of care, and an estimate of the cost savings generated as a result of such program. The Secretaryshall utilize such report in evaluating the effectiveness of each State’s drug use review program.

(h) Electronic claims management

(1) In generalIn accordance with chapter 35 of title 44 (relating to coordination of Federal information policy), the Secretaryshall encourage each State agency to establish, as its principal means of processing claims for coveredoutpatient drugs under this subchapter, a point-of-sale electronic claims management system, for the purpose ofperforming on-line, real time eligibility verifications, claims data capture, adjudication of claims, and assistingpharmacists (and other authorized persons) in applying for and receiving payment.

(2) EncouragementIn order to carry out paragraph (1) -

(A) for calendar quarters during fiscal years 1991 and 1992, expenditures under the State planattributable to development of a system described in paragraph (1) shall receive Federal financialparticipation under section 1396b(a)(3)(A)(i) of this title (at a matching rate of 90 percent) if the Stateacquires, through applicable competitive procurement process in the State, the most cost-effectivetelecommunications network and automatic data processing services and equipment; and

(B) the Secretary may permit, in the procurement described in subparagraph (A) in the application of part433 of title 42, Code of Federal Regulations, and parts 95, 205, and 307 of title 45, Code of FederalRegulations, the substitution of the State’s request for proposal in competitive procurement for advanceplanning and implementation documents otherwise required.

(i) Annual report

(1) In generalNot later than May 1 of each year the Secretary shall transmit to the Committee on Finance of the Senate, theCommittee on Energy and Commerce of the House of Representatives, and the Committees on Aging of theSenate and the House of Representatives a report on the (FOOTNOTE 7) operation of this section in thepreceding fiscal year.(FOOTNOTE 7) So in original.

(2) DetailsEach report shall include information on –

(A) ingredient costs paid under this subchapter for single source drugs, multiple source drugs, andnonprescription covered outpatient drugs;

(B) the total value of rebates received and number of manufacturers providing such rebates;



(C) how the size of such rebates compare with the size or (FOOTNOTE 8) rebates offered to otherpurchasers of covered outpatient drugs;(FOOTNOTE 8) So in original. Probably should be “of”.

(D) the effect of inflation on the value of rebates required under this section;

(E) trends in prices paid under this subchapter for covered outpatient drugs; and

(F) Federal and State administrative costs associated with compliance with the provisions of thissubchapter.

(j) Exemption of organized health care settings

(1) Covered outpatient drugs dispensed by * * * (FOOTNOTE 7) Health Maintenance Organizations, includingthose organizations that contract under section 1396b(m) of this title, are not subject to the requirements of thissection.

(2) The State plan shall provide that a hospital (providing medical assistance under such plan) that dispensescovered outpatient drugs using drug formulary systems, and bills the plan no more than the hospital’s purchasingcosts for covered outpatient drugs (as determined under the State plan) shall not be subject to the requirementsof this section.

(3) Nothing in this subsection shall be construed as providing that amounts for covered outpatient drugs paid bythe institutions described in this subsection should not be taken into account for purposes of determining the bestprice as described in subsection (C) of this section.

(k) DefinitionsIn this section -

(1) Average manufacturer priceThe term “average manufacturer price” means, with respect to a covered outpatient drug of a manufacturer for arebate period, the average price paid to the manufacturer for the drug in the United States by wholesalers fordrugs distributed to the retail pharmacy class of trade, after deducting customary prompt pay discounts.

(2) Covered outpatient drugSubject to the exceptions in paragraph (3), the term “covered outpatient drug” means -

(A) of those drugs which are treated as prescribed drugs for purposes of section 1396d(a)(12) of this title,a drug which may be dispensed only upon prescription (except as provided in paragraph (5)), and -(i) which is approved for safety and effectiveness as a prescription drug under section 505 or 507 of theFederal Food, Drug, and Cosmetic Act (21 U.S.C. 355, 357) or which is approved under section 505(j) ofsuch Act (21 U.S.C. 355(j));(ii)(I) which was commercially used or sold in the United States before October 10, 1962, or which isidentical, similar, or related (within the meaning of section 310.6(b)(1) of title 21 of the Code of FederalRegulations) to such a drug, and (II) which has not been the subject of a final determination by theSecretary that it is a “new drug” (within the meaning of section 201(p) of the Federal Food, Drug, andCosmetic Act (21 U.S.C. 321(p))) or an action brought by the Secretary under section 301, 302(a), or304(a) of such Act (21 U.S.C. 331, 332(a), 334(a)) to enforce section 502(f) or 505(a) of such Act (21U.S.C. 352(f), 355(a)); or(iii)(I) which is described in section 107(C)(3) of the Drug Amendments of 1962 and for which theSecretary has determined there is a compelling justification for its medical need, or is identical, similar, orrelated (within the meaning of section 310.6(b)(1) of title 21 of the Code of Federal Regulations) to such adrug, and (II) for which the Secretary has not issued a notice of an opportunity for a hearing under section505(e) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355(e)) on a proposed order of theSecretary to withdraw approval of an application for such drug under such section because the Secretaryhas determined that the drug is less than effective for some or all conditions of use prescribed,recommended, or suggested in its labeling; and



(B) a biological product, other than a vaccine which -(i) may only be dispensed upon prescription,(ii) is licensed under section 262 of this title, and(iii) is produced at an establishment licensed under such section to produce such product; and

(C) insulin certified under section 506 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 356).

(3) Limiting definitionThe term “covered outpatient drug” does not include any drug, biological product, or insulin provided as part of, oras incident to and in the same setting as, any of the following (and for which payment may be made under thissubchapter as part of payment for the following and not as direct reimbursement for the drug):

(A) Inpatient hospital services.

(B) Hospice services.

(C) Dental services, except that drugs for which the State plan authorizes direct reimbursement to thedispensing dentist are covered outpatient drugs.

(D) Physicians’ services.

(E) Outpatient hospital services.

(F) Nursing facility services and services provided by an intermediate care facility for the mentallyretarded.

(G) Other laboratory and x-ray services.

(H) Renal dialysis.Such term also does not include any such drug or product for which a National Drug Code number is notrequired by the Food and Drug Administration or a drug or biological (FOOTNOTE 9) used for a medicalindication which is not a medically accepted indication. Any drug, biological product, or insulin excludedfrom the definition of such term as a result of this paragraph shall be treated as a covered outpatient drugfor purposes of determining the best price (as defined in subsection (C)(1)(C) of this section) for suchdrug, biological product, or insulin.(FOOTNOTE 9) So in original. Probably should be “biological product”.

(4) Nonprescription drugsIf a State plan for medical assistance under this subchapter includes coverage of prescribed drugs as describedin section 1396d(a)(12) of this title and permits coverage of drugs which may be sold without a prescription(commonly referred to as “over-the-counter” drugs), if they are prescribed by a physician (or other personauthorized to prescribe under State law), such a drug shall be regarded as a covered outpatient drug.

(5) ManufacturerThe term “manufacturer” means any entity which is engaged in -

(A) the production, preparation, propagation, compounding, conversion, or processing of prescription drugproducts, either directly or indirectly by extraction from substances of natural origin, or independently bymeans of chemical synthesis, or by a combination of extraction and chemical synthesis, or

(B) in the packaging, repackaging, labeling, relabeling, or distribution of prescription drug products. Suchterm does not include a wholesale distributor of drugs or a retail pharmacy licensed under State law.

(6) Medically accepted indicationThe term “medically accepted indication” means any use for a covered outpatient drug which is approved underthe Federal Food, Drug, and Cosmetic Act (21 U.S.C. 301 et seq.) or the use of which is supported by one ormore citations included or approved for inclusion in any of the compendia described in subsection (g)(1)(B)(i) ofthis section.



(7) Multiple source drug; innovator multiple source drug; noninnovator multiple source drug; single source drug

(A) Defined(i) Multiple source drugThe term “multiple source drug” means, with respect to a rebate period, a covered outpatient drug (notincluding any drug described in paragraph (5)) for which there are 2 or more drug products which -

(I) are rated as therapeutically equivalent (under the Food and Drug Administration’s most recentpublication of “Approved Drug Products with Therapeutic Equivalence Evaluations”),(II) except as provided in subparagraph (B), are pharmaceutically equivalent and bioequivalent, asdefined in subparagraph (C) and as determined by the Food and Drug Administration, and(III) are sold or marketed in the State during the period.

(ii) Innovator multiple source drug The term “innovator multiple source drug” means a multiple sourcedrug that was originally marketed under an original new drug application approved by the Food and DrugAdministration.(iii) Noninnovator multiple source drugThe term “noninnovator multiple source drug” means a multiple source drug that is not an innovatormultiple source drug.(iv) Single source drugThe term “single source drug” means a covered outpatient drug which is produced or distributed under anoriginal new drug application approved by the Food and Drug Administration, including a drug productmarketed by any cross-licensed producers or distributers (FOOTNOTE 01) operating under the new drugapplication.(FOOTNOTE 01) So in original. Probably should be “distributors”.

(B) ExceptionSubparagraph (A)(i)(II) shall not apply if the Food and Drug Administration changes by regulation therequirement that, for purposes of the publication described in subparagraph (A)(i)(I), in order for drugproducts to be rated as therapeutically equivalent, they must be pharmaceutically equivalent andbioequivalent, as defined in subparagraph (C).

(C) DefinitionsFor purposes of this paragraph -(i) drug products are pharmaceuutically (FOOTNOTE 11) equivalent if the products contain identicalamounts of the same active drug ingredient in the same dosage form and meet compendial or otherapplicable standards of strength, quality, purity, and identity;(FOOTNOTE 11) So in original. Probably should be “pharmaceutically”.(ii) drugs are bioequivalent if they do not present a known or potential bioequivalence problem, or, if theydo present such a problem, they are shown to meet an appropriate standard of bioequivalence; and(iii) a drug product is considered to be sold or marketed in a State if it appears in a published nationallisting of average wholesale prices selected by the Secretary, provided that the listed product is generallyavailable to the public through retail pharmacies in that State.

(8) Rebate periodThe term “rebate period” means, with respect to an agreement under subsection (a) of this section, a calendarquarter or other period specified by the Secretary with respect to the payment of rebates under such agreement.

(9) State agencyThe term “State agency” means the agency designated under section 1396a(a)(5) of this title to administer orsupervise the administration of the State plan for medical assistance.

• SOURCE-

(Aug. 14, 1935, ch. 531, title XIX, Sec. 1927, as added Nov. 5, 1990, Pub. L. 101-508, title IV, Sec. 4401(a)(3),104 Stat. 1388-143; amended Nov. 4, 1992, Pub. L. 102-585, title VI, Sec. 601(a)-(c), 106 Stat. 4962-4964; Apr.12, 1993, Pub. L. 103-18, Sec. 2(a), 107 Stat. 54; Aug. 10, 1993, Pub. L. 103-66, title XIII, Sec. 13602(a), 107Stat. 613.)



• REFTEXT-

REFERENCES IN TEXTSection 107(C)(3) of the Drug Amendments of 1962, referred to in subsec. (k)(2)(A)(iii)(I), is section 107(c)(3) ofPub. L. 87-781 which is set out in an Effective Date of 1962 Amendment note under section 321 of Title 21, Foodand Drugs. The Federal Food, Drug, and Cosmetic Act, referred to in subsecs. (d)(4)(C) and (k)(6), is act June25, 1938, ch. 675, 52 Stat. 1040, as amended, which is classified generally to chapter 9 (Sec. 301 et seq.) of Title21. For complete classification of this Act to the Code, see section 301 of Title 21 and Tables.

• MISC2-

PRIOR PROVISIONSA prior section 1927 of act Aug. 14, 1935, was renumbered section 1928 and is classified to section 1396s of thistitle.

AMENDMENTS1993 - Subsec. (b)(1)(A). Pub. L. 103-66, Sec. 13602(a)(2)(A)(i)(II), which directed amendment of subpar. (A) bysubstituting “dispensed after December 31, 1990, for which payment was made under the State plan for suchperiod” for “dispensed under the plan during the quarter (or other period as the Secretary may specify)”, wasexecuted by making the substitution for “dispensed under the plan during the quarter (or such other period as theSecretary may specify)” to reflect the probable intent of Congress. Pub. L. 103-66, Sec. 13602(a)(2)(A)(i)(I),substituted “for a rebate period” for “each calendar quarter (or periodically in accordance with a schedulespecified by the Secretary)”. Subsec. (b)(2)(A). Pub. L. 103-66, Sec. 13602(a)(2)(A)(ii), substituted “each rebateperiod” for “each calendar quarter” and “units of each dosage form and strength and package size” for “dosageunits”, inserted “after December 31, 1990, for which payment was made” after “dispensed”, and substituted“during the period” for “during the quarter”. Subsec. (b)(3)(A)(i). Pub. L. 103-66, Sec. 13602(a)(2)(A)(iii),substituted “rebate period under the agreement” for “quarter” in two places. Subsec. (C). Pub. L. 103-66, Sec.13602(a)(1), added subsec. (c) and struck out former subsec. (C) which related to determination of amount ofrebate for certain drugs. Pub. L. 103-18 substituted “such drug, except that for the calendar quarter beginningafter September 30, 1992, and before January 1, 1993, the amount of the rebate may not exceed 50 percent ofsuch average manufacturer price;” for “such drug;” in par. (1)(B)(ii)(II).Subsecs. (d) to (f). Pub. L. 103-66, Sec. 13602(a)(1), added subsecs. (d) and (e), struck out former subsecs. (d)consisting of pars. (1) to (8) relating to limitations on coverage of drugs, (e) relating to denial of Federal financialparticipation in certain cases, and (f)(1) relating to reductions in pharmacy reimbursement limits, and struck outpar. designation for former par. (2) of subsec. (f) without supplying a new designation. The text of former subsec.(f)(2) is now the last par. of subsec. (e). Subsec. (k)(1). Pub. L. 103-66, Sec. 13602(a)(2)(B)(i), substituted “rebateperiod” for “calendar quarter” and inserted before period at end “, after deducting customary prompt paydiscounts”. Subsec. (k)(3). Pub. L. 103-66, Sec. 13602(a)(2)(B)(ii)(III), in concluding provisions, substituted “forwhich a National Drug Code number is not required by the Food and Drug Administration or a drug or biologicalused” for “which is used” and inserted at end “Any drug, biological product, or insulin excluded from the definitionof such term as a result of this paragraph shall be treated as a covered outpatient drug for purposes ofdetermining the best price (as defined in subsection (C)(1)(C) of this section) for such drug, biological product, orinsulin.”Subsec. (k)(3)(E). Pub. L. 103-66, Sec. 13602(a)(2)(B)(ii)(I), struck out “* * * *emergency room visits” after“services”. Subsec. (k)(3)(F). Pub. L. 103-66, Sec. 13602(a)(2)(B)(ii)(II), which directed amendment of subpar. (F)by substituting “services and services provided by an intermediate care facility for the mentally retarded” for“services”, was executed by making the substitution for “sevices” to reflect the probable intent of Congressbecause the word “services” did not appear. Subsec. (k)(6). Pub. L. 103-66, Sec. 13602(a)(2)(B)(iii), substituted“or the use of which is supported by one or more citations included or approved for inclusion in any of thecompendia described in subsection (g)(1)(B)(i) of this section.” for “, which appears in peer-reviewed medicalliterature or which is accepted by one or more of the following compendia: the American Hospital FormularyService-Drug Information, the American Medical Association Drug Evaluations, and the United StatesPharmacopeia-Drug Information.”Subsec. (k)(7)(A)(i). Pub. L. 103-66, Sec. 13602(a)(2)(B)(iv), substituted “rebate period” for “calendar quarter” inintroductory provisions.Subsec. (k)(8), (9). Pub. L. 103-66, Sec. 13602(a)(2)(B)(v), added par. (8) and redesignated former par. (8) as (9).1992 - Subsec. (a)(1). Pub. L. 102-585, Sec. 601(b)(1), substituted “manufacturer), and must meet therequirements of paragraph (5) (with respect to drugs purchased by a covered entity on or after the first day of thefirst month that begins after November 4, 1992) and paragraph (6)” for “manufacturer)”.



