Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
2000
Published by the
National Pharmaceutical Council, Inc.
1894 Preston White Drive
Reston, VA 20191-5433
Information for this compilation was acquired from multiple sources, including a
survey of Medicaid prescription drug programs, administered for the National
Pharmaceutical Council by The Lewin Group, Falls Church, Virginia. While we
have checked all secondary data in the book for consistency relative to the
original source, we have not validated the original data reported by the Health
Care Financing Administration (HCFA) and other organizations.
The data were compiled and the book prepared for publication by Catherine
Harrington, Dawn Bartoszewicz, Corinna Sorenson, Haejin Chung and Sheela
Raju of The Lewin Group; and Kimberly Dietrich of the National
Pharmaceutical Council.
Pharmaceutical Benefits 2000
INTRODUCTION
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 State
Medicaid program administrators and pharmacy consultants for Federal fiscal
year 1999, however, it still contains Medicaid population characteristics and
utilization based on the 1998 HCFA-2082 report. Once the HCFA-2082 report
for fiscal year 1999 is released by HCFA, the NPC and The Lewin Group will
update the information and make the full printed edition of the book available.
NPC gratefully acknowledges the cooperation and assistance of the many state
and federal program officials and their staffs, and The Lewin Group for
administering the survey and analyzing the data.
Gary Persinger
Vice President, Health Care Systems
National Pharmaceutical Council
TABLE OF CONTENTS
INTRODUCTION....................................................................................................................................iii
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
APPENDIXES
Appendix A: State and Federal Medicaid Contacts .................................................................... A-1
Appendix B: Medicaid Program Statistics – HCFA-2082 Report .............................................. B-1
Appendix C: Medicaid Rebate Law ............................................................................................ C-1
Appendix D: HCFA Upper Limits for Multiple Source Products............................................... D-1
Appendix E: Glossary ................................................................................................................. E-1
Section 1:
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 care
expenditures.1 Managing a Medicaid budget requires an understanding of the forces that influence
trends in spending including changes in policy at both the state and federal levels. Changes in policy
impact 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 on
understanding the trends in of Medicaid expenditures over the last decade (through 1999, the last year
data 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 1991
to $187.0 million in 1999; however, the spending growth rate has been affected by program changes
over the last decade.1 As seen in Figure 1-1, the rate of growth dropped throughout most of the decade
but then started to rise in 1997. During the early to mid 90’s, welfare reform, moderate growth of the
aged 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 care
affected utilization incentives and the supply of providers. More recently, in the late 90’s, eligibility
expansion due to the passage of State Children’s Health Insurance Plans (also known as Title XXI as
part of the Balanced Budget Act of 1997) has lead to an increase in the spending growth rate.1
$250
26.6% 25
$187.0
$200 $171.7
$159.8 20
$152.2
$144.1
$150 16.0% $133.7
$121.6
$108.2 15
$93.2
$100
12.4% 10
10.0%
8.9%
$50 7.7% 7.5% 5
5.6% 5.0%
$0 0
1991 1992 1993 1994 1995 1996 1997 1998 1999
Figure 1-2 shows that the majority of payments in Medicaid is for long-term care services which include
skilled nursing, mental retardation, home health care, and mental health institutions. The spending rate
increase 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 has
been 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 for
hospital inpatient services and physician services has decreased.3
$70
62^
1995
$60 55
51 52 1996
$50 1997
1998
$40
$30 26 25
23 22 21 21 20
18
$20 14
10 11 12
$10
$0
LTC± Hospital - Physician† Prescription Drugs
Inpatient‡
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 about
12 million Medicaid recipients since 1991, although recent changes to welfare laws and an improved
economy resulted in a decline in the number of eligible people (from 41.6 million in 1997 to 41.4 in
1998).4 In the past, it was automatically assumed that a person who was on welfare would qualify for
the Medicaid program. Recently, welfare reform has resulted in a break in the link between public
assistance 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 eligibility
requirements, applying for Medicaid is a confusing and difficult process for many people, resulting in
fewer enrollees. Besides the working poor and those on assistance, Medicaid coverage can be extended
to 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% of
persons served).5 In contrast, in 1998, children made up 53% of the total beneficiaries, yet only 14% of
all Medicaid expenditures went toward children.5 Figure 1-3 below examines the breakdown of
Medicaid expenditures by eligibility type.
$101.0
$100
$80
$60
$40
$20.5 18.3 M
$20 $14.8
7.9 M 10.6 M
$0
Adults Children Aged, Blind, & Disabled
Notes: Figures do not include spending for administration ($6.4 B) or disproportionate share hospitals ($15.9 B). Enrollment
figures are in millions.
The percentage of beneficiaries enrolled in Medicaid managed care increased from 9.5% in 1991 to
55.6% in 1999.6 The majority of those enrolled in managed care are non-disabled adults and children
where enrollment is mandatory. Over half of all Medicaid managed care enrollees are in a Health
Maintenance Organization (HMO) or Health Insuring Organization (HIO), organizations that contract on
a prepaid capitated risk basis to provide a comprehensive set of services. Room for further growth in
Medicaid 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 of
many managed care firms from both the Medicare and Medicaid markets.7
Physician participation in the fee-for-service Medicaid program is low. In many geographic areas patient
access to primary care services is limited. Physicians hesitate to take on Medicaid patients because
Medicaid reimburses at a much lower rate than does private insurance. By law, Medicaid cannot pay
more than Medicare. Medicare reimburses physicians using a fee schedule, the Resource Based Relative
Value Scale. A comparison of the 1993 Medicare Fee Schedule to average Medicaid payments in 1994
shows that Medicaid paid out an amount equal to an average of 77% of the Medicare Fee Schedule.8 In
contrast, typical physician payments by private insurers run from 115% to 120% of the Medicare Fee
Schedule.9 In addition, states have continued to limit physician payment rates; average fees for
physician services rose just 4.6% overall from 1993 to 1998.2
In some ways it is useful to consider Medicare and Medicaid as a combined entity since changes in one
program often dramatically impact the other. Both programs are federally financed (partially for
Medicaid) and are managed by the Health Care Financing Administration (HCFA). They also both
cover elderly and disabled persons, but differ in the range of services offered. Both programs enroll
about 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 home
coverage. Therefore, dually eligible people tend to receive hospital and physician services from
Medicare and prescription drug and nursing home services from Medicaid. Figure 1-4 illustrates the
spending pattern differences between Medicaid and Medicare.
$140
$120
$100
$80
$60 Hospitals
Physicians and Clinical Services
$40
Nursing Homes
$20
$0 Drugs
Medicare
Medicaid
Average annual growth in National Health Expenditures versus Medicaid growth rates are shown below
in Figure 1-5.
10%
8.9%
7.7% 7.5%
8%
5.6% 5.4%
6%
Growth
5.4% 5.6%
5.2% 5.0%
4% 4.8%
National
2%
Medicaid
0%
1995 1996 1997 1998 1999
Over the last decade, both national and Medicaid expenditures for nursing home services have risen
steadily. However, the rate of growth for both national and Medicaid nursing home spending has
declined from 1996 to 1999 (except for a significant increase in Medicaid spending from 1998 to 1999).1
See Figures 1-6a and 1-6b below. Most of this decline in the national growth rate was due to
restructuring of the Medicare Prospective Payment System (PPS) for skilled nursing home payments.
$100
$88.0 $90.0
$85.1
$79.9
$80 $74.6
National
Medicaid
$60
Billions
$20
$0
1995 1996 1997 1998 1999
Figure 1-6b: National versus Medicaid Nursing Home Expenditures, Growth Rates1
10%
9.1%
National
8% 7.1%
6.5% Medicaid
6%
6.6%
4.1%
5.3% 3.5%
4%
4.0%
2%
2.3% 2.3%
0%
1995 1996 1997 1998 1999
National hospital spending rose somewhat in the latter half of the 1990’s, while Medicaid hospital
spending grew significantly from 1998 to 1999, approximately 9.4%.1 See Figures 1-7a and 1-7b.
$450
$377.1 $390.9
$400 $367.7
$343.6 $355.9
$350
$300
National
Billions
$250 Medicaid
$200
$150
$100 $56.8 $58.0 $60.8 $66.5
$54.3
$50
$0
1995 1996 1997 1998 1999
10%
9.4%
8%
6% 4.8%
Billions
4.3% 4.5%
3.3%
4%
National home health spending rose consistently in the early 1990’s and then dropped after Medicare
changed 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 increase
with the implementation of the Olmstead law. The Olmstead ruling requires states to provide
community-based health services to disabled persons, when feasible.
$40
$33.6 $34.5 $33.5 $33.1
$30.5
$30
National
Billions
$20 Medicaid
$10
$4.5 $4.9 $5.4 $5.6
$4.2
$0
1995 1996 1997 1998 1999
Figure 1-8b: National versus Medicaid Home Health Care Expenditures, Growth Rate1
20%
17.1%
National
15%
Medicaid
10.1%
8.9%
10%
11.7%
10.3%
5% 2.8%
6.2%
4.1%
0%
-3.0% -1.4%
-5%
1995 1996 1997 1998 1999
The national rate of spending growth for prescription drugs rose rapidly in the 1990’s. The Medicaid
spending rate for prescription drugs also rose rapidly in the 1990’s, even more rapidly than the national
trend. See Figures 1-9a and 1-9b below. As the mix of enrollees increasingly changes from adults and
children towards the aged and disabled, spending for prescription drugs is likely to continue to rise
(since the latter group has greater need for medication).
$120
$99.6
$100
$85.2
$80 $75.1
$67.2 National
$60.8
Billions
$60 Medicaid
$40
$14.4 $17.1
$20 $9.7 $10.9 $12.3
$0
1995 1996 1997 1998 1999
Figure 1-9b: National versus Medicaid Prescription Drug Expenditures, Growth Rate1
25%
18.7%
20%
16.7%
13.7%
15% 12.4% 16.9%
12.0%
Rate
13.4%
10% 11.9%
11.2%
10.5%
5% National Rate
Medicaid Rate
0%
1995 1996 1997 1998 1999
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 growth
rate. Compared to a national growth rate between 4.8% and 5.6% throughout the latter half of
the 1990’s, the rate of growth in Medicaid was between 5.0% and 8.9%. The Medicaid growth
rate rose significantly from 1997 to 1999 due to program expansions.
• Most Medicaid spending is for long-term care services. Home health and personal care service
expenditures 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 costs
still 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 Medicaid
SCHIP Expansion or Part B premium payments made by Medicaid.
2 Bruen B and Holahan J. Medicaid and the Uninsured. Slow Growth in Medicaid Spending
Continues in 1997. Issue Paper. The Henry J. Kaiser Foundation, November 1999.
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. Managed
Care Trends. www.hcfa.gov/medicaid/trends99.htm.
7 Iglehart JK. The American Health Care System. New England Journal of Medicine
1999;340(5):403-8.
8 Norton SA. 1994. The Declining Gap between Medicaid and Medicare Physician Fees. In
Winterbottom C, Liska DW, and Obermaier KM. State-Level Databook on Health Care Access and
Financing, Health Tracking, 2nd ed., Robert Wood Johnson Foundation, 1995, pg. 138.
10 1999 HCFA Statistics. Health Care Financing Administration. U.S. Department of Health and
Human Services.
Section 2:
Medicaid Managed Care
Since 1981, when Congress authorized states to implement Section 1915b and Section 1115 Medicaid waivers to
increase access to managed care and test innovative health care financing and delivery options, enrollment in
Medicaid managed care has grown considerably. Over the past five years, managed care enrollment as a
percentage of total Medicaid enrollment has increased by 140 percent (i.e., from 23.2% to 55.6%). In 1999, more
than 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 managed
care plan.
100%
52.2%
59.9%
70.6%
60% 76.8%
85.6%
40% 55.6%
53.6%
47.8%
20% 40.1%
29.4%
23.2%
14.4%
0%
1993 1994 1995* 1996 1997 1998 1999
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 to
calculate average Medicaid enrollees over 1995. The managed care population differs from the 11,619,929 reported in the 1995 report as
the number represented enrollment of some beneficiaries in more than one plan.
Medicaid managed care beneficiaries can be enrolled in one of five basic Medicaid managed care plans:
• Health Insuring Organization (HIO): an entity that provides for or arranges for the provision of care and
contracts on a prepaid capitated risk basis to provide a comprehensive set of services.
• Prepaid Health Plan (PHP): an entity that provides less than comprehensive services on an at-risk basis or
one that provides any benefit package on a non-risk basis.
• Primary Care Case Management (PCCM): a provider (usually a physician, physician group practice, or an
entity employing or having other arrangements with such physicians, but sometimes also including nurse
practitioners, nurse midwives, or physician assistants) who contracts to locate, coordinate, and monitor
covered primary care (and sometimes additional services). This category includes any PCCMs and those
PHPs 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.
Number of Number of
Plan Type Plans Enrollees
Health Insuring Organization 6 365,738
Comprehensive Managed Care Organization 237 8,488,107
Comprehensive Medicaid-only Managed Care Organization 136 3,524,049
Primary Care Case Management 60 4,274,456
Prepaid Health Plan 129 8,104,413
Other 13 20,192
Total 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.
In 1981, Congress authorized states to implement Section 1915b and Section 1115 Medicaid waivers to increase
access to managed care and test innovative health care financing and delivery options. The U.S. Department of
Health and Human Services granted these waivers to allow states to “waive” requirements in Sections 1902 and
1903 of the Social Security Act and “mandate” enrollment of Medicaid eligibles in managed care programs.
Section 1915b waivers are granted to give states the authority to conduct Medicaid programs outside of the scope
of the Medicaid statute, allowing them to waive freedom of choice, statewide access to care, and comparability
requirements under Section 1902 of the Social Security Act. With a 1915b waiver, a state can require mandatory
enrollment of Medicaid recipients in managed care plans. 1915b waivers cannot negatively impact beneficiary
access, quality of care of services, and must be cost-effective (cost must be less than the Medicaid program
would cost without the waiver). Section 1915b waivers are typically limited to a targeted geographical area or
population, are approved for an initial period of two years, and can be renewed in two-year increments if the state
reapplies.
Four options for 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 be
as simple as requiring each beneficiary to choose a primary care provider or as comprehensive as mandating
enrollment in a prepaid health plan.
• Subsection 2 - Central Broker: States are allowed to act as a central broker in assisting medical assistance
eligibles in selecting among competing health care plans, if such a restriction does not substantially impair
access to medically necessary services of adequate quality.
• Subsection 3 - Shared Cost Saving: States are allowed to share (through provision of additional services) cost
savings (resulting from use by the recipient of more cost-effective medical care) with recipients of medical
assistance under the State plan.
• Subsection 4 - Restrict Providers: States can limit the number of providers of certain services. These waivers
are sometimes referred to as selective contracting waivers and were gaining in popularity. Recently approved
1915b(4) waivers included programs to restrict the number of providers of transportation services, organ
transplants, and inpatient obstetrical care.
Refer to the table on page 2-13 for a listing of 1915b waivers.
Although Section 1915b waivers allow states to increase access to managed care plans, states are still limited
under Federal regulation and cannot use them to serve beneficiaries beyond Medicaid State Plan Eligibility or
change their benefits package. In order to expand their Medicaid programs even further than under 1915b
waivers, states apply for Section 1115 research and demonstration waivers.
Section 1115 research and demonstration waivers released states from standard Medicaid requirements, allowing
them the flexibility to test substantially new ideas of policy merit. Along with 1915b waivers, 1115 waivers
allowed 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, offer
benefits to new and expanded populations, and contract with managed care organizations that did not meet the
necessary criteria of Section 1903 of the Social Security Act.
To receive approval of a Section 1115 waiver, states submit a proposal to HCFA for discussion and review.
Once operational, states allow formal evaluations of the research and public policy value of the programs and to
demonstrate that their programs do not exceed costs which would have otherwise occurred under traditional
Medicaid programs (i.e., states must demonstrate budget neutrality). Section 1115 waivers are usually granted
for a five-year period and each state must request for continuation. For example, Arizona operated its program
under 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 their
1115 waivers. Refer to the table on page 2-16 for a listing of implemented 1115 waivers.
1915b
State Program(s) Approved Statutes Utilized Expiration
Maternity Waiver Program 1 9/30/99
Alabama Partnership Hospital Program 1, 4 3/29/01
st
Patient 1 1, 3, 4 6/29/01
Alaska None -- --
Arizona None -- --
Arkansas Non-Emergency Transportation 1 2/29/00
CALOPTIMA 1, 2, 4 5/06/00
Health Plan of San Mateo 1, 2, 3, 4 7/4/00
Hudman 4 7/21/00
Managed Care Network 1, 3, 4 11/25/99
Medi-Cal Mental Health Care Field Test 4 6/25/00
Medi-Cal Specialty Mental Health Services Consolidation 4 10/4/99
Partnership Health Plan of California 1, 2, 4 2/16/00
California
Primary Care Case Management Program 1, 2, 3, 4 8/09/01
Sacramento Geographic Managed Care – Medical 1, 2, 4 11/16/99
San Diego Geographic Managed Care 1, 2, 4 10/16/00
Santa Barbara Health Initiative 1, 2, 4 1/17/00
Santa Cruz County Health Option (SCCHO) 1, 2, 4 11/19/00
Selective Provider Contracting Program 4 12/12/01
Two-Plan Model Program 1, 2, 3, 4 12/16/00
Mental Health Capitation Program 1, 3, 4 3/8/00
Colorado
Managed Care Program 1, 2 2/28/00
Connecticut HUSKY A 1, 4 12/20/99
Delaware None -- --
District of Columbia DC Managed Care Program 1, 2, 4 3/31/00
MediPass 1 6/30/99
Florida Prepaid Mental Health Plan 1, 4 6/30/01
Sub-Acute Inpatient Psychiatric Program 3, 4 3/22/00
Georgia Better Health Care 1 7/01/00
Georgia
Mental Health/Mental Retardation Services 1, 4 2/19/00
Hawaii None -- --
Idaho Healthy Connections 1, 2 11/15/99
Illinois None -- --
Indiana Hoosier Healthwise 1 1/26/00
Iowa Plan for Behavioral Health 1, 3, 4 12/31/00
Iowa
Iowa Medicaid Managed Health Care 1, 2 5/9/01
KMMC: Prime Care Kansas 1, 2, 4 6/26/00
Kansas
KMMC: Health Connect 1, 2, 4 6/26/00
Human Services Transportation 4 10/30/00
Kentucky Kentucky Patient Access and Care System (KENPAC) 1 4/13/00
Kentucky Access 1, 3, 4 11/24/99
1915b
State Program(s) Approved Statutes Utilized Expiration
Louisiana Community Care Program 1 6/28/00
Maine None -- --
Maryland None -- --
Massachusetts None -- --
Comprehensive Health Care Program 1, 2, 4 12/27/99
Michigan
Specialty Community Mental Health Services 1, 4 9/30/00
Minnesota Consolidated Chemical Dependency Treatment Fund 1, 4 3/24/01
Mississippi None -- --
Missouri Managed Care Plus (MC+) 1, 2, 4 3/14/00
Mental Health Access Plan 1 6/30/99
Montana
Passport to Health 1 10/25/99
Medicaid Health Connection – MH/SA 1 6/30/99
Nebraska
Nebraska 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 1/13/00
New York Southwest Brooklyn Managed Care Demonstration Project 1, 4 8/16/00
The Westchester County Managed Care Program 1, 4 3/31/00
ACCESS II 1 11/29/99
Carolina Access 1 11/29/99
North Carolina Carolina Alternatives 1, 4 6/30/99
Health Care Connection 1 11/29/99
Health Maintenance Organization (HMO) 1 11/29/99
North Dakota North Dakota Access and Care Program 1 5/5/01
Ohio None -- --
Oklahoma None -- --
Oregon Tri-County Metro. Transportation District 4 1/25/01
Family Care Network 1 7/26/01
HealthChoices SE - Behavioral 1, 2, 3, 4 1/26/00
HealthChoices SE – Physical Health 1, 2, 3, 4 1/26/00
Pennsylvania
HealthChoices SW - Behavioral 1, 2, 3, 4 12/31/99
HealthChoices SW – Physical Health 1, 2, 3, 4 12/31/99
Lancaster Community Health Plan 1 7/21/00
Rhode Island None -- --
South Carolina High Risk Channeling Project (HRCP) 1, 3, 4 2/11/01
South Dakota Prime 1, 3 7/1/00
Tennessee None -- --
Lonestar Select I 4 9/3/00
Lonestar Select II 4 8/19/99
Texas HMO - STAR 1, 2, 3, 4 8/31/010
HMO - STAR Plus (+) 1, 2, 3, 4 1/31/00
PCCM - STAR Plus (+) 1, 2, 3, 4 1/31/00
1915b
State Program(s) Approved Statutes Utilized Expiration
Choice of Health Care Delivery 1, 2, 4 2/16/01
Utah
Prepaid Mental Health Program 4 10/28/99
Vermont None -- --
Medallion 1 9/24/99
Virginia
Medallion II 1, 4 9/27/00
Mental Health Services 1, 4 11/7/99
Washington Healthy Options 1, 4 2/24/01
Hospital Selective Contracting 4 12/31/00
Mountain Health Care Trust 1, 4 8/26/99
West Virginia
Physician 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. Department
of Health and Human Services, Health Care Financing Administration, Office of Managed Care.
Section 3:
State Characteristics
Source: The Lewin Group analysis of the Current Population Survey, March 2000 Supplement.
Source: The Lewin Group analysis of the Current Population Survey, March 2000 Supplement.
Source: The Lewin Group analysis of the Current Population Survey, March 2000 Supplement.
Source: The Lewin Group analysis of the Current Population Survey, March 2000 Supplement.
LEGEND
Physicians, 1998
Physicians Office Based Percent Primary Care Percent
State Physicians Per 1,000 Physicians Office Based Physicians Primary 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
Registered Nurses* Pharmacists** Pharmacists**
State Registered Nurses* per 1,000 (Licensed by State) per 1,000
National Total 2,161,700 8.1 334,851 1.2
Alabama 32,800 7.6 6,541 1.6
Alaska 6,300 10.3 518 0.8
Arizona 33,200 7.3 5,548 1.1
Arkansas 17,900 7.1 3,374 1.3
California 179,700 5.6 27,152 0.8
Colorado 30,900 7.9 5,254 1.3
Connecticut 33,400 10.2 4,265 1.3
Delaware 7,700 10.5 1,209 1.5
District of Columbia 8,900 16.8 1,350 2.6
Florida 119,300 8.1 19,425 1.3
Georgia 53,600 7.2 9,551 1.2
Hawaii 8,900 7.5 1,372 1.1
Idaho 7,100 5.9 1,447 1.1
Illinois 104,700 8.8 12,278 1.0
Indiana 46,900 8.0 8,038 1.4
Iowa 29,100 10.2 4,878 1.7
Kansas 21,600 8.3 3,540 1.4
Kentucky 30,400 7.8 4,746 1.2
Louisiana 32,400 7.4 5,774 1.3
Maine 13,300 10.7 1,267 1.0
Maryland 43,000 8.4 6,700 1.3
Massachusetts 73,300 12.0 9,283 1.5
Michigan 79,600 8.1 10,693 1.1
Minnesota 46,200 9.9 5,628 1.2
Mississippi 19,900 7.3 3,440 1.2
Missouri 51,200 9.5 6,317 1.2
Montana 7,100 8.1 1,262 1.4
Nebraska 15,200 9.2 2,445 1.4
Nevada 9,900 5.9 7,427 4.0
New Hampshire 11,200 9.6 1,824 1.5
New Jersey 67,100 8.3 15,542 1.9
New Mexico 11,700 6.8 2,258 1.2
New York 167,600 9.2 18,780 1.0
North Carolina 62,000 8.4 8,977 1.2
North Dakota 6,400 10.2 2,039 3.2
Ohio 101,200 9.1 13,797 1.2
Oklahoma 19,600 5.9 4,560 1.4
Oregon 26,500 8.2 3,952 1.2
Pennsylvania 126,300 10.5 16,894 1.4
Rhode Island 11,400 11.6 1,723 1.8
South Carolina 27,400 7.3 5,116 1.3
South Dakota 7,700 10.4 1,391 2.0
Tennessee 46,400 8.0 7,358 1.3
Texas 124,200 6.4 19,825 1.0
Utah 13,000 6.3 2,140 1.0
Vermont 5,300 9.0 793 1.3
Virginia 54,400 8.1 7,471 1.1
Washington 43,500 7.8 6,279 1.1
West Virginia 15,000 8.3 2,948 1.7
Wisconsin 45,600 8.8 5,837 1.1
Wyoming 4,200 8.8 1,001 2.1
Section 4:
Pharmacy Program
Characteristics
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 the
block grant Temporary Assistance for Needy Families (TANF) program (replaced the Aid to Families with
Dependent Children (AFDC) program); and, with a few exceptions, the aged, blind, and disabled who receive
Supplemental Security Income (SSI). Other groups that are categorically needy and thus automatically eligible
for 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. Optional
coverage may be extended to certain aged, blind, or disabled persons who do not normally qualify for mandatory
coverage due to higher incomes, but who are below the FPL. Coverage may also be extended to pregnant women
and infants up to age one who are not covered under mandatory coverage, but whose income is also below the
federal poverty level.
In addition to the “categorically needy” that must be covered by Medicaid programs, there are other groups who
are “medically needy” who may be included in Medicaid at the option of each state. States may elect to provide
services to persons whose income levels are above the level to qualify for Medicaid but have medical expenses so
excessive as to offset their incomes.
Along with designating groups of people who must be covered by a state’s Medicaid plan and defining other
groups that may be covered at the discretion of the state, the federal government specifies certain general
requirements that must be met for Medicaid eligibility. A state can provide coverage for persons who do not meet
these requirements (i.e., the uninsured), but state and/or local funds must be used to support the medical expenses
of these individuals. A Medicaid agency that chooses to cover other optional groups must provide Medicaid to all
eligible individuals in that group.
MEDICAID SERVICES
The original Title XIX legislation listed several types of medical care as eligible for federal funding. Federal
regulations pertaining to Medicaid mandate that in order to receive federal matching funds, certain basic services
must be offered to all “categorically needy” individuals. These services 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 for
Medicaid. The services to be provided to these persons may include case management, personal care services,
respite care services, adult day health services, homemaker/home health aide, rehabilitation, and other services
requested by the State and approved by HCFA.
Inpatient hospital services are those ordinarily furnished in a hospital for the care and treatment of inpatients. The
facility is one maintained primarily for the care and treatment of patients with disorders other than mental
diseases. There are several general federal limitations on inpatient hospital services that apply to all states with
Medicaid programs (42 CFR 440.10):
• The facility must be licensed or formally approved as a hospital by an officially designated authority for
state standard setting;
• The facility must meet the requirements for participation in Medicare;
• 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 refer to preventive, diagnostic, therapeutic, rehabilitative, or palliative services
provided to an outpatient. Three federal limitations are imposed on these services; though states are free to
specify other limits on outpatient hospital services and many have chosen to do so.
Rural health clinic (RHC) services became mandatory for the categorically needy in July 1978. Each RHC is
required to have a nurse practitioner (NP) or physician’s assistant (PA) on its staff. Therefore, a clinic can be
certified only if the state permits the delivery of primary care by an NP or PA. Services in certified clinics must
be 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 nurse
care and related medical supplies are provided if the clinic is located in a Health Manpower Shortage Area, the
services are furnished by nurses employed by the clinic, and the services are furnished to a homebound recipient
under a written plan of treatment.
Other laboratory and X-ray services are professional and technical laboratory and radiological services. As
specified 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 healing
arts within the scope of his or her practice, as defined by state law or ordered and billed by a physician but
provided by an independent laboratory;
• Provided in an office or similar facility other than a hospital inpatient or outpatient department or clinic;
and
• Provided by a laboratory that meets the requirements for participation in Medicare.
• In addition, the states can place limitations on “other laboratory and X-ray services.”
Skilled nursing facility (SNF) services are provided to individuals age 21 or older. They do not include services
provided in institutions for mental diseases (42 CFR 440.40(a)). These services must be required on a daily basis
and provided in an inpatient facility. Federal regulations require that the services be:
• Provided by a facility or a distinct part of a facility that is certified to meet the requirements for
participation. These requirements include provider agreements, facility certification, and facility
standards; 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 Secretary
of Health and Human Services. Further, the requirements concerning control of the utilization of Medicaid
services affect skilled nursing facility services in areas such as certification and re-certification of need for
inpatient care, individual written plan of care, etc.
Early and periodic screening, diagnosis and treatment (EPSDT) refers to screening and diagnostic services to
determine physical or mental defects in recipients under age 21, as well as health care, treatment and other
measures to correct or ameliorate any defects and chronic conditions discovered (42 CFR 440.40(b)). Certain
basic screening and treatment services must be provided by each state as a minimum (42 CFR 441.56). These
services include:
Family planning services and supplies are allowable for women of childbearing age as a means of enabling
individuals to freely determine the number and spacing of their children. Although there are no federal
regulations defining what family planning services a state can provide, provisional regulations define family
planning services as consultation (including counseling and patient education), examination, and treatment,
Voluntary sterilization must be included among the range of family planning services offered by a state. Federal
regulations require that the individual to be sterilized voluntarily give informed written consent and that the
individual 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 nursing
facility, or elsewhere. Such services must be within the physicians’ scope of practice of medicine or osteopathy
as defined by state law, and by or under the personal supervision of an individual licensed under state law to
practice medicine or osteopathy.
Prescribed Drugs
Prescribed drugs are simple or compound substances or mixtures of substances prescribed for the cure, mitigation,
or prevention of disease, or for health maintenance, which are prescribed by a physician or other licensed
practitioner of the healing arts within the scope of their professional practice, as defined and limited by Federal
and State law (42 CFR 440.120). The drugs must be dispensed by licensed authorized practitioners on a written
prescription that is recorded and maintained in the pharmacist’s or practitioner’s records.
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 not
required to be provided by the facility. Services provided must be on physicians’ orders as part of a written plan
of 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 (physical
therapy, occupational therapy, speech pathology, and audiology services) (42 CFR 440.70). These services are
defined as follows:
• Part-Time Nursing: Nursing that is provided on a part-time or intermittent basis by a home health agency.
If there is no home health agency in the area, services may be provided by a registered nurse who is
currently licensed to practice in the state, receives written orders from the patient’s physician, documents
the care and services provided, and has had orientation to acceptable clinical and administrative record
keeping from a health department nurse.
• Home Health Aide: Home health aide services provided by a home health agency.
• Medical Supplies and Equipment: Medical supplies, equipment, and appliances that are suitable for use in
the home.
• Physical Therapy (PT), Occupational Therapy (OT), Speech Pathology and Audiology Services: PT, OT,
speech and hearing services provided by a home health agency or a facility licensed by the State to
provide medical rehabilitation.
• Home health services are provided to categorically needy recipients age 21 and over and to those under
21 only if the state plan provides SNF services for them.
Personal support services consist of a variety of services including personal care, targeted case management,
home and community-based care for functionally disabled elderly, rehabilitative services, hospice services, and
nurse midwife, nurse practitioner, and private duty nursing. Details of these services are provided below:
• Personal Care Services: Services provided to an individual who is not an inpatient or resident of a
hospital, nursing facility, immediate care facility for the mentally retarded, or institution for mental
disease. Services are authorized by a physician in accordance with treatment or service plan authorized
by the state, provided by a qualified individual who is not a member of the recipients family, and
furnished in a home or other location.
• Rehabilitative Services: These services include any medical or remedial service recommended by a
physician or other licensed practitioner of the healing arts within the scope of state law. Services are for
the maximum reduction of physical or mental disability and restoration of a recipient to their best possible
functional level.
• Hospice Services: Hospice services can be received in a hospice facility or elsewhere. Services are
provided to terminally ill individuals by an authorized hospice program under a written plan established
and reviewed by the attending physician, medical director or physician designee of the program, and an
interdisciplinary group.
• Nurse Midwife: Services that encompass the management and care of mothers and newborns. Care is
provided throughout the maternity cycle and is furnished within the scope of practice authorized by the
state.
Nurse-Midwife Services
Nurse-midwife services are those concerned with management of the care of mothers and newborns throughout
the maternity cycle. The Omnibus Budget Reconciliation Act of 1980 required that payment be made providing
for nurse-midwife services to categorically needy recipients (42 CFR 440.165). These provisions require states to
provide coverage for nurse-midwife services to the extent that the nurse-midwife is authorized to practice under
state law or regulation. The statute also requires that states offer direct reimbursement to nurse-midwives as one
of the payment options. Nurse-midwives must be registered nurses who are either certified by an organization
recognized by the Secretary of HHS or who have completed a program of study and clinical experience that has
been approved by the Secretary.
The Omnibus Budget Reconciliation Act of 1989 provides for the availability and accessibility of services
furnished by a certified pediatric nurse practitioner (CPNP) or a certified family nurse practitioner (CFNP) to
Medicaid recipients. These provisions require that services be covered to the extent that the CPNPs or CFNPs are
authorized to practice under state law or regulation, regardless of whether they are supervised by or associated
with a physician or other health care provider. States are required to offer direct payment to CPNPs and CFNPs
as one of their payment options.
CPNP and CFNP certification requirements include a current license to practice as a registered nurse in the state,
meet the applicable state requirements for qualification of pediatric nurse practitioners or family nurse
practitioners, and be currently certified by the American Nurses’ Association as a pediatric nurse practitioner or a
family nurse practitioner.
Medicaid programs must offer Federally Qualified Health Center (FQHC) services and other ambulatory services
offered by an FQHC under the provisions of the Omnibus Budget Reconciliation Act of 1989. The definition of
FQHC services is the same as that of the services provided by rural health clinics (RHC). FQHC services include
physician services, services provided by physician assistants, nurse practitioners, clinical psychologists, clinical
social workers, and services and supplies incident to services normally covered if furnished by a physician or if
incident to a physician’s services.
FQHCs are facilities or programs more commonly known as Community Health Centers, Migrant Health Centers,
and Health Care for the Homeless. These centers may qualify as providers of service under Medicaid, under the
following conditions:
• The facility receives a grant under sections 329, 330, or 340 of the Public Health Service Act;
• The Health Resources and Services Administration recommends, and the HHS Secretary determines, that
the facility meets the requirements of the grant; or
• The Secretary determines that a facility may qualify through waivers of the requirements. Such a waiver
cannot exceed two years.
Within broad Federal guidelines and certain limitations, states may determine the amount and duration of services
offered under their Medicaid programs. Federal regulations require that the amount and/or duration of each type
of medical and remedial care and services furnished under a state’s program must be specified in the state plan,
and that these types of care and services must be sufficient in amount, duration, and scope to “reasonably achieve”
their purpose. States are required to provide Medicaid coverage for comparable amounts, duration, and scope of
service to all “categorically needy” and categorically-related eligible person.
Each state plan must include a description of the methods that will be used to assure that the medical and remedial
care and services delivered are of high quality, as well as a description of the standards established by the state to
assure high quality care. The regulations also require that the fee structures developed must result in participation
of a sufficient number of providers so that eligible persons can receive the medical care and services included in
the plan, at least to the extent that these are available to the general population. The law further requires that
services provided under the plan be available throughout the state. Recipients are to have freedom of choice with
regard to where they receive their care, including an option to obtain their care through organizations that provide
services or arrange for their availability on a prepayment basis, such as health maintenance organizations.
In 1998, the Medicaid program provided health care services to 40.6 million people, at a cost of $142 billion. The
Medicaid program operates on the basis of a division of responsibilities between the federal government and the
states with the federal government paying states for a portion of state medical expenditures and administrative
costs. Funding for the program is shared between the two bodies, with the federal government matching state
health care provider reimbursements at an authorized rate of between 50% and 83%, depending on the state’s per
capita 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 the
national average, the federal share is 50%. If a state’s per capita income is below the national average, the federal
share is increased up to a maximum of 83%.
The percentages apply to state expenditures for assistance payments and medical services. Federal statute
provides separate federal matching amounts for administrative costs. Cost sharing for administrative expenditures
vary with the services, i.e., 75% for training, 90% for designing, developing or installing mechanized claims
processing and information retrieval, etc. (Federal Medicaid Law (Section 1903(a)(2) et seq.)).
*Many services originally recognized as Home Health Care, Physicians, Other Practitioners and other services are now reported as
Personal 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.
*Many services originally recognized as Home Health Care, Physicians, Other Practitioners and other services are now reported as
Personal Support Services, please refer to page 4-8 for an explanation of these services.
‡Figures may not add to totals due to rounding.
* The "Enhanced Federal Medical Assistance Percentages" are for use in the new Children's Health Insurance Program under Title
XXI, 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 DSH
allotments under those titles. For other purposes, including programs remaining in Title IV of the Act, the percentage for Alaska is
54.13% and for the District of Columbia is 50.00%.
Source: Federal Register, January 12, 1999, Vol. 64, No. 7, pages 1805-1808.
On July 31, 1987, the Health Care Financing Administration (HCFA) published a notice of the final rule for limits
on payments for drugs in the Medicaid program. The regulations adopted in the rule became effective October
29, 1987 (52 FR 28648). In this final rule, HCFA attempted to (1) respond to public comments on the NPRM (51
FR 2956); (2) provide maximum flexibility to the states in their administration of the Medicaid program; (3)
provide responsible but not burdensome federal oversight of the Medicaid program; and (4) take advantage of
savings in the marketplace for multiple-source drugs.
To accomplish this, HCFA adopted a federal upper limit standard for certain multiple-source drugs, based on
application of a specific formula. The upper limit for other drugs is similar, in that it retains the estimated
acquisition cost (EAC) as the upper limit standard that state agencies must meet. However, this standard is
applied on an aggregate basis rather than on a prescription-specific basis. State agencies are therefore encouraged
to exercise maximum flexibility in establishing their own payment methods (see the Federal Register, Vol. 52,
No. 147, Friday, July 31, 1987, page 28648).
Multiple-Source Drugs
A multiple-source drug is one that is marketed or sold by two or more manufacturers or labelers, or a drug
marketed or sold by the same manufacturer or labeler under two or more different proprietary names or under a
proprietary name and without such a name.