Subsec. (a)(5), (6). Pub. L. 102-585, Sec. 601(b)(2), added pars. (5) and (6).Subsec. (b)(3)(D). Pub. L. 102-585, Sec. 601(b)(3), substituted “this paragraph or under an agreement with theSecretary of Veterans Affairs described in subsection (a)(6)(A)(ii) of this section” for “this paragraph”, “Secretaryor the Secretary of Veterans Affairs” for “Secretary”, and “except - “ and cls. (i) to (iii) for “except as the Secretarydetermines to be necessary to carry out this section and to permit the Comptroller General to review theinformation provided.”Subsec. (b)(4)(B)(ii). Pub. L. 102-585, Sec. 601(b)(4)(i), (ii), substituted “the calendar quarter beginning at least60 days” for “such period” and “the manufacturer provides notice to the Secretary.” for “of the notice as theSecretary may provide (but not beyond the term of the agreement).”Subsec. (b)(4)(B)(iv), (v). Pub. L. 102-585, Sec. 601(b)(4)(iii), added cls. (iv) and (v).Subsec. (C)(1)(B)(i). Pub. L. 102-585, Sec. 601(c)(1), which directed the substitution of “October 1, 1992,” for“January 1, 1993,”, was executed by making the substitution in introductory provisions and in subcl. (II), to reflectthe probable intent of Congress.Subsec. (C)(1)(B)(ii) to (v). Pub. L. 102-585, Sec. 601(c)(2), (3), added cls. (ii) to (v) and struck out former cl. (ii)which read as follows: “for quarters (or other periods) beginning after December 31, 1992, the greater of -“(I) the difference between the average manufacturer price for a drug and 85 percent of such price, or“(II) the difference between the average manufacturer price for a drug and the best price (as defined in paragraph(2)(B)) for such quarter (or period) for such drug.”Subsec. (C)(1)(C). Pub. L. 102-585, Sec. 601(a), substituted “(excluding any prices charged on or after October 1,1992, to the Indian Health Service, the Department of Veterans Affairs, a State home receiving funds undersection 1741 of title 38, the Department of Defense, the Public Health Service, or a covered entity described insubsection (a)(5)(B) of this section, any prices charged under the Federal Supply Schedule of the GeneralServices Administration, or any prices used under a State pharmaceutical assistance program, and excluding” for“(excluding”.

• CHANGE-

CHANGE OF NAMECommittee on Energy and Commerce of House of Representatives treated as referring to Committee onCommerce of House of Representatives by section 1(a) of Pub. L. 104-14, set out as a note preceding section 21of Title 2, The Congress. Committees on Aging of the Senate and House of Representatives probably mean theSpecial Committee on Aging of the Senate and the Select Committee on Aging of the House of Representativeswhich was abolished on Jan. 5, 1993, by House Resolution No. 5, One Hundred Third Congress.

• MISC4-

EFFECTIVE DATE OF 1993 AMENDMENTSSection 13602(d) of Pub. L. 103-66 provided that:“(1) Except as provided in paragraph (2), the amendments made by this section (amending this section andsections 1396a and 1396b of this title) shall take effect as if included in the enactment of OBRA-1990 (Pub. L.101-508).“(2) The amendment made by subsection (a)(1) (amending this section) (insofar as such subsection amendssection 1927(d) of the Social Security Act (subsec. (d) of this section)) and the amendment made by subsection(C) (amending section 1396a of this title) shall apply to calendar quarters beginning on or after October 1, 1993,without regard to whether or not regulations to carry out such amendments have been promulgated by such date.”Section 2(b) of Pub. L. 103-18 provided that: “The amendment made by subsection (a) (amending this section)shall take effect as if included in the enactment of section 601(C) of the Veterans Health Care Act of 1992 (Pub.L. 102-585).”EFFECTIVE DATE OF 1992 AMENDMENTSection 601(e) of Pub. L. 102-585 provided that: “The amendments made by this section (amending this section)shall apply with respect to payments to State plans under title XIX of the Social Security Act (this subchapter) forcalendar quarters (or periods) beginning on or after January 1, 1993 (without regard to whether or not regulationsto carry out such amendments have been promulgated by such date).”REPORTS ON BEST PRICE CHANGES AND PAYMENT OF REBATES Section 601(d) of Pub. L. 102-585provided that not later than 90 days after the expiration of each calendar quarter beginning on or after Oct. 1,1992, and ending on or before Dec. 31, 1995, Secretary of Health and Human Services was to submit toCongress a report containing information as to percentage of single source drugs whose best price eitherincreased, decreased, or stayed the same in comparison to best price during previous calendar quarter, medianand mean percentage increase or decrease of such price, and, with respect to drugs for which manufacturers



were required to pay rebates under subsec. (C) of this section, Secretary’s best estimate, on State-by-State andnational aggregate basis, of total amount of rebates paid under subsec. (C) of this section and percentages ofsuch total amounts attributable to rebates paid under pars. (1) to (3) of subsec. (C) of this section, limitedconsideration to drugs which are considered significant expenditures under medicaid program, and containedrequirements for initial report.DEMONSTRATION PROJECTS TO EVALUATE EFFICIENCY ANDCOST-EFFECTIVENESS OF PROSPECTIVE DRUG UTILIZATION REVIEWSection 4401(C) of title IV of Pub. L. 101-508 directed Secretary of Health and Human Services to establishstatewide demonstration projects to evaluate efficiency and cost-effectiveness of prospective drug utilizationreview and to evaluate impact on quality of care and cost-effectiveness of paying pharmacists under thissubchapter whether or not drugs were dispensed for drug use review services, with two reports to be submitted toCongress, the first not later than Jan. 1, 1994, and the second not later than Jan. 1, 1995.STUDY OF DRUG PURCHASING AND BILLING PRACTICES IN HEALTH CARE INDUSTRY; REPORTSection 4401(d) of title IV of Pub. L. 101-508, as amended by Pub. L. 104-316, title I, Sec. 122(i), Oct. 19, 1996,110 Stat. 3837, provided that:“(1) Study of drug purchasing and billing activities of various health care systems. -“(A) The Comptroller General shall conduct a study of the drug purchasing and billing practices of hospitals, otherinstitutional facilities, and managed care plans which provide covered outpatient drugs in the medicaid program.The study shall compare the ingredient costs of drugs for medicaid prescriptions to these facilities and plans andthe charges billed to medical assistance programs by these facilities and plans compared to retail pharmacies.“(B) The study conducted under this subsection shall include an assessment of -“(i) the prices paid by these institutions for covered outpatient drugs compared to prices that would be paid underthis section (enacting this section, amending sections 1396a, 1396b, and 1396s of this title, and enactingprovisions set out above and under section 1396b of this title),“(ii) the quality of outpatient drug use review provided by these institutions as compared to drug use reviewrequired under this section, and“(iii) the efficiency of mechanisms used by these institutions for billing and receiving payment for coveredoutpatient drugs dispensed under this title (see Tables for classification).“(C) By not later than May 1, 1991, the Comptroller General shall report to the Secretary of Health and HumanServices (hereafter in this section referred to as the ‘Secretary’), the Committee on Finance of the Senate, theCommittee on Energy and Commerce of the House of Representatives, and the Committees on Aging of theSenate and the House of Representatives on the study conducted under subparagraph (A).“(2) Report on drug pricing. - The Comptroller General shall submit to the Secretary, the Committee on Finance ofthe Senate, the Committee on Energy and Commerce (now Committee on Commerce) of the House ofRepresentatives, and the Committees on Aging of the Senate and House of Representatives (see Change ofName note above) a report on changes in prices charged by manufacturers for prescription drugs to theDepartment of Veterans Affairs, other Federal programs, hospital pharmacies, and other purchasing groups andmanaged care plans.“(3) Study on prior approval procedures. -“(A) The Secretary, acting in consultation with the Comptroller General, shall study prior approval proceduresutilized by State medical assistance programs conducted under title XIX of the Social Security Act (thissubchapter), including -“(i) the appeals provisions under such programs; and“(ii) the effects of such procedures on beneficiary and provider access to medications covered under suchprograms.“(B) By not later than December 31, 1991, the Secretary and the Comptroller General shall report to theCommittee on Finance of the Senate, the Committee on Energy and Commerce of the House of Representatives,and the Committees on Aging of the Senate and the House of Representatives on the results of the studyconducted under subparagraph (A) and shall make recommendations with respect to which procedures areappropriate or inappropriate to be utilized by State plans for medical assistance.“(4) Study on reimbursement rates to pharmacists. -“(A) The Secretary shall conduct a study on (i) the adequacy of current reimbursement rates to pharmacists undereach State medical assistance programs conducted under title XIX of the Social Security Act; and (ii) the extent towhich reimbursement rates under such programs have an effect on beneficiary access to medications coveredand pharmacy services under such programs.“(B) By not later than December 31, 1991, the Secretary shall report to the Committee on Finance of the Senate,the Committee on Energy and Commerce of the House of Representatives, and the Committees on Aging of theSenate and the House of Representatives on the results of the study conducted under subparagraph (A).



“(5) Study of payments for vaccines. - The Secretary of Health and Human Services shall undertake a study of therelationship between State medical assistance plans and Federal and State acquisition and reimbursementpolicies for vaccines and the accessibility of vaccinations and immunization to children provided under this title.The Secretary shall report to the Congress on the Study not later than one year after the date of the enactment ofthis Act (Nov. 5, 1990).”

• SECREF-

SECTION REFERRED TO IN OTHER SECTIONSThis section is referred to in sections 256b, 1396a, 1396b of this title; title 38 section 8126.


National Pharmaceutical Council D-1

Appendix D:HCFA Upper Limits forMultiple Source Products


D-2 National Pharmaceutical Council


SOURCE: B = Blue Book; M = Medi-Span; R = Red Book


The following list of multiple source drugs meets the criteria set forth in 42 CFR 447.332 and §1927(e) of theSocial Security Act, as amended by OBRA 1993. The development of the current Federal Upper Limit (FUL)listing has been accomplished by computer. Payments for multiple source drugs identified and listed in theaccompanying addendum must not exceed, in the aggregate, payment levels determined by applying to each drugentity a reasonable dispensing fee (established by the State and specified in the State plan), plus an amount basedon the limit per unit which HCFA has determined to be equal to a 150 percent applied to the lowest price listed(in package sizes of 100 units, unless otherwise noted) in any of the published compendia of cost information ofdrugs. The listing is based on data current as of January 2000 from the First Data Bank (Blue Book), Medi-Span,and the Red Book. The list does not reference the commonly known brand names. However, the brand namesare included in the FUL listing provided to the State agencies in electronic media format. The FUL price list is inMicrosoft Word format at http://www.hcfa/gov/medicaid/drug10.htm.

In accordance with current policy, Federal financial participation will not be provided for any drug on the FULlisting for which the FDA has issued a notice of an opportunity for a hearing as a result of the Drug EfficacyStudy and Implementation (DESI) program and which has been found to be less than effective or is identical,related, or similar (IRS) to the DESI drug. The DESI drug is identified by the Food and Drug Administration orreported by the drug manufacturer for purposes of the Medicaid drug rebate program.

The April 6, 2000 list has been amended with a new implementation date of no later than December 7, 2000.

Generic Name Upper Limit per Unit (Source)

Acebutolol HydrochlorideEq 200 mg base, Capsule, Oral 100 $0.4613 BEq 400 mg base, Capsule, Oral 100 0.6713 B

Acetaminophen; Codeine Phosphate300 mg; 15 mg, Tablet, Oral 100 0.0980 B300 mg; 30 mg, Tablet, Oral 100 0.1200 B300 mg; 60 mg, Tablet, Oral 100 0.2280 B

Acetaminophen; Hydrocodone Bitartrate500 mg; 5 mg, Capsule, Oral 100 0.1943 R500 mg; 5 mg, Tablet, Oral 100 0.1060 R500 mg; 7.5 mg, Tablet, Oral 100 0.2300 B650 mg; 7.5 mg, Tablet, Oral 100 0.1850 B650 mg; 10 mg, Tablet, Oral 100 0.1850 R750 mg; 7.5 mg, Tablet, Oral 100 0.1750 R

Acetaminophen; Oxycodone Hydrochloride500 mg; 5 mg, Capsule, Oral 100 0.2250 B325 mg; 5 mg, Tablet, Oral 100 0.1190 B

Acetaminophen; Propoxyphene Hydrochloride650 mg; 65 mg, Tablet, Oral 100 0.1688 B

Acetaminophen; Propoxyphene Napsylate650 mg; 100 mg, Tablet, Oral 100 0.2510 B





Acetazolamide125 mg, Tablet, Oral 100 0.0760 B250 mg, Tablet, Oral 100 0.2565 B

Acetic Acid, Glacial2%, Solution/Drops, Otic 15 ml 0.1380 R

Acetic Acid, Glacial; Hydrocortisone2%; 1%, Solution/Drops, Otic 10 ml 0.4500 B

Acetylcysteine10%, Solution, Inhalation 4 ml 0.8060 B10%, Solution, Inhalation 10 ml 0.7640 R20%, Solution, Inhalation 4 ml 0.9710 B20%, Solution, Inhalation 10 ml 0.9290 R

Acyclovir200 mg, Capsule, Oral 100 0.3530 B400 mg, Tablet, Oral 100 0.7050 R800 mg, Tablet, Oral 100 1.2160 B

Albuterol SulfateEq 0.5% base, Solution, Inhalation 20 ml 0.3330 REq 2 mg base/5 ml, Syrup, Oral 480 ml 0.0350 BEq 2 mg base, Tablet, Oral 100 0.0380 BEq 4 mg base, Tablet, Oral 100 0.0550 B

Allopurinol100 mg, Tablet, Oral 100 0.0510 B300 mg, Tablet, Oral 100 0.1198 B

Alprazolam0.25 mg, Tablet, Oral 100 0.0560 B0.5 mg, Tablet, Oral 100 0.0690 B1 mg, Tablet, Oral 100 0.0920 B

Amantadine Hydrochloride100 mg, Capsule, Oral 100 0.1572 R50 mg/5 ml, Syrup, Oral 480 ml 0.0720 R

Amiloride Hydrochloride; HydrochlorothiazideEq 5 mg Anhydrous; 50 mg, Tablet, Oral 100 0.0675 R

Aminophylline100 mg, Tablet, Oral 100 0.0278 R200 mg, Tablet, Oral 1000 0.0390 R





Amiodarone Hydrochloride200 mg, Tablet, Oral 500 1.8912 R

Amitriptyline Hydrochloride10 mg, Tablet, Oral 100 0.0315 B25 mg, Tablet, Oral 100 0.0330 R50 mg, Tablet, Oral 100 0.0400 B75 mg, Tablet, Oral 100 0.0592 B100 mg, Tablet, Oral 100 0.0760 R150 mg, Tablet, Oral 100 0.1800 B

Amitriptyline Hydrochloride; Perphenazine10 mg; 2 mg, Tablet, Oral 100 0.0652 B25 mg; 2 mg, Tablet, Oral 100 0.0870 B25 mg; 4 mg, Tablet, Oral 100 0.0983 B

Amoxapine25 mg, Tablet, Oral 100 0.3524 B50 mg, Tablet, Oral 100 0.5426 B100 mg, Tablet, Oral 100 0.9300 B150 mg, Tablet, Oral 30 1.5475 B

Amoxicillin250 mg, Capsule, Oral 100 0.0636 R500 mg, Capsule, Oral 100 0.1270 B125 mg/5 ml, Powder for reconstitution, Oral 100 0.0210 B125 mg/5 ml, Powder for reconstitution, Oral 150 0.0119 B250 mg/5 ml, Powder for reconstitution, Oral 100 0.0218 B250 mg/5 ml, Powder for reconstitution, Oral 150 0.0210 B250 mg, Tablet, Chewable, Oral 100 0.1600 B

Ampicillin/Ampicillin Trihydrate250 mg, Capsule, Oral 100 0.0850 B500 mg, Capsule, Oral 100 0.1115 B

Aspirin; Carisoprodol325 mg; 200 mg, Tablet, Oral 100 0.5960 R

Aspirin; Oxycodone Hydrochloride; Oxycodone Terephthalate325 mg; 4.5 mg; 0.38 mg, Tablet, Oral 100 0.1313 R

Atenolol25 mg, Tablet, Oral 100 0.0460 B100 mg, Tablet, Oral 100 0.0672 B

Atenolol; Chlorthalidone50 mg; 25 mg, Tablet, Oral 100 0.2550 B100 mg; 25 mg, Tablet, Oral 100 0.3730 B





Atropine Sulfate; Diphenoxylate Hydrochloride0.025 mg; 2.5 mg, Tablet, Oral 100 0.3743 R

Baclofen10 mg, Tablet, Oral 100 0.0899 B20 mg, Tablet, Oral 100 0.1688 R

Benzonatate100 mg, Capsule, Oral 100 0.3899 B

Benztropine Mesylate0.5 mg, Tablet, Oral 100 0.0360 B1 mg, Tablet, Oral 100 0.0380 B2 mg, Tablet, Oral 100 0.0430 B

Betamethasone DipropionateEq 0.05% base, Cream, Topical 15 gm 0.2130 BEq 0.05% base, Cream, Topical 45 gm 0.1313 BEq 0.05% base, Lotion, Topical 60 ml 0.1440 BEq 0.05% base, Ointment, Topical 15 gm 0.3350 BEq 0.05% base, Ointment, Topical 45 gm 0.2230 B

Betamethasone ValerateEq 0.1% base, Cream, Topical 15 gm 0.1130 BEq 0.1% base, Cream, Topical 45 gm 0.0750 BEq 0.1% base, Lotion, Topical 60 ml 0.1088 B

Brompheniramine Maleate; Codeine Phosphate; Phenylpropanolamine HCL2mg/5 ml; 10 mg/5 ml; 12.5 mg/5 ml, Syrup, Oral 480 ml 0.0260 B

Brompheniramine Maleate; Dextromethorphan Hydrobromide; Pseudoephedrine HCL2mg/5 ml; 10 mg/5 ml; 30 mg/5 ml, Syrup, Oral 480 ml 0.0160 B

Bumetanide0.5 mg, Tablet, Oral 100 0.1613 R1 mg, Tablet, Oral 100 0.2810 B2 mg, Tablet, Oral 100 0.3675 R

Captopril12.5 mg, Tablet, Oral 100 0.0480 B25 mg, Tablet, Oral 100 0.0560 B50 mg, Tablet, Oral 100 0.1180 B100 mg, Tablet, Oral 100 0.2020 M





Captolpril; Hydrochlorothiazide25 mg; 15 mg, Tablet, Oral 100 0.2313 R25 mg; 25 mg, Tablet, Oral 100 0.2313 R50 mg; 15 mg, Tablet, Oral 100 0.3629 R50 mg; 25 mg, Tablet, Oral 100 0.3629 R

Carbamazepine200 mg, Tablet, Oral 100 0.1500 R

Carbidopa; Levodopa10 mg; 100 mg, Tablet, Oral 100 0.1971 B25 mg; 100 mg, Tablet, Oral 100 0.2127 B25 mg; 250 mg, Tablet, Oral 100 0.2513 B

Carisoprodol350 mg, Tablet, Oral 100 0.3743 B

CefaclorEq 250 mg base, Capsule, Oral 100 0.9290 BEq 500 mg base, Capsule, Oral 100 1.7990 BEq 125 mg base/5 ml,

Powder for reconstitution, Oral 150 0.1320 REq 187 mg base/5 ml,

Powder for reconstitution, Oral 100 0.2000 REq 250 mg base/5 ml,

Powder for reconstitution, Oral 150 0.2440 BEq 375 mg base/5 ml,

Powder for reconstitution, Oral 100 0.3660 B

CephalexinEq 250 mg base, Capsule, Oral 100 0.1700 BEq 500 mg base, Capsule, Oral 100 0.2150 BEq 125 mg base/5 ml,



Powder for reconstitution, Oral 200 0.0450 B

Chlordiazepoxide Hydrochloride10 mg, Capsule, Oral 100 0.0950 B25 mg, Capsule, Oral 100 0.1090 B

Chlorhexidine Gluconate0.12%, Solution, Dental 480 ml 0.0150 B





Chlorpheniramine Maleate4 mg, Tablet, Oral 100 0.0100 M

Chlorpropamide100 mg, Tablet, Oral 100 0.1840 B250 mg, Tablet, Oral 100 0.3885 R

Chlorthalidone25 mg, Tablet, Oral 100 0.0510 B50 mg, Tablet, Oral 100 0.0560 B

CholestyramineEq 4 gm Resin/Packet, Powder, Oral 60 pk 0.9004 B

Cimetidine200 mg, Tablet, Oral 100 0.1238 B300 mg, Tablet, Oral 100 0.1080 R400 mg, Tablet, Oral 100 0.1178 R800 mg, Tablet, Oral 100 0.3261 B

Cimetidine HydrochlorideEq 1% Base, Solution, Topical 30 ml 0.1140 B

Clemastine Fumarate2.68 mg, Tablet, Oral 100 0.3572 R

Clindamycin HydrochlorideEq 150 mg Base, Capsule, Oral 100 0.9230 B

Clindamycin PhosphateEq 1% base, Solution, Topical 30 ml 0.2095 BEq 1% base, Solution, Topical 60 ml 0.3150 R

Clomipramine Hydrochloride25 mg, Capsule, Oral 100 0.3750 B50 mg, Capsule, Oral 100 0.4985 B75 mg, Capsule, Oral 100 0.6464 R

Clonazepam0.5 mg, Tablet, Oral 100 0.2760 B1 mg, Tablet, Oral 100 0.3210 B2 mg, Tablet, Oral 100 0.4390 B





Clonidine Hydrochloride0.1 mg, Tablet, Oral 100 0.0900 B0.2 mg, Tablet, Oral 100 0.1275 B0.3 mg, Tablet, Oral 100 0.1650 B

Clorazepate Dipotassium3.75 mg, Tablet, Oral 100 0.8351 R7.5 mg, Tablet, Oral 100 1.0388 B15 mg, Tablet, Oral 100 1.4094 R

Codeine Phosphate; Phenylephrine Hydrochloride;Promethazine Hydrochloride10 mg/5 ml; 5mg/5 ml; 6.25 mg/5 ml, Syrup, Oral 480 ml 0.0190 R

Codeine Phosphate; Promethazine Hydrochloride10 mg/5 ml; 6.25 mg/5 ml, Syrup, Oral 480 ml 0.0128 B

Codeine Phosphate; Pseudoephedrine Hydrochloride; Triprolidine Hydrochloride10 mg/5 ml; 30 mg/5 ml; 1.25 mg/5 ml, Syrup, Oral 480 ml 0.0190 B

Cyclobenzaprine Hydrochloride10 mg, Tablet, Oral 100 0.0910 B

Cyclopentolate Hydrochloride1%, Solution/Drops, Ophthalmic 15 ml 0.4810 B

Desipramine Hydrochloride25 mg, Tablet, Oral 100 0.0675 R50 mg, Tablet, Oral 100 0.0825 B75 mg, Tablet, Oral 100 0.0900 R100 mg, Tablet, Oral 100 0.4370 R

Desonide0.05%, Ointment, Topical 15 gm 0.5840 B0.05%, Ointment, Topical 50 gm 0.4077 B

Desoximetasone0.25%, Cream, Topical 15 gm 0.8130 B

Dexamethasone0.5 mg/5 ml, Elixir, Oral 240 ml 0.0400 B

Dexamethasone; Neomycin Sulfate; Polymyxin B Sulfate0.1%; Eq 3.5 mg base/gm; 10,000 units/gm, Ointment, Ophthalmic 3.5 gm 1.0713 B





Dextromethorphan Hydrobromide; Promethazine Hydrochloride15 mg/5 ml; 6.25 mg/5 ml, Syrup, Oral 120 ml 0.0199 B15 mg/5 ml; 6.25 mg/5 ml, Syrup, Oral 480 ml 0.0111 B

Diazepam2 mg, Tablet, Oral 100 0.0300 B5 mg, Tablet, Oral 100 0.0320 B10 mg, Tablet, Oral 100 0.0420 B

Diclofenac Potassiuim50 mg, Tablet, Oral 100 0.8630 B

Diclofenac Sodium50 mg, Tablet, Delayed Release, Oral 100 0.4748 B75 mg, Tablet, Delayed Release, Oral 100 0.6560 R

Dicyclomine Hydrochloride10 mg, Capsule, Oral 100 0.1223 B20 mg, Tablet, Oral 100 0.1428 M

Diflunisal500 mg, Tablet, Oral 60 0.4750 B

Diltiazem Hydrochloride30 mg, Tablet, Oral 100 0.1160 B60 mg, Tablet, Oral 100 0.1810 B90 mg, Tablet, Oral 100 0.2180 B120 mg, Tablet, Oral 100 0.3520 B

Diphenhydramine Hydrochloride25 mg, Capsule, Oral 100 0.0250 B12.5 mg/5 ml, Elixir, Oral 480 ml 0.0080 B

Dipivefrin Hydrochloride0.1%, Solution/Drops, Ophthalmic 5 ml 0.8700 B0.1%, Solution/Drops, Ophthalmic 10 ml 0.6360 B0.1%, Solution/Drops, Ophthalmic 15 ml 0.7280 B

Dipyridamole75 mg, Tablet, Oral 100 0.0770 B

Doxepin HydrochlorideEq 10 mg base, Capsule, Oral 100 0.1720 BEq 25 mg base, Capsule, Oral 100 0.1820 BEq 75 mg base, Capsule, Oral 100 0.1290 BEq 100 mg base, Capsule, Oral 100 0.3830 BEq 10 mg base/ml, Concentrate, Oral 120 ml 0.1144 B





Doxycycline HyclateEq 50 mg base, Capsule, Oral 50 0.0819 BEq 100 mg base, Capsule, Oral 50 0.1050 BEq 100 mg base, Tablet, Oral 50 0.0953 B

Erythromycin250 mg, Capsule, Delayed Released Pellets, Oral 100 0.1890 B2%, Solution, Topical 60 ml 0.0650 B

Erythromycin EthylsuccinateEq 200 mg base/5 ml, Suspension, Oral 480 ml 0.0340 B

Estazolam1 mg, Tablet, Oral 100 0.5954 B2 mg, Tablet, Oral 100 0.6563 B

Estradiol0.5 mg, Tablet, Oral 100 0.1793 B1 mg, Tablet, Oral 100 0.2205 B2 mg, Tablet, Oral 100 0.3060 B

Estropipate0.75 mg, Tablet, Oral 100 0.3453 R1.5 mg, Tablet, Oral 100 0.3614 B

Etodolac200 mg, Capsule, Oral 100 0.4800 B300 mg, Capsule, Oral 100 0.5100 B400 mg, Tablet, Oral 100 0.3450 B500 mg, Tablet, Oral 100 1.0032 R

Fenoprofen CalciumEq 600 mg base, Tablet, Oral 100 0.2990 B

Fluocinolone Acetonide0.01%, Solution, Topical 60 ml 0.1170 B

Fluocinonide0.05%, Cream, Topical 15 gm 0.1880 B0.05%, Cream, Topical 30 gm 0.1439 B0.05%, Cream, Topical 60 gm 0.1187 B0.05%, Solution, Topical 60 ml 0.2640 B

Fluorometholone0.1%, Suspension/Drops, Ophthalmic 5 ml 1.6590 R0.1%, Suspension/Drops, Ophthalmic 10 ml 1.1835 R0.1%, Suspension/Drops, Ophthalmic 15 ml 0.8950 B





Fluphenazine Hydrochloride1 mg, Tablet, Oral 100 0.2120 R2.5 mg, Tablet, Oral 100 0.2775 B5 mg, Tablet, Oral 100 0.3675 B10 mg, Tablet, Oral 100 0.4760 R

Flurazepam Hydrochloride15 mg, Capsule, Oral 100 0.0656 B30 mg, Capsule, Oral 100 0.0830 R

Flurbiprofen100 mg, Tablet, Oral 100 0.3680 B

Folic Acid1 mg, Tablet, Oral 100 0.0460 B

Furosemide10 mg/ml, Solution, Oral 60 ml 0.1300 B10 mg/ml, Solution, Oral 120 ml 0.0893 B20 mg, Tablet, Oral 100 0.0420 B40 mg, Tablet, Oral 100 0.0440 R80 mg, Tablet, Oral 100 0.0710 B

Gentamicin SulfateEq 0.1% Base, Ointment, Topical 15 gm 0.1740 BEq 0.3% Base, Ointment, Ophthalmic 3.5 gm 2.6786 BEq 0.3% Base, Solution/Drops, Ophthalmic 5 ml 0.4890 BEq 0.3% Base, Solution/Drops, Ophthalmic 15 ml 0.2560 B

Glipizide5 mg, Tablet, Oral 100 0.0650 R10 mg, Tablet, Oral 100 0.0937 B

Glyburide1.5 mg, Tablet, Oral 100 0.2550 R3 mg, Tablet, Oral 100 0.3204 R6 mg, Tablet, Oral 100 0.8471 R

Gramicidin; Neomycin Sulfate; Polymyxin B Sulfate0.025 mg/ml; Eq 1.75 mg base/ml; 10,000 units/ml

Solution/Drops, Ophthalmic 10 ml 1.6680 R

Griseofulvin, Ultramicrocrystalline125 mg, Tablet, Oral 100 0.3743 B250 mg, Tablet, Oral 100 0.5093 B330 mg, Tablet, Oral 100 0.6690 B





Guanabenz AcetateEq 4 mg base, Tablet, Oral 100 0.3675 REq 8 mg base, Tablet, Oral 100 0.5625 R

Guanfacine HydrochlorideEq 1 mg base, Tablet, Oral 100 0.5250 BEq 2 mg base, Tablet, Oral 100 0.7200 B

Haloperidol0.5 mg, Tablet, Oral 100 0.0360 B1 mg, Tablet, Oral 100 0.0400 R2 mg, Tablet, Oral 100 0.0440 B5 mg, Tablet, Oral 100 0.0570 R10 mg, Tablet, Oral 100 0.0770 B

Haloperidol LactateEq 2 mg Base/ml, Concentrate, Oral 120 ml 0.1500 B

Homatropine Methylbromide; Hydrocodone Bitartrate1.5 mg/5 ml; 5mg/5 ml, Syrup, Oral 480 ml 0.0240 B

Hydralazine Hydrochloride10 mg, Tablet, Oral 100 0.0350 B25 mg, Tablet, Oral 100 0.0450 B