A specific upper limit for a multiple-source drug may be established if the following requirements are met:
• All of the formulations of the drug approved by the Food and Drug Administration (FDA) have been
evaluated as therapeutically equivalent in the current edition of the publication, Approved Drug Products
with Therapeutically Equivalent Evaluations, and
• At least three suppliers list the drug (which is classified by the FDA as Category A in its publication) in
the current editions of published compendia of cost information for drugs available for sale nationally.
The upper limit for a multi-source drug for which a specific limit has been established does not apply if a
physician certifies in his or her own handwriting that a specific brand is “medically necessary” for a particular
recipient.
The handwritten phrase “brand necessary,” “medically necessary,” or “brand medically necessary” must appear
on the face of the prescription. The rule specifically states that a check-off box on a prescription form is not
acceptable, but it does not address the use of two-line prescription forms.
The formula to be used in calculating the aggregate upper limit of payment for certain multiple-source drugs will
be 150% of the least costly therapeutic equivalent that can be purchased by pharmacists in quantities of 100
tablets or capsules (or if the drug is not commonly available in quantities of 100, the package size commonly
listed), or in the case of liquids, the commonly listed size, plus a reasonable dispensing fee.
Other Drugs
A drug described as an “other drug” is (1) a brand name drug certified as medically necessary by the physician,
(2) a multiple-source drug not subject to the 150% formula; or (3) a single-source drug. Payments for these drugs
must not exceed, in the aggregate, payment levels determined by applying the lower of:
Other Requirements
The rule requires states to submit a state plan that describes their payment methods for prescribed drugs. The rule
does not prescribe a preferred payment method, as long as the state’s aggregate spending in each category is equal
to or below the upper limit requirements. States are also required to submit assurances to HCFA that the
requirements are met.
The rule does not prescribe a preferred payment method for the states, but gives states the flexibility to determine
how they will pay for prescription drugs under Medicaid. As long as the state’s aggregate spending is at or below
the amount derived from the formula, the state is free to maintain its current payment program or adopt other
methods. States can alter payment rates for individual drugs, balancing payment increases for certain products
with payment decreases for other drugs so that, in the aggregate, the program does not exceed the established
limit. With the establishment of upper limit payment maximums, some states may alter their current payment
methods to comply with the established limits.
State programs vary, depending upon whether or not state maximum allowable cost programs cover the same
drugs listed by HCFA. States with established MAC programs may be unaffected if their MAC rates are already
low, or they may have to make certain adjustments in their MAC levels to meet the federal aggregate expenditure
limits. States without MAC programs may develop a new payment method to increase the use of lower cost
generic drug products in order to stay within the upper payment limits, or may simply adopt HCFA’s formula for
listed drug products.
DRUG RECIPIENTS
Drug recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs. Today,
all 50 States and the District of Columbia cover drugs under the Medicaid program.
*Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively.
Source: HCFA, CMSO, HCFA-2082 Report, FY97, FY98.
Source: The Lewin Group analysis of HCFA Drug Utilization data, FY99.
‡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.
‡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.
In the course of the budget debate, the Office of Management and Budget (OMB) incorporated various
components 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 and
have in effect a national rebate agreement with the Secretary of the Department of Health and Human Services
(HHS) for States to receive federal funding for outpatient drugs dispensed to Medicaid patients.
The requirement for rebate agreements does not apply to the dispensing of a single-source or innovator multiple-
source drug if the state has determined that the drug is essential, rated 1-A by the FDA, and prior authorization is
obtained for the exception. Existing rebate agreements qualify under the law if the state agrees to report all
rebates to HHS and the agreement provides for a minimum aggregate rebate of 10% of the state’s expenditures for
the manufacturer’s products.
OBRA ‘90 was amended by the Veterans Health Care Act of 1992 which also required a drug manufacturer to
enter into discount pricing agreements with the Department of Veterans Affairs and with covered entities funded
by the Public Health Service in order to have its drugs covered by Medicaid. The Medicaid rebate law, as
amended, is included as Appendix C.
The drug rebate program is administered by 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 of
the average manufacturer’s price (AMP) or the difference between the AMP and the manufacturer’s "best
price," and (2) an additional rebate for any price increase for a product that exceeds the increase in the
Consumer Price Index (CPI-U) for all items since the fall of 1990. AMP is the average price paid by
wholesalers for products distributed to the retail class of trade. The best price is the lowest price offered
to any other customer, excluding Federal Supply Schedule prices, prices to state pharmaceutical
assistance programs, and prices that are nominal in amount, and includes all discounts and rebates.
• For generic drugs (non-innovator drugs), reimbursement requires: a rebate of 11 percent of each
product’s AMP.
A state Medicaid program can restrict coverage for a drug product through a formulary, if based on official
labeling or information in designated official medical compendia, “the excluded drug does not have a significant,
clinically meaningful therapeutic advantage in terms of safety, effectiveness or clinical outcome of such
treatment” over other drug products, and there is a written explanation (available to the public) of the basis for the
exclusion. However, drug products excluded from the formulary under these conditions, nevertheless, must be
available through prior authorization.
Drugs in certain specific classes may be restricted or excluded from coverage without regard to the formulary
conditions and need not be available through prior authorization. These classes include:
• Drugs used for anorexia, weight gain, fertility, hair growth, cosmetic effect, symptomatic relief of cough
or colds, or for cessation of smoking.
• Vitamins and minerals (except prenatal vitamins and fluoride preparations) or non-prescription drugs.
• Drugs that require tests or monitoring services to be purchased exclusively from the manufacturer or his
designee.
• Barbiturates or benzodiazepines.
PRIOR AUTHORIZATION
Whether or not a drug product is on a formulary, states may require physicians to request and receive official
permission before a particular product can be dispensed. This procedure is called Prior Authorization or Prior
Approval.
States may not operate prior authorization plans unless the state provides for a response within 24 hours of a
request and provides for a 72-hour emergency supply of the medication.
The Congressional intent for the prior authorization provision was not to encourage the use of such programs, but
rather to make them available to the states for the purpose of controlling utilization of products that have very
narrow indications or high abuse potential.
The majority of states report the establishment of prior authorization programs and have plans to apply prior
authorization to a select number of drugs. Some states will do so only after their Drug Utilization Review (DUR)
program has identified areas of therapeutic concern.
Drug Utilization Review (DUR) is defined as a structured and continuing program that reviews, analyzes, and
interprets 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 containing
health care costs. While there is a general belief that DUR is cost beneficial, it is difficult to isolate concrete
evidence that supports this view. The primary issue facing Medicaid DUR programs is whether or not the
systems currently in place (or envisioned) meet the two objectives outlined above.
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 and
pharmacists on common drug therapy problems and assessments of whether usage complies with predetermined
standards.
Prospective DUR is to be conducted at the point of sale (POS) before delivery of a medication by the pharmacist
to the Medicaid recipient or caregiver. The state is to establish standards for counseling patients and will require
the pharmacist to offer to discuss matters, which, in the exercise of the pharmacist’s professional judgement are
deemed significant, including the following:
• Name, address, telephone number, date of birth (or age) and gender;
• Individual history where significant, including a disease state or states, known allergies and drug
reactions, and a comprehensive list of medications and relevant devices; and
• Pharmacist comments relevant to the individual’s pharmaceutical therapy.
OBRA `90 required that retrospective review is to be ongoing, based on compendia standards and medical
literature, and to include remedial strategies for educational outreach through a wide range of interventions. Each
state is to establish a Drug Utilization Review board, consisting of no more than 51% physicians and at least one-
third pharmacists.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA = Prior Authorization, DME = Durable Medical Equipment
Source: As reported by state drug program administrators in the 2000 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA = Prior Authorization, DME = Durable Medical Equipment
Source: As reported by state drug program administrators in the 2000 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA= Prior Authorization, DME = Durable Medical Equipment
Source: As reported by state drug program administrators in the 2000 NPC Survey.
Coverage of Injectables
Reimbursement for Non Self-Administered Medicines via
the Prescription Drug Program (PDP) or Physician Payment (PP)
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA= Prior Authorization
Source: As reported by state drug program administrators in the 2000 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.
Prior Authorization
Analgesics,
State Anabolic Steroids Antipyretics, NSAIDs Anorectics
Alabama Covered, PA Required Covered, PA Required Not Covered
Alaska Covered Covered Not Covered
Arizona* - - -
Arkansas Covered Covered, PA Required Not Covered
California Covered, PA Required Covered, Some PA Required Covered, PA Required
Colorado Covered, PA Required Covered Partial Coverage
Connecticut Covered Covered Not Covered
Delaware Covered Covered Covered, PA Required
District of Columbia N/A N/A N/A
Florida Covered Covered Not Covered
Georgia Covered, PA Required Partial Coverage, PA Required Covered, PA Required
Hawaii Covered, PA Required Partial Coverage Partial Coverage
Idaho Covered Covered Not Covered
Illinois N/A N/A N/A
Indiana Covered N/A N/A
Iowa Covered Covered, PA Required Not Covered
Kansas Covered Covered Covered, PA Required
Kentucky Covered, PA Required Covered, Some PA Required Not Covered
Louisiana Covered Covered Not Covered
Maine Covered, PA Required Covered Covered, PA Required
Maryland Covered Covered Not Covered
Massachusetts Covered Covered Covered, PA Required
Michigan Not Covered Covered Not Covered
Minnesota Covered Covered Not Covered
Mississippi Covered Covered, PA Required Covered
Missouri Covered Covered Not Covered
Montana Covered Covered, PA Required Covered, PA Required
Nebraska Covered Covered Not Covered
Nevada Covered Covered Not Covered
New Hampshire Covered Covered Not Covered
New Jersey Partial Coverage Covered PA for ADD Diagnosis
New Mexico Covered Covered Covered
New York Covered Covered Not Covered
North Carolina Covered Covered Covered
North Dakota Not Covered Covered Not Covered
Ohio Covered, PA Required Covered Not Covered
Oklahoma Not Covered Covered, PA Required Not Covered
Oregon Covered Covered Covered
Pennsylvania Covered Covered Not Covered
Rhode Island N/A N/A N/A
South Carolina Covered Covered Partial Coverage
South Dakota Covered Covered Not Covered
Tennessee* - - -
Texas Covered Covered Not Covered
Utah Partial Coverage, PA Required Covered Covered
Vermont Covered Covered Covered
Virginia Not Covered Partial Coverage Partial Coverage, PA Required
Washington Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
West Virginia Covered Covered, PA Required Not Covered
Wisconsin Covered Covered Covered, PA Required
Wyoming Not Covered Covered Not Covered
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA = Prior Authorization
Source: As reported by state drug program administrators in the 2000 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA = Prior Authorization
Source: As reported by state drug program administrators in the 2000 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA = Prior Authorization
Source: As reported by state drug program administrators in the 2000 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PRODUR = Prospective Drug Utilization Review System
Source: As reported by state drug program administrators in the 2000 NPC Survey.
Prescribing/Dispensing Limits
Limits on
State Prescriptions Limits on Number, Quantity, and Refills of Prescriptions
Alabama Yes 5 refills per Rx
Alaska Yes 30 day supply per Rx
Arizona* - -
Arkansas Yes 30 day supply per Rx; 3 Rx per month (extension to 6); 5 refills per Rx within 6 months
California Yes 6 Rx per month without PA, other limitations specific to certain medications
Colorado No 100 day supply for maintenance medication
Connecticut 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 meds
Florida Yes Variable 6/8/10/12 Rxs per month (with exceptions); Max/min quantities for certain meds
Georgia Yes 30 day supply per Rx; 5 (adult)/6 (child) Rx per month; Per Rx limit: $1000/Rx
Hawaii Yes 30 day supply or 100 unit doses per Rx
Idaho Yes 34 day supply per Rx (with exceptions); 3 cycles of birth control
Illinois Yes Medically appropriate monthly quantity; 11 refills per Rx
Indiana No -
Iowa No -
Kansas Yes 34 day supply per Rx, other limitations specific to certain medications
Kentucky Yes Maximum 5 refills in 6 months; one dispensing fee per month for maintenance medication
Louisiana Yes 30 day supply or 100 unit doses (whichever is greater); 5 refills per Rx within 6 months
Maine No -
Maryland Yes 34 day supply per Rx; 2 refills per Rx
Massachusetts Yes 5 refills within 6 months per Rx
Michigan Yes No refills for Schedule II drugs; Schedule III & V, 5 refills per 180 days
Minnesota Yes 30 day supply for maintenance drugs; max 3 month supply
Mississippi Yes 34 day supply or 100 unit doses (whichever is greater); 5 Rx per month; 5 refills maximum
Missouri Yes 34 day supply or 100 unit doses; up to 90 day per Rx maximum
Montana Yes 34 day supply or 100 unit doses per Rx (whichever is greater)
Nebraska Yes 3 month supply maximum, 5 refills per Rx within 6 months for controlled substances
Nevada Yes 34 day supply per Rx; 3 Rx per month
New 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 Rx
New Mexico No 6 months supply maximum
New 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 month
North Dakota Yes 34 day supply per Rx
Ohio Yes Consistent with State/Federal requirements
Oklahoma Yes 3 Rx per month (21+; under 21 unlimited)
Oregon Yes 34 day supply per Rx
Pennsylvania Yes 34 day supply or 100 unit doses per Rx (whichever is greater); 5 refills within 6 months
Rhode Island Yes 30 day supply per Rx (non-maintenance); 5 refills per Rx
South Carolina Yes 100 day supply w/ unlimited Rx (children); 4 Rx per month
South Dakota No -
Tennessee* - -
Texas Yes 3 Rx per month with exceptions; unlimited Rxs for nursing home recipients or those < 21
Utah Yes Monthly quantity limit, maximum varies per person
Vermont No -
Virginia No -
Washington Yes 34 day supply per Rx; usually 2 refills per month; 4 refills for antibiotics or scheduled drugs
West Virginia Yes 10 Rx per month; 5 refills per Rx
Wisconsin No 34 day supply per Rx
Wyoming Yes 90 day supply for maintenance drugs and birth control, 34 day supply for all others
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.
• The estimated acquisition cost (EAC) of the drug (the price generally and currently paid by providers for
a particular drug in the package size most frequently purchased by providers), as determined by the
program 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. The
regulations do not prescribe a preferred payment method, but states are required to submit assurances to HCFA
that the requirements are met.
The Health Care Financing Administration’s (HCFA) publishes a list of multiple-source drugs (generic drugs) to
which 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 Medicaid
Manual - Part 6, Payment for Services.” Any price revisions are included in these issuances. The current version
of this list is included as Appendix D: Specific Upper Limits for Multiple Source and “Other” Drugs. The
formula does not apply to any prescription for which the prescriber certified in his or her own handwriting that a
certain 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 the
formula, the state is free to maintain its current payment program or adopt other methods. States can alter
payment rates for individual drugs, balancing payment increases for certain products with payment decreases for
other drugs so that, in the aggregate, the program does not exceed the established limit. State programs
implemented to comply with these requirements are frequently referred to as Maximum Allowable Cost (MAC)
programs.
States are permitted to require certain recipients to share some of the costs of Medicaid by imposing on them such
payments as enrollment fees, premiums, deductibles, coinsurance, copayments, or similar cost-sharing charges
(42 CFR 447.50). For states that impose cost-sharing payments, the regulations specify the standards and
conditions under which states may impose cost-sharing, set forth minimum amounts and the methods for
determining maximum amounts, and describe limitations on availability that relate to cost-sharing requirements.
With the passage of the Social Security Amendments of 1972, states were empowered to impose “nominal” cost-
sharing requirements on optional Medicaid services for cash assistance recipients, and on any services for the
medically needy. Section 131 of the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 introduced
major changes to Medicaid cost-sharing requirements. Under this act, states may impose a nominal deductible,
coinsurance, copayment, or similar charge on both categorically needy and medically needy persons for any
service offered under the state plan. Public Law 97-248, TEFRA, has been in effect since October 1982; it
prohibits imposition of cost-sharing on the following:
While emergency services are excluded from cost sharing, states may apply for waivers of nominal amounts for
non-emergency services furnished in hospital emergency rooms. Such a waiver allows states to impose a
copayment amount up to twice the current maximum for such services. Approval of a waiver request by HCFA is
based partly on the state’s assurance that recipients will have access to alternative sources of care.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.
Mandatory Substitution
Incentive Fee for Dispensing of Generic Dispensing of Lowest Cost
State Generic Substitution Multisource Required Multisource Required
Alabama No No No
Alaska No Yes No
Arizona* - - -
Arkansas No Yes No
California No No Yes
Colorado No Yes (if FUL or State MAC) No
Connecticut $0.50 No No
Delaware No Yes No
District of Columbia No No Yes
Florida No Yes No
Georgia No Yes (brand PA required) Yes
Hawaii No Yes (if FUL) No
Idaho No Yes No
Illinois No No No
Indiana No Yes No
Iowa No Yes No
Kansas No No No
Kentucky No Yes Yes
Louisiana No No No
Maine No Yes No
Maryland No No (payment based on generic) No
Massachusetts No Yes No
Michigan No No No
Minnesota No Yes Yes
Mississippi No No No
Missouri No No No
Montana No No No
Nebraska No No No
Nevada No Yes Yes
New Hampshire No Yes Yes
New Jersey No Yes No
New Mexico No Yes Yes
New York Yes Yes (if M.D. allows substitution) No
North Carolina No Yes No
North Dakota No No No
Ohio No No No
Oklahoma No Yes No
Oregon No Yes No
Pennsylvania No Yes No
Rhode Island No Yes No
South Carolina No Yes (if M.D. authorizes) Yes
South Dakota No No No
Tennessee* - - -
Texas No Yes No
Utah No Yes No
Vermont No Yes No
Virginia No No No
Washington No No (except MAC drug, 3+ labelers) No
West Virginia No Yes No
Wisconsin No No No
Wyoming No No No
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.
Source: 12000-2001 National Association of Boards of Pharmacy Law, Survey of Pharmacy Law; 2As reported by state drug program
administrators in the 2000 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.
Section 5:
State
Pharmacy Assistance
Programs
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.
• Iowa’s Pharmaceutical Discount Program: Iowa legislators have acquired federal funds to establish a
demonstration project to lower pharmaceutical costs for individuals and other purchasers through the
establishment of a prescription drug purchasing co-op. Individuals as well as local pharmacies would be
eligible 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 Iowa
would either directly or through a private sector contractor negotiate volume-purchasing discounts with drug
manufacturers. Members of the co-op would then pay the discounted rate when they purchase their
medications. 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, is
designed to provide direct subsidies to low-income seniors for the purchase of prescription drugs. The
minimum age for eligibility will be 67 years of age, and the income eligibility level will be 150% of the
federal 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 any
eligible resident who enrolls in the program. The law, which created the new program, also provides
authorization for the Commissioner of Human Services to establish maximum retail prices effective July
2003 “if prices paid under the Maine Rx program for the most common drugs are not reasonably comparable
to 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 the
two programs currently in effect in Massachusetts, this new program will offer benefits to individuals 65
years of age or older, or individuals under age 65 who work less than 40 hours per month and meet the
disability guidelines for CommonHealth. There will be no income eligibility requirement; however, monthly
premiums, deductibles, and copay will be based on income. This new program is scheduled to go into effect
on April 1, 2001.
• Nevada’s Subsidy Program: Nevada’s SenioRx is a prescription insurance subsidy program that began on
January 1, 2001. The program is comprised of two plans: the Basic Plan and the Enhanced Plan, with
monthly premiums of $74.76 and $98.31 respectively, the latter covering some brand name drugs. Both
include 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 with
income up to $21,500 would be eligible for less. The state will pay a maximum of $480 per year toward the
cost 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 federal
poverty 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. Senior
citizens enrolled in the SilverxCard program are not eligible for Medicaid and may not have other
prescription insurance coverage.
• Vermont’s Pharmacy Discount Program: The Pharmacy Discount Program is an expansion of the current
Vermont 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 all
individuals with incomes up to 300% federal poverty level who do not have a benefit program that includes
drug coverage. Beneficiaries have the ability to purchase drugs at a price that is equivalent to the price that is
available to the Medicaid program. Approximately 69,000 individuals are eligible for this program which
began on January 1, 2001.
• A Washington Alliance to Reduce Prescription-Drug Spending: The AWARDS program, in operation since
January 15, 2001, will offer Washington residents aged 55 and older significantly lower prescription drug
costs. Eligible beneficiaries will pay an annual fee of $15 per individual or $25 per family to join what will
be considered a “buyer's club.” Through combined agency purchasing power, beneficiaries can expect to
save 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 were
provided by state contacts on program characteristics, including eligibility criteria, funding and reimbursement
information, and drug coverage.
California
Discount Prescription Medication Program
Program Type: State-Negotiated Discounts
Year Operational: 2000
Estimated Eligibles (FY 00): 1,300,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Connecticut
ConnPACE
Program Type: Direct Assistance
Year Operational: 1986
Number of Recipients (FY 00): 31,666
(Elderly: 27,434; Disabled: 4,232)
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Delaware
Nemours Pharmacy Assistance
Program Type: Private Discount Program
Year Operational: 1981
Number of Recipients (FY 00): 26,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Delaware
Prescription Assistance Program (DPAP)
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients (FY 00): 2,203
(Elderly: 986; Disabled: 1,217)
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Illinois
Pharmaceutical Assistance Program (PAP)
Program Type: Direct Assistance
Year Operational: 1985
Number of Recipients (FY 00): 53,555
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Indiana
Prescription Drug Fund “HoosierRx”
Program Type: Refunds
Year Operational: 2000
Estimated Eligibles (FY 00): 66,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Maine
Low Cost Drugs for the Elderly and Disabled Program
Program Type: Direct Assistance
Year Operational: 1975
Number of Recipients (FY 99): 24,900
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Maryland
Pharmacy Assistance Program
Program Type: Direct Assistance
Year Operational: 1979
Number of Recipients (FY 00): 34,000
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Eligible Income Level (Single): $9,650 Eligible Income Level (Married): $10,450
Other Eligibility Notes: No age restriction on eligibility
DRUGS COVERAGE
PROGRAM CONTACT
Maryland
Short-Term Prescription Drug Subsidy Plan
Program Type: Direct Assistance
Enacted: 2000
Number of Recipients (FY 00): 1,004
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: N/A
Drugs Covered: N/A
Drug Coverage Restrictions: Maximum benefit of $1,000 per year
Notes:
PROGRAM CONTACT
Massachusetts
The Pharmacy Program
(formerly Senior Pharmacy Assistance Program)
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Massachusetts
Pharmacy Program Plus
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients (FY 00): 7,170
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Michigan
Emergency Pharmaceutical Program for Seniors (MEPPS)
Program Type: Direct Assistance
Year Operational: 1990
Number of Recipients (FY 99): 12,968
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Michigan
State Medical Plan
Program Type: Tax Credit
Year Operational: 1990
Number of Recipients (FY 00): 20,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Minnesota
Senior Citizen Drug Program
Program Type: Direct Assistance
Year Operational: 1999
Number of Recipients (00): 5,000
ELIGIBILITY CRITERIA
Funding Source: General Revenue Fund plus rebates (subject to budget appropriations)
Budget: $19 million for FY 00 and FY 01
Cost 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-on
Ingredient Cost Calculation: AWP – 9%
Enrollment Fee: None
Deductible Amount: $35/month
Copayment Amount: None
Dispensing Fee: None
DRUGS COVERAGE
PROGRAM CONTACT
Missouri
State Income Tax Credit for Legend Drugs
Program Type: Tax Credit
Year Operational: 1999
Number of Recipients (FY 00): N/A
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: N/A
Drugs Covered: Legend drugs only
Drug Coverage Restrictions: N/A
Notes:
PROGRAM CONTACT
New Hampshire
Senior Prescription Drug Discount Program
Program Type: State-Negotiated Discounts
Year Operational: 2000
Estimated Number of Eligibles: 75,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: No Formulary
Drugs Covered: Most frequently prescribed medication for this population for multiple
health problems
Drug Coverage Restrictions: N/A
Notes: Discounts will vary depending on pharmacy and medication.
Discounts could be up to 40% for generics and up to 15% for branded
products
PROGRAM CONTACT
New Jersey
Pharmaceutical Assistance to the Aged and Disabled (PAAD)
Program Type: Direct Assistance
Year Operational: 1975
Number of Recipients (FY 00): 187,358
(Elderly: 163,958; Disabled: 23,400)
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: No Formulary
Drugs Covered: All legend drugs, syringes, needles, and diabetic testing materials
Drug Coverage Restrictions: DESI drugs, non-rebatable drugs, and over-the-counter drugs
Prescription Drug Utilization: Branded: $273,946,609 (3,817,842 scripts)
Generic: $37,180,099 (2,455,755 scripts)
PROGRAM CONTACT
New York
Elderly Pharmaceutical Insurance Coverage (EPIC) Program
Program Type: Direct Assistance
Year Operational: 1987
Number of Recipients (FY 99): 118,431
ELIGIBILITY CRITERIA
Funding Source: State General Fund and tobacco tax and settlement funds
Budget: $252.2 million
Cost per Participant (FY 99): $890 (net state cost)
# of Rx’s Per Participant (FY 99): 32
Manufacturer Rebate Type: Same as Medicaid, with modified additional (CPI) rebates
Ingredient 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 status
Deductible Amount: Upper income seniors only (over $20,000 single; over $26,000
married); $530-$1,715 depending on total income and marital status
Copayment Amount: $3 to $20 based on cost of prescription
Dispensing 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 Formulary
Drugs Covered: All legend drugs, insulin, and insulin syringes and needles
Drug Coverage Restrictions: DESI drugs and non-participating manufacturers. Viagra limited to six
tables per month
Prescription Drug Utilization: 86% of prescription drug spending on branded; 16% spending on
generic
61% of scripts were branded; 39% of scripts were generic.
PROGRAM CONTACT
North Carolina
Prescription Drug Assistance Plan
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients (FY 00): 2,500
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: N/A
Drugs Covered: Only certain drugs used to treat cardiovascular disease and/or diabetes
Drug Coverage Restrictions: Program will not pay for other drugs
Notes: Prescriptions may be issued for up to a 100-day supply
PROGRAM CONTACT
Pennsylvania
Pharmaceutical Assistance Contract for the Elderly (PACE)
Type of Program: Direct Assistance
Year Operational: 1984
Number of Recipients (FY 00): 208,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Pennsylvania
PACE Needs Enhancement Tier (PACENET)
Program Type: Direct Assistance
Year Operational: 1996
Number of Recipients (FY 00): 22,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Rhode Island
Pharmaceutical Assistance for the Elderly (RIPAE)
Program Type: Direct Assistance
Year Operational: 1985
Number of Recipients (FY 99): 31,000
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): N/A
Eligible Income Level (Single): <$35,000 Eligible Income Level (Married): <$40,000
Other Eligible Groups: None
FUNDING AND REIMBURSEMENT
Funding Source: State General Revenue Fund
Budget: $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): 19.5
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 13%
Enrollment Fee: None
Deductible Amount: None
Copayment 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%
Vermont
VSCRIPT
Program Type: Direct Assistance
Year Operational: 1989
Number of Recipients (FY 00): 2,125
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: No Formulary
Drugs 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
Vermont
Health Access Plan (VHAP)
Program Type: Direct Assistance
Year Operational: 1996
Number of Recipients (FY 00): 7,303
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: No Formulary
Drugs Covered: Approved prescription medications
Drug Coverage Restrictions: No experimental or over-the-counter drugs
Notes: None
PROGRAM CONTACT
West Virginia
Senior Prescription Assistance Network II (SPAN II)
Program Type: State-Negotiated Discount
Year Operational: 2000
Number of Recipients (FY 00): 2,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: No Formulary
Drugs Covered: All FDA approved Federal legend pharmaceuticals
Drug Coverage Restrictions: Cannot be used in conjunction with other discount programs or
prescription drug coverage plans
Notes:
PROGRAM CONTACT
Wyoming
Minimum Medical Program
Program Type: Direct Assistance
Year Operational: 1988
Number of Recipients (FY 00): 550
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): Any age Eligibility Age (Disabled): Any age
Eligible Income Level (Single): $8,350 Eligible Income Level (Married): 100% of FPL
Other Eligible Groups: None
DRUGS COVERAGE
PROGRAM CONTACT
Section 6:
State Pharmacy Program
Profiles
ALABAMA
Medicaid Drug Rebate Contacts Title XIX Medical Care Advisory Committee
Technical: Jim Morrison, 334/242-2323 Medical Association of State of Alabama
Policy: Larry Tatum, 334/242-5489 Marsha D. Raulerson, M.D.
Audits: Jim Morrison 334/242-2323 1205 Belleville Avenue
Brewton, AL 36426-1304
Claims Submission Contact 334/867-3609
Ricky Pope
Roy T. Hager, M.D.
Account Manager, EDS
Institute for Total Eye Care
301 Technacenter Dr.
4255 Carmichael Ct. North
Montgomery, AL 36117
Montgomery, AL 36106
334/215-0111
334/277-9111
Medicaid Managed Care Contact Alabama Nursing Home Association
Vicki Huff Frank R. Brown, Jr.
Director, Managed Care P.O. Box 190
Alabama Medicaid Agency Cullman, AL 35056
501 Dexter Avenue 334/784-5573
Montgomery, AL 36103-5624
334/242-5011 Montgomery Area Council on Aging
Rose Posey
Disease Management Program/Initiative Contact 115 East Jefferson Street
Montgomery, AL 36104
Mary G. McIntyre, M.D. 334/263-0532
Associate Medical Director
Alabama Medicaid Agency Alabama State Medical Association
501 Dexter Avenue Jefferson Underwood, III, M.D.
Montgomery, AL 36103-5624 1031 Oak Street
334/242-5574 Montgomery, AL 36108
Physician-Administered Drug Program Contact Recipient Representative
Larry Tatum Charles G. Spradling, Jr.
334/242-5472 P.O. Box 11765
Birmingham, AL 35202
Alabama Medicaid Agency Officials 334/328-3540
Department of Health
Jim McVay, Director
343 Monroe Street
Montgomery, AL 36130-3017
334/206-5226
ALASKA
Formulary: No formulary.
Ted Summers
P.O. Box 3126
Palmer, AK 99645
ARIZONA
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
(AHCCCS - PRONOUNCED "ACCESS")
of primary care physicians was established to perform the
AHCCCS FEATURES gatekeeping function for the system. Because the primary
care physicians must approve all care, the primary care
The Arizona Health Care Cost-Containment System network eliminated self-referrals to specialists and
(AHCCCS) is a Title XIX (Medicaid) demonstration diminished excessive use of emergency rooms -- both of
project, jointly funded by the federal government and the which have contributed substantially to high medical
State of Arizona. Begun in October 1982, it serves as a costs.
model for providing medical services to the indigent in a
managed care system rather than through fee-for-service Prepaid Capitated Financing
arrangements. Typically, Medicaid programs have
incorporated the traditional hallmarks of the U.S. health It was the intent of the AHCCCS legislation that health
care system: namely, independent providers and fee-for- plans and their providers offer all covered services to
service reimbursement. In contrast, organized health groups of members within a geographical area for a fixed
plans and capitation mark the AHCCCS model. price, for a definite period. The law allowed for the
In traditional Medicaid programs, the states assume establishment of a statewide bidding process to
responsibility for contracting with individual pharmacies accomplish this. Services are provided on a county-by-
and reimbursing them. In the AHCCCS model however, county basis, by prepaid health plans. Providers may bid
the state contracts instead with pre-paid health plans, on a prepaid capitated basis for covered services to be
HMOs and HMO-like entities. These plans are paid on a provided within a particular county. The law allows for
capitation basis and are responsible for providing all of expansion and contraction of bids to achieve the best
the services covered by the program. Thus, the delivery possible system. In the event there are insufficient bids
of pharmacy services is the responsibility of each prepaid for a given area, the legislation permits capped fee-for-
plan. service arrangements. It is intended, however, that capped
fee-for-service will be authorized as a last resort only.
GENERAL INFORMATION
In essence, AHCCCS prepaid health plans (PHPs), health
The Arizona Health Care Cost Containment System maintenance organizations (HMOs), and other types of
(AHCCCS), developed in Senate Bill 1001, was passed by organized health delivery systems charge a fixed fee per
the Legislature and signed by the Governor in November individual enrolled (i.e., a capitation rate) and assume
1981. It contained six major mechanisms for restraining responsibility for providing a broad array of health care
health care costs at the same time ensuring that services to members.
appropriate levels of quality health care services are
provided to eligible persons in a dignified fashion. The Competitive Bidding Process
goal of these 6 items was to contribute to the
establishment of health care financing that is less The statewide competitive aspect of the bid process for
expensive than conventional fee-for-service systems. The selecting providers and offering prepaid capitated services
six mechanisms were: is the most unique feature of the AHCCCS model. A
competition of this magnitude had never been attempted
• Primary Care Physicians Acting as Gatekeepers in any other state. The AHCCCS administration believes
• Prepaid Capitated Financing competitive bidding for health care service contracts, as
• Competitive Bidding Process opposed to conventional negotiation processes, provides
• Cost Sharing accessible cost-effective delivery of health care without
• Limitations on Freedom-of-Choice sacrificing quality performance.
• Capitation of the State by the Federal
Government The AHCCCS administration issues an invitation to
qualified health plans once every five years. Qualified
Primary Care Physicians as Gatekeepers
health plans may bid to offer the full range of AHCCCS
services in one or more counties.
AHCCCS legislation provided that all members must be
under the care and supervision of a primary care physician
who assumed the role of gatekeeper. A statewide network
The fourth major device for containing costs in the Providers may participate in AHCCCS in 2 different
AHCCCS model is a provision for cost sharing by users. ways. First, they may contract with prepaid capitated plans
A statewide co-payment schedule was developed for this as either full or partial benefit providers.
purpose, and the medically needy participate in
coinsurance cost sharing. It is expected that the The second mode of participation is on a capped fee-for-
imposition of nominal co-payments will ensure optimal service basis. Here, providers agree to accept capped fee
effectiveness in the area of service utilization. The co- payments as payments in full for services provided on a
payment schedule accomplishes three objectives: FFS basis.
curtailment of over-utilization; enhancement of patient
dignity; and service utilization by members for truly Functions of the AHCCCS Administration
needed health care. There is no co-payment for drugs and
medication, prenatal care including all obstetrical visits, The Arizona Health Care Containment System
members in long care facilities and for visits scheduled by Administration (AHCCCSA) contracts with full benefit
the primary care physician or practitioner, and not at the capitated health plans to serve AHCCCS members
request of the member. through a network of providers.
The fifth major item for containing costs is a restriction on Under the Contracting Health Plan arrangement, plans are
provider/physician selection by AHCCCS members. defined in terms of explicit groups of providers organized
Unlike conventional delivery models, Arizona does not as entities that are more formal. These consortia, or
rely on fee-for-service arrangements. The goal is to have formal entities, are capable of providing the full range of
the state completely blanketed with prepaid capitated AHCCCS benefits within a defined service area for all
arrangements. Members are linked to selected or assigned AHCCCS members who elect to join the plans, up to a
plans for definite durations of time. Freedom-of-choice is predetermined capacity. This is the dominant mode of
permitted to the extent practicable for members to select operation within AHCCCS -- with two or more competing
the particular group with which to enroll, as well as the plans wherever possible.
primary care physician within the selected group. Capped
fee-for-service health service arrangements are used as a The Contracting Health Plans are delivery systems, not
last resort, and only in areas not covered by prepaid simply insurance plans, but they need not be Health
capitated plans. Maintenance Organizations by any legal or conventional
definition of the term. The AHCCCS legislation provides
CAPITATION BY THE FEDERAL for the creation of provider consortia for the purpose of
GOVERNMENT participation in the program. The Contracting Health Plan
may be a loosely organized system, but it must be capable
The State of Arizona will itself be capitated by the Federal of providing the full range of AHCCCS benefits to a
Government and therefore will be at financial risk for defined population at a capitation rate.
containing health care costs. Capitation rates will be
established according to sound actuarial principles, and The Organizational Role of AHCCCS
will represent no more than 95 percent of the estimated Administration
cost of services delivered in Arizona under conventional
fee-for-service arrangements. Capitation provides a key The AHCCCS Administration has been charged with the
incentive for the state to monitor health care costs on a general implementation and monitoring of the AHCCCS
careful and continuous basis. program.
The Operational Role of the AHCCCS Doctor’s Health Plan, P.C. 520/428-7801
Administration 517 Main Street
Stafford, AZ 85546
Organizationally, the AHCCCS Administration assumes
responsibility for the oversight of every day operations. Family Health Plan of NE Arizona 520/921-8944
P.O. Box 2069
The AHCCCS Administration has overall responsibility Cottonwood, AZ 86326
for the following activity areas:
Health Choice Arizona 602/968-6866
• Promotion of AHCCCS Suite 260
• Procurement of Health Plans 1600 West Broadway
• Quality Management Tempe, AZ 85282-1136
• Provider Management
• Provider, Member, and Public Relations Maricopa Managed Care Systems 602/681-8700
• Program Operations 2516 East University Drive
AHCCCS became effective December 1, 1981, and Phoenix, AZ 85034
services commenced October 1, 1982. Services include:
inpatient, outpatient, laboratory, x-ray, prescription drugs, Mercy Care Plan 602/230-9921
medical supplies, prosthetic devices, emergency dental 2800 North Central, Suite 400
care including extractions and dentures, treatment of eye Phoenix, AZ 85004
conditions and EPSDT.
Phoenix Health Plan 602/824-3700
Though AHCCCS was a three-year experiment that was to 2700 North 3rd Street
end in October 1985, the federal government continues to Phoenix, AZ 85004
extend funding for the program. In 1988, AHCCCS
received a five-year extension from the federal Pima Health System 602/512-5500
government and in 1993, it received an additional one- Suite A-200
year extension. In 1994, AHCCCS received a three-year 5055 East Broadway
extension and in 1998, it is expected to receive a one-year Tucson, AZ 85711
extension.
Regional AHCCCS Health Plan 520/426-6648
1955 North Casa Grande Avenue, #116
MEDICAL PLANS AND ADMINISTRATORS Casa Grande, AZ 85222
Contract terminated, effective 5/1/97
AHCCCS Contracted Health Plans
Access Blue Connection 602/864-4445 University Family Care 520/321-7248
2444 W. Las Palmaritas Drive 575 East River Road
Phoenix, AZ 85021 Tucson, AZ 85704
Contract terminated, effective 10/1/97
Phoenix Arizona Indian Health Services (IHS)
Arizona Health Concepts 602/331-5100 Two Renaissance Square 602/640-2120
7600 N. 16th Street, Suite 150 40 N. Central Avenue
Phoenix, AZ 85020 Phoenix, AZ 85004-5036
Arizona Physicians IPA, Inc. 602/274-6102 Phoenix Indian Medical Center 602/263-1200
3141 North 3rd Avenue 4212 North 16th Street
Phoenix, AZ 85013 Phoenix, AZ 85016
ARKANSAS
Physician Services
Dental Services
1
See Appendix E, page E-29, for a list of acronyms.
Vaccines: Vaccines reimbursable as part of the Vaccines Dispensing Fee: $5.51 effective 7/1/99.
for Children Program.
Ingredient Reimbursement Basis: EAC = AWP – 10.5%.
Unit Dose: Unit dose packaging reimbursable.
Prescription Charge Formula: Legend drugs: lower of the
EAC plus a dispensing fee or CFA/state upper limit plus a
dispensing fee. Total charge may not exceed provider’s
charge to the self-paying public.
Patient Cost Sharing: Effective 9/1/92, for each Scott Harris, P.D.
prescription reimbursed, the Medicaid recipient is 9601 I-630, Ext. 7
responsible for paying a copayment based on the Little Rock, AR 72205-1749
following: 501/202-1749
State Payment Copay
Benji Post, P.D.
$10.00 or less $0.50
$10.01 to $25.00 $1.00
Physicians
$25.01 to $50.00 $2.00
Thomas Lewellen, D.O.
$50.01 or more $3.00
105 West Waterman
ArKids $5.00
Dumas, AR 71639
870/382-1188
Services to individuals under 18, pregnant women,
nursing home residents, emergency services, family Michael N. Moody, M.D.
planning services, and services provided by an HMO to its P.O. Box 829
enrollees are excluded from the Medicaid copay policy. Salem, AR 72576
501/895-2541
Cognitive Services: Does not pay for cognitive services.
Charles Rodgers, M.D.
4202 South University
E. USE OF MANAGED CARE
Little Rock, AR 72204
501/562-4838
An estimated 230,000 Medicaid recipients were enrolled
with managed care organizations PCP and ArKids.
Medicaid Pharmacist
Pharmaceutical benefits are provided through the state.
Suzette Bridges
F. STATE CONTACTS Prescription Price Updating
Medicaid Drug Program Administrator First DataBank
1111 Bay Hill Drive
Suzette Bridges, P.D. San Bruno, CA 74066
Division of Medical Services 415/588-5454
Dept. of Human Services
P.O. Box 1437, Slot 4105
Medicaid Drug Rebate Contacts
Little Rock, AR 72203
T: 501/324-9141 Audits: Suzette Bridges, P.D., 501/324-9141
F: 501/324-9140 PA: Mary Alice Easterling, EDS, 501/374-6608
E-mail: suzette.bridges@medicaid.state.ar.us
Claims Submission Contact
Prior Authorization Contact John Herzog
EDS Federal Corp.
Suzette Bridges
500 East Markham, Ste 400
501/324-9141
Little Rock, AR 72201
501/374-6608
Dr. Judith McGhee
501/682-6442DUR Contact
Medicaid Managed Care Contact
Suzette Bridges
Bob Paladino
501/324-9141
P.O. Box 1437, Slot 1102
Little Rock, AR 772203
DUR Board
Pharmacists:
Steve Bryant, P.D.
Bryant’s Pharmacy
2000 Harrison Street
Batesville, AR 72501
501/793-3999
CALIFORNIA
Under the Health and Human Services Agency with direct Formulary/Prior Authorization
administration by the Department of Health Services.
Formulary: Closed formulary. Medi-Cal List of Contract
The Department of Health Services Pharmaceutical Unit Drugs: Over 600 drugs in differing strengths and dosage
of the Medi-Cal Policy Division monitors the full scope forms listed generically. A drug may be added to the list
and quality of pharmaceutical benefits covered under the on contractual agreement by the manufacturer to provide
provisions of the California Medical Assistance Program. the state a rebate based on the quantity reimbursed to
pharmacies for Medi-Cal recipients. The patient’s
D. PROVISIONS RELATING TO DRUGS physician or pharmacist may request prior authorization
from the field office Medi-Cal consultant for approval of
Benefit Design unlisted drugs or for listed drugs that are restricted to
specific use(s).
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Examples of general limitations and exclusions (other
combinations used for insulin; blood glucose test strips; uses require prior authorization):
and urine ketone test strips. Products covered with prior
1. CNS stimulants, i.e., amphetamines and
authorization: total parenteral nutrition and interdialytic
methylphenidate, are restricted to attention deficit
parenteral nutrition. Products not covered: cosmetics;
disorder in individuals between 4 and 16 years of age.
fertility drugs; and experimental drugs.
2. Diazepam is restricted to use in cerebral palsy,
Over-the-Counter Product Coverage: Products covered athetoid states, and spinal cord degeneration.
with prior authorization: allergy, asthma and sinus
3. Cimetidine, Famotidine are restricted to therapy
products; analgesics; cough and cold preparations; non-
lasting up to 90 days from the dispensing date of the
H2 antagonist digestive products; digestive products, H2
first prescription.
antagonists; feminine products; topical products; and
smoking deterrent products. 4. Most non-steroidal anti-inflammatory agents are
restricted to use for arthritis.
Therapeutic Category Coverage: Therapeutic categories
5. Many antibiotics have diagnostic and/or age
covered: chemotherapy agents and contraceptives. Prior
restrictions.
authorization required for: anabolic steroids; analgesics,
antipyretics, NSAIDs; antibiotics; anticoagulants; 6. Acyclovir capsules are restricted to herpes genitalis,
anticonvulsants; antidepressants; antidiabetic agents; immunocompromised patients and herpes zoster
antihistamine drugs; antilipemic agents; anti-psychotics; (shingles).
anxiolytics, sedatives, and hypnotics; cardiac drugs;
7. Codeine Combinations: payment to a pharmacy for
prescribed cold medications; ENT anti-inflammatory
ASA or APAP with codeine 30 mg is limited to a
agents; estrogens; growth hormones; hypotensive agents;
maximum dispensing quantity of 45 tablets or
misc. GI drugs; prescribed smoking deterrents;
capsules and a maximum of 3 claims for the same
sympathominetics (adrenergic); and thyroid agents. Medi-
beneficiary in any 75-day period.
Cal fee-for-service does not blanket exclude drug classes.
Drugs for the treatment of cancer or AIDS are exempt 8. Excluded from coverage: multivitamins for persons
from prior authorization. over five years of age (except pre-natal vitamin-
mineral products for pregnant women); cosmetic
Coverage of Injectables: Injectable medicines drugs and fertility drugs; and most OTC household
reimbursable through the Prescription Drug Program remedies.
when used in home health care, extended care facilities
9. Enteral nutritional supplements or replacements are
and through physician payment when used in physician
covered, subject to prior authorization, if used as a
offices.
therapeutic regimen to prevent serious disability or
death in patients with medically diagnosed conditions
Vaccines: Vaccines reimbursable by schedule as part of
that preclude the full use of regular foodstuffs.
the Vaccines for Children Program. Vaccines for adults
covered through the prescription drug program. 10. Cancer, AIDS, and DESI Drugs: Any antineoplastic
drug approved by FDA for the treatment of cancer
and any drug approved by FDA for the treatment of
AIDS or AIDS-related condition is covered through
the Medi-Cal List of Contract Drugs; most DESI
drugs rated less-than-effective by FDA are not Hospital Discharge Medications: Quantities furnished as
covered. discharge medications are limited to no more than a 10-
day supply. Charges are incorporated in the hospital’s
Prior Authorization: State currently has a formal prior
claims for inpatient services.
authorization procedure. Medi-Cal frequently petitions to
add drugs to the list of contract drugs. Denials of these Drug Utilization Review
petitions can be appealed to the director of the
Department of Health and Human Services by the PRODUR system implemented in August 1995. State
petitioner within 30 days after notice of the denial. currently has a DUR Board with a quarterly review.
Providers may appeal prior authorization decisions within
60 days of notification to the local field office and then to Pharmacy Payment and Patient Cost Sharing
field services headquarters if necessary. Beneficiaries also
have the ability to request a hearing to review the denial Dispensing Fee: $4.05, effective 8/85.
and must do so within 90 days of notification.
Ingredient Reimbursement Basis: EAC = AWP-5%, or
Approval may be obtained from a Medi-Cal consultant direct price for 11 specified manufacturers.
for: covered items or services not included on the Medi-
Cal List of Contract Drugs (including special Prescription Charge Formula: Reimbursement is based
circumstance override of multiple source drug price on the lowest of:
ceilings or minimum quantity/ frequency of billing
limitations); and for patients exceeding the 6 Rx per For Legend Drugs:
month limit. Statewide mail and fax requests are accepted 1. Estimated Acquisition Cost (EAC) + dispensing fee,
in the Stockton and Los Angeles Medi-Cal Field Offices. less $0.25.
Requests must include adequate information and 2. Federal Upper Limit (FUL) + dispensing fee, less
justification. Authorization may only be given for the $0.25.
lowest cost item or service that meets the patient’s 3. State Maximum Allowable Ingredient Cost (MAIC) +
medical needs. dispensing fee, less $0.25.
4. Pharmacy’s usual price to general public, less $0.25.
Beneficiary or Prescriber Prior Authorization: On a case
by case basis, the Dept. of Health Services restricts,
through the requirements of prior authorization, the For Over-the-Counter Drugs:
availability of designated prescription drugs to certain 1. Estimated acquisition cost (EAC) x 1.5, less $0.50.
beneficiaries or prescribers found by the Department to 2. Federal Upper Limit (FUL) x 1.5, less $0.50.
abuse those benefits. 3. State Maximum Allowable Ingredient Cost
(MAIC) x 1.5, less $0.50.
Prescribing or Dispensing Limitations 4. Pharmacy’s usual price to the general public, less
$0.50.
Prescription Refill Limit: A prescription refill can be
dispensed as authorized by prescriber. Exception is (Reimbursement is reduced by $0.25 per claim line as of
allowed for refill of a reasonable quantity when prescriber January 1, 2000.
is unavailable (pursuant to California law). Fee is pro-
rated so that total fee (for partial quantity and balance of Maximum Allowable Cost: State MACs are established
the prescription after prescriber is contacted) does not for 51 multi-source items. Override requires “Medically
exceed fee for same prescription when refilled as routine Necessary” or unavailability of drug products at or below
service. MAC. List is periodically revised and price limits
changed to reflect current market conditions.
Monthly Quantity Limit: This is flexible, but should be
consistent with the medical needs of the patient. Limited Incentive Fee: None.
to 100 tabs on some drugs, 100 days’ supply on others.
Many maintenance drugs are subject to minimum quantity Patient Cost Sharing: Copayment: $1.00 (optional).
or maximum frequency of billing controls.
Monthly Prescription Limit: Limited to 6 per month Cognitive Services: Does not pay for cognitive services,
without prior authorization. The limit does not apply to but this is under consideration.
family planning drugs, patients in nursing facilities or to
AIDS or cancer drugs.
Maxicare
1149 South Broadway, Suite 819
Los Angeles, CA 90015
COLORADO
OTHER, TOTAL
D. PROVISIONS RELATING TO DRUGS Monthly Quantity Limit: New prescriptions for chronic or
acute conditions are prescribed at the discretion of the
Benefit Design physician. However, reasonable amounts for more than a
30-day supply for chronic conditions are recommended.
Drug Benefit Product Coverage: Products covered: Maximum supply is 100 days for maintenance medication
prescribed insulin. Products covered with restriction:
disposable needles and syringe combinations used for Drug Utilization Review
insulin; blood glucose test strips; urine ketone test strips,
total parenteral nutrition; and interdialytic parenteral PRODUR system implemented in December 1998.
nutrition. Products not covered: cosmetics; DESI drugs;
fertility drugs; prescribed vitamins (except prenatal); and Lock-In Review Procedures: The Department receives
experimental drugs. computer processed printouts designed to discover over-
utilization of drugs prescribed by physicians, dispensed by
Over-the-Counter Product Coverage: Products covered vendors, and received by eligible recipients.
with restriction: analgesics (ASA only); cough and cold
preparations (except >21) and smoking deterrent products. Pharmacy Payment and Patient Cost Sharing
Products not covered: allergy, asthma and sinus products;
digestive products (non-H2 antagonist); digestive products Dispensing fee: $4.08 as of July 1, 1990. Institutional
(H2 antagonist); feminine products; and topical products. pharmacies will receive a dispensing fee equal to $1.89.
Dispensing physicians shall not receive a dispensing fee
Therapeutic Category Coverage: Therapeutic categories unless their offices or sites of practice are located more
covered: analgesics, antipyretics, NSAIDs; antibiotics; than 25 miles from the nearest participating pharmacy. In
anticoagulants; anticonvulsants; antidepressants; the latter case, physicians receive a fee equal to $1.89.
antidiabetic agents; antihistamine drugs; antilipemic
agents; anti-psychotics; anxiolytics, sedatives, and Ingredient Reimbursement Basis: EAC = AWP-10% or
hypnotics; cardiac drugs; chemotherapy agents (given in WAC (wholesaler acquisition cost) + 18%. Other: FUL,
home); contraceptives; ENT anti-inflammatory agents; state Mac, usual and customary.
estrogens; hypotensive agents; misc. GI drugs;
sympathominetics (adrenergic); and thyroid agents. Prescription Charge Formula: Benefit drugs shall be
Therapeutic categories partially covered: anorectics. Prior reimbursed at the lesser of the Medicaid allowable
authorization required for: anabolic steroids; prescribed reimbursement charge, or the provider’s usual and
cough and cold medication; growth hormones; vitamins; customary charge or whatever is accepted from any third
sexual dysfunction; Epogen; brand name and FUL drugs; party, discounts, rebates, etc.
and prescribed smoking deterrents.
The Medicaid allowable reimbursement charge is the sum
Coverage of Injectables: Injectable medicines of the ingredient cost of the drug dispensed and the
reimbursable through the Prescription Drug Program provider’s dispensing fee.
when used in home health care, extended care facilities
and through physician payment when used in physician Ingredient cost for retail pharmacies (estimated
offices. acquisition cost) is the price of the drug actually dispensed
as defined below or the MAC or the high volume EAC,
Vaccines: Vaccines reimbursable as part of the Vaccines whichever is less.
for Children Program.
The ingredient cost for institutional and government
Unit Dose: Unit dose packaging not reimbursable. pharmacies is defined as the actual cost of acquisition for
the drug dispensed or the MAC, or the high volume EAC,
Formulary/Prior Authorization whichever is less.
Formulary: Closed formulary Maximum Allowable Cost: The state MAC is the
maximum ingredient cost allowed by the Department for
certain multiple-source drugs. The establishment of a (1) The average wholesale price as it appears in the Red
MAC is subject, but not limited to, the following Book, its supplements, and Medi-Span will be the first
considerations: source. However, if there is a difference between the two
published average wholesale prices, the Department will
(1) Multiple manufacturers;
set the price as the published amount which is the closest
(2) Broad wholesale price span;
to the lowest average price charged by two drug
(3) Availability of drugs to retailers at the selected cost;
wholesalers doing business in Colorado.
(4) High volume of Medicaid recipient utilization;
(5) Bioequivalence or interchangeability.
(2) If there is a price change which does not appear
When federal MAC limits for multiple source drugs are immediately in the Red Book, its supplements, or in Medi-
announced, they will be adopted if they are less than state Span, then the Department will set the average wholesale
MACs or if no state MACs exist. price by averaging the wholesale prices of three drug
wholesalers doing business in Colorado, until the price is
The ingredient cost of any drug subject to MAC shall be published in the Red Book, its supplements, or in Medi-
limited to MAC or wholesale price as determined by the Span.
Department, whichever is less. Exceptions that will allow
reimbursement greater than MAC for a drug entity are (3) If the prices or changes do not appear in the
obtained through a prior authorization mechanism. An publications or the wholesalers’ records, then the
exception will be granted if the patient’s response to the distributors’ or manufacturers’ prices will be adjusted to
generic drug is not therapeutic, an allergic reaction is the wholesale pricing level and used in the drug pricing
involved, or any similar situation exists. file as the price of the drug.
If a recipient requests a brand name for a prescription that If the difference between the pharmacist’s invoice
is subject to MAC, then he/she may pay the ingredient purchase price and the average wholesale price which
cost difference between the MAC and brand name drug. appears in the Red Book, its supplements, or Medi-Span
The recipient must sign the prescription stating that he/she exceeds 18%, then the Department may adopt a lower
is willing to pay the difference in ingredient cost to the price after a survey is conducted to determine the validity
pharmacy. The pharmacy will be paid MAC plus a of the published prices. The price from the distributor or
dispensing fee or reimbursement charges, whichever is manufacturer will be adjusted the same as in 3 above.
lower.
Special Note: The Maximum Allowable Cost shall be
High volume Estimated Acquisition Cost (EAC): determined by the Division of Medical Assistance, based
Reimbursement for single source drugs or certain multiple upon professional determination of a quality product
source drugs which are most frequently prescribed will be available at the least expense possible.
based upon average wholesale prices (AWP) minus 10%,
or direct manufacturers’ prices for package sizes Exceptions to the above are:
containing quantities greater than 100 dosage units or less
if not available in 100’s. - Shelf package size oral liquid medications, in pint size
only, or smaller package size when not packaged in pint
Basis for inclusion in the high volume estimated size.
acquisition cost list includes but is not limited to: - Shelf package size oral tablet and capsule medications
(1) Single source manufacturers; in quantities of 100 only or smaller when not available in
(2) High volume Medicaid recipient utilization; package size of 100.
(3) Interchangeability problems with multiple source - Prescriptions for less than minimum amounts will be
drugs; denied reimbursement of the professional fee unless the
(4) Package sizes in excess of 100. physician notified the Department in writing of the
Drug Pricing: The Department will maintain a drug- medical need for amounts less than a 30-day supply.
pricing file that will be updated at least monthly. The Medical consultation determines the decision.
average wholesale price of a drug as determined by the
Incentive Fee: None.
Department, MAC, and high volume EAC, will be the
basis for setting the prices in the drug pricing file.
Patient Cost Sharing: Copay is $2.00 for brand name
products and $0.50 for generic.
The Department will determine the average wholesale
price that will be placed in the drug-pricing file as
Cognitive Services: Does not pay for cognitive services.
follows:
DUR Contact
E. USE OF MANAGED CARE
Allen Chapman, 303/886-3176
Approximately 210,000 total unduplicated number of
Medicaid recipients were enrolled in MCOs in FY 1999. Prescription Price Updating
Recipients receive pharmaceutical benefits through
managed care plans. Allen Chapman, 303/886-3176
CONNECTICUT
OTHER, TOTAL
State of Connecticut Department of Social Services through Formulary: Open formulary, however, the following
five regional offices and nine sub-offices. products are excluded from Medicaid prescription
coverage: experimental drugs, cosmetics, fertility drugs;
D. PROVISIONS RELATING TO DRUGS smoking cessation products; DESI drugs, and drugs
available free from the Department of Health Services.
Benefit Design
Prior Authorization: State currently has no prior
Drug Benefit Product Coverage: Products covered: authorization procedure.
prescribed insulin, disposable needles and syringe
combinations for insulin; blood glucose test strips; urine Prescribing or Dispensing Limitations
ketone test strips; total parenteral nutrition (except in
NH); and interdialytic parenteral nutrition (except in NH). Prescription Refill Limit: 6-month refill limit except for
Products not covered: cosmetics; fertility drugs; and oral contraceptives, which have a 12-month limit.
experimental drugs. Controlled substances have a 5 refill or 6-month limit.
Over-the-Counter Product Coverage: Products covered: Monthly Quantity Limit: Maximum 240 tablets or
digestive products (non-H2 antagonists); feminine capsules. Oral contraceptives: 3 months supply may be
products; analgesics; and cough and cold preparations dispensed at one time.
(children < 19 years). Products not covered: smoking Physicians are encouraged to prescribe drugs generically,
deterrent products; allergy, asthma and sinus products; when possible.
digestive products (H2 antagonists); topical products;
iron; calcium; oral contraceptives; and some trace Drug Utilization Review
elements. For nursing home patients, the department will
not pay for OTC drugs used in nursing facilities (such drugs PRODUR system implemented September 1996. Retro
are covered in the per diem rate). Some drugs require DUR since September 1991; the state currently has a
diagnosis for reimbursement such as CNS stimulants for DUR Board with a quarterly review.
ADD and narcolepsy. Pharmacy Payment and Patient Cost Sharing
Therapeutic Category Coverage: Therapeutic categories
covered: anabolic steroids; analgesics, antipyretics, Dispensing Fee: $4.10, effective 1/1/91.
NSAIDs; antibiotics; anticoagulants; anticonvulsants;
antidepressants; antidiabetic agents; antihistamine drugs; Ingredient Reimbursement Basis: EAC = AWP-12%.
antilipemic agents; anxiolytics, sedatives, and hypnotics;
cardiac drugs; chemotherapy agents; prescribed cold Prescription Charge Formula: Federal MAC or EAC plus
medications; contraceptives; ENT anti-inflammatory dispensing fee; or usual and customary if lower.
agents; estrogens; hypotensive agents; misc. GI drugs;
sympathominetics (adrenergic); thyroid agents; and Maximum Allowable Cost: State imposes Federal Upper
growth hormones. Therapeutic categories not covered: Limits on generic drugs. Override requires “Brand
anorectics and prescribed smoking deterrents. Medically Necessary.”
Coverage of Injectables: Injectable medicines reimbursable Incentive Fee: The Department will pay an incentive
through the Prescription Drug Program when used in home professional dispensing fee of $0.50 per prescription, in
health care, extended care facilities, and through physician addition to any other dispensing fee, for substituting a
payment when used in physicians offices. No injectable generically equivalent drug product.
drug list.
Patient Cost Sharing: None.
Vaccines: Vaccines reimbursable as part of the Children
Health Insurance Program. Cognitive Services: Does not pay for cognitive services.
Unit Dose: Unit dose packaging not reimbursable. E. USE OF MANAGED CARE
DELAWARE
OTHER, TOTAL
Over-the-Counter Product Coverage: Products covered: Ingredient Reimbursement Basis: EAC = AWP-12.9%.
allergy, asthma and sinus products; analgesics; cough and
cold preparations; digestive products (non-H2 antagonist); Prescription Charge Formula: Payment is based on
digestive products (H2 antagonists); and smoking AWP-12.9% or maximum allowable cost (MAC) plus a
deterrent products. Products covered with restriction: dispensing fee, or the usual and customary cost to the
feminine products (antifungals) and topical products (anti- general public, whichever is lower.
infectants).
Maximum Allowable Cost: State imposes Federal Upper
Therapeutic Category Coverage: Therapeutic categories Limits as well as state-specific limits on generic drugs.
covered: anabolic steroids; analgesics, antipyretics, State-specific MAC list contains 90 drugs. Override
NSAIDs; antibiotics; anticoagulants; anticonvulsants; requires “Brand Medically Necessary.”
antidepressants; antidiabetic agents; antihistamine drugs;
antilipemic agents; anti-psychotics; anxiolytics, sedatives, Incentive Fee: None.
and hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT anti- Patient Cost Sharing: None.
inflammatory agents; estrogens; hypotensive agents; misc.
GI drugs; prescribed smoking deterrents; Cognitive Services: Does not pay for cognitive services.
sympathominetics (adrenergic); and thyroid agents. Prior
authorization required for: anorectics and growth E. USE OF MANAGED CARE
hormones.
Approximately 68,000 total unduplicated number of
Coverage of Injectables: Injectable medicines Medicaid recipients were enrolled in MCOs in FY 1999.
reimbursable through the Prescription Drug Program and Recipients receive pharmaceutical benefits through the
physician payment when used in physician offices. state.
Reimbursable only through the Prescription Drug Program
when used in extended care facilities. Managed Care Organizations
DelawareCare
Vaccines: Vaccines reimbursable under the Vaccines for
2751 Centerville Road, Suite 400
Children program.
Wilmington, DE 19808
215/937-8285
Unit Dose: Unit dose packaging not reimbursable. No
price based on AWP.
First State Health Plan
1801 Rockland Road, Suite 300
Formulary/Prior Authorization
Wilmington, DE 19803
302/576-7603
Formulary: Open formulary.
DISTRICT OF COLUMBIA
Monthly Quantity Limit: In general, amounts dispensed D.C. Chartered Health Plan
are to be limited to quantities sufficient to treat an episode 820 First Street, NE, Ste. LL100
of illness. Maintenance drugs such as thyroid, digitalis, Washington, DC 20002
etc. may be dispensed in amounts up to a 30-day supply 202/408-4710
with 3 refills that must be dispensed within 4 months.
Antibiotic medications used in treatment of acute Capitol Community Health Plan
infections are not to be dispensed in excess of a 10-day 750 First Street, NE, Ste. 1120
supply. Birth control tablets may be dispensed in 3-cycle Washington, DC 20002
units with a maximum of 3 refills within one year. 202/408-0460
Monthly Dollar Limits: $1,500 limit. Physicians are to George Washington University Health Plan
request prior authorization for prescriptions that exceed 4550 Montgomery Avenue
this amount. Beheads, MD 20814
301/941-2044
Drug Utilization Review
Fiscal Intermediary
Jack Zaelo
First Health Services, Inc.
122 C Street, N. W.
Washington, DC 20001
202/783-5610
FLORIDA
Formulary/Prior Authorization
S. Shai Gold,
Medicaid Drug Rebate Contacts
Director, Business and Proposal Development Center
Technical: Ralph Quinn, 850/488-9190 The South Florida Community Care Network
Policy: Jerry Wells, 850/487-4441 1801 NW 9th Avenue, Ste 700
Audits: Jerry Wells, 850/487-4441 Miami, FL 33136
Disputes: Greg Bracko, 850/488-9193 T: 305/585-5187
F: 305/585-3815
E-mail: umimbdc@compusource.net
Claims Submission Contact
Mark Steck Diabetes:
PBM Director Virginia M. Dollar
Consultec, Inc. Coordinated Care Solutions
9040 Roswell Road, Suite 700 210 N. University Drive, Ste 700
Atlanta, GA 30350 Coral Springs, FL 33071
770/594-7799 T: 954/344-2444
F: 954/796-3688
Medicaid Managed Care Contact Asthma:
Ralph Anderson, R.N. ITG (program sponsor)
Agency for Health Care Administration
2727 Mahan Drive, BLD 1, Rm 323 Plans exist for disease management programs for End-
Tallahassee, FL 32308 Stage Renal Disease (ESRD) and congestive heart failure.
T: 850/487-0640 Contact: Bob Sharpe
F: 850/414-5418 Assistant Deputy Director for Medicaid
Agency for Health Care Administration
2727 Mahan Drive
Disease Management Program/Initiative Contact Tallahassee, FL 32308
850/488-3560
Hemophilia:
Michael L. Ansel
Accordant Health Services Physician-Administered Drug Program
5509-A West Friendly Avenue, Ste 101 Laura Rutledge
Greensboro, NC 27410 850/488-4481
T: 336/855-5870 ext.134
F: 336/852-7413
E-mail: mansel@accordant.com Executive Officers of State Medical and
Pharmaceutical Societies
George E. Hurrell, Jr.
Florida Medical Association, Inc.
Director, Disease Management
Charles S. Amorosino, Jr.
Caremark Inc.
P.O. Box 10269
1127 Bryn Mawr Avenue
123 S. Adams St.
Redlands, CA 92374
Tallahassee, FL 32301
T: 909/799-4160
904/224-6496
F: 909/7998-4335
E-mail: george.hurrell@mdmnetwork.com
Florida Pharmacy Association
Michael Jackson, R.Ph.
AIDS:
Executive Vice President
Peter D. Reis
610 North Adams Street
Director of Business Development
Tallahassee, FL 32301
AIDS Healthcare Foundation
850/222-2400
6255 West Sunset Blvd, 16th Fl.
Los Angeles, CA 90028
Florida Osteopathic Medical Association
T: 213/860-5200
Larry Mattingly, D.O.
F: 213/860-5235
2007 Apalachee Parkway
E-mail: pdreisjr@aol.com
The Hull Building
Tallahassee, FL 32301
850/878-7364
GEORGIA
HAWAII
By the State Department of Human Services through its Quantity of Medication: Physicians are encouraged to
Med-Quest Division and four county branch offices. prescribe a 30-day supply or 100 units.
Chuck Duarte
Administrator, Med-Quest Division
IDAHO
OTC Coverage: Products covered: prescribed insulin; Pharmacy Payment and Patient Cost Sharing
disposable needles and syringe combinations used for
insulin; permethrin; and oral iron salts. Products not Dispensing Fee: $4.94 ($5.54 for unit dose), effective
covered: allergy, asthma, and sinus; analgesics, cough and March 1999.
cold preparations; digestive products; feminine products;
topical products; and smoking deterrent products. Ingredient Reimbursement Basis: EAC = AWP-11% as
determined by First DataBank Data File Service or
Therapeutic Category Coverage: Therapeutic Categories manufacturer direct price for selected manufacturers.
covered: anabolic steroids; analgesics, antipyretics,
NSAIDs; antibiotics; anticoagulants; anticonvulsants; Prescription Charge Formula: Lower of FUL, SMAC or
antidepressants; antidiabetic agents; antihistamine drugs; EAC plus a dispensing fee or provider’s usual and
antilipemic agents; anti-psychotics; anxiolytics, sedatives, customary price to the general public.
and hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT anti- Maximum Allowable Cost: State imposes Federal Upper
inflammatory agents; estrogens; hypotensive agents; misc. Limits and state-specific limits on generic drugs. Override
GI drugs; sympathominetics (adrenergic); and thyroid requires prior authorization.
agents. Prior authorization required for: growth
hormones. Therapeutic categories not covered: anorectics Incentive Fee: None.
and prescribed smoking deterrents.
Patient Cost Sharing: No copayment.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program Cognitive Services: Does not pay for cognitive services.
when used in home health care, extended care facilities,
and through physician payment when used in physicians
offices.
E. USE OF MANAGED CARE
Vaccines: Vaccines reimbursable as part of the Children
Health Insurance Program, and the Vaccines for Children Does not use MCOs to deliver services to Medicaid
Program. recipients. Some Medicaid recipients are enrolled in
primary care case management and receive their benefits
Unit Dose: Unit dose packaging reimbursable when used from the state.
in unit dose systems.
Formulary Authorization
Cathy Hart
Executive Officers of State Medical and
Idaho Office on Aging
Pharmaceutical Societies
Statehouse, Room 108
Boise, ID 83720-0007 Idaho Medical Association
208/334-3833 Robert Seehusen
Executive Director
Sally Higginson 305 West Jefferson, P.O. Box 2668
Boise Alliance for the Mentally Ill Boise, ID 83702
331 N. Allumbaugh 208/344-7888
Boise, ID 83704
208/376-4304 Idaho State Pharmaceutical Association
Jo An Condie
Shirley Osborn Executive Director
5553 W. Lockport 305 W. Jefferson, P.O. Box 140117
Boise, ID 83703 Boise, ID 83714
208/334-3110 208/424-1107
ILLINOIS
Illinois Department of Public Aid, Division of Medical PRODUR system implemented in January 1993. State
Assistance. currently has a DUR board with a review on an as needed
basis.
D. PROVISIONS RELATING TO DRUGS
Pharmacy Payment and Patient Cost Sharing
Benefit Design
Dispensing Fee: $3.75/$3.45 for generic/branded drugs
Drug Benefit Product Coverage: Products covered: costing up to $37.50; 10.46% of the drug cost for drugs
prescribed insulin; disposable needles and syringe costing $37.51 and more; maximum of $15.70/$15.40 for
combinations used for insulin; blood glucose test strips; generic/branded drugs. Effective 7/1/99.
and urine ketone test strips. Products not covered:
cosmetics; DESI-ineffectives; fertility drugs; experimental Ingredient Reimbursement Basis: EAC = AWP - 10%,
drugs; total parenteral nutrition; and interdialytic AWP - 12% for multisource drugs.
parenteral nutrition.
Prescription Charge Formula: Lowest of 1) usual and
OTC Coverage: Products covered: digestive products (H2 customary, 2) Department's MAC plus fee. Professional
antagonists) and smoking deterrent products. Products fee: $3.58 up to EAC of $35.80; above EAC of $35.80,
requiring prior authorization: analgesics; digestive fee is 10% of EAC.
products (non-H2 antagonist); and topical products.
Products not covered: allergy, asthma, and sinus; cough Maximum Allowable Cost: State imposes Federal Upper
and cold preparations; and feminine products. Limits as well as state-specific limits on generic drugs.
All drugs are interchangeable in Illinois but not for those
Coverage of Injectables: Injectable medicines with a Federal MAC. Other drugs appear on the Illinois
reimbursable through the Prescription Drug Program MAC list where the Federal MAC was inappropriate.
when used in physician offices, home health care, and Override requires prior authorization.
extended care facilities.
Incentive Fee: None.
Vaccines: Vaccines are reimbursable as part of a special
program. Patient Cost Sharing: No copayment.
Unit Dose: Unit dose packaging not reimbursable. Cognitive Services: Does not pay for cognitive services.
INDIANA
OTHER
Drug Benefit Product Coverage: Products covered: Maximum Allowable Cost: State imposes Federal Upper
prescribed insulin; disposable needles and syringe Limits. Override requires “Brand Medically Necessary.”
combinations used for insulin; blood glucose test strips;
urine ketone test strips; total parenteral nutrition; and Incentive Fee: None.
interdialytic parenteral nutrition. Products not covered:
cosmetics; fertility drugs; and experimental drugs. Patient Cost Sharing: Copayment varies from $0.50 to
$3.00 for branded drugs and is $0.50 for generic drugs.
Over-the-Counter Product Coverage: Products covered if
prescribed by a physician: Indiana has a Medicaid OTC Cognitive Services: None.
drug formulary. Listed drugs are reimbursed based on
State MAC. E. USE OF MANAGED CARE
Therapeutic Category Coverage: All coverage in Approximately 330,000 total unduplicated number of
accordance with OBRA ’90 & ’93. Medicaid recipients were enrolled in MCOs in FY 2000.
Recipients receive pharmaceutical benefits through
Coverage of Injectables: Covered. managed care plans.
IOWA
− Permethrin Liquid 1%
C. ADMINISTRATION
− Pseudoephedrine Hydrochloride: 30/60 mg Tablets;
30mg/5mg Liquid
State Department of Human Services, Division of Medical
− Salicylic Acid Liquid 17%
Services.
− Senokot: 326 mg/tsp Granules for children aged 20
and under; 187 mg Tablets for children aged 20 and
D. PROVISIONS RELATING TO DRUGS under
− Sodium Chloride Solution 0.9% for inhalation, with
Benefit Design metered dispensing valve 90 ml, 240 ml
− Tolnaftate 1% Cream, Solution, Powder
Drug Benefit Product Coverage: Products covered:
− Nonprescription multiple vitamin and mineral
prescribed insulin. Products covered requiring prior
products specifically formulated and recommended for
authorization: PPIs; dipyridamole; epoetin; filgrastim;
use as a dietary supplement during pregnancy and
vitamins; ergotamine derivatives; narcotic agonist-
lactation
antagonist nasal sprays; isotretinoin; oral antifungals; non-
− With prior authorization, nonprescription multiple
parenteral vasopressin derivatives; and Serotonin 5-HT1
vitamins and minerals under the conditions specified
receptor agonists. Products not covered: fertility drugs;
in subparagraph 78.1(2) “a” (3)
experimental drugs; cosmetics; disposable needles and
syringe combinations for insulin; blood glucose test strips; − Insulin
urine ketone test strips; total parenteral nutrition; and − Oral solid forms of the above-covered items shall be
interdialytic parenteral nutrition. prescribed and dispensed in a minimum quantity of
100 units per prescription or the currently available
Over-the-Counter Product Coverage: Products covered consumer package size except when dispensed via a
with restriction (selected products): allergy, asthma and unit dose system. When used for maintenance therapy,
sinus products; analgesics; cough and cold preparations; all of the above-listed items may be prescribed and
H2 antagonists; and topical products. Products not dispensed in 90-day quantities
covered: digestive products; feminine products; and
smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories
covered: anabolic steroids; antibiotics; anticoagulants;
The Iowa Department of Human Services adopted an anticonvulsants; antidepressants; antidiabetic agents;
administrative rule that permits coverage for these non- antilipemic agents; anti-psychotics; anxiolytics, sedatives,
prescription drugs: and hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT anti-
− Aspirin: 325/650 mg Tabs; 81mg Chewable; Aspirin
inflammatory agents; estrogens; hypotensive agents;
Enteric Coated: 325/650mg Tabs; 81mg Chewable;
sympathominetics (adrenergic); and thyroid agents. Prior
Aspirin Tablets Buffered, 325 mg
authorization required for: analgesics, antipyretics,
− Acetaminophen: 325/500mg Tablets; 120mg/5ml and
NSAIDs; amphetamines; antihistamine drugs; growth
160mg/5mL Elixir; 100 mg/ml Solution; 120mg
hormones; and misc. GI drugs. Therapeutic categories not
Suppositories
covered: anorectics and prescribed smoking deterrents.
− Bacitracin Ointment 500 units/gm
− Benzoyl Peroxide 5% and 10%, Cleanser, Lotion,
Coverage of Injectables: Injectable medicines
Cream, Gel
reimbursable through the Prescription Drug Program
− Chlorpheniramine Maleate Tablets 4 mg when used in home health care, extended care facilities,
− Diphenhydramine Hydrochloride: 25 mg Capsules; and through physician payment when used in physicians
6.25mg/5mL and 12.5mg/5ml Liquid offices.
− Ferrous Sulfate: 300/325mg Tablets; 220mg/5ml
Elixir; 75 mg/0.6 ml Drops Vaccines: Vaccines reimbursable as part of the EPSDT
− Ferrous Gluconate: 300/325mg Tablets; 300mg/5ml service and the Vaccines for Children Program.