Hydrochlorothiazide; Propranolol Hydrochloride25 mg; 40 mg, Tablet, Oral 100 0.0771 B25 mg; 80 mg, Tablet, Oral 100 0.1044 B

Hydrochlorothiazide; Spironolactone25 mg; 25 mg, Tablet, Oral 100 0.3225 B

Hydrochlorothiazide; Triamterene25 mg; 37.5 mg, Capsule, Oral 100 0.3181 B25 mg; 50 mg, Capsule, Oral 100 0.1130 B25 mg; 37.5 mg, Tablet, Oral 100 0.2438 R50 mg; 75 mg, Tablet, Oral 100 0.0530 B

Hydrocortisone0.5%, Cream, Topical, 30 gm 0.0380 B2.5%, Cream, Topical 20 gm 0.1814 B2.5%, Cream, Topical 30 gm 0.1820 B1%, Lotion, Topical 120 ml 0.0640 B

Hydroxychloroquine Sulfate200 mg, Tablet, Oral 100 0.8540 B





Hydroxyurea500 mg, Capsule, Oral 100 1.1666 B

Hydroxyzine Hydrochloride10 mg/5 ml, Syrup, Oral 480 ml 0.0370 B10 mg, Tablet, Oral 100 0.0248 B25 mg, Tablet, Oral 100 0.0347 B50 mg, Tablet, Oral 100 0.0450 R

Hydroxyzine PamoateEq 25 mg HCL, Capsule, Oral 100 0.0794 BEq 50 mg HCL, Capsule, Oral 100 0.1013 REq 100 mg HCL, Capsule, Oral 100 0.2710 B

Ibuprofen400 mg, Tablet, Oral 100 0.0640 B600 mg, Tablet, Oral 100 0.0740 R800 mg, Tablet, Oral 100 0.1070 B

Imipramine Hydrochloride10 mg, Tablet, Oral 100 0.1557 R25 mg, Tablet, Oral 100 0.1880 R50 mg, Tablet, Oral 100 0.2290 R

Indapamide1.25 mg, Tablet, Oral 100 0.1780 B2.5 mg, Tablet, Oral 100 0.2080 B

Indomethacin25 mg, Capsule, Oral 100 0.0440 B50 mg, Capsule, Oral 100 0.0501 B

Isoniazid300 mg, Tablet, Oral 100 0.0548 B

Isosorbide Dinitrate5 mg, Tablet, Oral 100 0.0242 B10 mg, Tablet, Oral 100 0.0280 B20 mg, Tablet, Oral 100 0.0248 B5 mg, Tablet, Sublingual 100 0.0300 R

Isosorbide Mononitrate10 mg, Tablet, Oral 100 0.6110 R20 mg, Tablet, Oral 100 0.4950 B

Ketoconazole200 mg, Tablet, Oral 100 2.7645 B





Ketoprofen50 mg, Capsule, Oral 100 0.4750 B

Ketorolac Tromethamine10 mg, Tablet, Oral 100 0.6374 B

Labetalol Hydrochloride100 mg, Tablet, Oral 100 0.4670 B200 mg, Tablet, Oral 100 0.6620 B300 mg, Tablet, Oral 100 0.8810 B

Lactulose10 gm/15 ml, Solution, Oral 480 ml 0.0219 B

Levobunolol Hydrochloride0.25%, Solution/Drops, Ophthalmic 10 ml 1.2749 B0.5%, Solution/Drops, Ophthalmic 5 ml 1.3950 R0.5%, Solution/Drops, Ophthalmic 10 ml 1.4930 B0.5%, Solution/Drops, Ophthalmic 15 ml 1.4190 R

Lidocaine Hydrochloride2%, Solution, Oral 100 ml 0.0278 M

Lindane1%, Shampoo, Topical 480 ml 0.1660 B

Loperamide Hydrochloride2 mg, Capsule, Oral 100 0.1500 B

Lorazepam0.5 mg, Tablet, Oral 100 0.4350 B1 mg, Tablet, Oral 100 0.5718 B2 mg, Tablet, Oral 100 0.8480 B

Meclizine Hydrochloride12.5 mg, Tablet, Oral 100 0.0370 B25 mg, Tablet, Oral 100 0.0390 B

Medroxyprogesterone Acetate5 mg, Tablet, Oral 100 0.2250 B

Megestrol Acetate20 mg, Tablet, Oral 100 0.5000 R40 mg, Tablet, Oral 100 0.8000 B





Meprobamate200 mg, Tablet, Oral 100 0.1080 B400 mg, Tablet, Oral 100 0.1580 R

Methazolamide25 mg, Tablet, Oral 100 0.3260 B50 mg, Tablet, Oral 100 0.5000 B

Methocarbamol500 mg, Tablet, Oral 100 0.1350 B750 mg, Tablet, Oral 100 0.1710 B

Methyclothiazide5 mg, Tablet, Oral 100 0.3689 B

Methyldopa250 mg, Tablet, Oral 100 0.1013 B500 mg, Tablet, Oral 100 0.1800 B

Methylphenidate Hydrochloride5 mg, Tablet, Oral 100 0.3020 B10 mg, Tablet, Oral 100 0.4224 B20 mg, Tablet, Oral 100 0.6180 B

Methylprednisolone4 mg, Tablet, Oral 100 0.4658 R

Metoclopramide HydrochlorideEq 5 mg base/5 ml, Solution, Oral 480 ml 0.0155 BEq 5 mg base, Tablet, Oral 100 0.1200 BEq 10 mg base, Tablet, Oral 100 0.0195 R

Metoprolol Tartrate50 mg, Tablet, Oral 100 0.1060 B100 mg, Tablet, Oral 100 0.1290 B

Metronidazole250 mg, Tablet, Oral 100 0.0640 B500 mg, Tablet, Oral 100 0.1350 B

Mexiletine Hydrochloride150 mg, Capsule, Oral 100 0.6452 B200 mg, Capsule, Oral 100 0.7784 R250 mg, Capsule, Oral 100 0.8568 R

Minocycline HydrochlorideEq 50 mg base, Capsule, Oral 100 0.5020 BEq 100 mg base, Capsule, Oral 50 0.7875 B





Minoxidil2.5 mg, Tablet, Oral 100 0.3170 B10 mg, Tablet, Oral 100 0.6970 B

Nadolol20 mg, Tablet, Oral 100 0.4650 B40 mg, Tablet, Oral 100 0.5780 B120 mg, Tablet, Oral 100 1.1220 B160 mg, Tablet, Oral 100 1.1540 B

Naphazoline Hydrochloride0.1%, Solution/Drops, Ophthalmic 15 ml 0.3140 R

Naproxen250 mg, Tablet, Oral 100 0.1035 B375 mg, Tablet, Oral 100 0.1335 B500 mg, Tablet, Oral 100 0.1628 B375 mg, Tablet, Delayed Release, Oral 100 0.6450 B500 mg, Tablet, Delayed Release, Oral 100 0.9750 B

Naproxen SodiumEq 250 mg base, Tablet, Oral 100 0.1670 REq 500 mg base, Tablet, Oral 100 0.2070 B

Niacin500 mg, Tablet, Oral 100 0.0390 R

Nicardipine Hydrochloride20 mg, Capsule, Oral 100 0.3380 B30 mg, Capsule, Oral 100 0.4050 B

Nifedipine20 mg, Capsule, Oral 100 0.2470 B

Nitrofurantoin, Macrocrystalline50 mg, Capsule, Oral 100 0.5040 R100 mg, Capsule, Oral 100 0.7425 B

Nortriptyline HydrochlorideEq 10 mg base, Capsule, Oral 100 0.1020 BEq 25 mg base, Capsule, Oral 100 0.1580 REq 50 mg base, Capsule, Oral 100 0.1720 BEq 75 mg base, Capsule, Oral 100 0.2204 B





Nystatin100,000 units/gm, Cream, Topical 15 gm 0.0900 R100,000 units/gm, Cream, Topical 30 gm 0.0760 B100,000 units/ml, Suspension, Oral 60 ml 0.0620 B100,000 units/ml, Suspension, Oral 480 ml 0.0425 R500,000 units, Tablet, Oral 100 0.3563 B

Nystatin; Triamcinolone Acetonide100,000 units/gm; 0.1%, Cream, Topical 15 gm 0.0990 B100,000 units/gm; 0.1%, Cream, Topical 30 gm 0.0940 B100,000 units/gm; 0.1%, Cream, Topical 60 gm 0.0747 B100,000 units/gm; 0.1%, Ointment, Topical 15 gm 0.0990 B100,000 units/gm; 0.1%, Ointment, Topical 30 gm 0.0975 B100,000 units/gm; 0.1%, Ointment, Topical 60 gm 0.0747 B

Oxazepam10 mg, Capsule, Oral 100 0.3100 R15 mg, Capsule, Oral 100 0.5160 B30 mg, Capsule, Oral 100 1.1200 B

Oxybutynin Chloride5 mg, Tablet, Oral 100 0.1650 B

Penicillin V PotassiumEq 125 mg base/5 ml, Powder for reconstitution, Oral 200 ml 0.0120 BEq 250 mg base/5 ml, Powder for reconstitution, Oral 100 ml 0.0220 BEq 250 mg base/5 ml, Powder for reconstitution, Oral 200 ml 0.0170 BEq 250 mg base, Tablet, Oral 100 0.0491 BEq 500 mg base, Tablet, Oral 100 0.0800 B

Pentoxifylline400 mg, Tablet, Extended Release, Oral 100 0.3150 B

Perphenazine2 mg, Tablet, Oral 100 0.2550 B4 mg, Tablet, Oral 100 0.3150 B8 mg, Tablet, Oral 100 0.4290 R16 mg, Tablet, Oral 100 0.6000 B

Phenylephrine Hydrochloride; Promethazine Hydrochloride5mg/5 ml; 6.25 mg/5 ml, Syrup, Oral 480 ml 0.0092 B

Pindolol5 mg, Tablet, Oral 100 0.1540 B10 mg, Tablet, Oral 100 0.1970 B





Piroxicam10 mg, Capsule, Oral 100 0.1090 B20 mg, Capsule, Oral 100 0.1480 B

Polymyxin B Sulfate; Trimethoprim Sulfate10,000 units/ml; Eq 1 mg base/ml, Solution/Drops, Opthalmic 10 ml 1.2360 B

Potassium Chloride8 mEq, Tablet, Extended Release, Oral 100 0.0773 R

Prazosin HydrochlorideEq 1 mg base, Capsule, Oral 100 0.0580 BEq 2 mg base, Capsule, Oral 100 0.0790 REq 5 mg base, Capsule, Oral 100 0.1380 R

Prednisolone15 mg/5 ml, Syrup, Oral 240 ml 0.2580 B15 mg/5 ml, Syrup, Oral 480 ml 0.2090 B

Prednisolone Acetate1%, Suspension/Drops, Ophthalmic 5 ml 1.8900 B1%, Suspension/Drops, Ophthalmic 10 ml 1.6200 B

Prednisolone Sodium PhosphateEq 0.9% Phosphate, Solution/Drops, Ophthalmic 5 ml 1.9200 B

Prednisone5 mg, Tablet, Oral 100 0.0332 B10 mg, Tablet, Oral 100 0.0550 B20 mg, Tablet, Oral 100 0.0760 B

Primidone250 mg, Tablet, Oral 100 0.3610 B

Probenecid500 mg, Tablet, Oral 100 0.7060 B

Procainamide Hydrochloride500 mg, Tablet, Extended Release, Oral 100 0.2460 B

Prochlorperazine MaleateEq 5 mg base, Tablet, Oral 100 0.3986 REq 10 mg base, Tablet, Oral 100 0.5766 B

Promethazine Hydrochloride6.25 mg/5 ml, Syrup, Oral 120 ml 0.0219 B6.25 mg/5 ml, Syrup, Oral 480 ml 0.0079 B





Proparacaine Hydrochloride0.5%, Solution/Drops, Ophthalmic 15 ml 0.4990 B

Propoxyphene Hydrochloride65 mg, Capsule, Oral 100 0.1350 B

Propranolol Hydrochloride10 mg, Tablet, Oral 100 0.0500 B20 mg, Tablet, Oral 100 0.0410 B40 mg, Tablet, Oral 100 0.0490 B80 mg, Tablet, Oral 100 0.0530 B

Quinidine Gluconate324 mg, Tablet, Extended Release, Oral 100 0.4200 R

Ranitidine HydrochlorideEq 150 mg base, Tablet, Oral, 100 0.3410 BEq 300 mg base, Tablet, Oral 100 0.6830 B

Selegiline Hydrochloride5 mg, Tablet, Oral 60 0.8230 R

Selenium Sulfide2.5%, Lotion/Shampoo, Topical 120 ml 0.0350 B

Spironolactone25 mg, Tablet, Oral 100 0.3000 B

Sucralfate1 gm, Tablet, Oral 100 0.3690 B

Sulfacetamide Sodium10%, Ointment, Ophthalmic 3.5 gm 1.4530 M10%, Solution/Drops, Opthalmic 15 ml 0.1240 B

Sulfamethoxazole; Trimethoprim200 mg/5 ml; 40 mg/5 ml, Suspension, Oral 480 ml 0.0230 B400 mg; 80 mg, Tablet, Oral 100 0.1325 B800 mg; 160 mg, Tablet, Oral 100 0.2070 B

Sulfasalazine500 mg, Tablet, Oral 100 0.1403 R

Sulindac150 mg, Tablet, Oral 100 0.2138 R200 mg, Tablet, Oral 100 0.3500 B





Temazepam15 mg, Capsule, Oral 100 0.1300 B30 mg, Capsule, Oral 100 0.1560 B

Tetracycline Hydrochloride500 mg, Capsule, Oral 100 0.0650 B

Theophylline80 mg/15 ml, Elixir, Oral 480 ml 0.0070 B100 mg, Tablet, Extended Release, Oral 100 0.0710 B200 mg, Tablet, Extended Release, Oral 100 0.0940 B300 mg, Tablet, Extended Release, Oral 100 0.1070 R450 mg, Tablet, Extended Release, Oral 100 0.2700 B

Thioridazine Hydrochloride100 mg/ml, Concentrate, Oral 120 ml 0.2376 B10 mg, Tablet, Oral 100 0.0939 R25 mg, Tablet, Oral 100 0.1103 R50 mg, Tablet, Oral 100 0.1760 B100 mg, Tablet, Oral 100 0.2324 R

Thiothixene1 mg, Capsule, Oral 100 0.0890 B2 mg, Capsule, Oral 100 0.1190 B5 mg, Capsule, Oral 100 0.1690 B10 mg, Capsule, Oral 100 0.2289 B

Timolol MaleateEq 0.25% base, Solution/Drops, Ophthalmic 5 ml 0.7500 BEq 0.25% base, Solution/Drops, Ophthalmic 10 ml 0.7970 BEq 0.25% base, Solution/Drops, Ophthalmic 15 ml 0.7500 BEq 0.5% base, Solution/Drops, Ophthalmic 5 ml 1.4070 BEq 0.5% base, Solution/Drops, Ophthalmic 10 ml 1.0310 BEq 0.5% base, Solution/Drops, Ophthalmic 15 ml 1.0000 B5 mg, Tablet, Oral 100 0.1538 B10 mg, Tablet, Oral 100 0.2138 B

Tobramycin0.3%, Solution/Drops, Ophthalmic 5 ml 0.7680 B

Tolazamide250 mg, Tablet, Oral 100 0.1038 B500 mg, Tablet, Oral 100 0.2480 B

Tolmetin SodiumEq 400 mg base, Capsule, Oral 100 0.7280 BEq 600 mg base, Tablet, Oral 100 0.9098 R