Elixir
− Ferrous Fumarate Tablets 300 mg, 325 mg Unit Dose: Unit dose packaging reimbursable.
− 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
Ingredient Reimbursement Basis: EAC = AWP - 10%. State Drug Program Administrator
Ronald Mahrenholz, R.Ph., M.S.
Prescription Charge Formula: Payment will be based on Pharmacist Consultant
the pharmacist's usual, customary and reasonable charge, Division of Medical Services
but payment may not exceed EAC plus a dispensing fee. Dept. of Human Services
Hoover State Office Bldg.
Maximum Allowable Cost: State imposes Federal Upper Des Moines, IA 50319
Limits on generic drugs. Override requires “Brand T: 515/281-6199
Medically Necessary.” F: 515/281-6230
E-mail: rmahren@dhs.state.ia.us
Incentive Fee: None.
Prior Authorization Contact
Patient Cost Sharing: Copayment of $1.00 branded and
generic (federal exclusions). Randy Brentnall, R.Ph.
Consultec, Inc.
Cognitive Services: Does not pay for cognitive services. P.O. Box 14422
Des Moines, IA 50306-3422
E. USE OF MANAGED CARE T: 515/327-1322
F: 515/327-0945
Iowa Medicaid recipients receive pharmaceutical benefits
through the state. DUR Contact
Iowa Assn. of Homes for the Aging Iowa State Association of Counties
William Thayer Virginia Bordwell
613 West North Street P.O. Box 889
Madrid, IA 50156 Washington, IA 52353
Community Mental Health Centers of IA Iowa Governor’s Planning Council for Developmental
Michelle Wray Disabilities
520 11th Street, N.W. Rick Shannon, DD Council
Cedar Rapids, IA 52405 617 E. 2nd Street
Des Moines, IA 50309
Iowa Dental Association
Robert Harpster Iowa Academy of Family Physicians
333 Insurance Exchange Building Dr. Dave Carlyle
Des Moines, IA 50309 1215 Duff Avenue
Ames, IA 50010
Iowa Council of Health Care Centers
George Appleby Iowa Physical Therapy Association
400 Homestead Building, Ste. 300 Steven Clark
Des Moines, IA 50309 2386 Scenic View Dr.
Adel, IA 50003
Iowa Osteopathic Medical Association
Norman Pawlewski Iowa Physician Assistant Society
950 12th St. Michael Farley
Des Moines, IA 50309 4524 Boulevard Pl.
Des Moines, IA 50311
Iowa Optometric Association
Gary Ellis Iowa Association of Nurse Practitioners
1454 30th Street, Suite 204 Wanda Marshall
West Des Moines, IA 50266-1312 2301 Beaver Avenue
Des Moines, IA 50310
Iowa Pediatric Medical Society
Rick DelPrado, D.P.M. Iowa Association of Rural Health Clinics
110 NW 9th, Suite 5 Ed Friedmann
Ankeny, IA 50021 1013 1st Street, Box C
Redfield, IA 50233
Iowa Psychological Association
Mark Peltan Iowa Occupational Therapy Association
North Iowa Mercy Health Center Angela Hanson-Abbas
84 Beaumont Drive 161 315th St.
Mason City, IA 50401-2921 Perry, IA 50220
KANSAS
OTHER
F. STATE CONTACTS
Medicaid Managed Care Contact
State Drug Program Administrator Bobbie Graff-Hendrixson
Karen Braman, R.Ph., M.S. Managed Care Team Leader
Department of Social and Rehabilitation Services Health Care Policy Division, Kansas Dept. of SRS
915 SW Harrison, Rm. 651-S DSOB Topeka, KS 66612-1570
Topeka, KS 66612-1570 T: 785/296-3981
T: 785/296-6968 F: 785/296-4813
F: 785/296-4813
E-mail: ksb@srskansas.org Social and Rehabilitation Services Department
Agency Internet Address: www.ink.org/public/srs/ Officials
Janet Schalansky
Prior Authorization Contact Secretary
Karen Braman, 785/296-6968 Department of Social and Rehabilitation Services
Docking State Office Bldg.
915 SW Harrison
DUR Contact Topeka, KS 66612-1570
Glenn McNees, R.Ph., M.S., BCPS 785/296-3981
DUR Program Director
KU School of Pharmacy Medical Care Advisory Committee Contact
6052 Malott Hall Robert Day, Ph.D.
Lawrence, KS 66045-2500 Medicaid Policy/Medicaid Director
T: 785/864-3264 Health Care Policy Division
F: 785/864-5849 Kansas Dept of SRS
915 SW Harrison
Topeka, KS 66612-1570
DUR Board 785/296-3981
Fiscal Manager
Rick Schultz
Health Care Policy Division
Kansas Dept. SRS
Room 651 S, Docking State Office Building
Topeka, KS 66612-1570
785/296-3981
KENTUCKY
OTHER
Department for Medicaid Services, within the Cabinet for Formulary: Closed Formulary. The Kentucky Medicaid
Health Services. Program maintains a drug file of approximately 96,800
drugs and covers all rebated products, some of which
D. PROVISIONS RELATING TO DRUGS require prior authorization.
Industry Representatives:
E. USE OF MANAGED CARE J. Scott Moody, Glaxo Wellcome
Kevin WeMett, Pharmacia & Upjohn
Approximately 300,000 total unduplicated number of
Medicaid recipients were enrolled in MCOs in FY 1999.
Recipients receive pharmaceutical benefits through the Drugs Technical Advisory Committee
state and managed care plans. Steve Adams, R.Ph.
Region 3 217 Lexington Street
Passport Health Plan, Fincastle Bldg. Lancaster, KY 40444
305 W. Broadway, 4th Floor
Louisville, KY 40202 R. N. Smith, R.Ph.
502/585-7900 P. O. Box 247
Burkesville, KY 42717
Bill Howe
Medicaid Drug Rebate Contact
Government Relations Manager
Pfizer Inc. Marie Couch
209 North Walnut, Suite C Program Coordinator
Lansing, MI 48933 CHR Building, 6th Floor
275 East Main Street
Ms. Marilyn Osborne, MSN, ARNP Frankfort, KY 40621
Perry County Health Center 502/564-3476
239 Lovern Street
Hazard, KY 41701
Claims Submission Contact
Vaughn Payne, M.D. Unisys Provider Services
6420 Dutchman’s Pkwy. P.O. Box 2100
Louisville, KY 40205 Frankfort, KY 40602
T: 502/226-1140
George C. Rodgers, Jr., M.D.* F: 502/226-1860
4250 Georgetown-Greenville Rd.
Georgetown, KY 47122-8816 Medicaid Managed Care Contact
LOUISIANA
Unit Dose: Unit dose packaging reimbursable. Patient Cost Sharing: $ 0.50 - $3.00 copayment
dependent of the cost of the drug, effective 7/13/95.
Formulary/Prior Authorization
Cognitive Services: Does not pay for cognitive services
Formulary: Open formulary
E. USE OF MANAGED CARE
Prior Authorization: State currently does not have a
formal prior authorization procedure. Does not use MCOs to deliver services to Medicaid
recipients.
Prescribing or Dispensing Limitations
Region IV:
Physician-Administered Drug Program Contact
Paul Chachere, P.D.
W. Merwin McMahen, P.D. Kandis McDaniel
Donna White, P.D. 504/342-0127
Johnny Johnston, M.D.
Medicaid Drug Program Committee
Louisiana DUR Board Committee Members
Cathi Fontenot, M.D.
Ken Ardoin, Senior Manager LSU Medical Center
State Government Relations 1542 Tulane Avenue
Pfizer, Inc. New Orleans, LA 70112
7 Village Circle, Suite 400 504/568-4791
Westlake, TX 76262
817/491-8410 Naurang Agrawal, M.D.
Gastroenterologist
Brad Belding, P.D. Tulane University School of Medicine
Director of Pharmacy 1430 Tulane Avenue
Thibodaux Hospital New Orleans, LA 70112
402 Easy Street 504/588-5838
Thibodaux, LA 70301
504/493-4786 Keith C. Ferdinand, M.D.
1201 Poland Avenue
Sylvia Heidingsfelder, M.D. New Orleans, LA 70117
5805 Highland Road 504/943-1177
Baton Rouge, LA 70808
225/358-1069
Tim Jacks
Professional Pharmacy Services
4106 Desiard Street
Monroe, LA 71203
318/345-2891
MAINE
Benefit Design Monthly Quantity Limit: 34 day for brand-name drugs and
90 days for generic drugs per month.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Drug Utilization Review
combinations used for insulin (not covered for nursing
home patients); blood glucose test strips; urine ketone test PRODUR system implemented in 1996. State currently
strips; total parenteral nutrition; interdialytic parenteral has a DUR Board.
nutrition; products not covered: vitamin and vitamin
preparations (except pregnancy); and injectables when
oral medication is available for equally effective Pharmacy Payment and Patient Cost Sharing
treatment.
Dispensing Fee: $3.35 for stock supply, or for solutions
Over-the-Counter Product Coverage: Products covered: or lotions involving no weighing. $4.35 for compounding
allergy, asthma, and sinus products (limited coverage after ointments and for solutions/lotions involving weighing
1/1/01); analgesics (limited coverage after 1/1/01); cough one or more ingredients and making home IV solutions.
and cold preparations (limited coverage after 1/1/01); $5.35 for compounding handmade supplies, pwd. papers,
digestive products, H2 antagonists (limited coverage after capsules and tablet priturates and for mixing home TPN
1/1/01); topical products; smoking deterrent products (by hyperalimentation.
Rx only); products not covered: digestive products (not
including H2 antagonists); feminine products. Ingredient Reimbursement Basis: EAC = AWP - 10%.
Therapeutic Category Coverage: Therapeutic categories Prescription Charge Formula: Lowest of usual and
covered: anabolic steroids; antibiotics; anticoagulants; customary, FUL, AWP-10%, or Maine MAC. Maine
anticonvulsants; antidepressants; antidiabetic agents; MAC includes approximately 50 drug products in addition
antilipemic agents; anti-psychotics; anxiolytics, sedatives, to FUL products.
and hypnotics; cardiac drugs; chemotherapy agents;
contraceptives; ENT anti-inflammatory agents; estrogens; Maximum Allowable Cost: State imposes Federal Upper
hypotensive agents; misc. GI drugs; prescribed smoking Limits as well as state-specific limits on generic drugs.
deterrents; sympathominetics (adrenergic); and thyroid Override requires “brand medically necessary” by the
agents. Prior authorization required for: analgesics, physician and prior authorization for some drugs.
antipyretics, NSAIDs; anorectics; antihistamine drugs;
prescribed cold medications; growth hormones. Incentive Fee: None.
Coverage of Injectables: Injectable medicines Patient Cost Sharing: Sliding copay scale based on cost:
reimbursable when used in physician offices, home health $0.50 to $3.00 for branded, $0.50-$2.00 for generic drugs.
care, and extended care facilities.
Cognitive Services: State does not pay for cognitive
Vaccines: Vaccines reimbursable based on cost as part of services.
the EPSDT service (admin. fees) and as part of the Bureau
of Health Immunization Program (vaccine fees). E. USE OF MANAGED CARE
Unit Dose: Unit dose packaging reimbursable. About 23,000 Medicaid recipients are enrolled in MCOs.
Formulary/Prior Authorization
MARYLAND
OTHER
Drug Benefit Product Coverage: Products covered: Prior authorization required from the HealthChoice and
prescribed insulin; disposable needles and syringe Acute Care Administration when the usual and customary
combinations used for insulin; and total parenteral charge exceeds $100 and the prescribed amount is a 34-
nutrition. Products not covered: cosmetics; fertility drugs; day supply or more. Preauthorization is needed for any
experimental drugs; blood glucose test strips; urine ketone prescription with a usual and customary charge exceeding
test strips; interdialytic parenteral nutrition; DESI drugs; $400. Prior authorization is also needed for early refills,
prescriptions and injections for central nervous system; nutritional supplements, and excessive quantities.
food supplements or infant formulas; products for which
Federal Financial Participation is not allowed, i.e., "less Prescribing or Dispensing Limitations
than effective" drugs and products whose manufacturers
have not signed rebate agreements; and (e) certain other Prescription Refill Limit: Maximum of two refills. The
items as specified in the state's Medicaid plan. original prescription and its refills may not exceed a 100-
day supply except for birth control pills and oral sodium
Over-the-Counter Product Coverage: Products covered: fluoride preparations. Refills may not be dispensed after
contraceptives; oral ferrous sulfide; and aspirin for 100 days of date of original prescription except for birth
arthritis. Products not covered: allergy, asthma and sinus control pills and oral sodium fluoride preparations
products; analgesics; cough and cold preparations;
Monthly Quantity Limit: The amount of medication to be
digestive products (H2 and non-H2 antagonists); feminine
dispensed on a prescription at one time is limited to a less
products; topical products; and smoking deterrent
than 34-day supply except for specific maintenance drugs
products.
for chronic conditions, where up to a 100-day supply may
be dispensed at one time.
Therapeutic Category Coverage: Therapeutic categories
covered: anabolic steroids; analgesics, antipyretics, Drug Utilization Review
NSAIDs; antibiotics; anticoagulants; anticonvulsants;
antidepressants; antidiabetic agents; antihistamine drugs; PRODUR system implemented January 1993. State
antilipemic agents; anti-psychotics; anxiolytics, sedatives, currently has a DUR Board with a quarterly review.
and hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT anti- Pharmacy Payment and Patient Cost Sharing
inflammatory agents; estrogens; hypotensive agents; misc.
GI drugs; prescribed smoking deterrents; Dispensing Fee: $4.21 as of July 1, 1996.
sympathominetics (adrenergic); and thyroid agents. Prior
authorization required for: growth hormones. Therapeutic Ingredient Reimbursement Basis: Estimated Acquisition
categories not covered: anorectics. Cost (EAC) equals/lowest of:
Coverage of Injectables: Injectable medicines 1. Wholesale Acquisition Cost (WAC) plus 10%.
reimbursable through the Prescription Drug Program 2. Direct cost plus 10%.
when used in home health care, extended care facilities, 3. Distributor's price plus 10%.
and through physician payment when used in physician 4. Average Wholesale Price (AWP) minus 10%.
offices.
Prescription Charge Formula: Reimbursement will be the
Vaccines: Vaccines reimbursable as part of the EPSDT lower of: (1) the calculated ingredient cost plus a
service. dispensing fee; (2) the usual and customary fee.
Unit Dose: Unit dose packaging reimbursable for nursing Maximum Allowable Cost: State imposes Federal Upper
home patients only for commercially available products. Limits as well as state-specific limits on generic drugs.
Approximately 1,000 drugs are listed on the state-specific
MAC list. Override requires “Brand Medically
Necessary” and a reason.
MASSACHUSETTS
Massachusetts Pharmacists
Linda Barry
617/736-0101
MICHIGAN
OTHER
D. PROVISIONS RELATING TO DRUGS Prior Authorization: State currently has a formal prior
authorization procedure. In order to appeal prior
Benefit Design authorization decisions, a department appeals section in
the Medicaid program sets up hearings for beneficiaries.
Drug Benefit Product Coverage: Products covered: The beneficiary is sent a letter with instructions on their
prescribed insulin; disposable needles and syringe appeal rights when appealing the coverage of an excluded
combinations used for insulin; blood glucose test strips; product.
and urine ketone test strips. Products covered with
restrictions: total parenteral nutrition (paid to medical Prescribing or Dispensing Limitations
suppliers) and interdialytic parenteral nutrition. Prior
authorization required for: brand name products Prescription Refill Limit: Based on state law.
equivalent to MACs; Accutane & Retin-A; Dexedrine and
Adderall; Persantine; Lactulose (Cephulac); Monthly Quantity Limit: Prescribed quantities should be
Methylphenidate (selected ages); selected limited to an amount necessary to keep the recipient
benzodiazepines; Epogen administered in the home supplied during the therapy regimen. In certain cases and
setting; dietary formulas; and drugs not listed on the conditions, more than a month’s supply will be
formulary. Products not covered: cosmetics; fertility appropriate. However, in no instance may more than 100
drugs; and experimental drugs. days supply be dispensed per prescription.
Cognitive Services: Does not pay for cognitive services. Family Health Plan of Michigan
2200 Jefferson Avenue
E. USE OF MANAGED CARE Toledo, OH 43624
800/231-8274
Approximately 1,000,000 total unduplicated number of 734/457-5370 (Monroe Office)
Medicaid recipients were enrolled in MCOs in FY 1999.
Recipients receive pharmaceutical benefits through the Good Health Michigan
state and managed care plans. 2000 S. Woodward, Ste. 200
Bloomfield Hills, MI 48302
Managed Care Organizations 248/454-1070
888/898-7969
American Family Care
2000 S. Woodward, Ste. 200 Great Lakes Health Plan, Inc.
Bloomfield Hills, MI 48302 17117 W. Nine Mile, Ste. 1600
248/454-1070 Southfield, MI 48075
888/898-7969 248/559-5656
800/903-5253
Blue Care Network
25925 Telegraph Road Health Alliance Plan
Southfield, MI 48086 2850 W. Grand Blvd.
248/799-6674 Detroit, MI 48202
800/414-3457 313/664-8360
800-801-1769
Botsford Health Plan
28050 Grand River Health Plan of Michigan
Farmington Hills, MI 48336 17515 W. Nine Mile, Ste. 650
248/473-6190 Southfield, MI 48075
800/479-5122 248/569-8640
888/437-0606
Cape Health Plan
17421 Telegraph, Suite 209
Detroit, MI 48219
888/354-2273
Robert Smedes
Deputy Director
Medical Services Administration
P. O. Box 30479
Lansing, MI 48909
MINNESOTA
Minnesota Department of Human Services, Health Care Formulary: Open formulary with general exclusions.
Management Division, Medical Assistance Program.
Prior Authorization: State currently has a prior
D. PROVISIONS RELATING TO DRUGS authorization procedure and a Drug Formulary
Committee. Recipient has the right to appeal Prior
Benefit Design authorization decisions and coverage of an excluded
product by appeals referee followed by an appeal in court.
Drug Benefit Product Coverage: Products covered:
cosmetics; fertility drugs; and experimental drugs. Prescribing or Dispensing Limitations
Products covered with restriction: interdialytic parenteral
nutrition. Prior Authorization required for: Desmopressin; Monthly Quantity Limit: 3 month supply. Minimum 30-
Epoetin Alpha; Filgrastim; Interferon Alfa; Interferon days for maintenance drugs. Contraceptives may be filled
Gamma-IB; Ondansetron; Granisetron; and Sargramostim to provide a 3-month supply.
Products not covered: prescribed insulin; disposable
needles and syringe combinations used for insulin; blood Drug Utilization Review
glucose test strips; urine ketone test strips; and total
parenteral nutrition. PRODUR system implemented in February 1996. State
currently has a DUR Board with a quarterly review.
Over-the-Counter Product Coverage: Products covered if
prescribed by a physician: digestive products (H2 Pharmacy Payment and Patient Cost Sharing
antagonists). Products covered with restrictions: allergy,
asthma and sinus products; analgesics; cough and cold Dispensing Fee: $3.65, effective 7/1/97.
preparations; digestive products (non-H2 antagonist);
feminine products (antifungals covered); topical products; Ingredient Reimbursement Basis: EAC = AWP - 9%.
and smoking deterrent products (within deterrent
program). Prescription Charge Formula: Reimbursement is based
on the lesser of submitted AWP minus 9% plus a
Therapeutic Category Coverage: Therapeutic categories dispensing fee, MAC plus a dispensing fee, or usual and
covered: anabolic steroids; analgesics, antipyretics, customary.
NSAIDs; antibiotics; anticoagulants; anticonvulsants;
antidepressants; antidiabetic agents; antihistamine drugs; Maximum Allowable Cost: State imposes Federal Upper
antilipemic agents; anti-psychotics; anxiolytics, sedatives, Limits on generic drugs. Override requires “brand
and hypnotics; cardiac drugs; chemotherapy agents; medically necessary.”
contraceptives; ENT anti-inflammatory agents; estrogens;
growth hormones; hypotensive agents; prescribed Incentive Fee: None.
smoking deterrents; sympathominetics (adrenergic); and
thyroid agents. Prior authorization required for: misc. GI Patient Cost Sharing: No copayment.
drugs (proton pump inhibitor). Therapeutic categories not
covered: anorectics and tretinoin products (covered only Cognitive Services: Does not pay for cognitive services.
for acne).
E. USE OF MANAGED CARE
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program Approximately 280,000 total unduplicated number of
when used in home health care, extended care facilities, Medicaid recipients were enrolled in MCOs in FY 1999.
and through physician payment when used in physician Recipients receive pharmaceutical benefits through
offices. managed care plans.
MISSISSIPPI
Division of Medicaid, Office of the Governor. Formulary: Open formulary, however, general exclusions
include:
D. PROVISIONS RELATING TO DRUGS 1. Drugs used for anorexia or weight gain.
2. Drugs when used for the symptomatic relief of cough
Benefit Design and colds (except quaifenesin syrup 100 mg/5 ml,
iodinated glycerol tablets 30 mg, which are covered).
Drug Benefit Product Coverage: Products covered: 3. Prescription vitamins and mineral products (except
prescribed insulin, syringe combinations used for insulin; prenatal vitamins and fluoride preparations, which are
total parenteral nutrition; and interdialytic parenteral covered).
insulin. Products not covered: cosmetics; fertility drugs; 4. Covered outpatient drugs for which the manufacturer
experimental drugs; disposable needles used for insulin; requires (as a condition of sale) that associated tests
blood glucose test strips; and urine ketone test strips. or monitoring services be purchased exclusively from
Prior authorization required for: Sandimmune; Viagra; the manufacturer or its designee.
enteral feeding products; Clozaril (must be prescribed by 5. Barbiturates (except amobarbital, butabarbital,
Board Certified or Board Eligible Psychiatrist);* mephobarbital, pentobarbital, phenobarbital,
Protropin and Humatrope;* all Antihemophilic Factors secobarbital, which are covered).
including VIII and IX;* and all Home IV Drug Therapies. 6. Benzodiazepines (except Klonopin, Lorazapam,
Diazepam and Temazepam which are covered).
* These products are covered only for children ages 0-21 7. DESI drugs (those drugs that are designated less than
years through the Early and Periodic Screening, Diagnosis effective by the FDA).
and Treatment Program (EPSDT).
Prior Authorization: Administrative hearing require to
Over-the-Counter Product Coverage: Products covered: appeal prior authorization decisions.
ASA, generic Tylenol; generic Robitussin, Benadryl; iron
supplements; and calcium supplements. Products not Prescribing or Dispensing Limitations
covered: allergy, asthma, and sinus products; digestive
products; feminine products; topical products; and Prescription Refill Limit: Limited to five (5).
smoking deterrent products.
Monthly Quantities Limit: 34-day supply or 100 units or
doses, whichever is greater. Birth control pills may be
Therapeutic Category Coverage: Therapeutic categories
supplied in 3-month quantities.
covered: anabolic steroids; anorectics; antibiotics;
anticoagulants; anticonvulsants; antidepressants; Monthly Prescription Limit: Total prescriptions dispensed
antidiabetic agents; antihistamine drugs; antilipemic per month per recipient are limited to 5. With prior
agents; anti-psychotics; anxiolytics, sedatives, and authorization recipients may get up to 10.
hypnotics; cardiac drugs; chemotherapy agents;
contraceptives; ENT anti-inflammatory agents; estrogens; Drug Utilization Review
hypotensive agents; misc. GI drugs; sympathominetics
(adrenergic); and thyroid agents. Prior authorization PRODUR system implemented in 1993. No state DUR
required for: analgesics, antipyretics, NSAIDS; and Board exists.
growth hormones. Therapeutic categories not covered:
prescribed cold medications and prescribed smoking Pharmacy Payment and Patient Cost Sharing
deterrents.
Dispensing Fee: $4.91.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program Ingredient Reimbursement Basis: EAC = AWP - 10%,
when used in home health care, extended care facilities, effective July 1, 1990.
and through physician payment when used in physicians
offices. Prescription Charge Formula: Reimbursement for legend
drugs will be at the lessor of AWP-10% plus a dispensing
fee or usual and customary charge. OTC drugs will be
Vaccines: Vaccines reimbursable as part of the EPSDT
paid at lessor of AWP plus a dispensing fee, AWP + 50%,
program.
or shelf price. OTC drugs are to be billed on pharmacy
invoice at shelf price.
Unit Dose: Unit dose packaging not reimbursable.
Maximum Allowable Cost: State imposes Federal Upper Robert McMurry, M.D.
Limits on generic drugs. Override requires “Brand University of MS Medical Center
Medically Necessary.” L525 Clinical Sciences Bldg.
2500 North State St.
Incentive Fee: None. Jackson, MS 39216
601/362-4471 ext.1865
Patient Cost Sharing: Copayment $1.00.
Cindy Nobel, Pharm.D.
Cognitive Services: Pays for Disease Management University of MS
Services for arthritis, diabetes, hyperlipidemia, asthma, Department of Family Medicine
and coagulatory disorders (effective 8/1/98). Pays $20 for 2500 North State St.
average 30-minute encounter. Jackson, MS 39216
601/984-5425
E. USE OF MANAGED CARE
Richard Ogletree, Pharm.D.
No Medicaid recipients receive health benefits through University of MS
MCOs. Department of Pharmacy
2500 North State St.
F. STATE CONTACTS Jackson, MS 39216
601/984-2055
MISSOURI
Approximately 270,000 Medicaid recipients are enrolled State Drug Program Administrator
in managed care organizations. All receive pharmacy
Susan McCann, R.Ph.
services through managed care.
Pharmaceutical Consultant
Division of Medical Services
Managed Care Organizations
P.O. Box 6500
Healthcare USA Jefferson City, MO 65102-6500
100 South 4th Street, Suite 1100 T: 573/751-6963
St. Louis, MO 63102 F: 573/526-4650
314/444-7239 E-mail: susanmccann@mail.medicaid.state.mo.us
Blue Advantage Plus Health Plan
Social Services Department Officials
P.O. Box 419130
2301 Main St. Gary J. Stangler, Director
Kansas City, MO 64141 Department of Social Services
816/395-3891 Broadway State Office Building
P.O. Box 1527
Mercy Health Plan Jefferson City, MO 65102
1508 S. Grand
St. Louis, MO 63104 Gregory Vadner, Director
314/214-8000 Division of Medical Services
615 Howerton Court, P.O. Box 6500
Care Partners Health Plan Jefferson City, MO 65102
The Clayton Center
120 S. Central, 8th Floor Prior Authorization Contact
St. Louis, MO 63105
Allison Lauf, R.N.
314/505-5400
Nurse Consultant
Division of Medical Services
Community Care Plus Health Plan
P.O. Box 6500
5615 Pershing Avenue, Suite 29
Jefferson City, MO 65102
St. Louis, MO 63112
573/751-3762
314/454-0055 ext. 234
MONTANA
OTHER, TOTAL
Drug Benefit Product Coverage: Products covered: Prior Authorization: State has a formal prior authorization
prescribed insulin. Products not covered: cosmetics; procedure. Prescriber letter documenting evidence for use
fertility drugs; experimental drugs; disposable needles of prescribed medication in treatment of disease is
used for insulin, syringe combinations for insulin use; reviewed by DUR Board for appeal of excluded product.
blood glucose test strips; urine ketone test strips; total An appeal procedure through the Department possible for
parenteral nutrition; and interdialytic parenteral nutrition. PA decisions.
Prior authorization required for Dipyridamole; Carafate;
Ambien; Sonata; Cilostazol; Pentoxifylline; Isoproterenol; Prescribing or Dispensing Limitations
Isoetherine; Viagra; Thalidomide; DMARDs; Mobic, Prescription Refill Limit: 25% grace period over a 3-
Celebrex, and Vioxx; anti-obesity drugs; Duract; Stadol; month period is allowed.
Tretinoin; and Zoloft (50mg); migraine headache drugs;
single-source non-steroidal anti-inflammatory drugs; Monthly Quantity Limit: 100 doses or 34-day supply,
growth hormones; smoking cessation; oral Ketorolac; H2- whichever is greater.
antagonists, proton pump inhibitors, single source
benzodiazepines; hair growth products; and fertility
agents. Drug Utilization Review
PRODUR system implemented in September 1994. State
Over-the-Counter Product Coverage: Products covered: DUR Board has 6 members and meets monthly.
analgesics (Aspirin only); digestive products; head lice
treatment products (permethrin and pyrethrin combination Pharmacy Payment and Patient Cost Sharing
products); H-2 antagonists. Products not covered: allergy,
asthma, and sinus products; cold and cough preparations; Dispensing Fee: $2.00-4.20; effective 7/1/98. Additional
feminine products; topical products; and smoking $0.75 is added to prescriptions unit dosed by the
deterrent products. pharmacy.
Therapeutic Category Coverage: Therapeutic categories Ingredient Reimbursement Basis: EAC = AWP - 10%, or
covered: anabolic steroids; antibiotics; anticoagulants; manufacturer’s direct price, if available.
anticonvulsants; antidepressants; antidiabetic agents;
antihistamine drugs; antilipemic agents; anti-psychotics; Prescription Charge Formula: The lower of EAC, the
cardiac drugs; chemotherapy agents; contraceptives; ENT Federal MAC (plus a dispensing fee), or the provider
anti-inflammatory agents; estrogens; hypotensive agents; usual and customary charge.
sympathominetics (adrenergic); and thyroid agents. Prior
authorization required for: anorectics; anxiolytics, Maximum Allowable Cost: State imposes Federal Upper
sedatives, and hypnotics; analgesics, antipyretics, Limits on generic drugs. Override requires “Brand
NSAIDs; misc. GI drugs; growth hormones; and Necessary.”
prescribed smoking deterrents.
Incentive Fee: None.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program Patient Cost Sharing: Copayment - $1.00 for all generic;
when used in home health care, extended care facilities, $2.00 for all others; effective 5/1/94.
and through physician payment when used in physician
offices. Cognitive Services: Does not pay for cognitive services.
NEBRASKA
State Department of Health and Human Services, Finance Formulary: Open formulary. General exclusions include:
and Support, Medicaid Division. 1. More than a three-month supply of birth control
tablets;
D. PROVISIONS RELATING TO DRUGS 2. Experimental drugs or non-FDA approved drugs;
3. Drugs or items when the prescribed use is not for a
Benefit Design medically accepted indication;
4. Liquors (any alcoholic beverages);
Drug Benefit Product Coverage: Products covered: 5. DESI drugs and all identical, related, or similar
prescribed insulin with prior approval on pre-filled drugs;
syringes. Products not covered: disposable needles and 6. Personal care items (e.g. non-medical mouthwashes,
syringe combinations for insulin; blood glucose test strips; deodorants, talcum powders, bath powders, soaps,
urine ketone test strips; total parenteral nutrition; dentrifices, eye washes, and contact solutions);
interdialytic parenteral nutrition; cosmetics; fertility drugs; 7. Medical supplies and certain drugs for nursing facility
and experimental drugs. Prior authorization required for: and intermediate care facility for the mentally
methadone; IV infusions; and protein replacement retarded (IDF/MR) patients;
supplements. 8. Over-the-counter (OTC) drugs not listed on the
Department’s Drug Name/License number Listing
Over-the-Counter Product Coverage: Products covered: microfiche;
allergy, asthma, and sinus products; analgesics; topical 9. Baby foods or metabolic agents (Lofenalac, etc.,)
products; cough and cold preparations; digestive products normally supplied by the Nebraska Department of
(H2 antagonists); and feminine products. Products not Health;
covered: smoking deterrent products. 10. Drugs distributed or manufactured by certain drug
manufacturers or labelers that have not agreed to
Therapeutic Category Coverage: Therapeutic categories participate in the drug rebate program.
covered: anabolic steroids; analgesics, antipyretics,
NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti- Drugs, items, or manufacturers that are identifiable as
depressants; antidiabetic agents; antihistamine drugs; non-covered are so designated on the NE-POP system,
antilipemic agents; anti-psychotics; anxiolytics, sedatives, and on the Department’s Drug Name/License Number
and hypnotics; cardiac drugs; chemotherapy agents; Listing microfiche.
prescribed cold medications; contraceptives; ENT anti-
inflammatory agents; estrogens; hypotensive agents; misc. Prior Authorization: The Department requires that
GI drugs; sympathominetics (adrenergic); and thyroid authorization be granted prior to payment for certain
agents. Prior authorization required for: growth products. Prior authorization can be verified through the
hormones; sunscreens; Erythropoetin (e.g., Epogen, NE-POP System, or by contacting the Department. (or its
Procrit); modified versions of FUL or SMAC drugs; designated contractor) if authorization is not verified
convenience packaged drugs (e.g., Refresh Ophthalmic through the NE-POP System.
0.3 ml and Novalin penfil insulin); drugs to prevent or
treat Respiratory Syncytial Virus Immune Globulin (e.g., Prescribing or Dispensing Limitations
Palivizumab, RSV-IG); and drugs for sexual dysfunction Prescription Refill Limit: As authorized by the prescribing
(e.g., Sildenafil, Alprostadil). Therapeutic categories not physician. For controlled substances, maximum 5 refills
covered: anorectics and prescribed smoking deterrents. every 6 months.
Coverage of Injectables: Injectables reimbursable through Monthly Quantity Limit: 90-day supply or 100 dosage
the Pharmacy program when used medicine used in home units, whichever is greater.
health care, extended care facilities and through physician
payment when used in physician offices. Drug Utilization Review
Vaccines: Vaccines reimbursable by Medicaid for PRODUR system implemented in April 1995. State
individuals under 21 years of age through the Vaccines for currently has a DUR Board with a monthly review.
Children Program, the Children Health Insurance Program
and as part of the EPSDT service.
Maximum Allowable Cost: State imposes Federal Upper Richard Raymond, M.D., Acting Director
Limits as well as state-specific limits on generic drugs. Department of Health and Human Services
Approximately 450 drugs are listed on the state-specific 301 Centennial Mall
MAC list. Override requires an MC-6 form signed by the Lincoln, NE 68509
physician. 402/471-9105
Cognitive Services: State provides additional payment for Ms. Kris Azimi
cognitive services, effective January 2000. Utilization Review Consultant
402/471-9365
E. USE OF MANAGED CARE
Christine Wright, M.D., Medical Director
Approximately 122,006 unduplicated Medicaid recipients Medicaid Division
were enrolled in managed care in 1999. None received 402/471-9136
pharmacy services through managed care.
Prior Authorization Contact
Managed Care Organizations
John Franklin, Pharm.D., R.Ph.
Share Advantage Clinical Pharmacist
United HealthPlans of the Midlands HHSS-Medicaid Division
2717 North 118th Circle P.O. Box 95026; NSOB 5th Fl.
Omaha, NE 68164 Lincoln, NE 68509-5026
402/471-9301
Wellness Option
Exclusive Health Care, Inc.
10250 Regency Circle
Suite 250
Omaha, NE 68114
Primary Care +
NEVADA
Coverage of Injectables: Injectable medicines Plans to implement PRODUR system in February 2001.
reimbursable through the Prescription Drug Program State currently has a DUR Board with a quarterly review.
when used in home health care, extended care facilities, or
through physician payment when used in physicians Pharmacy Payment and Patient Cost Sharing
offices.
Dispensing Fee: $4.76, effective 10/1/98.
Vaccines: Vaccines reimbursable at cost plus an
administration fee ($3.83) as part of the EPSDT service. Ingredient Reimbursement Basis: EAC = AWP - 10%.
Unit Dose: Unit dose packaging reimbursable. Prescription Charge Formula: The lowest of (1) specific
upper limit (SUL) plus a dispensing fee, (2) estimated
Formulary/Prior Authorization acquisition cost (EAC) plus a dispensing fee, or (3) the
pharmacy's usual charge to the general public.
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).
Mary Loherry
Maximum Allowable Cost: State imposes Federal Upper
Deputy Administrator
Limits on generic drugs. Override requires “Brand
Nevada Medicaid Welfare Division
Medically Necessary.”
2527 N. Carson Street
Carson City, NV 89710
Incentive Fee: None.
702/687-4378
Patient Cost Sharing: None.
Prior Authorization Contact
Cognitive Services: Does not pay for cognitive services.
Laurie Squartsoff, R.Ph.
E. USE OF MANAGED CARE T: 702/687-4869
Linda Gellinger
Claims Submission Contact
1500 West Warm Springs
Henderson, NV 89014
Anthem Blue Cross/Blue Shield
P.O. Box 12127
James Boscacci
Reno, NV 89510-2127
3061 Conte Drive
775/448-4020
Carson City, NV 89701
Medicaid Managed Care Contact
Executive Officers of State Medical and
Pharmaceutical Societies
Hilary Jones, R.N.
Medicaid Services Specialist III
Nevada State Medical Association
1100 E. Williams St., Ste 204
Larry Matheis
Carson City, NV 89701
Executive Director
775/687-4176
3660 Baker Lane, Suite 101
Reno, NV 89509
Physician-Administered Drug Program Contact
702/825-6788
Laurie Squartsoff, R.Ph. Nevada Pharmaceutical Association
Nevada Medicaid Office Mary Grear, R.Ph.
2527 North Carson Street Executive Director
Carson City, NV 89710 3006 S. Amryland Parkway, #400
702/687-4869 Las Vegas, NV 89109
Medical Care Advisory Group Nevada Osteopathic Medical Association
Patrick J. Boland, D.O.
Robert J. Burn Secretary-Treasurer
77 Pringle Way 2950 E. Flamingo Road, Suite E-4
Reno, NV 89502 Las Vegas, NV 89121
702/731-0304
David England, Pharm.D.
4430 N. Cheiftain State Board of Pharmacy
Las Vegas, NV 89129 Keith W. MacDonald, R.Ph.
Executive Secretary
Mary Guinan, M.D. 1201 Terminal Way
Nevada State Health Officer Suite 212
505 East King Street, Room 201 Reno, NV 89502
Carson City, NV 89701-4797 702/322-0691
J. Gordon Kinard, D.D.S. Nevada Association of Hospitals and Health Systems
4121 West Sahara Avenue Jeanette Belz
Las Vegas, NV 89102 President, CEO
4600 Kietzke Lane
Jon Sasser Suite A-108
650 Tahoe Reno, NV 89502
Reno, NV 89509 702/827-0184
Mitchell Miller, M.D.