Trazodone Hydrochloride50 mg, Tablet, Oral 100 0.0640 B100 mg, Tablet, Oral 100 0.0952 R150 mg, Tablet, Oral 100 0.4280 B

Triamcinolone Acetonide0.025%, Cream, Topical 15 gm 0.0950 R0.025%, Cream, Topical 454 gm 0.0132 B0.1%, Cream, Topical 15 gm 0.0810 B0.1%, Cream, Topical 80 gm 0.0420 B0.1%, Cream, Topical 454 gm 0.0295 R0.5%, Cream, Topical 15 gm 0.1889 B0.1%, Lotion, Topical 60 ml 0.1215 B0.1%, Ointment, Topical 15 gm 0.0810 B0.1%, Ointment, Topical 80 gm 0.0502 B0.1%, Ointment, Topical 454 gm 0.0381 B0.1%, Paste, Dental 5 gm 0.8250 B

Triazolam0.125 mg, Tablet, Oral 100 0.4000 R

Trifluoperazine HydrochlorideEq 1 mg base, Tablet, Oral 100 0.2433 BEq 2 mg base, Tablet, Oral 100 0.3552 BEq 5 mg base, Tablet, Oral 100 0.4271 BEq 10 mg base, Tablet, Oral 100 0.5400 B

Trimethoprim100 mg, Tablet, Oral 100 0.1553 B

Tropicamide0.5%, Solution/Drops, Ophthalmic 15 ml 0.6550 B1%, Solution/Drops, Ophthalmic 15 ml 0.7000 B

Valproic Acid250 mg, Capsule, Oral 100 0.2100 B250 mg/5 ml, Syrup, Oral 480 ml 0.0670 B

Verapamil Hydrochloride120 mg, Capsule, Extended Release, Oral 100 0.8250 B180 mg, Capsule, Extended Release, Oral 100 0.8700 B240 mg, Capsule, Extended Release, Oral 100 0.9900 B40 mg, Tablet, Oral 100 0.1840 R80 mg, Tablet, Oral 100 0.0620 B120 mg, Tablet, Oral 100 0.0860 B180 mg, Tablet, Extended Release, Oral 100 0.2352 B240 mg, Tablet, Extended Release, Oral 100 0.2175 B





Warfarin Sodium1 mg, Tablet, Oral 100 0.4361 B2 mg, Tablet, Oral 100 0.4553 B2.5 mg, Tablet, Oral 100 0.4692 B3 mg, Tablet, Oral 100 0.4718 R4 mg, Tablet, Oral 100 0.4724 B5 mg, Tablet, Oral 100 0.4761 B6 mg, Tablet, Oral 100 0.6752 R7.5 mg, Tablet, Oral 100 0.6981 B10 mg, Tablet, Oral 100 0.7244 B





National Pharmaceutical Council E-1

Appendix E:Glossary


E-2 National Pharmaceutical Council



GLOSSARY OF MEDICAL, MEDICAID,AND MANAGED CARE TERMS

Term Definition

Access A patient’s ability to obtain medical care. The ease of access is determined bycomponents such as the availability of medical services and their acceptabilityto the patient, the location of health care facilities, transportation, hours ofoperation and affordability of care.

Actual Acquisition Cost The pharmacist’s net payment made to purchase a drug product, after takinginto account such items as purchasing allowances, discounts, and rebates.

Actual Charge The amount a physician or other provider actually bills a patient for aparticular medical service, procedure or supply in a specific instance. Theactual charge may differ from the usual, customary, prevailing, and/orreasonable charge.

Acute Care Medical treatment rendered to individuals whose illnesses or health problemsare of a short-term or episodic nature. Acute care facilities are those hospitalsthat mainly serve persons with short-term health problems.

Additional Drug Benefit List A list of pharmaceutical products approved by a health plan and employer fordispensing in larger quantities than the standards covered under a benefitpackage in order to facilitate long-term patient use. The list is subject toperiodic review and modification by the health plan. Also called “drugmaintenance list.”

Adjudication Processing a claim through a series of edits in order to determine properpayment.

Administrative Costs The costs incurred by a carrier, such as an insurance company or HMO, forservices such as claims processing, billing and enrollment, and overheadcosts. Administrative costs can be expressed as a percentage of premiums oron a per member per month basis. Additional costs that are often expressed asadministrative include those related to utilization review, insurance marketing,medical underwriting, agents’ commissions, premium collection, claimsprocessing, insurer profit, quality assurance activities, medical libraries andrisk management.

Administrative Services Only (ASO) An insurance arrangement requiring the employer to be at risk for the cost ofhealth care services provided, while a separate company deliversadministrative services. This is a common arrangement when an employersponsors a self-funded health care program.

Adverse Selection A term used to describe a situation in which a health plan disproportionallyenrolls a population that is prone to higher than average utilization of benefits,thereby driving up costs and increasing financial risk.



Term Definition

Aged For purposes of Medicare enrollment, persons 65 years of age or over areconsidered to be aged. Medicaid eligibility is determined on the basis offinancial need for people who meet Supplemental Security Income eligibilitycriteria (aged, blind, or disabled individuals) and Aid to Families withDependent Children criteria (adults and children). Eligibility determinationsare made for an entire economic unit or “case” (sometimes a family) based onwhether or not one member of a case meets the criteria. For example, an“aged” case could consist of a 66 year old male and his 63 year old wife. Incontrast, a disabled enrollee could be over 65 years of age. May also bedefined as “Elderly.”

Agency for Health Care Policy andResearch (AHCPR)

A federal agency under Health and Human Services (HHS) whose purpose isto enhance the quality and effectiveness of healthcare by funding healthcareservices research, conducting health technology assessments and outcomesstudies, and developing and disseminating clinical practice guidelines.

Aid to Families with DependentChildren (AFDC)

A state-based federal cash assistance program for low-income families. In allstates, AFDC recipiency may be used to establish Medicaid eligibility. Nowknown as Temporary Assistance to Needy Families (TANF).

Allied Health Personnel Specially trained and licensed (when necessary) health workers other thanphysicians, dentists, optometrists, chiropractors, podiatrists and nurses. Theterm is sometimes used synonymously with paramedical personnel, all healthworkers who perform tasks that must otherwise be performed by a physician,or health workers who do not usually engage in independent practice.

Allowable Charge The maximum fee that a third party will reimburse a provider for a givenservice. An allowable charge may not be the same amount as either areasonable or customary charge.

Allowable Costs Charges for services rendered or supplies furnished by a health provider,which qualify for an insurance reimbursement.

Ambulatory Care All types of health services that are provided on an outpatient basis, incontrast to services provided in the home or to persons who are inpatients.While many inpatients may be ambulatory, the term ambulatory care usuallyimplies that the patient must travel to a location to receive services which donot require an overnight stay.

Ambulatory Surgery Any minor surgical procedures that can be performed at any type of medicalfacility on an outpatient basis, i.e., not requiring an overnight stay.

American National Standards Institute(ANSI)

A nonprofit organization that coordinates the development of voluntarynational standards in both the public and private sectors.

Ancillary Charge (1) The fee associated with additional service performed prior to and/orsecondary to a significant procedure. (2) Also referred to as hospital “extras”or miscellaneous hospital charges. They are supplementary to a hospital’sdaily room and board charge. They include such items as charges for drugs,medicines and dressings, lab services, x-ray examinations, and use of theoperating room.



Term Definition

Ancillary Services Hospital services other than room, board, and professional services. Theymay include X-rays, lab tests, or anesthesia.

Antitrust A legal term encompassing a variety of efforts on the part of government toassure that sellers do not conspire to restrain trade or fix prices for their goodsor services in the market.

Any Willing Provider A requirement that a health insurance plan or a health maintenanceorganization (HMO) must sign a contract for the delivery of healthcareservices with any provider in the area that would like to provide such servicesto the plan’s or HMO’s enrollees, and can meet the terms of a contract.

Assignee The person to whom the rights to a health insurance policy are assigned, eitherin part or in whole, by the original policyholder.

Assignment of Benefits A method under which a claimant requests that his/her benefits under a claimbe paid to some designated person or institution, usually a physician orhospital.

At-Risk Accepting prepayment as full coverage for a predetermined healthcare benefitand assuming financial liability for any loss that occurs when premiums paidare less than the cost of services provided.

Authorization As it applies to managed care, authorization is the approval of care, such ashospitalization.

Average Cost Per Claim The average dollar amount of administrative and/or medical services renderedfor the unit of measure within each expenditure category. The calculation is$amount / #of units.

Average Manufacturer Price (AMP) The average price paid by wholesalers for products distributed to the retailclass of trade.

Average Wholesale Price (AWP) The published suggested wholesale price of a drug. It is often used bypharmacies as a cost basis for pricing prescriptions.

Barriers To Access Barriers to access can be financial (insufficient monetary resources),geographic (distance to providers), organizational (lack of availableproviders) and sociological (e.g., discrimination, language barriers). Efforts toimprove access often focus on providing/improving health coverage.

Behavioral Health Care Assessment and treatment of mental and/or psychoactive substance abusedisorders.

Beneficiary An individual who receives benefits from or is covered by an insurance policyor other health care financing program. Also known as a "member","enrollee," "subscriber," or "insured."

Benefit A service provided under an insurance policy or prepayment plan.

Benefit Maximum Specifies a dollar limit for the total reimbursement of health care costs duringa benefit period.



Term Definition

Benefit Package Services an insurer, government agency, or health plan offers to a group orindividual under the terms of a contract.

Best Price For purposes of Medicaid rebate calculations, lowest price paid for a productby any purchaser other than Federal agencies and state pharmaceuticalassistance programs.

Biological Equivalents Those chemical equivalents which, when administered in the same amounts,will provide the same biological or physiological availability, as measured byblood levels, urine levels, etc.

Blue Book (MDBT) The generic name for a widely used pricing guide entitled the AmericanDruggist First Databank Annual Directory of Pharmaceuticals. Brand nameand generic drugs are listed by product, manufacturer, National Drug orUniversal Price Codes, direct price and average wholesale price (AWP).Other pricing guides are the Red Book and Medispan’s Pricing Guide.

Brand-Name Name identifying a drug as the product of a specific pharmaceutical company.Also known as proprietary trademark name.

Cafeteria Plan An employee benefit plan under which all participants are permitted to chooseamong two or more benefit options according to their needs and/or ability topay. Also called a flexible benefit plan of “flex plan.”

Capitation A method of payment in which a health plan, such as an HMO or a specifichealth care provider, receives a fixed amount for each person eligible toreceive services ($ per member per month), which is made whether or not thecovered person becomes an active patient and without regard to the numberand mix of services used by that patient.

Capitation Fund A fund based on the number of members multiplied by the budgeted orcapitated amount each member pays. Some HMOs, in lieu of reimbursingphysicians on a direct capitation basis, may establish such a fund. Physiciansare then reimbursed on a fee-for-service basis from the capitation fund. TheHMO monitors patient visits for over-utilization; patients exceeding the normare notified.

Card Programs The use of a drug benefit identification card which, when presented to aparticipating pharmacy by employees or their dependents, usually entitlesthem to receive the medication for a copay.

Care Coordinator A primary health care practitioner: (1) who provides primary care services toan enrollee, (2) who is generally responsible for coordinating the enrollee’shealthcare, and (3) with whom, other than in an emergency, a patient mustconsult to obtain a referral to a specialist provider in order to obtain thehighest level of benefits available under a health plan. Care coordinators aresometimes called “gatekeepers.”

Carve Out A decision to purchase separately a service that is typically a part of anindemnity or HMO plan. Example: an HMO may “carve out” the behavioralhealth benefits and select a specialized vendor to supply these services on astand-alone basis.



Term Definition

Case Management (1) A process whereby covered persons with specific health care needs areidentified and a plan designed to efficiently utilize healthcare resources isformulated and implemented to achieve the optimum patient outcome in themost cost-effective manner. (2) A utilization management program that assiststhe patient in determining the most appropriate and cost-effective treatmentplan. It is used for patients who have prolonged expensive or chronicconditions, helps determine the treatment location (hospital, or otherinstitution, or home), and authorizes payment for such care if it is not coveredunder the patient’s benefit agreement.

Case Manager An experienced professional (e.g., nurse, doctor or social worker) who workswith patients, providers and insurers to coordinate all services deemednecessary to provide the patient with a plan of medically necessary andappropriate health care.

Categorically Needy Under Medicaid, categorically needy causes are aged, blind, or disabledindividuals or families and children who meet financial eligibilityrequirements for Aid to Families with Dependent Children, SupplementalSecurity Income, or an optional state supplement.

Certificate of Need (CON) A certificate issued by a government body, where required, to an individual ororganization proposing to construct or modify a health facility, acquire majornew medical equipment, or offer a new or different health service. Suchissuance recognizes that a facility or services, when available, will meet theneeds of those for whom it is intended.

Chain Pharmacy One of a group of pharmacies, usually three or more, under the samemanagement or ownership.

Charity Care Pools The assets of several funds combined to cover health care costs to the poorand uninsured. The pools are established by organizations such as hospitalsand insurance companies to offset a portion of the cost for providing healthcare to the indigent.

Chemical Equivalents Those multiple-source drug products containing identical amounts of the sameactive ingredients, in equivalent dosage forms, and meeting existingphysical/chemical standards.

Chronic Care Care and treatment rendered to individuals whose health problems are of along-term and continuing nature. Rehabilitation facilities, nursing homes, andmental hospitals may be considered chronic care facilities.

Claim Information on medical services provided that is submitted by a provider or acovered person from which processing for payment to the provider or coveredperson is made. The term generally refers to the liability for health careservices received by covered persons.

Claims Administration A carrier function involving the review of health insurance claims submittedfor payment, by individual claim or in the aggregate. Claims administration,as it relates to professional review programs, is an identification procedure,screening treatment or charge pattern, for subsequent peer review andadjudication.

Claims Clearinghouse System A system which allows electronic claims submission through a single source.



Term Definition

Claims Review The method by which an enrollee’s health care service claims are reviewedbefore reimbursement is made. The purpose of this monitoring system is tovalidate the medical appropriateness of the provided services and to be surethe cost of the service is not excessive.

Clearinghouse Capability A company capable of submitting electronic and/or paper claims to severalthird-party payers.

Clinical Indicator A tool or marker used to monitor and evaluate care to assure desirableoutcomes and to explain or prevent undesirable outcomes.

Clinical Outcome The status of the patient’s health, especially after receipt of medical careservices. Assessment of outcomes may be dependent upon targeted goals,clinical markers, and the ability to provide objective measurements.

Clinical Practice Guidelines Guidelines that specify the appropriate course(s) of treatment for specifiedhealth conditions.

Closed-Panel HMO Generally offers the services of a relatively limited number of healthcareproviders, e.g., physicians employed by the HMO. Staff- and group-modelHMOs are usually referred to as being in this category.

Coinsurance The portion of covered healthcare costs for which the covered person has afinancial responsibility, usually according to a fixed percentage. Oftencoinsurance applies after first meeting a deductible requirement.

Community Rating A method of determining a premium structure that is influenced not by theexpected level of benefit utilization by specific groups, but by expectedutilization by the population as a whole. Most often based on the entirepopulation of a metropolitan statistical area (MSA). The intent is to spreadrisk over a large number of covered lives.

Competitive Medical Plan (CMP) A status granted by the federal government to an organization meetingspecified criteria, enabling that organization to obtain a Medicare riskcontract.

Compliance The degree to which patients follow treatment recommendations.

Comprehensive Benefits Plan A variation of the major medical plan which carries copayment requirements,usually 10-20 percent of all health expenses and deductibles ranging from$100 to $1,000.

Concurrent Drug Evaluation An electronic assessment of claims at the point of service to detect potentialproblems that should be addressed prior to dispensing drugs to patients.

Consolidated Omnibus ReconciliationAct (COBRA)

A federal law that, among other things, requires employers to offer continuedhealth insurance coverage to certain employees and their beneficiaries whosegroup health insurance coverage has been terminated.

Consumer Price Index (CPI) A price index constructed monthly by the U.S. Bureau of Labor using retailprices of goods and services sold in large cities across the country.

Continuous Quality Improvement(CQI)

A formal process of constantly seeking better ways to achieve stated goals.



Term Definition

Continuum of Care A range of clinical services provided to an individual or group, which mayreflect treatment rendered during a single inpatient hospitalization, or care formultiple conditions over a lifetime. The continuum provides a basis foranalyzing quality, cost and utilization over the long term.

Contract Pharmacy System Pharmaceutical benefit delivery arrangement in which an HMO contracts withcommunity pharmacies (chain or selected independents) to providemedications to members. Reimbursement may be by fee-for-service,capitation, or some other arrangement.

Contributory Program A method of payment for group coverage in which part of the premium is paidby the employee and part is paid by the employer or union.

Copay/Copayment A cost-sharing arrangement in which a covered person pays a specified chargefor a specified service, such as $10 for an office visit. The covered person isusually responsible for payment at the time the healthcare is rendered.Typical copayments are fixed or variable flat amounts for physician officevisits, prescriptions or hospital services. Some copayments are referred to ascoinsurance, with the distinguishing characteristics that copayments are flat orvariable dollar amounts and coinsurance is a defined percentage of thecharges for services rendered.

Cosmetic Procedures Those procedures which involve physical appearance, but which do notcorrect or materially improve a physiological function and are not deemedmedically necessary.

Cost Sharing Any provision of a health insurance policy that requires the insured to paysome portion of medical expenses. The general term includes deductibles,copayments, and coinsurance.

Cost Shifting The redistribution of payment sources. Typically, cost shifting occurs whenone payer obtains a discount on provider services, and the providers increasecosts to another payer to make up the difference.

Cost-Based Reimbursement Payment by third party insurers in which the amount is based on the cost tothe provider of delivering services.

Cost-Effectiveness Usually considered as a ratio, the cost-effectiveness of a drug or procedure,for example, relates the cost of that drug or procedure to the health benefitsresulting from it. In health terms, it is often expressed as the cost per year perlife saved.

Cost-Sharing A general set of financing arrangements via deductibles, copays and/orcoinsurance in which a person covered by the health plan must pay some ofthe costs to receive care. See also “Copayment”, “Coinsurance”, and“Deductible”.

Counter Detailing A process of re-educating or influencing prescribers in a closed or controlledHMO plan. Usually done in order to gain more compliance with a formulary.In a counter-detailing program, techniques used by pharmaceutical salesrepresentatives are adapted to a “counter” objective, i.e., to provide doctorswith basic pharmacological information designed to influence theirprescribing habits.

Coverage Entire range of protection provided under an insurance contract.



Term Definition

Covered Expenses Medical and related costs, experienced by those covered under the policy, thatqualify for reimbursement under terms of the insurance contract.

Covered Services The specific services and supplies for which Medicaid will providereimbursement. Covered services under Medicaid consist of a combination ofmandatory and optional services within each state.

Credentialing A process of review to approve a provider who applies to participate in ahealth plan. Specific criteria and prerequisites are applied in determininginitial and ongoing participation in the health plan.

Customary Charge The charge a physician or supplier usually bills his patients for furnishing aparticular service or supply is called the customary charge.

Customary, Prevailing, and ReasonableCharges

Method of reimbursement which limits payment to the lowest of thefollowing: physician’s actual charge, physician’s median charge in a recentprior period (customary), or the 75th percentile of charges in the same timeperiod (prevailing).

Day Supply Maximum The maximum amount of medication a person may receive at one time,usually the amount needed for 30 (acute) or 90 (maintenance) days of therapy,as defined by the drug benefit.

Deductible An amount the insured person must pay before payments for covered servicesbegin. For example, an insurance plan might require the insured to pay thefirst $250 of covered expenses during a calendar year before the insurancecompany will begin payment.

Demand The amount of care a population seeks to obtain through the health deliverysystem.

Dependent An individual who relies on an employee for support or obtains healthcoverage through a spouse, parent, or grandparent who is the covered person.

Depot Price The price(s) available to any depot of the federal government, for purchase ofdrugs from the Manufacturer through the depot system of procurement.

Diagnostic Center Freestanding or hospital-based facility that specializes in diagnosing illnessesand injuries.

Diagnostic Related Group (DRG) A system of classification for inpatient hospital services based on principaldiagnosis, secondary diagnosis, surgical procedures, age, sex and presence ofcomplications. This system of classification is used as a financing mechanismto reimburse hospital and selected other providers for services rendered.

Disability (1) Any condition that results in functional limitations that interfere with anindividual’s ability to perform his/her customary work and which results insubstantial limitation in one of more major life activities. (2) Condition(s) thatprevent or limit an individual’s ability to engage in normal activities. Thesemay be temporary.

Disability Income Insurance Type of health insurance that periodically pays a disabled subscriber toreplace income lost during the period of disability.



Term Definition

Disease Management An effort to improve patient outcomes and lower costs by organizing managedcare initiatives around patients with a particular disease or condition.

Dismemberment Loss of body parts stemming from accidental physical injury.

Dispense As Written (DAW) A prescribing directive issued by physicians to indicate that the pharmacyshould not in any way alter a prescription. Such alterations are usually donein order to substitute a generic drug for the brand-name drug ordered.

Dispensing, Fill or Professional Fee The amount paid to a pharmacy for each prescription, in addition to thenegotiated formula for reimbursing ingredient cost.

Drug Detailing Presenting information about a brand-name drug product to prescribers toeducate them about its activity, uses, side effects, proper dosage andadministration, etc.

Drug Formulary A listing of prescription medications which are preferred for use by a healthplan and which may be dispensed through participating pharmacies to coveredpersons. This list is subject to periodic review and modification by the healthplan. A plan that has adopted an “open or voluntary” formulary allowscoverage for both formulary and non-formulary medications. A plan that hasadopted a “closed, select or mandatory” formulary limits coverage to thosedrugs in the formulary.

Drug Use Evaluation (DUE) Evaluations of prescribing patterns of prescribers to specifically determine theappropriateness of drug therapy. There are three forms of DUE: prospective(before or at the time of prescription dispensing), concurrent (during thecourse of drug therapy), and retrospective (after the therapy has beencompleted). Same as “Drug Utilization Review.”

Drug Utilization The prescribing, dispensing, administering and ingestion or use ofpharmaceutical products.

Drug Utilization Review (DUR) A quantitative evaluation of prescription drug use, physician prescribingpatterns or patient drug utilization to determine the appropriateness of drugtherapy. Most often focuses on over utilization.

Early and Periodic Screening,Diagnosis, and Treatment (EPSDT)

The EPSDT program covers screening and diagnostic services to determinephysical or mental defects in recipients under age 21, as well as health careand other measures to correct or ameliorate any defects and chronicconditions discovered.

Electronic Data Interchange (EDI) The computer-to-computer exchange of business or other information. Thedata may be in either a standardized or priority format.

Employee Benefits Program Health insurance and other benefits, beyond salaries, offered to employees attheir place of work. The employer typically picks up all or part of the cost ofthese benefits.

Employee Retirement Income SecurityAct of 1974, Public Law 93-406(ERISA)

A Federal act passed in 1974, that established new standards andreporting/disclosure requirements for employer-funded pension and healthbenefit programs. To date, self-funded health benefit plans operating underERISA have been held to be exempt from state insurance laws.



Term Definition

Enrollment The total number of covered persons in a health plan. Also refers to theprocess by which a health plan signs up groups and individuals formembership, or the number of enrollees who sign up in any one group.

Estimated Acquisition Cost (EAC) An estimate of the price generally, and currently, paid by providers for a drugmarketed or sold by a particular manufacturer or labeler in the package sizemost frequently purchased by providers.

Exclusions Specific conditions or circumstances listed in the contract or employee benefitplan for which the policy or plan will not provide benefit payments.

Exclusivity Clause A part of a contract which prohibits physicians from contracting with morethan one health maintenance organization or preferred provider organization.

Expenditures Under Medicaid, “expenditures” refers to an amount paid out by a stateagency for the covered medical expenses of eligible participants.

Experience Rating The process of setting rates based partially or in whole on previous claimsexperience and projected required revenues for a future policy year for aspecific group or pool of groups.

Experimental, Investigational orUnproven Procedures

Medical, surgical, psychiatric, substance abuse or other healthcare services,supplies, treatments, procedures, drug therapies or devices that are determinedby the health plan (at the time it makes a determination regarding coverage ina particular case) to be either: not generally accepted by informed healthcareprofessionals in the U.S. as effective in treating the condition, illness ordiagnosis for which their use is proposed; or not proven by scientific evidenceto be effective in treating the condition, illness or diagnosis for which theiruse is proposed.

Extended Care Long-term care, ranging from routine assistance for daily activities tosophisticated medical and nursing care for those needing it. The care, coveredunder certain insurance policies, can be provided in homes, day-care centersor other facilities.

Family Planning Services Any medically approved means, including diagnosis, treatment, drugs,supplies and devices, and related counseling which are furnished or prescribedby or under the supervision of a physician for individuals of childbearing agefor purposes of enabling such individuals freely to determine the number orspacing of their children.

Favorable Selection A tendency for utilization of health services in a population group to be lowerthan expected or estimated.

Federally Qualified HMOs HMOs that meet certain federally stipulated provisions aimed at protectingconsumers: e.g., providing a broad range of basic health services, assuringfinancial solvency, and monitoring the quality of care. HMOs must apply tothe federal government for qualification. The Office of Prepaid Health Care ofthe Health Care Financing Administration (HCFA) administers the process.

Fee Maximum The maximum amount a participating provider may be paid for a specifichealthcare service provided to a covered person under a specific contract.Sometimes called “fee max.”



Term Definition

Fee Schedule A listing of codes and related services with pre-established payment amountsthat could be percentages of billed charges, flat rates or maximum allowableamounts.

Fee-for-Service Reimbursement The traditional healthcare payment system, under which physicians and otherproviders receive a payment that does not exceed their billed charge for eachunit of service provided. Fees are paid as care is rendered.

First-Dollar Coverage Health policies that pay all or a portion of medical expenses upon enrollment,without a deductible charge.

Fiscal Agent A contractor that processes or pays vendor claims on behalf of a Medicaidagency.

Fiscal Intermediary The agent that has contracted with providers of service to process claims forreimbursement under health care coverage. In addition to handling financialmatters, it may perform other functions such as providing consultativeservices or serving as a center for communication with providers and makingaudits of providers’ records.

Fiscal Year Any predetermined set of 12 months for which annual accounts are kept. TheFederal Government’s fiscal year extends from Oct. 1 to the following Sept.30.

Fixed Fee An established “fee” schedule for pharmacy services allowed by certaingovernment and private third-party programs in lieu of cost-of-doing businessmarkups.

Formulary See “Drug Formulary.”

Free-Standing Hospital Any hospital that is not affiliated with a multihospital system.

Freedom-of-Choice (FOC) Legislation requiring managed care organizations to allow members to chooseproviders whether or not they connect with the plans (often coupled with anywilling provider (AWP) legislation).

Gatekeeper See “Care Coordinator.”

Generic Drug A chemically equivalent copy of a brand-name drug whose patent has expired.Drug formulations must be of identical composition with respect to the activeingredient (i.e., meet official standards of identity, purity, and quality of activeingredient). Also called generic equivalent.

Generic Equivalent See “Generic Drug.”

Generic Substitution Dispensing a generic drug in place of a brand-name medication.

Global Target A financing method identical to a global budget except that no enforcementmechanism is used to keep providers and hospitals within budget (i.e.,providers and hospitals will receive additional funding if their costs exceedtheir budgeted payments).

HCFA 1500 A universal form developed by the government agency known as Health CareFinancing Administration (HCFA), for providers of services to billprofessional fees to health carriers.



Term Definition

HCFA Common Procedural CodingSystem (HCPCS)

A listing of services, procedures and supplies offered by physicians and otherproviders. HCPCS includes current procedural terminology (CPT) codes,national alphanumeric codes and local alphanumeric codes. The nationalcodes are developed by HCFA in order to supplement CPT codes. Theyinclude physician services not included in CPT as well as non-physicianservices such as ambulance, physical therapy and durable medical equipment.The local codes are developed by local Medicare carriers in order tosupplement the national codes. HCPCS codes are 5-digit codes, the first digita letter followed by four numbers. HCPCS codes beginning with A through Vare national; those beginning with W through Z are local.

Health Care Financing Administration(HCFA)

The government agency within the Department of Health and Human Serviceswhich directs the Medicare and Medicaid programs (Titles XVIII and XIX ofthe Social Security Act) and conducts research to support those programs.

Health Care Prepayment Plan (HCPP) A cost contract with the HCFA that prepays a health plan a flat amount permonth to provide Medicare-eligible Part B medical services to enrolledmembers. Members pay premiums to cover the Medicare coinsurance,deductibles and copayments, plus any additional non-Medicare coveredservices that the plan provides. The HCPP does not arrange for Part Aservices.

Health Insurance Financial protection against the medical care costs arising from disease oraccidental bodily injury. Such insurance usually covers all or part of themedical costs of treating the disease or injury. Insurance may be obtained oneither an individual or a group basis.

Health Insuring Organization (HIO) An entity that provides for or arranges for the provision of care and contractson a prepaid capitated risk basis to provide a comprehensive set of services.

Health Maintenance Organizations(HMO’s)

(1) An entity that provides, offers or arranges for coverage of designatedhealth services needed by plan members for a fixed, prepaid premium. Thereare four basic models of HMOs: staff model, group model, network modeland individual practice association; (2) Under the federal HMO Act, an entitymust have three characteristics to call itself an HMO: (a) An organized systemfor providing healthcare or otherwise assuring healthcare delivery in ageographic area, (b) An agreed upon set of basic and supplemental healthmaintenance and treatment services, and (c) A voluntary enrolled group ofpeople.

Health Plan An organization that provides a defined set of benefits; this term usually refersto an HMO-like entity, as opposed to an indemnity insurer.

Health Plan Employer Data andInformation Set (HEDIS)

A core set of performance measures to assist employers and other healthpurchasers in understanding the value of healthcare purchases and evaluatinghealth plan performance. HEDIS 3.0 is currently used and distributed byNCQA (National Committee for Quality Assurance).

HMO - Group Model A healthcare model involving contracts with physicians organized as apartnership, professional corporation, or other association. The health plancompensates the medical group for contracted services at a negotiated rate,and that group is responsible for compensating its physicians and contractingwith hospitals for care of their patients.



Term Definition

HMO - Individual Practice Association(IPA)

A healthcare model that contracts with physicians and other communityhealthcare providers, to provide services in return for a negotiated fee.Physicians continue in their existing individual or group practices and arecompensated on a per capita, fee schedule, or fee-for-service basis.

HMO - Network Model An HMO type in which the HMO contracts with more than one physiciangroup, and may contract with single- and multi-specialty groups. Thephysician works out of his/her own office. The physician may share inutilization savings, but does not necessarily provide care exclusively for HMOmembers.

HMO - Staff Model A healthcare model that employs physicians to provide healthcare to itsmembers. All premiums and other revenues accrue to the HMO, whichcompensates physicians by salary and incentive programs.