762 14th Street
Elko, NV 89801
NEW HAMPSHIRE
OTHER, TOTAL
Drug Benefit Product Coverage: Products covered: PRODUR system implemented in July 1995. State
prescribed insulin; disposable needles and syringe currently has a DUR Board with a quarterly review.
combinations for insulin; blood glucose test strips; urine
ketone test strips; total parenteral nutrition; and Pharmacy Payment and Patient Cost Sharing
interdialytic parenteral nutrition. Products not covered:
cosmetics; fertility drugs; and experimental drugs. Dispensing Fee: AWP-12%+$2.50, effective 2/1/96.
Over-the-Counter Product Coverage: Products covered: Ingredient Reimbursement Basis: EAC = AWP - 12%.
allergy, asthma, and sinus products; analgesics; cough and
cold preparations; digestive products (H2 antagonists), Prescription Charge Formula:
feminine products; smoking deterrents; and topical
products. 1. Lower of usual and customary charge or AWP - 12%
or HCFA Upper Limit plus a dispensing fee.
Therapeutic Category Coverage: Therapeutic categories 2. Maintenance medications are reimbursed by the
covered: anabolic steroids; analgesics, antipyretics, above formula once every 34 days per recipient per
NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti- provider: any refills of maintenance medications
depressants; antidiabetic agents; antihistamine drugs; within the 34-day period are reimbursed at cost only.
antilipemic agents; anti-psychotics; anxiolytics, sedatives, Maximum Allowable Cost: State imposes Federal Upper
and hypnotics; cardiac drugs; chemotherapy agents; Limits on generic drugs. Override requires “Brand
prescribed cold medications; contraceptives; ENT anti- Medically Necessary.”
inflammatory agents; estrogens; growth hormones;
hypotensive agents; misc. GI drugs; sympathominetics Incentive Fee: None.
(adrenergic); thyroid agents; and prescribed smoking
deterrents. Therapeutic categories not covered: Patient Cost Sharing: Copayment - $0.50 to $1.00.
anorectics. Copayments apply to all recipients except nursing home
patients in SNF or ICF facilities; home and community
Coverage of Injectables: Injectable medicines based care waived recipients holding form 949; pregnant
reimbursable through the Prescription Drug Program women; children under 18 years; and prescriptions for
when used in home health care, extended care facilities family planning drugs.
and though physician payment when used in physician
offices. Cognitive Services: Does not pay for cognitive services.
Vaccines: Vaccines reimbursable as part of the EPSDT,
E. USE OF MANAGED CARE
CHIP, and VCP service. Childhood immunization
vaccine is provided to all children through the Division of
Approximately 5,000 Medicaid recipients are enrolled in
Public Health Services. The Medicaid program does not
MCOs. None receive pharmaceutical benefits through
reimburse providers for routine vaccines, although an
managed care.
administration fee is allowed.
Managed Care Organizations
Unit Dose: Unit dose packaging reimbursable for
residents in long-term care facilities only. Anthem Blue Cross/Blue Shield of New Hampshire
Matthew Thornton Health Plan
Formulary/Prior Authorization 3000 Goffs Falls Road
Manchester, NH 03103-6020
Formulary: Open formulary. General exclusions include
anorectics, anorexiants (stimulants) except for treatment Tufts Associated Healthplans of New England
of narcolepsy and hyperkinetic children, cosmetic agents 333 Wyman Street
for hair growth, experimental and fertility drugs. Waltham, MA 02254-9112
NEW JERSEY
Over-the-Counter Product Coverage: Products covered: Pharmacy Payment and Patient Cost Sharing
allergy, asthma, and sinus products; analgesics; topical
products; and cough and cold preparations for children Dispensing Fee: $3.73 for legend drugs. Additional add-
under age 21. Products not covered: digestive products; ons per/Rx shall be given to pharmacy providers who
feminine products; and smoking deterrent products. provide the following:
Therapeutic Category Coverage: Therapeutic categories 1. 24-hr Emergency Service: add $0.11
covered: analgesics, antipyretics, NSAIDs; antibiotics; 2. Patient Consultation: add $0.08
anticoagulants; anticonvulsants; anti-depressants;
antidiabetic agents; antihistamine drugs; anti-psychotics; 3. Impact Area Location: add $0.15 (provider shall have
anxiolytics, sedatives, and hypnotics; cardiac drugs; a combined Medicaid, NJ KidCare and PAAD
chemotherapy agents; prescribed cold medications; prescription volume equal to or greater than 50% of
contraceptives; ENT anti-inflammatory agents; estrogens; total prescription volume.
hypotensive agents; misc. GI drugs; sympathominetics
(adrenergic); and thyroid agents. Prior authorization Ingredient Reimbursement Basis: EAC = AWP - 10%,
required for: antilipemic agents. Partial coverage for: WAC + 30%. AAC for injectables, effective 5/1/00.
anabolic steroids; anorectics (for ADD); growth
hormones; and prescribed smoking deterrents. Prescription Charge Formula: “Maximum Allowable
Cost,” or Average Wholesale Price – 10% (reduction from
Coverage of Injectables: Injectable medicines AWP is pharmacy specific) plus a dispensing fee or the
reimbursable when used in physician offices, home health provider’s usual and customary charge, whichever is
care, and extended care facilities. lower.
Vaccines: Vaccines reimbursable at AWP as part of the Maximum Allowable Cost: State imposes Federal Upper
EPSDT program and the Vaccines for Children Program. Limits on generic drugs. Override requires “Brand
Medically Necessary”.
Unit Dose: Unit dose packaging reimbursable in long-
term care facilities only, not in retail settings (unless u/d is Incentive Fee: None.
only way item is packaged).
Patient Cost Sharing: None.
Formulary/Prior Authorization
Cognitive Services: State pays for cognitive services.
Formulary: Open formulary. General exclusions include
experimental drugs, cosmetics, fertility drugs, DESI
drugs, and drugs for which FFP is not available (OBRA
'90).
NEW MEXICO
Drug Benefit Product Coverage: Prior Authorization Ingredient Reimbursement Basis: EAC = AWP - 12.5%,
required for: amphetamines and stimulants for ADD. effective 7/1/97.
Products not covered: drugs for treatment of tuberculosis;
cosmetics; experimental drugs; fertility drugs; drugs and Prescription Charge Formula: Prescriptions reimbursed
immunizations available from any other source; at the lesser of the following:
medications supplied by the New Mexico State Hospital
to clients on convalescent leave from hospital; legend 1. Cost (EAC or MAC) dispensed plus a dispensing fee
multiple vitamins; tonic preparations and combinations or,
with minerals, hormones, stimulants; hematinics (except 2. The usual and customary charge by the pharmacy to
non-sustained release forms of Ferrous Sulfate, Ferrous the general public.
Gluconate, Ferrous Fumarate); drugs classified by FDA as
“ineffective”; and hypnotic drugs (barbiturates). Maximum Allowable Cost: State imposes Federal Upper
Limits as well as state-specific limits on generic drugs.
Over-the-Counter Product Coverage: insulin; antacids for Over 72 drugs are listed on the state-specific MAC list.
active gastric and duodenal ulcers; infant vitamin drops Override requires “Brand Medically Necessary.”
for up to 1 year; Salicylates and acetaminophen; non-
sustained release forms of Ferrous Sulfate, Ferrous Incentive Fee: None.
Gluconate, Ferrous Fumarate; Scabicides and
Pediculocides; Laxatives, stool softeners, calcium, Patient Cost Sharing: No copayment.
nicotine replacement, ibuprofen, antihistamines,
decongestants, expectorants, cough suppressants, anti- Cognitive Services: Does not pay for cognitive services.
candida, and antifungals.
E. USE OF MANAGED CARE
Coverage of Injectables: Injectable medicines
reimbursable when used in physician offices, home health Full-risk capitation managed care program implemented
care, and extended care facilities. on July 1, 1997. Recipients receive pharmaceutical
benefits through managed care plans.
Vaccines: Vaccines reimbursable at acquisition cost plus
35% as part of the EPSDT program. F. STATE CONTACTS
Unit Dose: Does not reimburse for unit dose packaging. State Drug Program Administrator
Formulary/Prior Authorization
Neil Solomon
Formulary: Open formulary Drug Program Administrator
Medical Services Bureau
Prior Authorization: State currently has a formal prior P. O. Box 2348
authorization procedure screening for drug classes. Santa Fe, NM 87504-2398
T: 505/827-3174
Prescribing or Dispensing Limitations F: 505/827-3185
Joie Glen
Fiscal Intermediary
Executive Director
New Mexico Association for Home Care Diane Gately
3200 Carlisle N.E., Suite 115 Consultec
Albuquerque, NM 87110 510 N. Guadelupe, Suite C
Santa Fe, NM 87501
Dr. Norton Kalishman 505/983-5555
Chief Medical Officer
Department of Health
P.O. Box 26110
Santa Fe, NM 87502-6110
NEW YORK
Over-the-Counter Product Coverage: Products covered: Pharmacy Payment and Patient Cost Sharing
digestive products (H2 antagonists) and smoking deterrent
products. Products covered with restrictions: allergy, Dispensing Fee: $3.50 for brand name drugs, $4.50 for
asthma and sinus products; analgesics; cough and cold generic drugs. Effective 8/1/98.
preparations; digestive products (non H2 antagonist);
feminine products; and topical products. Ingredient Reimbursement Basis: EAC = AWP - 10%.
Stephen L. Giroux
Middleport Family Health Center
81 Rochester Road, Box 188
Middleport, NY 14105
716/735-7550
NORTH CAROLINA
Over-the-Counter Product Coverage: Products not Ingredient Reimbursement Basis: EAC = AWP-10%.
covered: allergy, asthma and sinus products; analgesics;
cough and cold preparations; non-H2 antagonist digestive Prescription Charge Formula: The lowest price of AWP
products; digestive products, H2 antagonists; feminine minus 10% or MAC, plus a dispensing fee for each
products; topical products; and smoking deterrent different drug dispensed during a month, or AWP plus the
products. lowest dispensing fee accepted from other third party
payers. The pharmacist filling the original prescription
Therapeutic Category Coverage: Therapeutic categories will not be reimbursed for refills for the same drug within
covered: anabolic steroids; analgesics, antipyretics, a calendar month.
NSAIDs; anorectics; antibiotics; anticoagulants;
anticonvulsants; antidepressants; antidiabetic agents; Maximum Allowable Cost: State imposes Federal Upper
antihistamine drugs; antilipemic agents; anti-psychotics; Limits on generic drugs. 223 drugs are listed on the state-
anxiolytics, sedatives, and hypnotics; cardiac drugs; specific MAC list. Override requires “Brand Medically
chemotherapy agents; prescribed cold medications; Necessary.”
contraceptives; ENT anti-inflammatory agents; estrogens;
growth hormones; hypotensive agents; misc. GI drugs; Incentive Fee: None.
prescribed smoking deterrents; sympathominetics
(adrenergic); and thyroid agents. Patient Cost Sharing: $1.00 copayment/Rx (includes
refills).
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program Cognitive Services: Does not pay for cognitive services.
when used in home health care, extended care facility, and
through physician payment when used in physician
E. USE OF MANAGED CARE
offices.
Approximately 689,000 total unduplicated number of
Vaccines: Vaccines reimbursable as part of the Health
Medicaid recipients were enrolled in MCOs in FY 1999.
Check service.
Recipients receive pharmaceutical benefits through the
state.
Unit Dose: Unit dose packaging reimbursable if packaged
in unit dose only.
Managed Care Organizations
Formulary/Prior Authorization
The Wellness Plan of NC, Inc.
Formulary: Closed formulary. Tim O’Brien
1409 East Blvd, Ste. 204
Prior Authorization: State currently does not have a Charlotte, NC 28203-5476
formal prior authorization procedure. A hearing officer is 704/370-0090
required to appeal prior authorization decisions.
NORTH DAKOTA
OTHER
Unit Dose: Unit dose packaging not reimbursable. Rick Detwiller, R.Ph.
Administrator, Pharmacy Services
Department of Human Services
Formulary/Prior Authorization
600 East Boulevard Avenue, Dept. 325
Bismarck, ND 58505-0261
Formulary: Open formulary
701/328-4023
Fax 701/328-1544
Prior Authorization:
Pat Kramer, R.Ph.
Prescribing or Dispensing Limitations
Director, Utilization Management
Prescription Refill Limit: A prescription drug may be Pharmacy Services, Medical Services
refilled for 12 months after the date of the original Department of Human Services
prescription, provided that such refills have been State Capital
authorized by the physician. 600 East Boulevard Avenue
Bismarck, ND 58505-0261
Monthly Quantity Limit: 34-day supply. 701/328-4893
OHIO
Ohio Department of Job and Family Services. Formulary: Closed formulary with approximately 38,000
NDC-specific trade and generic drugs. Products excluded
D. PROVISIONS RELATING TO DRUGS include obesity, fertility, and experimental drugs.
Unit Dose: Unit dose packaging not reimbursable. Patient Cost Sharing: No copayment.
Physician Administered Drug Program Contact Executive Officers of State Medical and
Pharmaceutical Societies
Robert Reid, R.Ph.
Bureau of Health Plan Policy Ohio State Medical Association
30 East Broad St., 27th Floor D. Brent Mulgrew
Columbus, OH 43266-0423 1500 Lakeshore Drive
T: 614/466-6420 Columbus, OH 43204
F: 614/466-2908 614/486-2401
OKLAHOMA
Prime Advantage
Medicaid Drug Rebate Contacts
1602 SW 82nd St.
Lawton, OK 73505 Technical: Judi Worsham, 405/530-3222
Policy: Jim Hancock 405/530-3268
Unicare Director: Tom Simonson 405-522-7327
P.O Box 268985
Oklahoma City, OK 73126 Claims Submission Contact
Laura Dickey-Hottel
F. STATE CONTACTS DP Analyst/Planning Specialist III
Oklahoma Health Care Authority
State Drug Program Administrator 4545 N. Lincoln, Ste. 124
Oklahoma City, OK 73105-7378
John M. Crumley, R.Ph., MHA T: 405/522-7228
Pharmacy Programs Director F: 405/522-7378
Oklahoma Health Care Authority E-mail: Hottell@ohca.state.ok.us
4545 N. Lincoln, Ste. 124
Oklahoma City, OK 73105
Medicare Managed Care Contact
T: 405/522-7325
F: 405/522-7378 John M. Crumley, 405/522-7325
E-mail: crumlyj@ohca.state.ok.us
Agency Internet Address: www.ohca.state.ok.us Disease Management Program/Initiative Contact
Kathe Eastham, R.N
Prior Authorization Contact
Nurse Manager III
Oklahoma Health Care Authority
John M. Crumley, 405/522-7325
4545 N. Lincoln, Ste. 124
Oklahoma City, OK 73105-9901
DUR Contact T: 405/522-7115
John M. Crumley, 405/522-7325 F: 405/522-7378
E-mail: Easthamk@ohca.state.ok.us
Medicaid DUR Board
Physician-Administered Drug Program Contact
Rick Crensaw, D.O.
Dick Robinson, R.Ph. Lynn Mitchell, M.D.
Dorothy Gourley, R.Ph. Medical Director
Cliff Meece, R.Ph. 4545 N. Lincoln, Ste. 124
Gary Kirk, R.Ph. Oklahoma City, OK 73105
Cathy E. Hollen, R.Ph. 405/530-3365
Francois DuToit, M.D.
Thomas Whitsett, M.D. (Chair)
Oklahoma Health Care Authority Officials
Dan McNeill, Ph.D., PA-C
(Vacant position pending OSMA recommendation) Michael Fogarty, J.D.
Chief Executive Officer
Oklahoma Health Care Authority
Prescription Price Updating
4545 N. Lincoln, Ste. 124
Angela Thomasson Oklahoma City, OK 73105
Pharmacy Claims Specialist
Oklahoma Health Care Authority Michael Fogarty, J.D.
4545N Lincoln Blvd, Ste. 124 State Medicaid Director
Oklahoma City, OK 73105-9901 4545 N. Lincoln, Ste. 124
T: 405/522-7307 Oklahoma City, OK 73105
F: 405/522-7378
E-mail: thomassa@ohca.state.ok.us Darcedia McCauley, Ph.D.
Director of Quality Assurance
405/530-3355
Fiscal Agent
UNISYS
405/841-3400
OREGON
Over-the-Counter Product Coverage: Products covered: 1) $4.05 for providers filling between 15,000 and
analgesics; feminine products; and smoking deterrent 30,000 total prescriptions annually;
products. Products requiring prior authorization and
physician prescription: allergy, asthma, and sinus; cough 2) $4.05 for providers filling 1-15,000 or providers
and cold preparations; digestive products (non-H2 filling between 15,000 and 30,000 with greater than
antagonist); digestive products (H2 antagonists); and 20% Medicaid prescription volume annually;
topical products.
3) $4.28 for providers filling 1-15,000 total
Therapeutic Category Coverage: Therapeutic categories prescriptions annually with greater than 20%
covered: Anabolic steroids; analgesics, antipyretics, Medicaid prescription volume annually or providers
NSAIDs; anorectics; antibiotics; anticoagulants; operating with a True or Modified Unit Dose
anticonvulsants; anti-depressants; antidiabetic drugs; Delivery System.
antilipemic agents; antipsychotics; anxiolytics, sedatives,
and hypnotics; cardiac drugs; chemotherapy agents; Ingredient Reimbursement Basis: EAC = AWP - 11%.
contraceptives; ENT anti-inflammatory agents; estrogens;
hypotensive agents; prescribed smoking deterrents; Prescription Charge Formula: Estimated acquisition cost
sympathominetics (andrenergic); and thyroid agents. (EAC) defined as the lesser of: (1) AWP - 11% (2) HCFA
Therapeutic categories requiring prior authorization: upper limits for multiple source drugs or (3) the usual and
selected antihistamine drugs; prescribed cold medications customary charge plus a dispensing fee.
(selected products); growth hormones; selected
antifungals; legend laxatives; coal tar preparations; and Maximum Allowable Cost: State imposes Federal Upper
misc. GI drugs (selected products). Limits on generic drugs. Override requires “Brand
Medically Necessary.”
Coverage of Injectables: Injectable medicines
reimbursable through physician payment when used in Incentive Fee: None.
physician offices, home health care, and extended care
facilities. Patient Cost Sharing: No copayment.
Vaccines: Vaccines reimbursable by Medicaid as part of Cognitive Services: Does not pay for cognitive services.
the Vaccines for Children Program.
Formulary/Prior Authorization
Kaiser Permanente
500 NE Multnomah, Ste. 100
Portland, OR 97232-2099
(800) 813-2000
PENNSYLVANIA
Office of Medical Assistance, Department of Public Quantity Limit: Not to exceed a 34-day supply or 100
Welfare. units, whichever is greater.
Cognitive Services: Does not pay for cognitive services. F. STATE CONTACTS
Kenneth J. Pierce
Executive Officers of State Medical and
Pennsylvania State Welfare Rights Organization
Pharmaceutical Associations
119 Camp Avenue
Braddock, PA 15104 Pennsylvania Medical Society
412/271-1426 Roger F. Mecum
Executive Vice President
Charles Pruitt, Jr. 777 E. Park Drive
Seniorcare Solutions LLC Harrisburg, PA 17105-8820
1215 Hulton Road 717/558-7750
Oakmont, PA 15139
412/826-6100 Pennsylvania Pharmaceutical Association
Carmen A. DiCello, R.Ph.
Mary Ellen Rehrman Executive Director
National Alliance for the Mentally Ill 508 North Third Street
2149 N. Second Street Harrisburg, PA 17101-1199
Harrisburg, PA 17110 717/234-6151
717/268-1514
Pennsylvania Osteopathic Medical Association
Virginia Schierscher Mario E.J. Lanni
HAP Executive Director
4750 Lindle Road 1330 Eisenhower Boulevard
P.O. Box 8600 Harrisburg, PA 17111
Harrisburg, PA 17105-8600 717/939-9318
717/657-1222
Pennsylvania Podiatry Association
David E. Shapter, D.D.S. Nancy Sullivan
Pennsylvania Dental Association Assistant Executive Director
4934 Peach Street 757 Poplar Church Road
Erie, PA 16509 Camp Hill, PA 17011
814/868-8673 717/763-7665
RHODE ISLAND
SOUTH CAROLINA
1. Vitamins and vitamin combinations for the treatment Monthly Quantity Limit: Children (birth to age 21) are
of vitamin deficiencies for male patients as well as allowed unlimited prescriptions per month. Recipients
female patients of non-childbearing age. Oral dosage over the age of 21 are limited to a maximum of four
forms of iron preparations, multivitamins (whether prescriptions per month.
legend or OTC) and folic acid are routinely covered
for females of childbearing age. Oral iron Quantity Limit per Prescription: 100-day supply
preparations prescribed for children in the prevention maximum. In chronic conditions and for maintenance
and treatment of iron deficiency are routinely drugs, a minimum of a 30-day supply where appropriate.
covered. The category of oral iron preparations
includes: ferrous fumarate, ferrous gluconate, ferrous Monthly Dollar Limit: None.
sulfate, and polysaccharide-iron complex. Special
authorization is necessary in order for Medicaid to Drug Utilization Review
reimburse for vitamins and vitamin/mineral
combination products dispensed to children. Fluoride Plans are under development for PRODUR system. State
vitamins for children are routinely covered. currently has a DUR Board with a monthly review.
2. Compounded prescriptions when the primary or most
expensive ingredient is NOT a routinely covered Pharmacy Payment and Patient Cost Sharing
product. Special authorization requests should not be
submitted for compounds that are commercially Dispensing Fee: $4.05, effective 7/1/89.
available in similar formulations.
Ingredient Reimbursement Basis: EAC = AWP - 10%.
3. Non-routinely covered OTC medications.
4. The following home-administered injectable Prescription Charge Formula: Medicaid reimbursement
products: Intravenous hydration therapies, injectable for pharmacy services will be based on the lowest of: the
immune serums, injectable vitamins, and Estimated Acquisition Cost (EAC); federal or state
Serostim.Immunosuppressants such as CellCept, maximum allowable cost (MAC); or the provider's
Imuran, Neoral, Prograf, Sandimmune, submitted usual and customary charge.
Zenapax, and Simulect.
Maximum Allowable Cost: State imposes Federal Upper
5. Prior Authorization: Medicare for a period of 36 Limits as well as state-specific limits on generic drugs.
months from the date of discharge following a Override requires “Brand Necessary” or “Brand
hospital stay during which the Medicare covered Medically Necessary” handwritten certification by the
organ or tissue transplant surgery was performed. prescriber.
6. Pharmaceutical products used to treat erectile
Incentive Fee: None.
dysfunction (ED) regardless of route of
administration. This category of products currently
Patient Cost Sharing: $2.00 copayment per prescription.
includes pharmaceuticals such as alprostadil and
sildenafil citrate. Special authorization will only be
considered for males, age 21 and older, diagnosed Cognitive Services: Does not pay for cognitive services.
with ED resulting from a defined organic cause,
medical condition, and/or a specific disease. Special
Darlynn Thomas
Chief
Bureau of Health Services
803/898-2870
SOUTH DAKOTA
TENNESSEE -- TennCare
In 1994, Tennessee made history by withdrawing from the TennCare services are offered through managed care
Medicaid Program and implementing an innovative new organizations (MCOs) and behavioral health organizations
health care reform plan called TennCare. TennCare (BHOs) under contract with the State. These MCOs,
replaced the existing Medicaid Program with a program of spread out over the twelve regions of Tennessee, are paid
managed health care. TennCare required no new taxes a fixed amount which averages $116 per enrollee per
and extended health coverage not only to the nearly month for the MCO services. BHOs are paid $319.41 for
800,000 Tennesseans in the Medicaid population, but also priority participants and a variable rate for all other
to an approximately 400,000 uninsured or uninsurable TennCare enrollees and state onlys. The MCOs and BHOs
persons using a system of managed care. Enrollment was negotiate payment rates with individual providers.
open in 1994 to eligible persons in the uninsured, Enrollees have a choice of MCOs (and their
uninsurable, and Medicaid-eligible categories. corresponding BHO partner plan) from those available in
their geographic area. Effective January 1, 1997, all
On January 1, 1995, TennCare reached 90% of its target services are delivered within a strict "gatekeeper" model
enrollment and closed enrollment in the uninsured system requiring primary care providers to manage
category. However, on April 1, 1997, enrollment in the enrollees' health care.
uninsured category re-opened to children under the age of
18 who do not have access to health insurance through a TennCare services, as determined medically necessary by
parent or guardian. On May 21, 1997, TennCare the MCO, cover inpatient and outpatient hospital care,
enrollment became available for eligible dislocated physician services, prescription drugs, lab and x-ray
workers. Enrollment remains open to persons and their services, medical supplies, home health care, hospice care,
dependents who have lost access to a COBRA insurance and ambulance transportation. Excluded from TennCare
plan and do not have access to other health insurance. In managed care services are long-term care services and
an effort to expand coverage to more of Tennessee's Medicare cross-over payments which are continuing as
uninsured children, the Bureau of TennCare opened they were under the former Medicaid system.
enrollment on January 1, 1998 to uninsured Tennesseans
under the age of nineteen (19) with access to health TennCare is financed by pooling current federal, state and
insurance whose individual family incomes are below local expenditures for indigent health care, which include
200% of the poverty level. Effective January 1, 1998, $2.4 billion for the TennCare/Medicaid Program in the
uninsured children under age nineteen (19) who meet the 1998-99 fiscal year's budget. Pooled resources total
TennCare criteria for uninsured are being allowed to $3.779 billion, including $226 million in local Certified
enroll in TennCare indefinitely. The Bureau of TennCare Public Expenditures. Within this budget, $1.418 billion is
eliminated deductibles and limited co-payments to 2% for identified as funding for long-term care programs, Home
these new eligibility populations and all uninsured and Community Based Services Waiver programs,
children under eighteen (18) years of age who enrolled in Medicare cross-overs through the Medicaid system,
TennCare during previous open enrollment periods. Medicare premiums, and administration for the total
Enrollment remains open to persons who are Medicaid- program. The remaining $2.361 billion has been identified
eligible or who are uninsurable as determined by an to fund the current year of the TennCare Program. In the
insurance company's denial (for medical reasons) of health future, competition among managed care networks,
insurance to the individual. Current enrollment (5/30/00) combined with the enrollment cap, should enable
is approximately 1,316,216, of which 795,968 are TennCare to grow at a predictable rate not exceeding the
Medicaid eligibles and 520,248 are in the annual rate of growth in state spending.
uninsured/uninsurable categories.
Source: TennCare Home Page on the World Wide Web,
last updated 08/09/00. http://www.state.tn.us/tenncare/
The State of Tennessee was granted approval by the
Health Care Financing Administration for a five-year
demonstration project under Section 1115 of the Social ELIGIBILITY FOR TENNCARE COVERAGE
Security Act. State rules were promulgated to assist in
administering the statewide program (TSOP). The initial Currently, Medicaid eligible persons, children under age
five-year demonstration project ended December 31, 19 with no access to health insurance, dislocated workers
1998. HCFA approved a waiver extension for three years who previously had health insurance through employers
beginning January 1, 1999 through December 31, 2001. and become uninsured due to a bona fide closure of a
business or plant, and persons with proof of
uninsurability, are eligible for TennCare coverage. To
provide proof of uninsurability, one must have a letter of Formulary: Varying formularies used by the individual
denial from an insurance company, on company letterhead MCOs. Most are closed formularies. MCO formularies
stationary, that is licensed in the State of Tennessee. The must conform to TennCare guidelines. TennCare must
TennCare applicant may then send in their application approve formulary additions/deletions.
along with a copy of this letter to the address provided on
the TennCare application. Prior Authorization: Prior authorization procedures are
administered by the individual MCOs.
Someone is not uninsurable if they cannot afford health
insurance. Someone is not a dislocated worker if they are Copayment: Deductibles and copayments apply to
laid-off or terminated at a plant that continues to operate. services other than preventive services (e.g.,
The Tennessee Department of Human Services makes immunizations) based on a sliding scale according to
decisions for most Medicaid eligibility categories. The income. Medicaid recipients and persons or families with
Social Security Administration makes decisions regarding income under 100% of the federal poverty level are not
eligibility for Medicaid for disabled individuals. The required to pay premiums, deductibles, or copayments in
Tennessee Department of Labor determines bona fide order to participate in the TennCare program.
closures of businesses or plants. In some TennCare
eligibility categories, persons may be eligible in cases C. USE OF MANAGED CARE
where COBRA coverage is offered. In some TennCare
eligibility categories, persons may not be eligible until Medicaid recipients and the uninsured/uninsurable are
their opportunity to purchase COBRA coverage has enrolled in MCOs through the TennCare program. All
expired. Contact the TennCare Hotline with questions. receive pharmacy benefits through managed care.
Keith Gaither
Fiscal Director
Office of Business, Finance & Research
Joanna Damons
Division of Long Term Care
Consultec, Inc.
T: 877/296-1935
TEXAS
Texas Department of Health. Vendor drug program was Formulary: Open formulary; however, products must be
implemented September 1, 1971. listed in the Texas Drug Code Index. General exclusions
(diseases, drug categories, etc.) include: amphetamines,
D. PROVISIONS RELATING TO DRUGS appliances, durable medical equipment (bedpans, etc. -
either rental or purchase), elastic stockings, first aid
Benefit Design supplies, medical supplies, oxygen, supports and
suspensories, and trusses.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles (pen needles only) Prior Authorization: Prior authorization procedure
and syringe combinations used for insulin. Products not screening for drug classes and individual drugs.
covered: cosmetics; fertility drugs; experimental drugs;
total parenteral nutrition; and interdialytic parenteral Prescribing or Dispensing Limitations
nutrition; blood glucose test strips; urine ketone test strips. Prescription Refill Limit: Five refills, but total amount
Prior authorization required for: human growth hormones may not exceed 6-month supply.
and dextramphetamines.
Monthly Quantity Limit: Prescribed quantity cannot
Over-the-Counter Product Coverage: Products covered: exceed 6-month supply.
feminine products; topical products; allergy, asthma, and
sinus products; analgesics; cough and cold preparations; Monthly Prescription Limit: Limited to 3 per month
digestive products (non-H2 antagonist); smoking deterrent except for recipients under age 21 and nursing home
products; digestive products (H2 antagonists). Certain recipients.
OTC drugs are covered on a prescription basis except as
otherwise provided in the reimbursement formula and Other Limit: Recipients in managed care pilots receive
vendor payment to hospitals, nursing homes and unlimited prescription coverage.
institutions.
Drug Utilization Review
Therapeutic Category Coverage: Therapeutic categories
covered: anabolic steroids; antibiotics; authorization: PRODUR system implemented in February 1995. State
analgesics, antipyretics, NSAIDs; anticoagulants; currently has a DUR board with a quarterly review.
anticonvulsants; anti-depressants; antidiabetic drugs;
antihistamine drugs; antilipemic agents; antipsychotics; Pharmacy Payment and Patient Cost Sharing
anxiolytics, sedatives, and hypnotics; cardiac drugs;
chemotherapy agents; contraceptives; prescribed cold Dispensing Fee: $5.27 +2%. The dispensing fee,
mediation; ENT anti-inflammatory agents; estrogens; including all costs of filling a prescription, was
hypotensive agents; misc. GI drugs; thyroid agents; established by cost accounting and service evaluation of
prescribed smoking deterrents; and sympathominetics the expenses involved in dispensing a prescription.
(adrenergic). Prior authorization required for: growth Therefore, fees paid to providers who experience different
hormones. Therapeutic categories not covered: anorectics. cost and service factors considered in arriving at the fee
may receive more or less than actual costs incurred in
Coverage of Injectables: Injectable medicines dispensing.
reimbursable through the Prescription Drug Program
when used in home health care, extended care facilities Ingredient Reimbursement Basis: EAC = AWP-15% or
and through physician payment when used in physicians WAC + 12%, whichever is lower, AAC for hospitals and
offices. public health providers.
Vaccines: Vaccines reimbursable as part of EPSDT Prescription Charge Formula: Average dispensing
service, not under the Vendor Drug program. expense (ADE) formula for payment:
1. (EAC + 5.27) divided by 0.980 = amount paid +
Unit Dose: Unit dose packaging reimbursable only when $0.15 delivery service.
there is not an added expense for the packaging. 2. DEAC only for Wyeth-Ayerst.
Insulin and approved non-legend drugs on prescription:
pharmacists and dispensing physicians will be reimbursed
on the basis of usual charges to the general public or cost
plus 50% of cost, whichever is lower; 50% of cost not to Debbie Blount
exceed assigned variable dispensing fee. Deputy Commissioner for Health Care Financing
Maximum Allowable Cost: State imposes Federal Upper Prior Authorization Contact
Limits as well as state-specific limits on generic drugs.
Barbara Dean, R.Ph.
465 drugs are listed on the state-specific MAC list.
Pharmacist III
Override requires “Brand Necessary” or “Brand
Texas Department of Health
Medically Necessary.”
1100 W. 49th Street
Austin, TX 78756-3174
Incentive Fee: None.
512/338-6920
E-mail: barbara.dean@tdh.state.tx.us
Cognitive Services: Does not pay for cognitive services.
Vendor Drug Program
Patient Cost Sharing: No copayment.
Martha McNeill, R.Ph.
E. USE OF MANAGED CARE Director, Product Enrollment Division
Texas Department of Health
An undisclosed number of Medicaid recipients are 1100 W. 49th Street
enrolled in MCOs (all of whom are AFDC/AFDC Austin, TX 78756-3174
related). 512/338-6965
E-mail: martha.mcneill@tdh.state.tx.us
Managed Care Organizations
Patsy Napier, R.Ph.
Physician Corporation of America Pharmacy Field Coordinator
8303 Mopac, Ste. 450 512/338-6992
Austin, TX 78759-8370
DUR Contact
Vista, Inc.
9310 North Lomar Curtis Burch, R.Ph.
Austin, TX 78753 Director, Drug Utilization Review Division
Texas Department of Health
Primary Care Case Management 1100 W. 49th Street
Austin, TX 78756-3174
F. STATE CONTACTS T: 512/338-6922
F: 512/338-6910
State Drug Program Administrator E-mail: curtis.burch@tdh.state.tx.us
UTAH
Coverage of Injectables: Injectable medicines Cognitive Services: Does not pay for cognitive services.
reimbursable when used in home health care, and
extended care facilities, and through physician payment. E. USE OF MANAGED CARE
Vaccines: Vaccines reimbursable at AWP minus 12% plus An unavailable number of Medicaid recipients are
a fee as part of the EPSDT service, Children Health enrolled in managed care; however the number of
Insurance Program, and the Vaccines for Children enrollees is listed for some of the following MCOs. The
Program. pharmacy benefits are through the state.
Carter Burke
Managed Care Organizations
Hoechst Marion Roussel
Altius 1912 Lawrence Circle
10421 S. Jordan Gateway South Jordan, UT 84065
South Jordan, UT 84095 801/254-9026
RaeDell Ashley
Division of Health Care Financing
Department of Health
288 N. 1460 West
Salt Lake City, UT 84114-2906
801/538-6495
VERMONT
Drug Benefit Product Coverage: Products covered: PRODUR system implemented in November 1993. State
prescribed insulin; disposable needles and syringe currently has a DUR board with a bimonthly review.
combinations used for insulin; blood glucose test strips;
urine ketone test strips; total parenteral nutrition; and Pharmacy Payment and Patient Cost Sharing
interdialytic parenteral nutrition. Products not covered:
cosmetics and experimental drugs. Dispensing Fee: $4.25, effective 7/1/96.
Over-the-Counter Product Coverage: Products covered Ingredient Reimbursement Basis: EAC = AWP – 11.9%.
with prior authorization: allergy, asthma and sinus
products; analgesics; cough and cold preparations; Prescription Charge Formula: Pharmacies bill their usual
digestive products (H2 antagonists); feminine products; and customary charge. Medicaid pays the lower of:
topical products; and smoking deterrent products.
1. Usual and customary charge;
2. EAC plus a dispensing fee; or
Therapeutic Category Coverage: Therapeutic categories
3. Maximum allowable cost plus a dispensing fee.
covered: anabolic steroids; analgesics, antipyretics,
NSAIDs; anorectics; antibiotics; anticoagulants;
Maximum Allowable Cost: State imposes Federal Upper
anticonvulsants; anti-depressants; antidiabetic agents;
Limits and State-specific limits on generic drugs.
antihistamine drugs; antilipemic agents; anti-psychotics;
Override requires “Dispense as Written.”
anxiolytics, sedatives, and hypnotics; cardiac drugs;
chemotherapy agents; prescribed cold medications;
Incentive Fee: None.
contraceptives; ENT anti-inflammatory agents; estrogens;
hypotensive agents; misc. GI drugs; sympathominetics
Patient Cost Sharing: Copayment of $1.00 per
(adrenergic); and thyroid agents. Prior authorization
dispensation required (excluding standard federal
required for: prescribed smoking deterrents.
exemptions). Copayment of $2.00 when ingredient cost
exceeds $29.99.
Coverage of Injectables: Injectable medicines
reimbursable when used in physician offices, home health
Cognitive Services: Does not pay for cognitive services.
care, and extended care facilities.
Formulary: Open formulary. General exclusions include State Drug Program Administrator
cosmetics and experimental drugs.
Pat House
Prior Authorization: Prior authorization procedure Operations Manager
screening for drug classes. PA is required for non- Office of Vermont Health Access
pregnancy multi-vitamins, smoking deterrents, 103 South Main Street
amphetamines, food supplements, and OTC drugs. Waterbury, VT 05671
T: 802/241-2765
Prescribing or Dispensing Limitations F: 802/241-2974
E-mail: pathouse@wpgate1.ahs.state.vt.us
Prescription Refill Limit: Up to 5 may be authorized by a
physician.
VIRGINIA
Department of Medical Assistance Services. Eligibility Prescription Charge Formula: Based upon the lower of
determination by the Department of Social Services. MAC or EAC plus a fee if legend, or the usual and
customary charge minus an applicable copayment.