Home Health Agency (HHA) A facility or program licensed, certified or otherwise authorized pursuant tostate and federal laws to provide healthcare services in the home.

Home Health Services Services and items furnished to an individual who is under the care of aphysician by a home health agency or by others under arrangements made bysuch agency. Services are furnished under a plan established and periodicallyreviewed by a physician. They are provided on a visiting basis in anindividual’s home and include: nursing, physical therapy, dietary, counseling,and social services; part-time or intermittent skilled nursing care; physical,occupational, or speech therapy; medical social services, medical supplies andappliances (other than drugs and biologicals); home health aide services; andservices of interns and residents.

Hospice A program that provides palliative and supportive care for terminally illpatients and their families, either directly or on a consulting basis with thepatient's physician or another community agency. Originally a medieval namefor a way station for crusaders where they could be replenished, refreshed,and cared for, hospice is used here for an organized program of care forpeople going through life's "last station." The whole family is considered theunit of care, and care extends through their period of mourning.

Indemnity Insurance An insurance program in which the insured person is reimbursed or theprovider is paid for covered expenses after services are rendered.

Inpatient Hospital Services Items and services furnished to a resident patient of a hospital by the hospital.May include such items as: bed and board; nursing and related services;diagnostic and therapeutic services; and medical or surgical services.

Integrated Behavioral Health A carve-out benefit plan that combines independent managed care servicesinto what is designed as a seamless delivery system for behavioral healthconcerns. Components could include employee assistance services, atelephone counseling triage, utilization management, behavioral healthtreatment networks, claims payment, and data management.

Integrated Delivery System A generic term referring to a joint effort of physician/hospital integration for avariety of purposes. Some models of integration include physician-hospitalorganization, group practice without walls, integrated provider organizationand medical foundation.



Term Definition

Intensive Care Skilled nursing services, usually in a hospital, prescribed by a physician forindividuals with serious medical conditions and delivered with the guidance ofa registered nurse.

Intermediate Care Facility (ICF) An institution that is licensed under state law to provide on a regular basis,health-related care and services to individuals who do not require the degreeof care or treatment which a hospital or skilled nursing facility is designed toprovide. Public institutions for care of the mentally retarded or people withrelated conditions are also included in the definition. The distinction between"health-related care and services" and "room and board" has often provendifficult to make but is important because ICFs are subject to quite differentregulations and coverage requirements than institutions which do not providehealth-related care and services.

International Classification of Diseases,9th Edition (Clinical Modification)(ICD-9-CM)

A listing of diagnoses and identifying codes used by physicians for reportingdiagnoses of health plan enrollees. The coding and terminology provide auniform language that can accurately designate primary and secondarydiagnoses and provide for reliable, consistent communications on claimforms.

Investigational Treatments Medical treatments, including drugs waiting for FDA approval, that areconsidered experimental and, therefore, may not be covered by insuranceplans. The definition of experimental currently varies from plan to plan.

Laboratory and Radiological Services Professional and technical laboratory and radiological services ordered by alicensed practitioner, provided in an office or similar facility (other than ahospital outpatient department or clinic) or by a qualified lab.

Legend Drug A drug that, by law, can be obtained only by prescription and bears the label,“Caution: federal law prohibits dispensing without a prescription.” See“Prescription Medication.”

Lifetime Maximum Benefit A limitation on financial coverage for healthcare for an individual stated by aninsurer. This amount serves as a cap on contractual liability and can beexceeded only in rare and unusual circumstances.

Long Term Care A set of health care, personal care and social services required by personswho have lost, or never acquired, some degree of functional capacity (e.g., thechronically ill, aged, disabled, or retarded) in an institution or at home, on along-term basis. The term is often used more narrowly to refer only to long-term institutional care such as that provided in nursing homes, homes for theretarded and mental hospitals. Ambulatory services such home health care,which can also be provided on a long-term basis, are seen as alternatives tolong-term institutional care.

Magnetic Resonance Imaging State-of-the-art machine used as a diagnostic tool, using fields to producecomprehensive pictures of the anatomy.

Managed Care (1) A system of healthcare delivery that influences utilization and cost ofservices and measures performance. The goal is a system that delivers valueby giving people access to high quality, cost-effective healthcare; (2) Asystemized approach which seeks to ensure the provision of the righthealthcare at the right time, place and cost.



Term Definition

Managed Care Organization (MCO) Broad term that encompasses various types of health plans, including HealthMaintenance Organizations (HMOs), Preferred Provider Organizations(PPOs), Point-of-Service plans (POSs) and Provider-Sponsored Organizations(PSOs). Often used to refer to a health plan that is similar to an HMO butwhich does not have an HMO license and serves only Medicaid beneficiaries.

Mandated Benefits Those benefits which health plans are required by state or federal law toprovide to policyholders and eligible dependents.

Maximum Allowable Cost, or“Reasonable Cost Range”

A maximum cost is fixed for which the pharmacist can be reimbursed forselected products, as identified in a “formulary.”

Maximum Out-of-Pocket Costs The limit on total member copayments, deductibles and coinsurance under abenefit contract.

Medicaid A Federally aided State-operated and administered program that providesmedical benefits for certain indigent or low-income persons in need of healthand medical care. The program, authorized by Title XIX of the SocialSecurity Act, is basically for the poor. It does not cover all of the poor,however, but only persons who meet specified eligibility criteria. Subject tobroad Federal guidelines, states determine the benefits covered, programeligibility, rates of payment for providers, and methods of administering theprogram.

Medicaid Buy-In A provision in certain health reform proposals whereby the uninsured wouldbe allowed to purchase Medicaid coverage by paying premiums on a slidingscale based on income.

Medicaid Management InformationSystem (MMIS)

Federally developed guidelines for a computer system designed to achievenational standardization of Medicaid claims processing, payment, review andreporting for all health care claims.

Medical Necessity The evaluation of healthcare services to determine if they are: medicallyappropriate and required to meet basic health needs; consistent with thediagnosis or condition and rendered in a cost-effective manner; and consistentwith national medical practice guidelines regarding type, frequency andduration of treatment.

Medical Savings Account (MSA) A non-taxable savings account used to cover medical expenses. Basedloosely on the idea of individual retirement accounts.

Medically Needy Under Medicaid, medically needy cases are aged, blind, or disabledindividuals or families and children who are not otherwise eligible forMedicaid, and whose income resources are above the limits for eligibility ascategorically needy (AFDC or SSI) but are within limits set under theMedicaid state plan.



Term Definition

Medicare (Part A/Part B) A U.S. health insurance program for people aged 65 and over, for personseligible for social security disability payments for two years or longer, and forcertain workers and their dependents who need kidney transplantation ordialysis. Monies from payroll taxes and premiums from beneficiaries aredeposited in special trust funds for use in meeting the expenses incurred bythe insured. It consists of two separate but coordinated programs: hospitalinsurance (Part A) and supplementary medical insurance (Part B).

Medicare Beneficiary A person designated by the Social Security Administration as entitled toreceive Medicare benefits.

Medicare Payment AdvisoryCommission (MedPAC)

A federal commission established under the Balanced Budget Act of 1997 toadvise and assist Congress and the Department of Health and Human Servicesin maintaining and updating the Medicare prospective payment system.MedPAC replaces and assumes the responsibilities of the Physician PaymentReview Commission (PPRC) and the Prospective Payment AssessmentCommission (ProPAC).

Medicare Supplemental Insurance A policy guaranteeing that a health plan will pay a policyholder’s coinsurance,deductible and copayments and will provide additional health plan or non-Medicare coverage for services up to a predefined benefit limit. In essence,the product pays for the portion of the cost of services not covered byMedicare. Also called “Medigap” or “Medicare wrap.”

Medigap (Medicare SupplementalInsurance)

See “Medicare Supplemental Insurance.”

Members A participant in a health plan (member or eligible dependent). Also used todescribe an individual specified within a subscriber contract that may receivehealth care services according to the terms of the subscriber policy. Alsoknown as "beneficiary," "enrollee," "subscriber," or "insured."

Modified Fee-for-Service A system in which providers are paid on a fee-for-service basis, with certainfee maximums for each procedure.

Most Favored Nations Discount orClause

A contractual agreement that stipulates that a vendor must provide to aparticular payor the lowest prices that would be available to any purchaser.The federal government often invokes most favored nation clauses forhealthcare contracts.

National Committee for QualityAssurance (NCQA)

A national organization founded in 1979 composed of 14 directorsrepresenting consumers, purchasers, and providers of managed health care. Itaccredits quality assurance programs in prepaid managed health careorganizations, and develops and coordinates programs for assessing thequality of care and service in the managed care industry, including the HEDISquality measures.

National Drug Code (NDC) A national classification system for identification of drugs. Similar to theUniversal Product Code (UPC).

Network Plan A phrase that generally refers to arrangements where providers contract withpayers or a managed care plan to provide services for patients enrolled in themanaged care plan. See “Managed Care.”



Term Definition

Other Practitioners’ Services Health care services of licensed practitioners other than physicians anddentists.

Out-of-Pocket Costs/Expenses (OOPs) The portion of payments for health services required to be paid by theenrollee, including copayments, coinsurance and deductibles.

Out-of-Pocket Limit The total payments toward eligible expenses that a covered person funds forhim/herself and/or dependents: i.e., deductibles, copays and coinsurance - asdefined per the contract. Once this limit is reached, benefits will increase to100% for health services received during the rest of that calendar year. Someout-of-pocket costs (e.g., mental health, penalties for non-precertification,etc.) are not eligible for out-of-pocket limits.

Outcome Measures Assessments which gauge the effect or results of treatment for a particulardisease or condition. Outcome measures include such parameters as: thepatient’s perception of restoration of function, quality of life and functionalstatus, as well as objective measures of mortality, morbidity and health status.

Outcomes Management Systematically improving healthcare results, typically by modifying practicesin response to data gleaned through outcomes measurement, then remeasuringand remodifying - often in a formal program of continuous qualityimprovement.

Outcomes Research Studies aimed at measuring the effect of a given product, procedure, ormedical technology on health or costs.

Outlier An observation in a distribution that is outside a certain range, often definedas two or three standard deviations from the mean or exceeding a specificpercentile. Frequently refers to a case or hospital stay that is unusually long orexpensive for its type, or to a physician practice that uses an abnormally highor low volume of resources.

Outpatient Services Outpatient services are medical and other services provided on a non-residentbasis (patients are not admitted to the facility) by a hospital or other qualifiedfacility, such as a mental health clinic, rural health clinic, mobile X-ray unit,or freestanding dialysis unit. Such services include outpatient physical therapyservices, diagnostic X-ray and laboratory tests, and X-ray and other radiationtherapy.

Over-the-Counter (OTC) A drug product that does not require a prescription under federal or state law.

Participating Provider A provider who has contracted with the health plan to provide medicalservices to covered persons. The provider may be a hospital, pharmacy, otherfacility or a physician who has contractually accepted the terms andconditions as set forth by the health plan.

Patient Health Status Survey Questionnaire used to solicit patient perceptions regarding the state of theirhealth. Questions may be general and address overall health status with regardto a specific condition (e.g., an arthritic patient’s ability to make a fist or anasthmatic patient’s ability to climb a flight of stairs).

Patient Satisfaction Survey Questionnaire used to solicit the perceptions the plan enrollees or patientshave regarding how a health plan meets their medical needs and how thedelivery of care is handled, (e.g., waiting time, access to treatments).



Term Definition

Payer A general term indicating the responsible party for the payment of medicalcare service expenses. Payers may be patients, insurance companies,government agencies, or a combination of these.

Peer Review The evaluation of quality of total healthcare provided, by medical staff withequivalent training.

Peer Review Organization (PRO) An entity established by the Tax Equity and Fiscal Responsibility Act of 1982(TERFA) to review quality of care and appropriateness of admissions,readmissions and discharges for Medicare and Medicaid. These organizationsare held responsible for maintaining and lowering admission rates, andreducing lengths of stay while insuring against inadequate treatment. Alsoknown as “Professional Standards Review Organization.”

Pharmacy And Therapeutics (P&T)Committee

An organized panel of physicians and pharmacists from varying practicespecialties, who function as an advisory panel to the plan regarding the safeand effective use of prescription medications. Often compromises the officialorganizational line of communication between the medical and pharmacycomponents of the health plan. A major function of such a committee is todevelop, manage and administer a drug formulary.

Physician Any doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who is dulylicensed and qualified under the law of jurisdiction in which treatment isreceived.

Physician-Hospital Organization(PHO)

A legal entity formed by a hospital and a group of physicians to further mutualinterests and to achieve market objectives. A PHO generally combinesphysicians and a hospital into a single organization for the purpose ofobtaining payer contracts. Doctors maintain ownership of their practices andagree to accept managed care patients according to the terms of a professionalservice agreement with the PHO. The PHO serves as a collective negotiatingand contracting unit. It is typically owned and governed jointly by a hospitaland shareholder physicians.

Point-Of-Service (POS) Plan A health plan allowing the covered person to choose to receive a service froma participating or non-participating provider, with different benefit levelsassociated with the use of participating providers. POS can be provided inseveral ways: an HMO may allow members to obtain limited services fromnon-participating providers; an HMO may provide non-participating benefitsthrough a supplemental major medical policy; a PPO may be used to provideboth participating and non-participating levels of coverage and access; orvarious combinations of the above may be used.

Portability Requirement that health plans guarantee continuous coverage without waitingperiods for persons moving between plans.

Practice Guideline Systematically developed statements on medical practice that assist apractitioner and a patient in making decisions about appropriate healthcare forspecific medical conditions. Managed care organizations frequently use theseguidelines to evaluate appropriateness and medical necessity of care. Termsused synonymously include practice parameters, standard treatment protocolsand clinical practice guidelines.

Practice Parameters See “Practice Guidelines.”



Term Definition

Practice Variation An assessment of the patterns of a practitioner’s practice to determine if theprovider’s care is significantly different from others with similar practices. Ifthere is a significant difference, the practitioner’s practice is analyzed todetermine the reasons for the variation and whether that practitioner’s practicepatterns should be modified.

Pre-Certification Review See “Utilization Review.”

Pre-Existing Condition (PEC) Any medical condition that has been diagnosed or treated within a specifiedperiod immediately preceding the covered person’s effective date of coverageunder the master group contract.

Preferred Provider Organization(PPO)

A program in which contracts are established with providers of medical care.Providers under such contracts are referred to as preferred providers. Usually,the benefit contract provides significantly better benefits (fewer copayments)for services received from preferred providers, thus encouraging coveredpersons to use these providers. Covered persons are generally allowedbenefits for non-participating providers’ services, usually on an indemnitybasis with significantly higher copayments. A PPO arrangement can beinsured or self-funded. Providers may be, but are not necessarily, paid on adiscounted fee-for-service basis.

Prepaid Group Practice Plans Organized medical groups of essentially full-time physicians in appropriatespecialties, as well as other professional and subprofessional personnel, who,for regular compensation, undertake to provide comprehensive care to anenrolled population for premium payments that are made in advance by theconsumer and/or their employers.

Prepaid Health Plan (PHP) An entity that provides a non-comprehensive set of services on eithercapitated risk or non-risk basis or the entity provides comprehensive serviceson a non-risk basis.

Prescribed Drugs Prescribed drugs are drugs dispensed by a licensed pharmacist on theprescription of a practitioner licensed by law to administer such drugs, anddrugs dispensed by a licensed practitioner to his own patients. This item doesnot include a practitioner’s drug charges that are not separable from his othercharges, or drugs covered by a hospital bill.

Prescription Medication A drug which has been approved by the Food and Drug Administration andwhich can, under federal and state law, be dispensed only pursuant to aprescription order from a duly licensed prescriber, usually a physician.