D. PROVISIONS RELATING TO DRUGS
Maximum Allowable Cost: State imposes Federal Upper
Benefit Design Limits as well as state-specific limits on generic drugs.
Override requires “Brand Necessary.”
Drug Benefit Product Coverage: Products not covered:
fertility drugs; hair growth products; designated DESI Incentive Fee: None.
drugs; experimental drugs; non-legend drugs; and expired
drugs. Patient Cost Sharing: Copayment is $1.00/Rx for all
qualifying prescriptions. Exclusions include less than 21
Over-the-Counter Drug Coverage: A majority of OTC years old, pregnancy related, family planning, and nursing
drugs reimbursable when used in nursing homes and home patients.
certain classes in outpatient populations.
Cognitive Services: Does not pay for cognitive services at
Therapeutic Category Coverage: Prior authorization present.
required for: amphetamines and growth hormones.
E. USE OF MANAGED CARE
Coverage of Injectables: Injectable medicines
reimbursable through physician payment when used in F*5&"&*6)7-#*5*&=*-">(#'(5*?)&5(+-A*6*2&)7-)>#$?9>
physician offices (through physician payment), home '(6(9*4-5(#*-"+(67<
health care, and extended care facilities. 1) Medallion - primary care physicians,
2) Options - optional enrollment for recipients into
Vaccines: Vaccines reimbursable based on HCPCS code HMOs, and
as part of the Health Department and Vaccines for 3) Medallion II - mandatory HMOs in the Tidewater
Children Program. region and the Richmond area.
WASHINGTON
Joan Baumgartner
Prescription Price Updating
Medical Consultant
MAA, P.O. Box 45540 Marilyn Mueller
Olympia, WA 98504-5540 Pharmacy Program Manager
360/586-5274 Medical Assistance Administrator-DSHS
P.O. Box 45506
Tim Fuller, R.Ph. Olympia, WA 98504-5506
Board of Pharmacy 360/725-1569
1948 Boyer Ave. East E-mail: meullerf@dshs.wa.gov
Seattle, WA 98112
360/753-6834
Medicaid Drug Rebate Contacts
Support Staff Manager: Sue Hilton, 360/586-7179
Johnna Dodge Technical: Rich Boyesen, 360/586-2593
206/586-5269 Policy: Geo Sego, 360/753-4259
Audits/Disputes: George Sego, 360/753-4259
Drug Utilization and Education Council PA: Gini Egan 360/664-8140
WEST VIRGINIA
D. PROVISIONS RELATING TO DRUGS Prescriptions are limited to 10 per recipient per month.
All covered outpatient drugs are reimbursed up to a 34-
Benefit Design day supply and five refills.
Over-the-Counter Product Coverage: Products covered: PRODUR system implemented in March 1995. State
feminine products and topical products. Selected currently has a DUR Board with a quarterly review.
coverage: allergy, asthma, and sinus products; analgesics;
cough and cold preparations; digestive products (non-H2 Pharmacy Payment and Patient Cost Sharing
antagonist). Prior authorization for: smoking deterrent
products. Products not covered: digestive products (H2 Dispensing Fee: $3.90, effective 1/1/96. For a
antagonists). compounded prescription, an additional $1.00 will be
added to the dispensing fee. A compound prescription is
Therapeutic Category Coverage: Therapeutic categories defined as any legend medication requiring a combination
covered: anabolic steroids; antibiotics; anticoagulants; of any two or more substances to exclude normal
anticonvulsants; anti-depressants; antidiabetic drugs; reconstitution operations.
antilipemic agents; antihistamine drugs; antipsychotics;
anxiolytics, sedatives, and hypnotics (partial coverage); Ingredient Reimbursement Basis: EAC = AWP - 12%.
cardiac drugs; chemotherapy agents; contraceptives;
prescribed cold mediation (partial coverage); ENT anti- Prescription Charge Formula: Reimbursement based on
inflammatory agents; estrogens; hypotensive agents; and the lowest of:
thyroid agents. Therapeutic categories requiring prior
authorization: analgesics, antipyretics, NSAIDs; growth 1. The estimated acquisition cost (EAC) plus a
hormones; prescribed smoking deterrents; and dispensing fee.
sympathominetics (adrenergic). Therapeutic categories 2. The maximum allowable cost (MAC) plus a
not covered: anorectics; and hair growth products. dispensing fee.
3. The usual and customary price charged by the
Coverage of Injectables: Injectable medicines pharmacy to the general public including any sale
reimbursable when used in physician offices, home health price that may be in effect on the date of service.
care, and extended care facilities; most require prior 4. Children under age of 18 years.
approval.
Maximum Allowable Cost: State imposes Federal Upper
Vaccines: Vaccines reimbursable as part of the EPSDT Limits on generic drugs. Override will require physician
service and the Vaccines for Children Program. certification of “Brand Medically Necessary.”
Unit Dose: Unit dose packaging reimbursable. Incentive Fee: None.
Formulary/Prior Authorization
Patient Cost Sharing: Copayment varies - $0.50 to $2.00. Prior Authorization Contact
Exclusions include:
Steve Small, R.Ph., M.S.
1. Family planning services and supplies. Director, Rational Drug Therapy Program
2. Prescriptions originating with the Early and Periodic Robert C. Byrd Health Sciences Center
Screening, Diagnosis and Treatment Program. P.O. Box 9511
Morgantown, WV 26506-9511
3. Nursing home residents.
800/847-3859
E-mail: ssmall@hsc.wvu.edu
Cognitive Services: Does not pay for cognitive services.
WISCONSIN
John Chapin
Administrator
Division of Health
Peggy L. Bartels
Director
Division of Health Care Financing, Medicaid
WYOMING
C. ADMINISTRATION
Unit Dose: Unit dose packaging not reimbursable. Patient Cost Sharing: Copayment is $2.00. The following
recipients 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
Cognitive Services: Does not pay for cognitive services.
Appendix A:
State and Federal
Medicaid Contacts
ALABAMA CALIFORNIA
Louise F. Jones J. Kevin Gorospe, Pharm.D.
Pharmacy Program Manager Chief, Pharmaceutical Unit
Alabama Medicaid Agency Medi-Cal Policy Division
501 Dexter Avenue 714 P Street, Room 1540
P.O. Box 5624 Sacramento, CA 95814
Montgomery, AL 36103-5624 P: 916/657-4213
P: 334/242-5039 F: 916/654-0513
F: 334/353-7014 E-mail: kgorospe@dhs.ca.gov
E-mail: lljones@Medicaid.state.al.us Agency Internet Address: http://www.dhs.ca.gov
Agency Internet Address: www.medicaid.state.al.us
COLORADO
ALASKA
Allen Chapman
Dave Campana, R.Ph. Department of Health Care Policy & Financing
Pharmacy Program Manager 1575 Sherman Street, 5th Floor
Division of Medical Assistance Denver, CO 80203
4501 Business Park Blvd., Suite 24 P: 303/866-3176
Anchorage, AK 99503 F: 303/866-2573
P: 907/273-3224
F: 907/561-1684 CONNECTICUT
E-mail: david_campana@health.state.ak.us Elizabeth A. Geary
Health Program Supervisor
ARIZONA Department of Social Services
25 Sigourney Street
Juman Abujbara, M.D.
Hartford, CT 06106
Director
P: 860/424-5150
Arizona Health Care Containment System
F: 860/951-9544
801 E. Jefferson Street
E-mail: elizabeth.geary@po.state.ct.us
Phoenix, AZ 85034
Agency Internet Address: http://www.dss.state.ct.us
P: 602/417-4241
F: 602/254-1769
DELAWARE
ARKANSAS Phile Soulé
Medicaid Pharmacy Director
Suzette Bridges, P.D.
Delaware Health and Social Services
Department of Human Services
1901 N. Dupont Highway
Division of Medical Services
New Castle, DE 19720
Pharmacy Program
P: 302/577-4900
P.O. Box 1437, Slot 4105
F: 302/577-4405
Little Rock, AR 72203
P: 501/324-9141
F: 501/324-9140
E-mail: suzette.bridges@Medicaid.state.ar.us
FLORIDA ILLINOIS
Jerry Wells Marvin L. Hazelwood
Agency for Healthcare Administration Services Illinois Department of Public Aid
2727 Mahan Drive, Building 1, Room 170 Division of Medical Assistance
Tallahassee, FL 32308 1001 N. Walnut St.
P: 850/922-0681 Springfield, IL 62702
F: 850/922-0685 P: 217/524-7112
E-mail: wellsj@fdhc.state.fl.us F: 217/524-7194
Agency Internet Address: www.fdhc.state.fl.us E-mail: Aidd2958@mail.idpa.state.il.us
Agency Internet Address: www.state.il.us/dpa/
GEORGIA
INDIANA
Etta L. Hawkins, R.Ph.
Department of Community Health-Medical Division Marc Shirley, R.Ph.
2 Peachtree Street, 37th Floor Pharmacy Program Director-Indiana Medicaid
Atlanta, GA 30303-3159 Office of Medicaid Policy and Planning
P: 404/657-7239 Indiana State Government Center South-Rm. W382
F: 404/656-8366 402 W. Washington Street
E-mail: ehawkins@dch.state.ga.us Indianapolis, IN 46204-2739
Agency Internet Address: www.state.ga.us/dch P: 317/232-4343
F: 317/232-7382
HAWAII E-mail: mshirley@fssa.state.in.us
KANSAS MARYLAND
Karen Braman, R.Ph., M.S. Frank Tetkoski
Health Care Policy Division Pharmacy Services Manager
Kansas Department of Social and Rehabilitation Division of Pharmacy and Clinic Services
Services 201 West Preston Street
915 SW Harrison, Room 651-South DSOB Baltimore, MD 21201
Topeka, KS 66612-1570 P: 410/767-1455
P: 785/296-6968 F: 410/333-7049
F: 785/296-4813 E-mail: tetkoskif@dhmh.state.md.us
E-mail: ksb@srskansas.org Agency Internet Address: www.dhmh.state.md.us
Agency Internet Address: www.ink.org/public/srs
MASSACHUSETTS
KENTUCKY
Gary P. Gilmore, R.Ph.
Debra Bahr, R.Ph. Division of Medical Assistance
Pharmacy Services Program Manger 600 Washington Street
Department for Medicaid Services Boston, MA 02111
CHR Building, 6th Floor P: 617/210-5593
275 East Main Street F: 617/210/5597
Frankfort, KY 40621 E-mail: ggilmore@nt.dma.state.ma.us
P: 502/564-6511
F: 502/564-3852 MICHIGAN
E-mail: debra.bahr@mail.state.ky.us
James Kenyon, R.Ph.
Pharmacist Consultant
LOUISIANA
MDCH/ Medical Services Administration
M.J. Terrebonne, P.D. 400 South Pine Street
Pharmacy Program Director Lansing, MI 48933
Department of Health and Hospitals P: 517/335-5265
P.O. Box 91030 F: 517/335-5294
Baton Rouge, LA 70821 E-mail: kenyonj@state.mi.us
P: 225/342-9479 Agency Internet Address: www.mdch.state.mi.us
F: 225/342-3893
E-mail: mterrebo@dhh.state.la.us MINNESOTA
Cody Wiberg, Pharm.D., R.Ph.
MAINE
Acting Pharmacy Program Manager
Christine Gee Minnesota Department of Human Services
Director of Pharmacy Programs 444 Lafayette Road
Department of Health Services St. Paul, MN 55155-3853
Bureau of Medical Services P: 651/296-8515
Pharmacy Programs F: 651/282-6744
Building 205, 3rd Fl. E-mail: cody.c.winberg@state.mn.us
11 State House Station
Augusta, ME 04333
P: 207/287-4018
F: 207/287-8601
E-mail: christine.gee@state.me.us
MISSISSIPPI NEVADA
James G. (Jack) Lee, R.Ph. Laurie Squartsoff, R.Ph.
Division of Medicaid, Office of the Governor Pharmaceutical Consultant
Robert E. Lee Building Nevada Medicaid Office
239 North Lamar Street, Suite 801 2527 N. Carson Street, Capitol Complex
Jackson, MS 39201-1399 Carson City, NV 89710
P: 601/359-6296 P: 702/687-4869
F: 601/359-4185 F: 702/687-8724
E-mail: msjgl@medicaid.state.ms.us E-mail: lsquarts@govmail.state.nv.us
NEW JERSEY
MONTANA
Carl D. Tepper, R.Ph.
Dorothy D. Poulsen
Department of Human Services
Pharmacy Program Officer
Division of Medical Assistance and Health Services
Department of Public Health and Human Services
P.O. Box 712, Room 202
Medicaid Services Bureau
Trenton, NJ 08625-0712
P.O. Box 202951
P: 609/588-2724
1400 Broadway
F: 609/588-3889
Helena, MT 59620-2951
E-mail: cdtepper@dhs.state.nj.us
P: 406/444-2738
F: 406/444-1861
E-mail: dpoulsen@state.mt.gov NEW MEXICO
Neil Solomon
NEBRASKA Medicaid Assistance Division
P. O. Box 2348
Gary J. Cheloha M.B.A., R.Ph.
Santa Fe, NM 87504
Department of Health and Human Services
P: 505/827-3174
Finance and Support, Medicaid Division
F: 505/827-3185
P.O. Box 95026
301 Centennial Mall S., 5th Fl.
Lincoln, NE 68509
P: 402/471-9379
F: 402/471-9092
E-mail: gary.cheloha@hhss.state.ne.us
Agency Internet Address: www.hhs.state.ne.us
TENNESSEE VIRGINIA
Jeff Stockard, D.Ph. David B. Shepherd, R.Ph.
Director of Pharmacy Department of Medical Assistance Services
Bureau of TennCare 600 East Broad Street, Ste 1300
729 Church Street, 1st Floor Richmond, VA 23219
Nashville, TN 37247-6501 P: 804/225-2773
P: 615/532-3107 F: 804/786-0414
F: 615/741-0882 E-mail: dshepher@dmas.state.va.us
Agency Internet Address:
www.state.tn.us/health/tenncare/ WASHINGTON
Siri A. Childs, Pharm D.
TEXAS
Pharmacy Research Specialist
Robert P. Harriss Medical Assistance Administration, DSHS
Director, TX Department of Health 805 Plum Street, SE
Vendor Drug Program P.O. Box 45506
1100 W. 49th Street Olympia, WA 98504-5506
Austin, TX 78756-3174 P: 360/725-1564
P: 512/338-6961 F: 360/664-3884
F: 512/338-6910 E-mail: childsa@dshs.wa.gov
E-mail: bob.harriss@tdh.state.tx.us
WEST VIRGINIA
UTAH
Peggy A. King, R.Ph.
RaeDell Ashley, R.Ph.
Pharmaceutical Coordinator
Pharmacy Director
WV Department of Human Services
Division of Health Care Financing
350 Capitol St., Room 251
Utah Department of Health
Charleston, WV 25301-3707
288 N. 1460 West, P.O. Box 143102
P: 304/558-1753
Salt Lake City, UT 84114-2905
F: 304/558-1542
P: 801/538-6495
E-mail: pking@wvdhhr.org
F: 801/538-6099
E-mail: rashley@doh.state.ut.us
WISCONSIN
Roma Rowlands, R.Ph.
Division of Health Care Financing
Department of Health and Family Services
One West Wilson Street
P.O. Box 309
Madison, WI 53701-0309
P: 608/266-3753
F: 608/266-1096
E-mail: rowlarm@dhfs.state.wi.us
Agency Internet Address:
www.dhfs.state.wi.us/medicaid
WYOMING
Roxanne Homar, R.Ph.
Deputy Administrator
Shannon Whalen, Medicaid Pharmacist
Community and Family Health Division
Primary Care Services
2300 Capital Avenue
Hathaway Building, 1st Floor
Cheyenne, WY 82002
P: 307/777-6016
F: 307/777-6964
E-mail: rhomar@.state.wy.us
State Contact
Vic Walker, R.Ph. B.C.P.P.
Sr. Pharmaceutical Consultant
Medi-Cal Policy Division
CALIFORNIA
714 P Street, Rm. 1540
In-House DUR
Sacramento, CA 95814
P: 916/657-0785
F: 916/654-0513
E-mail: vwalker@dhs.ca.gov
State Contact
Chrisopher Keeyes, Pharm.D.
DISTRICT OF President
COLUMBIA Clinical Pharmacy Administration
In-House DUR 11710 Beltsville Drive, Ste. 510
Calberton, MD 20705
P: 301/572-1616
State Contact
Jean B. Cox, R.Ph.
DUR Coordinator
GA Dept. of Community Health
GEORGIA
2 Peachtree St. NW
In-house DUR
Atlanta, GA 30303
P: 404/657-7241
F: 404/656-8366
E-mail: Jcox@dch.state.ga.us
State Contact
Kathleen Kang-Kaulupali
Pharmacy Consultant
HAWAII Med-Quest Division
In-House DUR PO Bopx 339
Honolulu, HI 96809-0339
P: 808/692-8115
F: 808/692-8131
State Contact
Starlin Haydon Greatting, R.Ph.
Pharmacist Consultant
DUR Coordinator
ILLINOIS
Illinois Department of Public Aid
In-House DUR
1001 N. Walnut St.
Springfield, IL 62702
P: 217/524-7112
F: 217/524-7194
State Contact
Mary Beth Reinke, Pharm.D.
DUR Coordinator
Minnesota Dept. of Human Services
MINNESOTA
444 Lafayette Rd.
In-House DUR
St. Paul, MN 55155-3853
P: 651/215-1239
F: 651/282-6744
E-mail: Mary.beth.reinke@state.mn.us
State Contact
Laurie Squartsoff, R.Ph.
Pharmacy Services Consultant
NEVADA Nevada Medicaid
In-House DUR 2527 N. Carson St., Capitol Complex
Carson City, NV 89710
P: 702/687-4869
F: 702/687-8724
State Contact
Edward Vaccaro, R.Ph.
Assistant Director, OHSA
Division of Medical Assistance and Health
Services
NEW JERSEY
Office of Health Service Administration, P.O.
In-House DUR
Box 712
Trenton, NJ 08625-0712
P: 609/588-2721
F: 609/588-3889
E-mail: ejvaccaro@dhs.state.nj.us
State Contact
Michael Zegarelli
DUR Manager, Office of Medicaid
Management
NEW YORK NYS Dept. of Health
In-House DUR 99 Washington Ave, Suite 601
Albany, NY 12210
P: 518/474-6866
F: 518/473-5332
E-mail: maz03@health.state.ny.us
State Contact
Sharman Leinwand
DUR Coordinator
NORTH CAROLINA N.C. Division of Medical Assistance
In-House DUR 2515 Mail Service Center
Raleigh, NC 27699-2515
P: 919/733-3590
F: 919/715-7706
State Contact
Pat Kramer
Director, Utilization Management
Human Services
NORTH DAKOTA
600 E. Blvd., Dept. 325
In-House DUR
Bismarck, ND 58505-0250
P: 701/328-4893
F: 701/328-1544
E-mail: sokrap@state.nd.us
State Contact
PRODUR – EDS/ RETRODUR – University
PENNSYLVANIA
of Maryland
In-House DUR
P.O. Box 8046
Harrisburg, PA 17105
TENNESSEE
Within Federal and State guidelines, individual managed care and pharmacy benefit
DUR is conducted at management organizations make formulary/drug decisions.
the plan level.
State Contact
Curtis Burch
Director
Drug Utilization Review Division
TEXAS Texas Department of Health
In-House DUR 1100 West 49th Street
Austin, TX 78756-3174
P: 512/338-6922
F: 512/338-6910
E-mail: curtis.burch@tdh.state.tx.us
State Contact
Duane Parke
DUR Coordinator
UTAH Health Care Financing
In-House DUR 288 N. 1460 West, P.O. Box 143102
Salt Lake City, UT 84114-2905
P: 801/538-6452
F: 801/538-6099
State Contact
Siri A. Childs, Pharm D.
Pharmacy Research Specialist
Medical Assistance Administration, DSHS
WASHINGTON 805 Plum Street, SE
In-House DUR P.O. Box 45506
Olympia, WA 98504-5506
P: 360/725-1564
F: 360/664-3884
E-mail: childsa@dshs.wa.gov
ALABAMA COLORADO
Ricky Pope Consultec, Inc.
Account Manager, EDS 600 17th Street
301 Technacenter Dr. Suite 600 North
Montgomery, AL 36117 Denver CO 80203
P: 334/215-0111 P: 800/237-0757
F: 303/534-0435
ALASKA
CONNECTICUT
Rose-Ellen Hope
Pharmacist Twila Smith
First Health Account Manager
565 Union St. NE #205 EDS
Salem, OR 97301 100 Stanley Drive
P: 503/391-0184 New Britain, CT 06053
P: 860/832-5800
ARIZONA
DELAWARE
AHCCCS/DBF/CLMS
Lori Petre, Claims Administrator Thomas Ignudo
701 E. Jefferson Account Manager
Phoenix, AZ 85034 EDS
P: 602/417-4547 248 Chapman Rd
Newark, DE 19702
ARKANSAS
DISTRICT OF COLUMBIA
John Herzog
Account Manager Contact not provided
EDS Federal Corp
500 East Markham, Suite 400 FLORIDA
Little Rock, AR 72201
P: 501/374-6608 Mark Steck
F: 501/372-2971 PBM Director
E-mail: John.herzog@Medicaid.state.ar.us Consultec, Inc.
9040 Roswell Rd. Suite 700
Atlanta, GA 30350
CALIFORNIA
P: 770/594-7799
Dennis Dworman
Executive Program Director GEORGIA
EDS-Medi-Cal
Electronic Data Systems Cheryl Collier
3215 Prospect Park Drive Account Manager, EDS
Rancho Cordova, CA 95670 736 Park North Blvd
P: 916/636-1000 P.O. Box 736
F: 916/636-1000 Clarkston, GA 30021
P: 404/297-3700
F: 404/298-1031
HAWAII LOUISIANA
Luukia Abbley Department of Health and Hospitals
Supervisor, Medicaid Susan Taskin, Chief, MMIS
HMSA - Medicaid Claims Service P.O. Box 91030
P.O. Box 860 Baton Rouge, LA 70821
Honolulu, HI 96808 P: 225/342-9494
P: 808/948-5361
MAINE
IDAHO
Marcia Pykare
EDS Goold Health Systems
P.O. Box 1168 12 Stone Street
Boise, ID 83701 Augusta, ME 04332
P: 208/395-2000 P: 207/622-7153
ILLINOIS MARYLAND
Self-administered Charlotte Krueger, Chief
First Health Services Corporation
INDIANA Division of Claims Processing
201 W. Preston St.
EDS Baltimore, MD 21201
950 North Meridan Street, 11th Floor P: 401/767-5347
Indianapolis, IN 46204 F: 410/333-7186
P: 317/488-5000
MASSACHUSETTS
IOWA
Unisys
Kristi Sheakley P.O. Box 9101
Account Manager Somerville, MA 02145
Consultec, Inc. P: 617/576-4451
P.O. Box 14422
Des Moines, IA 50306-3422
MICHIGAN
P: 515/327-0950 x1108
F: 515/327-0945 First Health Services Corp.
4300 Cox Rd.
KANSAS Glen Allen, VA 23060
KENTUCKY MISSISSIPPI
Unisys-Provider Services Terry Childress
P.O. Box 2100 Director of Systems
Frankfort, KY 40602 239 North Lamar St.
P: 502/226-1140 Jackson, MS 39201-1399
F: 502/226-1860 P: 601/359-6050
E-mail: PPTCC@medicaid.state.ms.us
OREGON UTAH
Mariellen Rich, R.Ph. Brenda Bryant (In-House)
Director, Pharmacist Account Manager Health Care Financing
First Health Service, Corporation 288 North 1460 West
565 Union St., NE, Suite 205 Salt Lake City, UT 84114
Salem, OR 97310
P: 503/391-1980 VERMONT
F: 503/391-1979
E-mail: merich@fhsc.com EDS
312 Hurricane Lane, Ste 101
Williston, VT 05495
PENNSYLVANIA
P: 802/879-4450
EDS F: 802/878-3440
E-mail: mossesm@vtxix.slg.eds.com
RHODE ISLAND
VIRGINIA
Contact not provided.
First Health Services
SOUTH CAROLINA Glen Allen, VA
Rod Davis
WASHINGTON
Bureau Chief, Bureau of Information Systems
S.C. Department of Health & Human Services Chris Johnson
P.O. Box 8206 Claims Processing Manager
Columbia, SC 29202-8206 Medical Assistance Administrator
P: 803/898-2610 P.O. Box 45560
E-mail: davisr@dhhs.state.sc.us Olympia, WA 98504-5506
P: 360/725-1067
SOUTH DAKOTA F: 360/586-4994
E-mail: Johnsc2@dshs.wa.gov
Meredith Heerman
SD Dept. of Social Services
WEST VIRGINIA
Claims Processing Supervisor
700 Governors Dr. Consultec, Inc.
Pierre, SD 57501 Leslie Bratton, Account Manager
P: 605/773-3495 9040 Roswell Road, Suite 700
E-mail: meredith_heerman@state.sd.us Atlanta, GA 30350
P: 800/358-2381
TENNESSEE F: 800/793-2305
E-mail: Lbratton@consultec-inc.com
Contact not provided
WISCONSIN
TEXAS
Mark Gajewski
Texas Dept. of Health Account Director
Patsy McElroy, Director, Electronic Claims EDS
Management 6406 Bridge Road
1100 West 49th Street Madison, WI 53713
Austin, TX 78756 P: 608/221-9326
P: 512/338-6909
E-mail: patsy.mcelroy@tdh.state.tx.us
WYOMING
Consultec, Inc.
Jennifer Dillinger, Account Manager
P.O. Box 667
Cheyenne, WY 82003
P: 307/777-5500
ALABAMA CONNECTICUT
First DataBank First DataBank
1111 Bayhill Drive, Suite 350 1111 Bayhill Drive
San Bruno, CA 94066 San Bruno, CA 94066
P: 650/588-5454 P: 650/588-5454
ALASKA DELAWARE
Dave Campana, R.Ph Cynthia Denemark
Pharmacy Program Manager Pharmacist Consultant
Division of Medical Assistance EDS
4501 Business Park Blvd., Ste. 24 248 Chapman Road, Suite 200
Anchorage, AK 99503 Newark, DE 197029720
P: 907/273-3224 P: 302/453-8453
F: 907/561-1684 F: 302/454-7603
E-mail: david_campana@health.state.ak.us E-mail: cynthia.denemark@eds.com
Allen Chapman
HAWAII
Department of Health Care Policy and Financing
1575 Sherman St., 5th Floor First DataBank
Denver, CO 00008-0203 111 Bayhill Dr.
P: 303/866-3176 San Bruno, CA 94066
F: 303/866-2573 P: 800/633-3453
IDAHO LOUISIANA
Gary Duerr, R.Ph. Maggie Vick
Pharmacy Services Specialist Unisys
Idaho Medicaid Policy PO Box 3396
Americana Terrace, Suite 140 Baton Rouge, LA 70809
PO Box 83720 P: 225/219-3251
Boise, ID 83720-0036 F: 225/219-4164
P: 208/364-1829 E-mail: margaret.vick@unisys.com
F: 203/364-1846
MAINE
ILLINOIS
Kathy Chadwick
First Data Bank First DataBank
1111 Bay Hill Drive 1111 Bay Hill Drive
San Bruno, CA 94066 San Bruno, CA 94066
P: 650/588-5454 P: 800/633-3453
E-mail: kathy_chadwick@firstdatabank.com
INDIANA
MARYLAND
First DataBank
1111 Bay Hill Drive First DataBank
San Bruno, CA 94066 1111 Bayhill Drive, Suite 350
P: 650/588-5454 San Bruno, CA 94066
P: 650/588-5454
IOWA
MASSACHUSETTS
Sherey Swanson
Deputy Account Manager Christopher Burke
Consultec, Inc. Pharmacy Program Analyst
P.O. Box 14422 Division of Medical Assistance
Des Moines, IA 50306-3422 600 Washington Street
P: 515/327-0950 x1107 Boston, MA 02111
F: 515/327-0945 P: 617/210-5592
F: 617-210-5597
KANSAS
MICHIGAN
Karen Braman, R.Ph., M.S.
Health Care Policy Division First DataBank
Kansas Department of Social and Rehabilitation 1111 Bayhill Drive, Suite 350
Services San Bruno, CA 94066
915 SW Harrison, Room 651-South DSOB P: 650/588-5454
Topeka, KS 66612-1570 F: 650/827-4578
P: 785/296-3981
KENTUCKY
Unisys-Provider Services
P.O. Box 2100
Frankfort, KY 40602
P: 502/226-1140
VIRGINIA
David B. Shepherd, R.Ph.
Pharmacy Consultant
Department of Medical Asisstance Services
600 East Broad Street, Suite 1300
Richmond, VA 23112
P: 804/786-8057
F: 804/786-0414
WASHINGTON
Marilyn Mueller
Pharmacy Program Manager
Medical Assistance Administration--DSHS
P.O. Box 45506
Olympia, WA 98504-5506
P: 360/725-1569
E-mail: muellmf@dshs.wa.gov
WEST VIRGINIA
Leslie Bratton
Account Manager
Consultec, Inc.
9040 Roswell Road, Suite 700
Atlanta, GA 30350
P: 800/358-2381
F: 800/793-2305
E-mail: LBratton@consultec-inc.com
WISCONSIN
First DataBank
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
P: 650/588-5454
F: 650/827-4578
WYOMING
First DataBank
1111 Bayhill Drive
San Bruno, CA 94066
P: 800/633-3453
ALABAMA COLORADO
Jim Morrison Vince Sherry
Alabama Medicaid Agency Department of Health Care Policy and Financing
501 Dexter Avenue 1575 Sherman St., 5th Floor
Montgomery, AL 36103-5624 Denver, CO 00008-0203
334/242-2323 P: 303/866-5408
E-mail: jmorrison@medicaid.state.al.us F: 303/866-2573
ALASKA CONNECTICUT
Dave Campana, R.Ph Ellen Arce, R.Ph.
Pharmacy Program Manager Pharmacy Team Lead
Division of Medical Assistance EDS
4501 Business Park Blvd., Ste. 24 100 Stanley Drive
Anchorage, AK 99503 New Britain, CT 06053
P: 907/273-3224 P: 860/832-5885
F: 907/561-1684 F: 860/832-5832
ARIZONA DELAWARE
AHCCCS/DBF/CLMS Christine Whitlock
Lori Petre, Claims Administrator Rebate Analyst
701 E. Jefferson EDS
Phoenix, AZ 85034 248 Chapman Road
P: 602/417-4547 Newark, DE 19702
P: 302/454-7622
ARKANSAS F: 302/454-7603
E-mail: christine.whitlock@eds.com
Suzette Bridges, P.D.
Department of Human Services
DISTRICT OF COLUMBIA
Division of Medical Services
Pharmacy Program Contact not provided
P.O. Box 1437, Slot 4105
Little Rock, AR 72203 FLORIDA
P: 501/324-9141
Greg Bracko
Rebate Coordinator
CALIFORNIA
AHCA
Craig Miller 2727 Mahan Dr.
Chief, Contracting Unit Tallahassee, FL 32308
Medi-Cal Policy Division P: 850/488-9193
714 P Street, Room 1540 E-mail: Brackog@fdhc.state.fl.us
Sacramento, CA 95814
P: 916/654-0532
F: 916/654-0513
E-mail: cmiller2@dhs.ca.gov
GEORGIA IOWA
Susan Oh Rocco Russo
Drug Rebate Coordinator Third Party Liability Manager
Department of Community Health Consultec, Inc.
2 Peachtree St. 37th Floor P.O. Box 14422
Atlanta, GA 30303 Des Moines, IA 50306-3422
P: 404/657-9181 P: 515/327-0950 x1114
F: 404/656-8366
E-mail: so@dch.state.ga.us KANSAS
Karen Braman, R.Ph., M.S.
HAWAII
Health Care Policy Division
Brian Pang KS Dept of Social and Rehabilitation Services
Finance Officer 915 SW Harrison, Room 651-South DSOB
Department of Human Services Topeka, KS 66612-1570
Med QUEST Division P: 785/296-3981
P.O. Box 339
Honolulu, HI 96809-0339 KENTUCKY
P: 808/692-7956
F: 808/692-7989 Marie Couch
Department for Medicaid Services
275 E. Main St.
IDAHO
Frankfort, KY 40621
David Mendoza P: 502/564-3476
Medicaid Programs F: 502/564-3852
P.O.Box 83720
Boise, ID 83720-0036 LOUISIANA
P: 208/364-1838
F: 208/364-1846 Susan Taskin, Chief, MMIS
E-mail: mendodr@mmis.state.id.us Department of Health and Hospitals
P.O. Box 91030
Baton Rouge, LA 70821
ILLINOIS
P: 225/342-9494
Alberta Levan
Supervisor MAINE
Illinois Department of Public Aid
110 West Lawrence Rossi Rowe
Springfield, IL 62763 TPL Manager
P: 217/524-7161 DHS/BMS
F: 217/524-5176 Building 205, 2nd Fl.
Augusta, ME 04333-0011
P: 207/287-1838
INDIANA
F: 207/287-1788
EDS E-mail: rossi.rowe@state.me.us
950 North Meridan Street, 11th Floor
Indianapolis, IN 46204
P: 317/488-5000
MARYLAND MISSOURI
Kenneth Smoot Lynn Hebenheimer
Deputy Director Pharmacy Rebate Manager
Office of Management and Finance Division of Medical Services
201 W. Preston St. P.O. Box 6500
Baltimore, MD 21201 Jefferson City, MO 65102
P: 401/767-5186 P: 573/751-2005
F: 410/333-5409 F: 573/526-2045
E:mail:
MASSACHUSETTS lynnhebenheimer@mail.medicaid.state.mo.us
Paula McAree
MONTANA
Drug Rebate Specialist
Division of Medical Assistance Betty DeVaney
600 Washington St. Drug Rebate Coordinator
Boston, MA 02111 Dept. of Public Health and Human Services
P: 617/210-5594 P.O. Box 202951
F: 617/210-5597 Helena, MT 59620-2951
E-mail: pmcaree@nt.dma.state.ma.us P: 406/444-3457
F: 406/444-1861
MICHIGAN Bdevaney@state.mt.us
ALASKA ARKANSAS
Governor Governor
Honorable Tony Knowles Honorable Mike Huckabee
P.O. Box 110001 State Capitol Building
Juneau, AK 99811-0001 Little Rock, AR 72201
907/465-3500 501/682-2345
Single State Agency Director Single State Agency Director
Ms. Karen Perdue Mr. Kurt Knickrehm, Director
Commissioner Department of Human Services
Department of Health and Social Services P.O. Box 1437, Slot 329
P.O. Box 110601 Little Rock, AR 72203-1437
Juneau, AK 99811-0601 501/682-8650
907/465-3030 Fax 501/682-6836
Medicaid Director E-mail – kurt.knickrehm@state.ar.us
Mr. Bob Labbe Medicaid Director
Director Mr. Ray Hanley, Director
Division of Medical Assistance Division of Medical Services Dept. of Human Services
Department of Health and Social Services P.O. Box 1437, Slot 1100
P.O. Box 110660 Little Rock, AR 72203-1437
Juneau, AK 99811-0660 50l/682-8292
907/465-3355 F: 501/682-1197
F: 907/465-2204 E-mail – Ray.Hanley@medicaid.state.ar.us
E-mail – Blabbe@health.state.ak.us
CALIFORNIA CONNECTICUT
Governor Governor
Honorable Gray Davis Honorable John G. Rowland
State Capitol, First Floor State Capitol, Room 202
Sacramento, CA 958l4 Hartford, CT 06l06
916/445-2841 860/566-4840
F: 916/445-4633 Single State Agency Director
Single State Agency Director Ms. Patricia Wilson-Coker, Commissioner
Ms. Diana M. Bonta, Director Department of Social Services
714 P Street, Room 1253 25 Sigourney Street
Sacramento, CA 95814 Hartford, CT 06106-5033
916/657-1425 860/424-5008
Medicaid Director Medicaid Director
Ms. Gail M. Margolis, Deputy Director Mr. David Parella, Deputy Commissioner
Medical Care Services Department of Social Services
Department of Health Services 25 Sigourney Street
714 P Street, Room 1253 Hartford, CT 06106-5116
Sacramento, CA 95814 860/424-5116
916/654-0391 F: 860/424-5114
F: 916/657-1156 E-mail – David.Parrella@PO.state.ct.us
E-mail – gmargolis@dhs.ca.gov
DELAWARE
COLORADO
Governor
Governor Honorable Thomas R. Carper
Honorable Bill Owens Tatnall Building
State Capitol William Penn Street
Room 136 Dover, DE 19901
Denver, CO 80203 302/739-4101
303/866-2471 Single State Agency Director
F: 303/866-2003 Mr. Greg Sylvester
Single State Agency Director Secretary
Mr. James T. Rizzuto Department of Health and Social Services
Executive Director 1901 North DuPont Highway
Department of Human Services New Castle, DE l9720
l575 Sherman Street 302/421-6705
Denver, CO 80203-1714 Medicaid Director
303/866-5096 Mr. Philip Soulé, Sr.