Preventive Care Comprehensive care emphasizing priorities for prevention, early detection andearly treatment of conditions, generally including routine physicalexaminations, immunization and well person care.

Primary Care Basic or general healthcare traditionally provided by family practice,pediatrics and internal medicine. See also “Secondary Care.”

Primary Care Case Management(PCCM)

Managed care arrangements where primary care providers receive a per capitamanagement fee to coordinate a patient's care in addition to reimbursement(fee-for-service or capitation) for the medical services they provide.



Term Definition

Primary Care Physician (PCP) The primary care practitioner (e.g., internist, family/general practitioner,pediatrician, and in some cases, OB/Gyn) in managed care organizations whodetermines whether the presenting patient needs to see a specialist or requiresother non-routine services. See Care Coordinator.

Prior Authorization The process of obtaining prior approval as to the appropriateness of a serviceor medication. Prior authorization does not guarantee coverage.

Prospective Financing Financing for health care services based on prices or budgets determined priorto the delivery of service. Payments can be per unit of service, per member, orper time period. In all its forms prospective financing differs from cost-basedreimbursement, under which a provider is paid for costs incurred.

Protocol See “Practice Guidelines.”

Provider Network See “Network Plan.”

Providers A physician, hospital, group practice, nurse, nursing home, pharmacy or anyindividual or group of individuals that provides a healthcare service.

Quality assurance (QA) or qualityimprovement (QI)

A formal set of activities to review and affect the quality of services provided.Quality assurance includes assessment and corrective actions to remedy anydeficiencies identified in the quality of direct patient, administrative andsupport services.

Rate Setting A form of financing under which hospitals or nursing homes are paid pricesthat are prospectively determined, generally by a state agency. Prospectivelydetermined prices may be paid by all payers for all covered services, as in allpayer systems, or by only some payers. The unit of payment can be service,patient, or time period. See “Prospective Financing.”

Rational Drug Therapy Prescribing the right drug for the right patient, at the right time, in the rightamount, and with due consideration of relative cost.

Reasonable Charge In processing claims for Supplementary Medical Insurance benefits, carriersuse HCFA guidelines to establish the reasonable charge for services rendered.The reasonable charge is the lowest of: the actual charge billed by thephysician or supplier; the charge the physician or supplier customarily billshis patients for the same services, and the prevailing charge which mostphysicians or suppliers in that locality bill for the same service. Increases inthe physicians’ prevailing charge levels are recognized only to the extentjustified by an index reflecting changes in the costs of practice and in generalearnings.

Reasonable Cost In processing claims for Health Insurance benefits, intermediaries use HCFAguidelines to determine the reasonable cost incurred by the individualproviders in furnishing covered services to enrollees. The reasonable cost isbased on the actual cost of providing such services, including direct andindirect costs of providers, excluding any costs that are unnecessary in theefficient delivery of services covered by the insurance program.

Rebate A monetary amount that is returned to a payer from a prescription drugmanufacturer based upon utilization by a covered person or purchases by aprovider.



Term Definition

Recipient A recipient of Medicaid is an individual who has been determined to beeligible for Medicaid and who has used medical services covered underMedicaid.

Referral The process of sending a patient from one practitioner to another for healthcare services. Health plans may require that designated primary care providersauthorize a referral for coverage of specialty services.

Restrictive Formulary A term often used synonymously with closed formulary. See “DrugFormulary.”

Retrospective Review Determination of medical necessity and/or appropriate billing practice forservices already rendered.

Risk Responsibility for paying for or otherwise providing a level of health careservices based on an unpredictable need for these services.

Risk Contract (1) An agreement between HCFA and an HMO or competitive medical planrequiring the HMO to furnish at a minimum all Medicare covered services toMedicare eligible enrollees for an annually determined, fixed monthlypayment rate from the government and a monthly premium paid by theenrollee. The HMO is then liable for services regardless of their extent,expense or degree. (2) An agreement between a provider and payer, orintermediary, on behalf of a payer, that requires the provider to furnish allspecified services for a specified enrollee for a set fee, usually prepaid, andfor a set period of time (usually one year). The provider is then liable forservices regardless of their extent, expense or degree. Such stated limitationsfor such liability are stated in advance and may be subject to reinsurance.

Rural Health Clinic A rural health clinic is an outpatient facility which is primarily engaged infurnishing physicians’ and other medical and health services, which meetscertain other requirements designed to ensure the health and safety of theindividuals served by the clinic. The clinic must be located in an area that isnot urbanized as defined by the Census Bureau and that is designated by theSecretary of DHHS either as an area with a shortage of personal healthservices, or as a health manpower shortage area, and has filed an agreementwith the Secretary not to charge any individual or other person for items orservices for which such individual is entitled to have payment made byMedicare, except for the amount of any deductible or coinsurance amountapplicable.

Secondary Care Services provided by medical specialists, such as cardiologists, urologists anddermatologists, who generally do not have first contact with patients. See also“Primary Care.”

Section 1115 Waivers Section 1115 of the Social Security Act grants the Secretary of Health andHuman Services broad authority to waive certain laws relating to Medicaid forthe purpose of conducting pilot, experimental or demonstration projects.Section 1115 demonstration waivers allow states to change provisions of theirMedicaid programs, including: eligibility requirements, the scope of servicesavailable, the freedom to choose a provider, a provider’s choice to participatein a plan, the method of reimbursing providers, and the statewide applicationof the program. Projects typically run three to five years.



Term Definition

Section 1915(b) Waivers Prior to the passage of the Balanced Budget Act (BBA) of 1997, Section1915(b) freedom-of-choice waivers allowed states to require Medicaidrecipients to enroll in HMOs or other managed care plans in an effort tocontrol costs. The waivers allowed states to: implement a primary care case-management system; require Medicaid recipients to choose from a number ofcompeting health plans; provide additional benefits in exchange for savingsresulting from recipients’ use of cost-effective providers; and limit theproviders from which beneficiaries can receive non-emergency treatment.Under the BBA, states can enroll recipients into managed care withoutapplying for 1915(b) waivers.

Self-Referral Restrictions Restrictions on or prohibitions against providers referring patients to adesignated health service (e.g., pharmacies, clinical laboratories, andoutpatient surgery) in which the provider or the provider’s immediate familymember has a financial interest.

Sin Taxes Taxes imposed on items considered harmful to public health interests, such astobacco and alcohol.

Skilled Nursing Facility (SNF) A facility, either freestanding or part of a hospital, that accepts patients inneed of rehabilitation and medical care that is of a lesser intensity than thatreceived in a hospital.

Skilled Nursing Facility Services All services furnished to inpatients of, and billed for by, a formally certifiedskilled nursing facility that meets standards set by Secretary of DHHS.

Spend-Down Under Medicaid, “spend-down” refers to a method by which an individualestablishes Medicaid eligibility by reducing gross income through incurringmedical expenses until net income (after medical expenses) meets Medicaidfinancial requirements.

State Buy-In The term given to the process by which a state may provide SupplementaryMedical Insurance coverage for its needy eligible persons through anagreement with the Federal government under which the state pays thepremiums for them.

State Mandated Benefits Laws State laws requiring insurance contracts to provide coverage for certain healthservices (e.g., in vitro fertilization) or services provided by certain health careproviders (e.g., audiologists). Self-insureds are exempt from theserequirements. There are over 800 mandates nationwide.

State Plan The Medicaid State Plan is a comprehensive written commitment by aMedicaid agency to administer or supervise the administration of a Medicaidprogram in accordance with Federal requirements.

Stop Loss That point at which a third party has reinsurance to protect against the overlylarge single claim or the excessively high aggregate claim during a givenperiod of time. Large employers, who are self-insured, may also purchase“reinsurance” for stop-loss purposes.

Supplemental Security Income (SSI) A federal cash assistance program for low-income aged, blind and disabledindividuals established by Title XVI of the Social Security Act. States mayuse SSI income limits to establish Medicaid eligibility.



Term Definition

Tax Equity and Fiscal ResponsibilityAct of 1982 (TEFRA)

The federal law which created the current risk and cost contract provisionsunder which health plans contract with HCFA and which defined the primaryand secondary coverage responsibilities of the Medicare program.

Temporary Assistance to NeedyFamilies (TANF)

Federal-state welfare program which replaces Aid to Families with DependentChildren. Authorized by the 1996 Welfare Reform Act. States may useTANF to establish Medicaid eligibility.

Therapeutic Alternatives Drug products containing different chemical entities but which should providesimilar treatment effects, the same pharmacological action or chemical effectwhen administered to patients in therapeutically equivalent doses.

Therapeutic Substitution Dispensing by a pharmacist of a product different from that which wasprescribed, but which is deemed to be therapeutically equivalent. In moststates such a practice requires the prescribing physician’s authorization beforethe substitution may occur. A pharmacy and therapeutics committee (P&T)most often approves the rationale for therapeutic equivalency prior to suchpractice.

Third-Party Administrator (TPA) An independent person or corporate entity (third party) that administers groupbenefits, claims and administration for a self-insured company/group. A TPAdoes not underwrite the risk.

Third-Party Liability Under Medicaid, third-party liability exists if there is any entity (i.e., othergovernment programs or insurance) which is or may be liable to pay all orpart of the medical cost or injury, disease, or disability of an applicant orrecipient of Medicaid.

Total Quality Management (TQM) See “Continuous Quality Improvement.”

Universal Access The availability of affordable public or private insurance coverage for everyUnited States citizen or legal resident. There is no guarantee, however, that allindividuals will actually choose to purchase or have the funds to purchasecoverage. See “Universal Coverage.”

Universal Coverage The guaranteed provision of at least basic health care services to every UnitedStates citizen or legal resident. See “Universal Access.”

Usual, Customary and ReasonableCharges

A term used to refer to the commonly charged or prevailing fees for healthservices within a geographic area. A fee is considered to be reasonable if itfalls within the parameters of the average or commonly charged fee for theparticular service within that specific community.

Utilization The extent to which the members of a covered group use a program or obtaina particular service, or category of procedures, over a given period of time.Usually expressed as the number of services used per year or per 100 or 1,000persons eligible for the service.

Utilization Management (UM) A process of integrating review and case management of services in acooperative effort with other parties, including patients, providers, and payers.

Utilization Review A formal assessment of the medical necessity, efficiency, and/orappropriateness of healthcare services and treatment plans on a prospective,concurrent or retrospective basis.



Term Definition

Vendor A medical vendor is an institution, agency, organization, or individualpractitioner that provides health or medical products and/or services either toa medical provider, who in turn interfaces with patients, or directly to thepublic.

Vendor Payments In welfare programs, direct payments are made by the state to providers suchas physicians, pharmacists and health care institutions rather than to thewelfare recipient himself.

Waiver A rider or clause in a health insurance contract excluding an insurer’s liabilityfor some sort of pre-existing illness or injury. Also refers to a planamendment, such as a HCFA waiver or plan modification.

Withhold “At-risk” portion of a claim deducted and withheld by the health plan beforepayment is made to a participating physician as an incentive for appropriateutilization and quality of care. This amount – for example, 20% of the claim– remains within the plan and is credited to the doctor’s account. Can be usedwhere the plan needs additional funds to pay for claims. The withhold may bereturned to the physician in varying levels which are determined based onanalysis of his/her performance or productivity compared against his/herpeers. Also called “physician contingency reserve (PCR).”





ACRONYMS

AABD Aid to Aged, Blind, and DisabledAB Aid to the BlindAFDC Aid to Families with Dependent ChildrenAHCPR Agency for Health Care Policy and ResearchAIDS Acquired Immune Deficiency SyndromeAMP Average Manufacturer PriceANSI American National Standards InstituteAPTD Aid to the Permanently and Totally DisabledARF Area Resource FileASO Administrative Services OnlyAWP Any Willing Provider OR Average Wholesale PriceBBA Balanced Budget Act of 1997CFR Code of Federal RegulationsCMP Competitive Medical PlanCNAB Categorically Needy Aid to the BlindCNAFDC Categorically Needy Aid to Families with Dependent ChildrenCNAPTD Categorically Needy Aid to the Permanently and Totally DisabledCNOAA Categorically Needy Old Age AssistanceCOBRA Consolidated Omnibus Reconciliation Act of 1985CON Certificate of NeedCPI Consumer Price IndexCPR Customary Prevailing, and Reasonable (charges)CPT Current Procedural TerminologyCQI Continuous Quality ImprovementDAW Dispense As Writtendba Doing Business AsDEFRA Deficit Reduction Act of 1984DHHS Department of Health and Human ServicesDRGs Diagnostic Related GroupingsDUE Drug Use EvaluationDUR Drug Utilization ReviewEAC Estimated Acquisition CostEDI Electronic Data InterchangeEPSDT Early and Periodic Screening, Diagnostic and TreatmentERISA Employee Retirement Income Security ActESRD End Stage Renal DiseaseFFP Federal Financial ParticipationFFS Fee-for-ServiceFMAP Federal Medical Assistance Percentage



FOC Freedom of ChoiceFPL Federal Poverty LevelFY Fiscal YearHCFA Health Care Financing AdministrationHCPCS HCFA Common Procedural Coding SystemHCPP Health Care Prepayment PlanHEDIS Health Plan Employer Data and Information SetHH Home HealthHIO Health Insuring OrganizationsHIPAA Health Insurance Portability and Accountability ActHMO Health Maintenance OrganizationICF Intermediate Care FacilityICF-MR Intermediate Care Facility for the Mentally RetardIPA Individual Practice AssociationMAC Maximum Allowable CostMAIC Maximum Allowable Ingredient CostMCO Managed Care OrganizationMMIS Medicaid Management Information SystemMNAB Medically Needy Aid to the BlindMNAFDC Medically Needy Aid to Families with Dependent ChildrenMNAPTD Medically Needy Aid to the Permanently and Totally DisabledMNOAA Medically Needy Old Age AssistanceMQC Medicaid Quality ControlMSA Medical Savings AccountNDC National Drug CodeNMCUES National Medicare Care Utilization and ExpenditureNP Nurse PractitionerOAA Old Age AssistanceOACT Office of the ActuaryOASDI Old Age, Survivors, and Disability InsuranceOBRA Omnibus Budget Reconciliation ActOHS Outpatient Hospital ServicesORD Office of Research and DemonstrationsOT Occupational TherapyOTC Over-the-Counter (drugs)P&T Pharmacy and Therapeutics CommitteePA Physician’s Assistant OR Prior AuthorizationPCCM Primary Care Case ManagementPCF Program Characteristics FilePCP Primary Care PhysicianPMPM Per Member Per MonthPHO Physician-Hospital Organization



POS Point-of-ServicePPO Preferred Provider OrganizationPRO Peer Review OrganizationProPAC Prospective Payment Assessment CommissionPT Physical TherapyQA/QI Quality Assurance/Quality ImprovementRHC Rural Health ClinicRPH Registered PharmacistRx PharmaceuticalSFO State Funds OnlySNF Skilled Nursing FacilitySSA Social Security AdministrationSSI Supplemental Security IncomeSSP State Supplemental PaymentsTANF Temporary Assistance for Needy FamiliesTDOC Total Days of CareTEFRA Tax Equity & Fiscal Responsibility ActTPA Third-Party AdministratorTQM Total Quality ManagementUCR Usual, Customary and ReasonableUM Utilization ManagementUR Utilization ReviewWAC Weighted Average Cost OR Wholesale Acquisition Cost



Date post:	10-Apr-2015
Category:	Documents
Upload:	national-pharmaceutical-council
View:	1,627 times
Download:	9 times

Pharmaceutical Benefits Under State Medical Assistance Programs, 2000

Documents