F: 303/866-4740 Director
E-mail – jimt.rizzuto@state.co.us Medical Assistance Program
Medicaid Director Department of Health and Social Services
Mr. Richard Allen P.O. Box 906, Lewis Building
Executive Director 1901 North DuPont Highway
Department of Health Care Policy and Financing New Castle, DE 19720
l575 Sherman Street 302/577-4901
Denver, CO 80203-1714 F: 302/577-4577
303/866-5401 E-mail – Psoule@state.de.us
F: 303/866-2803
TDD 303/866-3883
E-mail – Richard.allen@state.co.us
HAWAII ILLINOIS
Governor Governor
Honorable Carl Benjamin J. Cayetano Honorable George H. Ryan
State Capitol 207 Capitol Building
Honolulu, HI 968l3 State Capitol
808/586-0034 Springfield, IL 62706
Single State Agency Director 2l7/782-6830
Ms. Susan M. Chandler, Director Single State Agency Director
Department of Human Services Ms. Ann Patla, Dr.HL, Director
P.O. Box 339 Department of Public Aid
Honolulu, HI 96809-0339 201 South Grand Avenue, East, Third Floor
808/586-4997 Springfield, IL 62763-0001
Medicaid Director 2l7/782-6717
Mr. Chuck C. Duarte, Administrator F: 217/524-7979
Med-Quest Division Medicaid Director
Department of Human Services Mr. Matt Powers, Administrator
P.O. Box 399 Department of Public Aid
Honolulu, HI 96809-0339 20l South Grand Avenue, East, Third Floor
808/692-8056 Springfield, IL 62763-0001
F: 808/692-8173 2l7/782-2570
E-mail – Chuck@I-one.com F: 217/524-7979
E-mail – aidd0007@mail.idpa.state.il.us
IDAHO
INDIANA
Governor
Honorable Dirk Kempthorne Governor
P.O. Box 83720 Honorable Frank O’Bannon
Boise, ID 83720-0034 State House, Room 206
208/334-2100 Indianapolis, IN 46204
Single State Agency Director 3l7/232-4567
Mr. Karl Kurtz, Director Single State Agency Director
Department of Health and Welfare Mr. Peter Sybinsky, Secretary
450 West State Street Family and Social Services Administration
Boise, ID 83720-0036 Room 461, Mail Stop 25
208/334-5500 P.O. Box 7083
F: 208/334-6558 402 W. Washington Street
Medicaid Director Indianapolis, IN 46207-7083
Mr. Joe Brunson, Administrator 317/233-4452
Division of Medicaid E-Mail: Vmoore@fssa.state.in.us
Department of Health and Welfare Medicaid Director
Americana Building Ms. Kathleen D. Gifford, Assistant Secretary
P.O. Box 83720 Medicaid Policy and Planning
Boise, ID 83720-0036 Family and Social Services Administration
208/364-1802 402 W. Washington Street, Room W382
F: 208/334-1811 Indianapolis, IN 46204-2739
E-mail: Allynkp@mmis.state.id.us 317/233-4455
F: 317/232-7382
E-Mail: Kgifford@fssa.state.in.us
IOWA KENTUCKY
Governor Governor
Honorable Thomas J. Vilsack Honorable Paul E. Patton
State Capitol Building State Capitol Building
Des Moines, IA 503l9 700 Capitol Avenue
5l5/28l-5211 Frankfort, KY 4060l
F: 515/281-6611 502/564-2611
Single State Agency Director Single State Agency Director
Jessie K. Rasmussen, Director Mr. Jimmy D. Helton, Commissioner
Department of Human Services Department for Medicaid Services
Hoover State Office Building Third Floor
Fifth Floor 275 East Main Street
Des Moines, IA 503l9-0114 Frankfort, KY 40621
5l5/28l-5452 502/564-4321
F: 515/281-4597 Medicaid Director
Medicaid Director Mr. Dennis Boyd, Commissioner
Dennis Headlee, Administrator Department for Medicaid Services
Division of Medical Services Third Floor
Department of Human Services 275 East Main Street
Hoover State Office Building Frankfort, KY 40621
Fifth Floor 502/564-4321
Des Moines, IA 503l9-0114 F: 502/564-0509
5l5/281-8621 E-mail- Lmccarthy@mail.state.ky.us
F: 515/281-7791
LOUISIANA
KANSAS
Governor
Governor Honorable M. J. “Mike” Foster
Honorable Bill Graves State Capitol
2nd Floor P.O. Box 94004
State Capitol Building Baton Rouge, LA 70804
Topeka, KS 66612-1590 504/342-7015
785/296-3232 F: 504/342-7099
F: 785/296-7973 Single State Agency Director
Single State Agency Director Mr. David W. Hood, Secretary
Ms. Janet Schalansky, Secretary Department of Health and Hospitals
Kansas Department of Social and Rehabilitation Services P.O. Box 629, Bin #2
State Office Building Baton Rouge, LA 70821-0629
Topeka, KS 66612 504/342-9500
785/296-3271 F: 504/342-5568
F: 785/296-4685 Medicaid Director
E-mail – JKS@srsexec.wpo.state.ks.st Mr. Thomas D. Collins, Director
Medicaid Director Bureau of Health Services Financing
Mr. Robert Day, Commissioner Department of Health and Hospitals
Adult and Medical Services P.O. Box 91030
Department of Social and Rehabilitation Services Baton Rouge, LA 70821-9030
Docking State Office Building 504/342-3891
915 Harrison Street F: 504/342-9508
Topeka, KS 66612 E-mail – TCOLLINS@dhhmail.dhh-state.la.us
785/296-8904
F: 785/296-4813
E-mail – ODG@srmspo.wpo.state.ks.us
MAINE MASSACHUSETTS
Governor Governor
Honorable Angus S. King, Jr. Honorable Argeo Paul Cellucci
1 State House Station Executive Office, State House
Augusta, Maine 04333-0001 Room 360
207/287-3531 Boston, MA 02133
Single State Agency Director 617/727-9173
Mr. Kevin Concannon, Commissioner Single State Agency Director
Department of Human Services Mr. Bruce Bullen, Commissioner
State House Station 11 Division of Medical Assistance
Augusta, ME 04333-0011 Medicaid Division
207/287-2736 600 Washington Street
Medicaid Director Boston, MA 02111
Mr. Francis T. Finnegan, Jr., Director 617/210-5690
Bureau of Medical Services Medicaid Director
Department of Human Services Mr. Bruce Bullen, Commissioner
State House Station 11 Division of Medical Assistance
Augusta, ME 04333-0011 600 Washington Street
207/287-2093 Boston, MA 02111
F: 207/287-2675 617/210-5690
E-mail: fran.finnegan@state.me.us F: 617/210-5697
E-mail: Bbullen@nt.dma.state.ma.us
MARYLAND
MICHIGAN
Governor
Honorable Parris N. Glendening Governor
State House Honorable John Engler
Annapolis, MD 21401 P.O. Box 30013
410/974-3901 Lansing, MI 48909
Single State Agency Director 5l7/373-3400
Georges Benjamin, M.D. Single State Agency Director
Secretary Mr. James K. Haveman, Jr., Director
Department of Health & Mental Hygiene Michigan Department of Community Health
Herbert R. O'Connor Building Lewis Cass Building
201 West Preston Street 320 South Walnut Street
Fifth Floor Lansing, MI 48913
Baltimore, MD 21201 517/335-0267
410/225-6535 Medicaid Director
Medicaid Director Mr. Robert M. Smedes, Chief Executive Officer
Debbie Chang Medical Services Administration
Deputy Secretary for Health Care Financing Michigan Department of Community Health
Department of Health & Mental Hygiene 400 S. Pine Street
201 West Preston Street Lansing, MI 48909
Baltimore, MD 21201 517/335-5001
410/767-4664 F: 517/335-5007
F: 410/333-7687 E-mail – smedes@state.mi.us
E-mail – Dchang@dhmh.md.state.us
MINNESOTA MISSOURI
Governor Governor
Honorable Jesse Ventura Honorable Mel Carnahan
130 State Capitol State Capitol Building
St. Paul, MN 55155-1099 P.O. Box 720
651/296-3391 Jefferson City, MO 65101
Single State Agency Director 573/751-3222
Mr. Michael O’Keefe, Commissioner F: 573/751-1495
Minnesota Department of Human Services Single State Agency Director
444 Lafayette Road North Mr. Gary J. Stangler, Director
St. Paul, MN 55155-3815 Department of Social Services
651/296-2701 P.O. Box 1527
F: 651/297-3230 Jefferson City, MO 65102
E-mail – Michael.Okeefe@state.mn.us 573/751-4815
Medicaid Director F: 573/751-3203
Ms. Mary B. Kennedy, Medicaid Director Medicaid Director
Assistant Commissioner Health Care Mr. Gregory A. Vadner
Minnesota Department of Human Services Division of Medical Services
444 Lafayette Road Department of Social Services
St. Paul, MN 55l55-3852 615 Howerton Court
651/282-9921 P.O. Box 6500
F: 651/297-3230 Jefferson City, MO 65102-6500
E-mail – mary.kennedy@state.mn.us 573/751-6922
F: 573/751-6564
E-mail – Victornine@aol.com
MISSISSIPPI
Governor
MONTANA
Honorable Kirk Fordice
State Capitol Governor
P.O. Box 139 Honorable Marc Racicot
Jackson, MS 39205 Capitol Station
60l/359-3150 Helena, MT 59620-0801
Single State Agency Director 406/444-3111
Ms. Helen Wetherbee, Executive Director Single State Agency Director
Division of Medicaid Ms. Laurie Ekanger, Director
Office of the Governor Department of Public Health and Human Services
Suite 801, Robert E. Lee Building P.O. Box 4210
239 North Lamar Street 111 N. Sanders
Jackson, MS 39201-1399 Helena, MT 59604-4210
601/359-6050 406/444-5622
Medicaid Director Medicaid Director
Ms. Helen Wetherbee, Executive Director Ms. Nancy Ellery, Administrator
Division of Medicaid Division of Health Policy and Services
Office of the Governor Department of Public Health and Human Services
Suite 801, Robert E. Lee Building 1400 Broadway
239 North Lamar Street Helena, MT 59601
Jackson, MS 39201-1399 406/444-4141
601/359-6050 F: 406/444-1861
F: 601/359-6048 E-mail – Nellery@state.mt.us
E-mail – Exgaw@medicaid.state.ms.us
Region III Suite 216, The Public Ledger Building Delaware, District of Columbia,
Philadelphia Regional Office 150 South Independence Mall West Maryland, Pennsylvania, Virginia,
Philadelphia, PA 19106 West Virginia
215/861-4263
Region VI 1301 Young Street, Room 714 Arkansas, Louisiana, New Mexico,
Dallas Regional Office Dallas, TX 75202 Oklahoma, Texas
214/767-6301
Region VII Richard Bolling Federal Building Iowa, Kansas, Missouri, Nebraska
Kansas City Regional Office 601 East 12th Street, Room 235
Kansas City, MO 64106-2808
816/426-5925
Region VIII Colorado State Bank Building Colorado, Montana, North Dakota,
Denver Regional Office 1600 Broadway, Suite 700 South Dakota, Utah, Wyoming
Denver, CO 80202-4367
303/844-1977
Region IX 75 Hawthorne Street, 4th & 5th Floors Arizona, California, Hawaii, Guam
San Francisco Regional Office San Francisco, CA 94105-3901 Nevada, and Pacific Islands
415/744-3568
Director
Tim Westmoreland
410/786-3870
Deputy Director
Rachel Block
410/786-3230
Appendix B:
Medicaid Program Statistics --
HCFA-2082 Report
Historically, States summarized and reported the data processed through their
Medicaid claims processing and payment operations unless they opted to
participate in the Medicaid Statistical Information System (MSIS) project. Prior
to Federal fiscal year 1999, MSIS was a voluntary program and those States
participating in the MSIS project provide data tapes from their claims processing
systems to HCFA in lieu of the 2082 tables. However, in accordance with the
Balanced Budget Act of 1997, all claims processed on or after January 1, 1999,
must be submitted electronically in the MSIS format.
FY 1998 HCFA-2082 The Federal Fiscal Year 1998 (October 1997-September 1998) HCFA-2082 data
CAVEATS AND DATA tables are based on information reported to HCFA on an annual basis by the 50
LIMITATIONS* States, the District of Columbia, Puerto Rico, and the Virgin Islands. These
tables reflect fiscal year 1998 data submitted by the States through September
1999. When using the data, note the following caveats and data limitations.
GENERAL
• The 1998 reports include managed care capitation payments on the Medicaid
Medical Vendor Payments tables and managed care recipients are now
included on the Medicaid Recipient tables. Managed care utilization and
payments are also broken out in the Type of Service tables. Tables 33
through 48 are specifically managed care tables.
STATE-SPECIFIC
• Alabama submitted totals only for their Prepaid Health Care and PCCM
recipients and payments. This data is reported as Unknown. The total Child
eligible population went up 25%. This was the result of the new program
called ARKIDSFIRST.
• 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 data
appears to include a misallocation of eligibles between the adult and child
categories.
• The total Child eligible population went up 67%. Maryland's FFY 1997
data counted some children as adults; the FFY 1998 data is correct. They
also implemented the Maryland Children Health Program in July of 1998.
• The total Child eligible population went up 32%. Massachusetts made a lot
of corrections to their data in FFY 1998 causing the counts to go up. Health
Care Reform also increased the eligible population for Children.
• New York's PCCM payments and eligibles in Section K (2) (Table 33) are
not correct. These counts include Targeted Case Management data. The total
adult eligible population went up 56%. The increase was due to New York's
new Medicaid Managed Care Waiver - Home and Community Based
program. The increase in this area was about 400K adults.
• Puerto Rico submitted a total recipient count only. The vendor payment
amount was taken from the HCFA-64. Their data is reported as Unknown.
• The total adult eligible population went up 25%. South Carolina always
used the midpoint of the FFY (03/31) to determine age, under MSIS they use
09/30 as the date.
• The total adult eligible population went up 17%. This was due to Vermont's
expansion of Medicaid population. More adults are now eligible for
Medicaid and more services are provided to these adults.
*Readers of the book should be cautioned that discrepancies in the 2082 data
can 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.
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 4. Medicaid Recipients Who Receive Cash Payments by Basis of Eligibility and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 5. Medically Needy Medicaid Recipients by Basis of Eligibility and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 6. Poverty Related Medicaid Recipients by Basis of Eligibility and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 7. Medicaid Recipients of Other Coverage Groups by Basis of Eligibility and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 9. Medicaid Medical Vendor Payments by Basis of Eligibility of Recipient and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Foster Other/
State Name Adults Children Unknown
National Total $14,833,097,385 $2,346,800,698 $3,701,624,687
Alabama 33,684,838 17,825,019 515,831,625
Alaska 61,419,264 9,653,683 1,082,304
Arizona 296,765,130 7,850,767 -
Arkansas 99,324,540 28,862,820 (235,913,708)
California 2,149,128,619 249,516,816 151,764,013
Colorado 124,900,958 101,216,640 44,060,428
Connecticut 175,979,323 17,216,272 -
Delaware 54,956,394 1,613,313 3,530,883
District of Columbia 53,304,930 15,804,439 86,725,854
Florida 549,341,749 51,456,136 25,343,764
Georgia 458,044,573 23,957,528 51,495,589
Hawaii 88,877,805 5,394,682 10,470,407
Idaho 37,809,908 2,492,581 40,351,514
Illinois 686,289,405 332,957,232 -
Indiana 175,348,016 22,734,889 18,275,912
Iowa 134,057,212 18,582,204 3,574,601
Kansas 59,588,457 7,397,334 14,108,399
Kentucky 239,916,610 43,231,020 9,658,235
Louisiana 238,273,512 154,433 -
Maine 43,739,741 26,400,465 12,007,410
Maryland 238,767,249 40,001,794 36,240,542
Massachusetts 397,513,145 981,948 -
Michigan 514,607,970 51,626,985 378,367,342
Minnesota 196,885,958 36,699,762 18,957,763
Mississippi 119,880,832 12,397,385 3,451,912
Missouri 156,676,911 46,608,272 12,620,841
Montana 38,484,670 6,016,000 6,282,321
Nebraska 66,708,154 36,223,877 -
Nevada 52,414,904 41,064,196 23,825,970
New Hampshire 33,867,455 24,126,996 1,346,112
New Jersey 370,456,043 97,454,744 13,921,892
New Mexico 104,703,118 26,174,965 5,793,510
New York 2,090,773,539 367,220,635 -
North Carolina 396,970,898 44,483,297 -
North Dakota 22,899,991 10,113,325 2,796,604
Ohio 554,468,305 71,394,614 -
Oklahoma - - 1,177,853,941
Oregon 576,396,640 36,617,022 17,148,103
Pennsylvania 457,250,934 97,843,918 2,301,914
Puerto Rico - - 250,000,000
Rhode Island 59,149,256 13,369,237 12,801,491
South Carolina 162,109,475 51,231,425 259,713,158
South Dakota 26,827,646 3,785,087 -
Tennessee 632,709,631 57,825,355 400,251,557
Texas 871,515,674 44,174,708 -
Utah 79,480,227 29,836,160 71,943,390
Vermont 46,777,227 15,461,003 1,237,394
Virgin Islands 2,715,637 - -
Virginia 200,657,760 9,388,574 -
Washington 353,872,825 21,906,690 132,128,776
West Virginia 101,663,671 32,282,729 122,838,895
Wisconsin 123,315,198 34,706,174 (3,168,696)
Wyoming 21,825,458 1,465,548 602,725
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 10. Medicaid Medical Vendor Payments by Type of Service and by State: FY 1998
Inpatient Nursing
Total Inpatient General Mental Facility ICF Mentally
State Name Payments Hospital Hospital Services Retarded
National Total $142,317,903,795 $21,498,719,619 $2,800,541,598 $31,892,064,551 $9,481,723,907
Alabama 1,902,300,047 42,908,107 26,475,030 522,825,844 55,663,840
Alaska 330,378,398 55,725,816 13,764,917 45,782,809 293,827
Arizona 1,643,966,305 75,903,069 20,966 16,458,558 -
Arkansas 1,375,797,421 178,532,888 54,470,602 300,012,732 108,852,817
California 14,236,592,915 2,539,212,053 7,648,556 2,158,053,360 559,948,974
Colorado 1,439,366,499 186,830,191 5,955,144 333,591,591 26,124,204
Connecticut 2,420,791,474 166,380,038 23,576,663 858,713,862 203,094,688
Delaware 419,732,143 15,358,566 10,648,377 83,062,656 32,687,748
District of Columbia 731,292,552 198,380,143 2,498,290 155,399,067 71,613,329
Florida 5,686,844,862 1,038,563,277 14,638,423 1,340,608,163 255,636,949
Georgia 3,012,346,312 668,075,530 - 603,835,584 107,450,025
Hawaii 507,433,146 36,301,298 - 144,973,700 10,066,595
Idaho 424,512,387 68,827,832 770,647 90,878,627 44,777,200
Illinois 6,172,865,261 1,690,971,723 355,291,866 1,268,060,053 661,728,014
Indiana 2,564,005,047 411,039,286 19,825,621 699,667,232 314,681,105
Iowa 1,288,770,390 144,960,334 18,447,053 318,547,045 179,085,736
Kansas 916,323,608 115,383,465 5,935,917 189,319,221 73,011,007
Kentucky 2,425,288,141 277,720,828 42,689,470 491,196,404 79,305,645
Louisiana 2,383,508,985 527,916,078 15,963,066 490,677,315 322,468,549
Maine 747,027,618 47,116,426 19,950,621 169,130,251 27,011,643
Maryland 2,489,280,148 324,719,290 56,546,963 546,941,004 55,095,149
Massachusetts 4,609,360,933 546,768,099 30,800,067 1,276,236,770 250,951,685
Michigan 4,345,007,824 792,887,794 39,700,896 898,994,947 92,056,064
Minnesota 2,924,447,719 252,541,378 16,286,663 843,536,749 234,768,692
Mississippi 1,442,373,276 324,944,298 15,483,002 313,037,056 125,503,877
Missouri 2,569,646,129 313,541,971 248,998 677,899,462 101,104,939
Montana 361,238,668 48,271,464 308,414 95,255,260 16,269,810
Nebraska 753,162,904 97,977,946 5,651,820 234,516,077 42,963,860
Nevada 462,087,777 106,004,413 11,508,517 72,595,501 28,894,383
New Hampshire 606,004,232 34,844,009 1,904,281 195,434,499 1,519,278
New Jersey 4,218,822,993 402,674,879 72,438,654 1,154,707,872 347,217,754
New Mexico 862,144,872 90,148,335 2,077,546 138,825,024 16,317,149
New York 24,298,610,635 3,972,442,080 1,525,566,813 5,032,111,363 2,196,796,587
North Carolina 4,013,996,742 692,184,068 26,557,229 760,826,548 361,838,061
North Dakota 341,015,420 30,884,006 3,918,724 111,162,630 44,567,046
Ohio 6,120,967,557 870,502,764 4,452,888 1,911,111,609 537,681,556
Oklahoma 1,177,853,941 - - - -
Oregon 1,377,514,740 12,124,512 35,339,858 188,522,343 77,395,292
Pennsylvania 6,080,191,710 539,676,985 85,078,979 1,961,739,776 442,232,151
Puerto Rico 250,000,000 - - - -
Rhode Island 919,353,410 178,178,042 12,260,928 234,578,181 4,930,618
South Carolina 2,018,620,428 522,891,024 47,960,982 302,667,749 167,959,347
South Dakota 355,833,902 67,004,925 2,818,786 101,120,652 19,582,925
Tennessee 3,167,188,993 76,296 - 1,066,992,955 -
Texas 7,139,928,843 1,643,167,234 - 1,384,415,773 728,574,336
Utah 618,675,433 90,973,076 218 90,411,547 43,954,818
Vermont 351,341,290 19,306,558 1,219,044 74,038,926 1,031,673
Virgin Islands 10,097,973 3,739,587 - 1,194,261 -
Virginia 2,118,202,866 334,376,705 101,470,932 394,719,042 143,102,604
Washington 2,044,234,831 265,579,863 101,471 496,372,294 8,999,877
West Virginia 1,243,150,526 194,479,017 24,905,723 256,580,323 47,738,110
Wisconsin 2,206,398,750 210,485,418 37,293,417 748,856,930 198,693,920
Wyoming 192,004,819 29,216,635 68,556 45,867,354 10,480,451
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 10. Medicaid Medical Vendor Payments by Type of Service and by State: FY 1998 (Con’t)
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 10. Medicaid Medical Vendor Payments by Type of Service and by State: FY 1998 (Con’t)
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 10. Medicaid Medical Vendor Payments by Type of Service and by State: FY 1998 (Con’t)
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 11. Medicaid Medical Vendor Payments for Recipients Who Receive Cash Payments
by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 12. Medicaid Medical Vendor Payments for Medically Needy Recipients by Basis of Eligibility
and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 13. Medicaid Medical Vendor Payments for Poverty Related Medicaid Recipients by Basis of
Eligibility and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 14. Medicaid Medical Vendor Payment for Recipients of Other Coverage Groups by Basis of Eligibility
and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 14. Medicaid Medical Vendor Payment for Recipients of Other Coverage Groups by Basis of Eligibility
and by State: FY 1998 (Con’t)
Foster Other/
State Name Adults Children Unknown
National Total $2,260,701,158 $2,346,800,698 $589,554
Alabama 8,976,726 17,825,019 239,701
Alaska 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 17,926
Colorado 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 2,451
Louisiana 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 36,699,762 157,342
Mississippi 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 41,088
Texas 140,771,391 44,174,708 -
Utah 22,336,531 29,836,160 -
Vermont 3,199,564 15,461,003 131,046
Virgin 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 -
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 15. Medicaid Eligibles by Full-Year, Partial Year and Months Covered and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 16. Medicaid Eligibles by Maintenance Assistance Status and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 17. Medicaid Eligibles by Basis of Eligibility and by State: FY 1998 (Con’t)
Foster Other/
State Name Adults Children Unknown
National Total 8,712,861 743,588 1,432,520
Alabama 54,419 4,673 -
Alaska 23,946 1,362 -
Arizona 160,345 6,876 -
Arkansas 82,815 4,853 314
California 1,511,094 137,334 30
Colorado 67,095 15,446 -
Connecticut 85,395 8,918 -
Delaware 30,964 609 -
District of Columbia 30,139 2,328 1,648
Florida 400,324 22,419 1
Georgia 209,091 14,342 5
Hawaii 64,575 3,193 1,864
Idaho 17,936 1,690 -
Illinois 417,213 133,417 -
Indiana 101,308 6,416 -
Iowa 80,997 4,949 159
Kansas 41,714 4,818 -
Kentucky 107,045 7,717 3
Louisiana 111,937 57 3,267
Maine 42,014 2,559 -
Maryland 124,162 16,301 -
Massachusetts 189,180 605 -
Michigan 413,701 1,546 651
Minnesota 102,477 7,925 210
Mississippi 60,329 3,526 3
Missouri 122,206 16,699 -
Montana 19,930 3,420 66
Nebraska 30,255 10,623 -
Nevada 21,207 3,677 13
New Hampshire 16,029 2,569 8
New 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 - - 459,570
Oregon 229,567 12,537 109
Pennsylvania 347,440 26,872 -
Puerto Rico - - 964,015
Rhode Island 31,162 4,623 -
South Carolina 151,444 7,168 20
South Dakota 12,618 1,277 -
Tennessee 501,663 11,545 376
Texas 455,759 18,231 -
Utah 47,504 4,046 94
Vermont 40,026 2,163 85
Virgin Islands 5,659 - -
Virginia 106,021 4,925 -
Washington 194,023 20,311 3
West Virginia 70,294 6,222 -
Wisconsin 87,424 16,158 3
Wyoming 10,636 615 3
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 18. Medicaid Eligibles Who Receive Cash Payments by Basis of Eligibility and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 20. Poverty Related Medicaid Eligibles by Basis of Eligibility and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 21. Medicaid Eligibles of Other Coverage Groups by Basis of Eligibility and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 21. Medicaid Eligibles of Other Coverage Groups by Basis of Eligibility and by State: FY 1998 (Con’t)
Foster Other/
State Name Adults Children Unknown
National Total 1,894,189 743,588 128
Alabama 20,880 4,673 -
Alaska 4,237 1,362 -
Arizona 60,842 6,876 -
Arkansas 6,080 4,853 -
California 535,889 137,334 30
Colorado 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 2
Louisiana 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 12
Mississippi 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 1
Texas 87,960 18,231 -
Utah 15,532 4,046 -
Vermont 3,558 2,163 83
Virgin 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 -
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 22. Medicaid Recipients of Medical Care by Age and by State: FY 1998
Total Ages From Ages From Ages From Ages From Ages
State Name Recipients Under 1 1 to 5 6 to 14 15 to 20 21 to 44
National Total 40,649,482 1,558,643 6,933,058 8,552,786 3,770,295 8,835,632
Alabama 527,078 27,969 111,576 111,380 43,098 93,433
Alaska 74,508 3,402 13,768 17,224 7,395 20,429
Arizona 507,668 46,561 110,446 119,360 43,213 122,185
Arkansas 424,727 16,248 77,228 93,906 48,658 88,600
California 7,082,175 138,898 1,206,917 1,534,178 753,019 1,694,033
Colorado 344,916 17,393 70,592 76,847 30,328 75,406
Connecticut 381,208 11,337 61,527 91,304 38,712 94,144
Delaware 101,436 3,611 18,017 24,015 10,825 28,552
District of Columbia 166,146 3,164 23,730 28,842 10,957 28,937
Florida 1,904,591 72,385 360,477 457,266 175,370 424,619
Georgia 1,221,978 64,474 255,052 280,857 129,665 225,920
Hawaii 184,614 10,481 26,262 34,392 16,114 48,768
Idaho 123,176 5,313 26,308 26,804 10,351 25,513
Illinois 1,363,856 89,743 260,125 302,023 125,509 327,306
Indiana 607,293 27,842 125,480 137,858 55,705 126,370
Iowa 314,936 11,800 55,265 66,549 32,200 84,025
Kansas 241,933 10,427 47,237 54,610 26,317 51,939
Kentucky 644,482 22,487 108,103 136,877 56,460 153,490
Louisiana 720,615 57,639 144,132 158,730 64,869 139,767
Maine 170,456 4,257 22,420 36,703 18,827 42,537
Maryland 561,085 23,208 102,693 133,175 50,928 128,022
Massachusetts 908,238 36,321 126,727 178,469 79,006 245,415
Michigan 1,362,890 44,555 236,433 317,589 128,690 336,515
Minnesota 538,413 17,157 93,654 136,544 66,890 121,112
Mississippi 485,767 26,367 90,526 96,034 42,668 95,579
Missouri 734,015 27,330 142,186 181,373 81,044 147,058
Montana 100,760 3,530 17,888 22,870 9,490 25,881
Nebraska 211,188 17,290 39,175 49,790 22,657 43,831
Nevada 128,144 7,618 29,865 30,159 9,140 24,882
New Hampshire 93,970 2,499 16,657 24,433 9,903 20,093
New Jersey 813,251 26,256 149,651 181,330 73,879 195,093
New Mexico 329,418 12,877 70,445 97,061 42,995 58,552
New York 3,073,241 101,784 503,121 616,071 285,914 771,013
North Carolina 1,167,988 79,785 213,089 250,288 117,711 243,112
North Dakota 62,280 2,060 10,456 13,214 5,921 13,706
Ohio 1,290,776 91,067 220,394 276,683 123,728 307,773
Oklahoma 342,475 - - - - -
Oregon 511,171 14,102 80,111 94,824 47,731 164,643
Pennsylvania 1,523,120 43,654 248,534 360,366 160,445 374,254
Puerto Rico 964,015 - - - - -
Rhode Island 153,130 4,288 25,004 34,289 13,617 37,367
South Carolina 594,962 27,168 100,788 130,359 64,024 131,514
South Dakota 89,537 6,767 18,085 21,985 9,632 16,246
Tennessee 1,843,661 33,132 191,472 284,213 152,278 410,025
Texas 2,324,810 144,065 558,876 574,293 179,470 417,767
Utah 215,801 13,992 46,317 40,620 19,690 46,322
Vermont 123,992 2,410 15,757 26,550 12,569 35,932
Virgin Islands 19,764 840 4,553 4,168 2,103 5,059
Virginia 653,236 41,524 123,243 152,702 66,403 125,801
Washington 1,413,208 25,861 167,150 235,062 107,258 197,921
West Virginia 342,668 12,093 56,474 73,311 35,841 76,345
Wisconsin 518,595 20,872 98,851 114,714 46,662 112,151
Wyoming 46,121 2,740 10,221 10,522 4,416 10,675
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 22. Medicaid Recipients of Medical Care by Age and by State: FY 1998 (Con’t)
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 23. Medicaid Recipients of Medical Care by Sex and by State: FY 1998
Total
State Name Recipients Male Female Unknown
National Total 40,649,482 14,733,230 22,376,441 3,539,811
Alabama 527,078 196,812 322,644 7,622
Alaska 74,508 29,343 44,064 1,101
Arizona 507,668 - - 507,668
Arkansas 424,727 157,095 266,608 1,024
California 7,082,175 2,755,161 3,905,643 421,371
Colorado 344,916 134,691 208,059 2,166
Connecticut 381,208 147,258 233,950 -
Delaware 101,436 40,392 60,894 150
District of Columbia 166,146 45,453 72,968 47,725
Florida 1,904,591 747,611 1,144,816 12,164
Georgia 1,221,978 466,356 748,398 7,224
Hawaii 184,614 74,800 93,280 16,534
Idaho 123,176 45,716 69,818 7,642
Illinois 1,363,856 531,086 831,848 922
Indiana 607,293 230,233 366,725 10,335
Iowa 314,936 124,286 189,435 1,215
Kansas 241,933 95,628 144,097 2,208
Kentucky 644,482 253,917 386,239 4,326
Louisiana 720,615 278,337 442,067 211
Maine 170,456 66,832 101,902 1,722
Maryland 561,085 209,354 329,915 21,816
Massachusetts 908,238 361,068 547,170 -
Michigan 1,362,890 514,653 775,234 73,003
Minnesota 538,413 219,165 313,992 5,256
Mississippi 485,767 176,349 304,322 5,096
Missouri 734,015 288,756 444,292 967
Montana 100,760 41,104 57,722 1,934
Nebraska 211,188 81,843 122,002 7,343
Nevada 128,144 48,510 74,729 4,905
New Hampshire 93,970 36,484 56,954 532
New Jersey 813,251 297,939 511,141 4,171
New Mexico 329,418 137,842 190,255 1,321
New York 3,073,241 1,201,561 1,871,645 35
North Carolina 1,167,988 443,966 724,022 -
North Dakota 62,280 23,579 37,224 1,477
Ohio 1,290,776 497,750 793,007 19
Oklahoma 342,475 - - 342,475
Oregon 511,171 219,412 281,633 10,126
Pennsylvania 1,523,120 602,675 919,434 1,011
Puerto Rico 964,015 - - 964,015
Rhode Island 153,130 57,293 93,137 2,700
South Carolina 594,962 205,046 369,944 19,972
South Dakota 89,537 35,541 51,522 2,474
Tennessee 1,843,661 603,827 836,338 403,496
Texas 2,324,810 910,233 1,414,555 22
Utah 215,801 75,205 112,713 27,883
Vermont 123,992 52,636 69,697 1,659
Virgin Islands 19,764 6,652 13,112 -
Virginia 653,236 253,854 399,382 -
Washington 1,413,208 355,421 504,765 553,022
West Virginia 342,668 132,574 187,552 22,542
Wisconsin 518,595 204,135 307,665 6,795
Wyoming 46,121 17,796 27,911 414
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 24. Medicaid Recipients of Medical Care by Race/Ethnicity and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 24. Medicaid Recipients of Medical Care by Race/Ethnicity and by State: FY 1998 (Con’t)
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 25. Medicaid Vendor Payments of Medical Care by Age and by State: FY 1998
Total Ages From Ages From Ages From Ages From Ages
State Name Payments Under 1 1 to 5 6 to 14 15 to 20 21 to 44
National Total $142,317,903,795 $4,181,702,420 $8,603,546,258 $11,154,216,158 $8,423,079,186 $35,470,454,641
Alabama 1,902,300,047 22,820,090 67,146,126 137,864,651 45,748,090 204,929,306
Alaska 330,378,398 18,512,179 26,147,375 46,203,751 32,941,090 98,122,887
Arizona 1,643,966,305 150,504,669 164,096,117 209,815,378 137,883,403 420,953,820
Arkansas 1,375,797,421 69,985,612 170,587,004 157,649,124 121,005,431 350,725,626
California 14,236,592,915 159,027,699 1,099,696,397 1,488,518,619 961,974,962 4,035,630,454
Colorado 1,439,366,499 37,548,894 91,164,647 122,067,919 114,342,985 347,447,472
Connecticut 2,420,791,474 37,449,638 105,518,904 119,339,122 81,403,500 585,828,450
Delaware 419,732,143 9,896,557 29,854,591 50,307,997 35,039,968 117,558,642
District of Columbia 731,292,552 14,424,526 46,265,668 41,119,366 39,854,823 177,387,401
Florida 5,686,844,862 207,214,109 426,888,964 428,913,238 295,567,125 1,379,641,858
Georgia 3,012,346,312 130,274,039 256,674,945 228,998,832 229,873,552 737,273,945
Hawaii 507,433,146 13,215,325 37,860,256 42,742,017 21,814,656 101,708,497
Idaho 424,512,387 14,402,838 27,319,923 30,021,260 28,677,864 120,915,949
Illinois 6,172,865,261 369,710,789 297,236,608 394,413,854 529,742,708 1,861,505,117
Indiana 2,564,005,047 86,166,403 149,572,250 165,692,398 129,727,953 638,727,347
Iowa 1,288,770,390 31,010,044 73,834,267 115,849,468 108,926,139 347,901,735
Kansas 916,323,608 31,073,118 43,044,576 65,465,347 63,337,713 262,174,644
Kentucky 2,425,288,141 39,767,195 182,568,410 257,295,529 170,759,041 571,166,507
Louisiana 2,383,508,985 168,716,699 139,107,477 164,913,424 157,908,697 611,395,836
Maine 747,027,618 7,245,901 31,281,848 77,280,919 59,429,808 193,621,824
Maryland 2,489,280,148 59,865,791 176,722,191 242,862,808 154,004,636 641,599,245
Massachusetts 4,609,360,933 122,380,919 198,016,371 288,877,243 192,799,760 1,220,375,985
Michigan 4,345,007,824 103,768,590 242,082,971 287,871,822 210,654,465 1,177,273,480
Minnesota 2,924,447,719 61,200,048 208,440,363 232,135,456 170,201,289 746,278,109
Mississippi 1,442,373,276 55,834,210 96,211,119 111,359,490 104,913,877 310,382,434
Missouri 2,569,646,129 72,341,660 163,428,780 176,213,721 140,570,168 589,861,158
Montana 361,238,668 9,996,360 18,294,856 33,302,058 29,089,839 83,126,095
Nebraska 753,162,904 41,094,566 38,081,715 60,523,842 46,255,062 177,550,894
Nevada 462,087,777 20,897,202 44,967,398 56,851,800 42,129,982 112,883,176
New Hampshire 606,004,232 5,371,744 23,485,035 62,338,125 37,075,477 147,223,561
New Jersey 4,218,822,993 62,638,007 242,197,724 282,906,145 209,346,536 1,046,385,654
New Mexico 862,144,872 31,342,287 91,463,467 143,247,036 118,582,902 173,657,451
New York 24,298,610,635 465,752,704 1,098,859,279 1,573,592,359 1,031,876,055 6,368,540,586
North Carolina 4,013,996,742 219,104,317 233,057,550 335,643,471 294,081,459 991,888,410
North Dakota 341,015,420 5,421,612 13,258,687 20,678,612 19,985,618 86,326,115
Ohio 6,120,967,557 312,960,286 219,216,802 360,697,356 306,294,127 1,501,817,268
Oklahoma 1,177,853,941 - - - - -
Oregon 1,377,514,740 15,545,694 98,235,110 162,365,217 101,366,690 393,343,003
Pennsylvania 6,080,191,710 82,817,865 357,914,294 666,490,834 421,800,531 1,287,454,674
Puerto Rico 250,000,000 - - - - -
Rhode Island 919,353,410 12,399,211 48,529,981 59,308,455 38,847,474 224,855,093
South Carolina 2,018,620,428 79,118,760 117,683,342 163,537,315 146,855,007 426,843,487
South Dakota 355,833,902 22,685,147 19,035,793 29,797,699 27,517,415 85,332,923
Tennessee 3,167,188,993 30,739,369 139,001,982 237,099,354 253,428,307 763,980,092
Texas 7,139,928,843 428,826,197 681,906,816 523,617,923 410,885,398 1,602,967,227
Utah 618,675,433 32,591,866 53,961,059 52,186,345 56,276,177 183,641,866
Vermont 351,341,290 4,365,501 15,573,132 37,715,946 30,298,880 94,383,464
Virgin Islands 10,097,973 551,923 1,032,869 827,904 781,957 2,812,008
Virginia 2,118,202,866 114,024,927 126,666,594 147,224,727 122,588,008 552,938,255
Washington 2,044,234,831 35,769,579 154,415,362 166,326,790 124,864,608 521,145,517
West Virginia 1,243,150,526 17,099,015 59,891,308 92,021,543 87,059,121 279,277,299
Wisconsin 2,206,398,750 28,368,530 142,851,338 187,435,648 114,819,943 453,779,746
Wyoming 192,004,819 7,862,209 13,196,617 14,686,901 11,868,910 57,913,049
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 25. Medicaid Vendor Payments of Medical Care by Age and by State: FY 1998 (Con’t)
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 26. Medicaid Vendor Payments of Medical Care by Sex and by State: FY 1998
Total
State Name Payments Male Female Unknown
National Total $142,317,903,795 $54,505,135,169 $84,263,344,977 $3,549,423,630
Alabama 1,902,300,047 428,934,012 901,448,396 571,917,639
Alaska 330,378,398 143,251,512 186,841,052 285,834
Arizona 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 8,415,698,843 136,572,213
Colorado 1,439,366,499 568,161,269 828,441,298 42,763,932
Connecticut 2,420,791,474 909,770,244 1,511,021,230 -
Delaware 419,732,143 176,105,564 243,128,737 497,842
District of Columbia 731,292,552 290,532,181 373,738,633 67,021,738
Florida 5,686,844,862 2,186,073,956 3,480,296,751 20,474,155
Georgia 3,012,346,312 1,024,630,832 1,966,718,337 20,997,143
Hawaii 507,433,146 205,541,343 258,176,979 43,714,824
Idaho 424,512,387 161,041,265 250,861,633 12,609,489
Illinois 6,172,865,261 2,683,512,469 3,489,312,513 40,279
Indiana 2,564,005,047 996,709,219 1,558,922,286 8,373,542
Iowa 1,288,770,390 524,987,594 761,274,005 2,508,791
Kansas 916,323,608 370,328,914 541,562,987 4,431,707
Kentucky 2,425,288,141 908,938,450 1,510,527,921 5,821,770
Louisiana 2,383,508,985 917,846,494 1,465,177,548 484,942
Maine 747,027,618 308,154,135 435,970,254 2,903,229
Maryland 2,489,280,148 1,003,696,022 1,458,030,690 27,553,436
Massachusetts 4,609,360,933 1,775,376,600 2,833,984,333 -
Michigan 4,345,007,824 1,536,838,141 2,436,083,617 372,086,066
Minnesota 2,924,447,719 1,199,637,751 1,716,317,648 8,492,320
Mississippi 1,442,373,276 495,820,726 945,154,295 1,398,255
Missouri 2,569,646,129 969,602,591 1,599,417,760 625,778
Montana 361,238,668 137,459,729 222,222,218 1,556,721
Nebraska 753,162,904 277,327,336 465,517,769 10,317,800
Nevada 462,087,777 187,811,985 254,846,778 19,429,014
New Hampshire 606,004,232 233,111,156 372,103,000 790,076
New Jersey 4,218,822,993 1,514,612,537 2,696,699,305 7,511,151
New Mexico 862,144,872 354,666,166 502,159,764 5,318,942
New York 24,298,610,635 10,246,955,529 14,050,848,812 806,292
North Carolina 4,013,996,742 1,537,982,121 2,476,014,620 -
North Dakota 341,015,420 138,869,223 200,950,010 1,196,187
Ohio 6,120,967,557 2,219,780,890 3,891,587,868 9,598,794
Oklahoma 1,177,853,941 - - 1,177,853,941
Oregon 1,377,514,740 560,534,420 810,785,923 6,194,397
Pennsylvania 6,080,191,710 2,244,847,299 3,833,695,224 1,649,187
Puerto Rico 250,000,000 - - 250,000,000
Rhode Island 919,353,410 367,807,751 547,415,973 4,129,686
South Carolina 2,018,620,428 691,382,912 1,072,190,466 255,047,050
South Dakota 355,833,902 144,940,742 209,534,188 1,358,972
Tennessee 3,167,188,993 1,050,449,413 1,719,918,660 396,820,920
Texas 7,139,928,843 2,628,419,621 4,511,436,002 73,218
Utah 618,675,433 248,855,565 322,010,723 47,809,145
Vermont 351,341,290 141,585,986 209,045,938 709,366
Virgin 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 1,250,021,549 131,485,160
West Virginia 1,243,150,526 431,380,707 695,486,096 116,283,723
Wisconsin 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
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 27. Medicaid Vendor Payments of Medical Care by Race/Ethnicity and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 27. Medicaid Vendor Payments of Medical Care by Race/Ethnicity and by State: FY 1998 (Con’t)
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 28. Medicaid Eligibles of Medical Care by Age and by State: FY 1998
Total Ages From Ages From Ages From Ages From Ages
State Name Eligibles Under 1 1 to 5 6 to 14 15 to 20 21 to 44
National Total 41,361,532 2,014,962 7,205,401 9,131,328 3,979,331 9,305,563
Alabama 628,220 33,381 131,578 147,209 52,664 104,960
Alaska 87,873 3,974 16,913 22,459 9,082 23,394
Arizona 649,302 60,354 133,626 161,127 57,260 158,158
Arkansas 426,080 17,345 74,684 94,746 49,952 88,040
California 6,191,269 208,178 1,103,640 1,452,046 674,192 1,519,166
Colorado 346,928 20,123 70,573 79,258 30,454 76,396
Connecticut 402,547 13,284 63,646 95,206 41,559 99,390
Delaware 105,153 4,017 18,666 24,597 11,233 29,434
District of Columbia 138,722 3,743 25,888 33,624 13,270 34,185
Florida 2,040,541 84,616 373,694 484,949 194,122 468,339
Georgia 1,223,439 70,643 254,844 288,518 132,840 224,595
Hawaii 182,460 10,481 26,262 34,392 16,114 48,768
Idaho 116,718 6,340 27,952 29,758 10,539 23,646
Illinois 1,784,159 122,734 354,562 402,627 165,950 446,101
Indiana 610,146 33,629 129,822 147,188 61,334 121,762
Iowa 321,119 13,467 56,116 69,327 33,328 84,648
Kansas 246,598 11,944 48,477 57,433 26,869 51,149
Kentucky 653,553 24,325 110,623 143,371 57,300 151,955
Louisiana 723,864 56,922 139,567 167,148 66,428 140,092
Maine 195,839 5,469 25,250 42,943 22,027 52,479
Maryland 603,562 27,373 109,740 143,818 57,635 151,227
Massachusetts 953,469 231,669 123,853 149,432 59,606 198,095
Michigan 1,354,718 55,629 246,010 340,091 139,279 338,950
Minnesota 557,232 19,738 98,267 144,380 70,801 125,605
Mississippi 526,604 29,728 100,482 120,046 48,018 94,316
Missouri 772,622 32,650 148,577 198,866 87,406 149,716
Montana 93,298 4,200 16,669 21,898 8,699 23,703
Nebraska 210,261 20,971 38,945 49,960 22,187 43,716
Nevada 130,662 9,005 29,982 32,428 9,332 24,927
New Hampshire 98,340 3,012 18,259 27,046 10,544 20,723
New Jersey 857,898 30,492 154,605 193,382 81,961 198,073
New Mexico 339,527 15,914 70,406 100,440 44,618 60,024
New York 3,500,292 124,586 524,368 656,138 316,777 940,604
North Carolina 1,201,681 88,252 211,122 255,365 119,267 248,009
North Dakota 62,115 2,174 10,539 13,859 6,085 13,805
Ohio 1,402,364 58,716 253,059 335,401 148,880 337,620
Oklahoma 459,570 - - - - -
Oregon 537,465 19,886 83,913 100,302 51,793 175,945
Pennsylvania 1,720,000 54,408 261,002 386,151 181,316 457,350
Puerto Rico 964,015 - - - - -
Rhode Island 148,797 4,717 24,666 34,432 13,936 36,881
South Carolina 656,263 30,163 112,674 152,085 75,061 158,586
South Dakota 83,111 6,417 17,077 20,752 8,679 14,791
Tennessee 1,454,799 35,630 192,922 286,070 154,441 416,376
Texas 2,680,583 162,406 627,209 680,891 219,455 485,901
Utah 198,730 15,377 46,724 43,188 21,001 47,592
Vermont 131,639 2,840 16,871 28,804 13,767 38,585
Virgin Islands 19,914 - - - - -
Virginia 689,571 46,016 128,645 168,243 69,331 126,533
Washington 915,214 33,407 175,278 249,653 114,589 211,109
West Virginia 373,090 15,738 64,968 85,709 42,926 90,418
Wisconsin 538,229 25,868 100,815 122,134 50,547 117,638
Wyoming 51,367 3,011 11,371 12,438 4,877 12,088
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 28. Medicaid Eligibles of Medical Care by Age and by State: FY 1998 (Con’t)
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 29. Medicaid Eligibles of Medical Care by Sex and by State: FY 1998
Total
State Name Eligibles Male Female Unknown
National Total 41,361,532 16,061,565 23,757,344 1,542,623
Alabama 628,220 246,111 373,496 8,613
Alaska 87,873 37,351 50,522 -
Arizona 649,302 254,985 394,317 -
Arkansas 426,080 158,087 267,867 126
California 6,191,269 2,549,535 3,641,730 4
Colorado 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 83,970 160
Florida 2,040,541 813,906 1,226,635 -
Georgia 1,223,439 472,711 750,722 6
Hawaii 182,460 75,609 94,239 12,612
Idaho 116,718 47,979 68,733 6
Illinois 1,784,159 734,788 1,049,370 1
Indiana 610,146 240,536 369,610 -
Iowa 321,119 128,417 192,702 -
Kansas 246,598 99,884 146,688 26
Kentucky 653,553 265,594 387,906 53
Louisiana 723,864 286,802 436,987 75
Maine 195,839 81,408 114,382 49
Maryland 603,562 230,580 372,969 13
Massachusetts 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 1
Missouri 772,622 311,009 461,612 1
Montana 93,298 39,042 54,256 -
Nebraska 210,261 84,200 121,169 4,892
Nevada 130,662 52,910 77,583 169
New Hampshire 98,340 39,193 59,112 35
New Jersey 857,898 322,247 535,634 17
New Mexico 339,527 144,024 195,499 4
New York 3,500,292 1,405,012 2,025,906 69,374
North Carolina 1,201,681 462,274 739,407 -
North Dakota 62,115 24,403 37,687 25
Ohio 1,402,364 557,553 844,807 4
Oklahoma 459,570 - - 459,570
Oregon 537,465 236,268 301,187 10
Pennsylvania 1,720,000 688,234 1,031,766 -
Puerto Rico 964,015 - - 964,015
Rhode Island 148,797 57,441 91,354 2
South Carolina 656,263 233,707 422,372 184
South Dakota 83,111 34,135 48,961 15
Tennessee 1,454,799 610,842 843,949 8
Texas 2,680,583 1,075,529 1,605,019 35
Utah 198,730 79,772 117,584 1,374
Vermont 131,639 57,749 73,890 -
Virgin Islands 19,914 - - 19,914
Virginia 689,571 274,850 414,721 -
Washington 915,214 381,162 533,998 54
West Virginia 373,090 158,690 213,237 1,163
Wisconsin 538,229 217,485 320,744 -
Wyoming 51,367 20,880 30,474 13
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 30. Medicaid Eligibles of Medical Care by Race/Ethnicity and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 30. Medicaid Eligibles of Medical Care by Race/Ethnicity and by State: FY 1998 (Con’t)
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 31. Medicaid Inpatient Hospital Recipients, Discharges, and Days of Care by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 32. Medicaid Long-Term Care Recipients and Days of Care by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 33. Medicaid Eligibles and Premium Payments for Capitation Plans and PCCM by State:
FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 33. Medicaid Eligibles and Premium Payments for Capitation Plans and PCCM by State:
FY 1998 (Con’t)
PCCM Unduplicated
State Name Eligibles Payments Enrolled Eligibles
National Total 4,569,691 $18,007,746 21,813,135
Alabama 151,910 3,830,786 362,272
Alaska - - -
Arizona - - 655,571
Arkansas 229,092 5,405,229 318,625
California 52,402 6,943,824 5,044,803
Colorado - - 308,035
Connecticut - - 271,411
Delaware - - 85,147
District of Columbia 8,403 1,003,654 66,873
Florida 835,207 17,980,527 1,411,107
Georgia 877,799 21,797,455 906,717
Hawaii - - 131,761
Idaho 45,745 1,389,468 45,745
Illinois 16,414 710,585 286,520
Indiana 241,557 4,936,728 477,480
Iowa 80,287 1,001,800 247,483
Kansas 118,281 1,618,536 152,288
Kentucky - - 194,314
Louisiana 40,729 - 40,729
Maine - - 9,345
Maryland - - 451,757
Massachusetts 621,146 9,288,830 720,576
Michigan - - 747,895
Minnesota - - 318,088
Mississippi - - 17,654
Missouri - - 333,096
Montana 57,957 1,460,907 88,872
Nebraska 17,466 - 110,606
Nevada 26,047 4,009,342 55,886
New Hampshire - - 11,097
New Jersey - - 542,826
New Mexico 101,119 754,694 272,499
New York 51,530 20,295,994 920,302
North Carolina 617,827 13,163,095 697,376
North Dakota 32,099 476,322 32,525
Ohio - - 452,511
Oklahoma 71,297 - 154,270
Oregon 11,112 231,444 481,050
Pennsylvania - - 897,853
Puerto Rico - - -
Rhode Island - - 94,563
South Carolina - - 17,186
South Dakota - - -
Tennessee - - 1,436,197
Texas 153,672 - 437,898
Utah - - 144,199
Vermont - - 69,440
Virgin Islands - - -
Virginia 110,559 1,697,486 259,808
Washington - - 613,060
West Virginia - - 131,349
Wisconsin 34 11,040 286,470
Wyoming - - -
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 34. Prepaid Health Care Medicaid Recipients by Maintenance Assistance Status and by State:
FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 35. Prepaid Health Care Medicaid Recipients by Basis of Eligibility and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 36. PCCM Medicaid Recipients by Maintenance Assistance Status and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 37. PCCM Medicaid Recipients BY Basis OF Eligibility and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 38. Prepaid Health Care Medicaid Recipients by Age and by State: FY 1998
Total Ages From Ages From Ages From Ages From Ages
State Name Recipients Under 1 1 to 5 6 to 14 15 to 20 21 to 44
National Total 20,202,887 586,976 3,726,967 4,846,633 2,005,878 4,409,601
Alabama 344,907 - - - - -
Alaska - - - - - -
Arizona 368,344 - - - - -
Arkansas 244,768 13,179 48,721 59,642 21,325 46,099
California 6,022,536 56,292 1,108,708 1,464,620 682,263 1,447,924
Colorado 316,060 17,262 67,679 74,094 26,941 66,164
Connecticut 271,411 10,871 60,801 89,814 36,608 67,780
Delaware 85,239 3,444 17,309 22,468 9,761 25,181
District of Columbia 100,867 2,641 19,421 18,281 5,993 13,089
Florida 791,752 25,307 186,752 255,561 82,666 173,104
Georgia 78,463 2,229 19,706 26,211 7,937 17,074
Hawaii 144,744 - - - - -
Idaho - - - - - -
Illinois 142,429 10,484 40,833 43,205 14,486 31,492
Indiana 271,005 12,142 48,975 55,463 21,345 50,822
Iowa 246,582 11,271 51,530 63,471 28,943 72,874
Kansas 44,003 3,404 13,485 13,873 5,066 7,758
Kentucky 194,164 9,272 39,495 47,868 17,430 46,322
Louisiana - - - - - -
Maine 9,324 384 2,140 3,127 1,285 2,236
Maryland 449,825 22,652 99,718 130,238 46,561 106,271
Massachusetts 768,831 42,031 137,135 186,284 83,429 238,823
Michigan 758,185 27,295 157,771 223,507 78,367 198,428
Minnesota 318,854 12,140 66,172 98,887 46,762 60,530
Mississippi 17,628 1,137 3,869 4,417 1,681 3,684
Missouri 336,057 15,942 91,094 118,237 47,507 60,498
Montana 96,701 3,460 17,369 22,449 9,091 24,731
Nebraska 159,614 - - - - -
Nevada 55,923 5,115 16,955 17,228 4,340 10,263
New Hampshire 11,176 293 3,420 4,307 1,118 1,946
New Jersey 545,380 23,743 135,270 157,051 52,252 121,812
New Mexico 263,256 12,298 63,597 90,410 37,956 44,362
New York 884,443 25,673 208,860 255,227 91,352 243,955
North Carolina 220,700 27,921 72,570 84,209 24,303 10,149
North Dakota 1,549 60 433 515 159 363
Ohio 453,265 40,450 115,360 138,417 47,374 105,364
Oklahoma - - - - - -
Oregon 481,498 13,741 78,629 91,859 45,563 158,953
Pennsylvania 902,896 26,835 167,058 245,379 98,823 236,745
Puerto Rico - - - - - -
Rhode Island 96,178 4,132 22,851 30,097 10,917 25,675
South Carolina 17,195 1,385 5,695 6,140 1,265 1,734
South Dakota 83,998 6,678 17,267 21,408 8,925 14,926
Tennessee 1,764,279 33,019 190,961 282,970 149,889 402,126
Texas - - - - - -
Utah 170,319 12,991 43,238 32,720 12,441 29,518
Vermont 69,682 1,451 10,400 17,383 7,553 25,745
Virgin Islands - - - - - -
Virginia 159,392 5,828 38,319 53,444 20,703 32,357
Washington 1,146,180 23,579 152,663 207,568 86,439 123,579
West Virginia 52 - - - - -
Wisconsin 293,233 18,945 84,738 88,584 29,059 59,145
Wyoming - - - - - -
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 38. Prepaid Health Care Medicaid Recipients by Age and by State: FY 1998 (Con’t)
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 39. Prepaid Health Care Medicaid Recipients by Sex and by State: FY 1998
Total
State Name Recipients Male Female Unknown
National Total 20,202,887 7,517,298 10,692,036 1,993,553
Alabama 344,907 - - 344,907
Alaska - - - -
Arizona 368,344 - - 368,344
Arkansas 244,768 97,329 147,370 69
California 6,022,536 2,557,879 3,458,672 5,985
Colorado 316,060 126,797 188,593 670
Connecticut 271,411 106,677 164,734 -
Delaware 85,239 34,763 50,469 7
District of Columbia 100,867 24,161 36,541 40,165
Florida 791,752 327,441 463,397 914
Georgia 78,463 29,947 48,492 24
Hawaii 144,744 - - 144,744
Idaho - - - -
Illinois 142,429 53,960 88,469 -
Indiana 271,005 101,216 169,207 582
Iowa 246,582 103,230 143,285 67
Kansas 44,003 18,121 25,844 38
Kentucky 194,164 77,712 116,183 269
Louisiana - - - -
Maine 9,324 3,703 5,618 3
Maryland 449,825 182,425 265,394 2,006
Massachusetts 768,831 318,398 450,433 -
Michigan 758,185 309,665 447,232 1,288
Minnesota 318,854 129,936 188,448 470
Mississippi 17,628 6,847 10,777 4
Missouri 336,057 136,846 199,198 13
Montana 96,701 39,763 55,389 1,549
Nebraska 159,614 - - 159,614
Nevada 55,923 21,770 33,168 985
New Hampshire 11,176 4,657 6,516 3
New Jersey 545,380 201,674 343,276 430
New Mexico 263,256 114,919 148,119 218
New 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 1,941
Pennsylvania 902,896 358,234 544,610 52
Puerto Rico - - - -
Rhode Island 96,178 36,784 59,012 382
South Carolina 17,195 7,733 9,452 10
South Dakota 83,998 33,826 48,327 1,845
Tennessee 1,764,279 596,030 821,259 346,990
Texas - - - -
Utah 170,319 61,485 82,572 26,262
Vermont 69,682 30,965 38,487 230
Virgin Islands - - - -
Virginia 159,392 62,955 96,437 -
Washington 1,146,180 260,243 349,451 536,486
West Virginia 52 - - 52
Wisconsin 293,233 114,613 172,685 5,935
Wyoming - - - -
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 40. Prepaid Health Care Medicaid Recipients by Race/Ethnicity and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 40. Prepaid Health Care Medicaid Recipients by Race/Ethnicity and by State: FY 1998 (Con’t)
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Total Ages From Ages From Ages From Ages From Ages
State Name Recipients Under 1 1 to 5 6 to 14 15 to 20 21 to 44
National Total 4,066,440 208,733 990,902 1,133,983 395,065 710,818
Alabama 151,910 - - - - -
Alaska - - - - - -
Arizona - - - - - -
Arkansas 243,266 10,847 67,949 79,230 29,061 42,828
California 54,471 670 10,010 15,117 5,858 15,607
Colorado 48,907 - - - - -
Connecticut - - - - - -
Delaware - - - - - -
District of Columbia 8,623 2 2,425 2,926 742 1,992
Florida 841,304 35,739 217,755 251,721 78,934 164,192
Georgia 879,554 56,272 237,384 259,590 95,548 125,516
Hawaii - - - - - -
Idaho 50,665 2,123 15,103 14,634 3,906 8,231
Illinois 16,414 250 4,741 8,802 2,581 40
Indiana 242,844 16,216 75,121 80,552 27,026 40,561
Iowa 80,428 3,173 21,332 25,611 8,366 20,645
Kansas 123,902 5,434 31,823 36,226 14,274 25,934
Kentucky - - - - - -
Louisiana - - - - - -
Maine - - - - - -
Maryland - - - - - -
Massachusetts 264,035 10,836 57,169 67,929 22,604 72,465
Michigan 53,733 - - - - -
Minnesota - - - - - -
Mississippi - - - - - -
Missouri - - - - - -
Montana 59,578 2,789 14,733 17,575 6,471 14,161
Nebraska 27,577 - - - - -
Nevada 28,638 401 10,149 10,258 2,103 4,636
New Hampshire - - - - - -
New Jersey - - - - - -
New Mexico 103,867 630 29,335 39,046 9,883 16,651
New York 804 - 104 575 123 2
North Carolina 591,740 55,325 143,750 169,050 62,918 116,133
North Dakota 32,566 1,626 8,416 10,298 3,943 7,453
Ohio - - - - - -
Oklahoma - - - - - -
Oregon 11,163 103 1,189 1,961 823 2,105
Pennsylvania - - - - - -
Puerto Rico - - - - - -
Rhode Island - - - - - -
South Carolina - - - - - -
South Dakota 39,858 4,310 11,230 11,337 4,446 7,010
Tennessee - - - - - -
Texas - - - - - -
Utah - - - - - -
Vermont - - - - - -
Virgin Islands - - - - - -
Virginia 110,559 1,987 31,177 31,535 15,451 24,648
Washington - - - - - -
West Virginia - - - - - -
Wisconsin 34 - 7 10 4 8
Wyoming - - - - - -
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 41. PCCM Medicaid Recipients by Age and by State: FY 1998 (Con’t)
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Total
State Name Recipients Male Female Unknown
National Total 4,066,440 1,608,714 2,165,338 292,388
Alabama 151,910 - - 151,910
Alaska - - - -
Arizona - - - -
Arkansas 243,266 102,544 140,652 70
California 54,471 22,083 31,140 1,248
Colorado 48,907 - 48,907
Connecticut - - - -
Delaware - - - -
District of Columbia 8,623 3,026 5,377 220
Florida 841,304 369,971 466,367 4,966
Georgia 879,554 385,892 493,361 301
Hawaii - - - -
Idaho 50,665 21,294 28,702 669
Illinois 16,414 8,198 8,216 -
Indiana 242,844 100,600 141,339 905
Iowa 80,428 32,228 48,200 -
Kansas 123,902 51,985 71,238 679
Kentucky - - - -
Louisiana - - - -
Maine - - - -
Maryland - - - -
Massachusetts 264,035 104,035 160,000 -
Michigan 53,733 - - 53,733
Minnesota - - - -
Mississippi - - - -
Missouri - - - -
Montana 59,578 25,894 33,502 182
Nebraska 27,577 - - 27,577
Nevada 28,638 11,597 16,805 236
New Hampshire - - - -
New Jersey - - - -
New Mexico 103,867 46,250 57,616 1
New York 804 394 410 -
North Carolina 591,740 244,990 346,750 -
North Dakota 32,566 12,534 19,717 315
Ohio - - - -
Oklahoma - - - -
Oregon 11,163 4,298 6,829 36
Pennsylvania - - - -
Puerto Rico - - - -
Rhode Island - - - -
South Carolina - - - -
South Dakota 39,858 16,338 23,087 433
Tennessee - - - -
Texas - - - -
Utah - - - -
Vermont - - - -
Virgin Islands - - - -
Virginia 110,559 44,545 66,014 -
Washington - - - -
West Virginia - - - -
Wisconsin 34 18 16 -
Wyoming - - - -
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 43. PCCM Medicaid Recipients by Race/Ethnicity and by State: FY 1998 (Con’t)
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 44 Medicaid Medical Vendor Payments for Prepaid Health Care Medicaid Recipients
by Maintenance Assistance Status and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 45. Medicaid Medical Vendor Payments for Prepaid Health Care by Basis of Eligibility and by State:
FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 46. Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Age
and by State: FY 1998
Total Ages From Ages From Ages From Ages From Ages
State Name Payments Under 1 1 to 5 6 to 14 15 to 20 21 to 44
National Total $19,296,223,487 $663,270,071 $2,571,271,634 $3,072,843,689 $1,713,753,844 $5,178,849,381
Alabama 288,972,436 - - - - -
Alaska - - - - - -
Arizona 1,431,418,497 - - - - -
Arkansas 4,359,975 165,478 956,290 884,160 305,391 957,597
California 2,867,713,795 13,209,454 515,347,850 766,649,821 298,185,030 680,351,715
Colorado 238,585,930 5,851,482 37,932,814 53,024,495 23,780,778 54,695,564
Connecticut 377,212,893 27,836,189 84,970,120 83,856,221 50,253,265 119,608,032
Delaware 122,048,974 7,444,938 14,473,261 18,190,902 12,883,886 45,342,960
District of Columbia 98,238,002 3,743,655 18,013,512 10,816,349 3,944,788 8,037,555
Florida 701,322,837 20,416,040 97,246,070 104,294,029 57,717,411 221,554,555
Georgia 57,871,451 1,574,558 9,292,110 9,452,878 6,107,675 20,822,290
Hawaii 213,612,580 - - - - -
Idaho - - - - - -
Illinois 241,278,075 19,435,778 62,557,061 36,908,645 24,814,153 89,640,324
Indiana 167,977,207 11,690,185 31,209,886 25,648,505 14,574,725 40,060,244
Iowa 107,189,198 3,540,487 17,655,792 21,208,108 14,551,222 40,819,219
Kansas 17,201,600 3,358,384 4,260,169 1,694,930 3,159,391 4,504,848
Kentucky 311,526,039 10,065,260 53,935,311 74,499,203 27,021,626 80,383,927
Louisiana - - - - - -
Maine 4,237,958 452,074 1,004,906 966,790 622,067 1,058,095
Maryland 851,988,946 35,760,475 98,755,759 111,236,613 72,296,988 289,111,724
Massachusetts 477,932,296 11,606,162 68,653,269 99,211,663 40,656,305 153,404,081
Michigan 823,728,725 33,633,121 91,911,136 78,169,032 61,786,742 328,737,518
Minnesota 483,228,011 31,205,609 119,766,946 76,326,241 51,642,893 92,932,142
Mississippi 22,152,325 5,762,963 3,021,071 1,412,028 1,562,621 4,537,547
Missouri 277,652,554 28,275,079 85,689,665 73,232,376 35,930,476 50,514,480
Montana 53,600,495 123,307 1,051,688 17,091,288 14,450,375 12,081,374
Nebraska 72,980,602 - - - - -
Nevada 32,332,069 3,891,345 6,014,421 4,438,112 4,666,812 11,939,029
New Hampshire 12,128,535 155,925 3,796,335 4,988,385 1,151,685 1,949,400
New Jersey 617,591,322 47,468,930 149,390,573 107,664,770 65,997,142 206,213,047
New Mexico 372,647,285 14,531,960 49,072,446 89,770,157 68,706,455 93,634,772
New York 1,638,382,814 54,914,302 190,982,711 182,006,374 94,094,647 593,575,857
North Carolina 85,665,363 9,640,707 12,397,979 32,014,625 19,230,997 9,976,490
North Dakota 1,319,356 53,367 300,097 260,043 222,968 445,350
Ohio 494,845,239 116,389,364 62,355,148 76,664,074 62,884,487 161,461,589
Oklahoma - - - - - -
Oregon 665,872,224 11,991,839 76,050,828 99,495,632 58,776,145 233,035,657
Pennsylvania 1,801,084,202 33,729,565 221,515,046 366,521,522 190,539,526 549,111,806
Puerto Rico - - - - - -
Rhode Island 114,870,881 9,353,107 26,101,164 16,604,258 15,284,178 42,375,112
South Carolina 17,172,147 569,572 1,495,569 1,188,910 509,547 1,359,628
South Dakota 3,797,234 276,666 897,180 1,126,800 404,718 488,728
Tennessee 1,859,127,110 30,658,983 132,596,542 204,177,921 193,056,223 587,144,169
Texas - - - - - -
Utah 147,730,653 10,553,967 18,670,383 16,976,877 7,198,759 34,292,229
Vermont 53,890,106 1,725,324 6,337,145 7,320,476 5,831,121 21,520,117
Virgin Islands - - - - - -
Virginia 186,255,441 9,030,622 33,615,628 30,826,600 24,253,318 57,608,532
Washington 529,020,076 22,773,492 84,295,694 75,975,889 48,454,641 162,010,235
West Virginia 26,573,906 - - - - -
Wisconsin 321,886,123 10,410,356 77,682,059 90,047,987 36,242,667 71,551,843
Wyoming - - - - - -
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 46. Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Age
and by State: FY 1998 (Con’t)
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 47. Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Sex
and by State: FY 1998
Total
State Name Payments Male Female Unknown
National Total $19,296,223,487 $6,371,960,186 $10,460,328,903 $2,463,934,398
Alabama 288,972,436 - - 288,972,436
Alaska - - - -
Arizona 1,431,418,497 - - 1,431,418,497
Arkansas 4,359,975 1,848,704 2,511,984 (713)
California 2,867,713,795 1,188,412,224 1,678,818,709 482,862
Colorado 238,585,930 98,538,857 133,558,184 6,488,889
Connecticut 377,212,893 125,688,730 251,524,163 -
Delaware 122,048,974 46,701,836 75,344,650 2,488
District of Columbia 98,238,002 20,235,744 25,051,743 52,950,515
Florida 701,322,837 256,733,902 444,264,447 324,488
Georgia 57,871,451 16,504,588 41,354,442 12,421
Hawaii 213,612,580 - - 213,612,580
Idaho - - - -
Illinois 241,278,075 71,473,133 169,804,676 266
Indiana 167,977,207 56,394,499 111,493,455 89,253
Iowa 107,189,198 38,730,632 68,457,620 946
Kansas 17,201,600 5,294,188 11,892,866 14,546
Kentucky 311,526,039 132,639,343 178,638,239 248,457
Louisiana - - - -
Maine 4,237,958 1,599,611 2,636,996 1,351
Maryland 851,988,946 328,225,186 522,678,351 1,085,409
Massachusetts 477,932,296 191,883,979 286,048,317 -
Michigan 823,728,725 286,073,576 526,353,707 11,301,442
Minnesota 483,228,011 177,115,708 305,904,004 208,299
Mississippi 22,152,325 8,252,448 13,882,598 17,279
Missouri 277,652,554 110,451,332 167,199,462 1,760
Montana 53,600,495 25,061,257 28,385,587 153,651
Nebraska 72,980,602 - - 72,980,602
Nevada 32,332,069 8,159,170 23,625,902 546,997
New Hampshire 12,128,535 5,147,550 6,978,285 2,700
New Jersey 617,591,322 186,936,733 430,388,230 266,359
New Mexico 372,647,285 154,292,150 218,178,420 176,715
New York 1,638,382,814 626,743,732 1,011,639,074 9
North 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 2,415,072
Oklahoma - - - -
Oregon 665,872,224 270,264,196 394,817,726 790,302
Pennsylvania 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 1,787,966
South Carolina 17,172,147 4,484,249 12,686,153 1,745
South Dakota 3,797,234 1,640,282 2,117,756 39,196
Tennessee 1,859,127,110 648,037,009 1,023,539,781 187,550,320
Texas - - - -
Utah 147,730,653 46,210,088 61,515,574 40,004,991
Vermont 53,890,106 21,314,625 32,451,496 123,985
Virgin Islands - - - -
Virginia 186,255,441 62,219,339 124,036,102 -
Washington 529,020,076 113,052,671 294,131,756 121,835,649
West Virginia 26,573,906 - - 26,573,906
Wisconsin 321,886,123 119,895,624 200,379,589 1,610,910
Wyoming - - - -
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 48. Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Race/Ethnicity
and by State: FY 1998
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Table 48. Medicaid Vendor Payments for Prepaid Health Care Medicaid Recipients by Race/Ethnicity
and by State: FY 1998 (Con’t)
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Readers should be cautioned that discrepancies in the 2082 data can extend beyond HCFA’s caveats and data limitations.
Appendix C:
Medicaid Rebate Law
(1) In general
In order for payment to be available under section 1396b(a) of this title for covered outpatient drugs of a
manufacturer, the manufacturer must have entered into and have in effect a rebate agreement described in
subsection (b) of this section with the Secretary, on behalf of States (except that, the Secretary may authorize a
State to enter directly into agreements with a manufacturer), and must meet the requirements of paragraph
(5)(with respect to drugs purchased by a covered entity on or after the first day of the first month that begins after
November 4,1992) and paragraph (6). Any agreement between a State and a manufacturer prior to April 1, 1991,
shall be deemed to have been entered into on January 1, 1991, and payment to such manufacturer shall be
retroactively calculated as if the agreement between the manufacturer and the State had been entered into on
January 1,1991. If a manufacturer has not entered into such an agreement before March 1, 1991, such an
agreement, subsequently entered into, shall not be effective until the first day of the calendar quarter that begins
more than 60 days after the date the agreement is entered into.
(3) Authorizing payment for drugs not covered under rebate agreements
Paragraph (1), and section 1396b(i)(10)(A) of this title, shall not apply to the dispensing of a single source drug or
innovator multiple source drug if (A)(i) the State has made a determination that the availability of the drug is
essential to the health of beneficiaries under the State plan for medical assistance; (ii) such drug has been given
a rating of 1-A by the Food and Drug Administration; and (iii)(I) the physician has obtained approval for use of
the drug in advance of its dispensing in accordance with a prior authorization program described in subsection
(d) of this section, or (II) the Secretary has reviewed and approved the State’s determination under
subparagraph (A); or (B) the Secretary determines that in the first calendar quarter of 1991, there were
extenuating circumstances.
(6) Requirements relating to master agreements for drugs procured by Department of Veterans Affairs and certain
other Federal agencies
(A) In general
A manufacturer meets the requirements of this paragraph if the manufacturer complies with the provisions
of section 8126 of title 38, including the requirement of entering into a master agreement with the
Secretary of Veterans Affairs under such section.
(A) In general
A rebate agreement under this subsection shall require the manufacturer to provide, to each State plan
approved under this subchapter, a rebate for a rebate period in an amount specified in subsection (C) of
this section for covered outpatient drugs of the manufacturer dispensed after December 31, 1990, for
which payment was made under the State plan for such period. Such rebate shall be paid by the
manufacturer not later than 30 days after the date of receipt of the information described in paragraph (2)
for the period involved.
(B) Audits
A manufacturer may audit the information provided (or required to be provided) under subparagraph (A).
Adjustments to rebates shall be made to the extent that information indicates that utilization was greater
or less than the amount previously specified.
(A) In general
Each manufacturer with an agreement in effect under this section shall report to the Secretary - (i) not
later than 30 days after the last day of each rebate period under the agreement (beginning on or after
January 1, 1991), on the average manufacturer price (as defined in subsection (k)(1) of this section) and,
(for single source drugs and innovator multiple source drugs), the manufacturer’s best price (as defined in
subsection (C)(2)(B) of this section) for covered outpatient drugs for the rebate period under the
agreement, and (ii) not later than 30 days after the date of entering into an agreement under this section
on the average manufacturer price (as defined in subsection (k)(1) of this section) as of October 1, 1990
(FOOTNOTE 1) for each of the manufacturer’s covered outpatient drugs.
(FOOTNOTE 1) So in original. Probably should be followed by a comma.
(C) Penalties
(i) Failure to provide timely information
In the case of a manufacturer with an agreement under this section that fails to provide information
required under subparagraph (A) on a timely basis, the amount of the penalty shall be increased by
$10,000 for each day in which such information has not been provided and such amount shall be paid to
the Treasury, and, if such information is not reported within 90 days of the deadline imposed, the
agreement shall be suspended for services furnished after the end of such 90-day period and until the
date such information is reported (but in no case shall such suspension be for a period of less than 30
days).
(A) In general
A rebate agreement shall be effective for an initial period of not less than 1 year and shall be
automatically renewed for a period of not less than one year unless terminated under subparagraph (B).
(B) Termination
(i) By the Secretary
The Secretary may provide for termination of a rebate agreement for violation of the requirements of the
agreement or other good cause shown. Such termination shall not be effective earlier than 60 days after
the date of notice of such termination. The Secretary shall provide, upon request, a manufacturer with a
hearing concerning such a termination, but such hearing shall not delay the effective date of the
termination.
(ii) By a manufacturer
A manufacturer may terminate a rebate agreement under this section for any reason. Any such
termination shall not be effective until the calendar quarter beginning at least 60 days after the date the
manufacturer provides notice to the Secretary.
(iii) Effectiveness of termination
Any termination under this subparagraph shall not affect rebates due under the agreement before the
effective date of its termination.
(iv) Notice to States
In the case of a termination under this subparagraph, the Secretary shall provide notice of such
termination to the States within not less than 30 days before the effective date of such termination.
(v) Application to terminations of other agreements
The provisions of this subparagraph shall apply to the terminations of agreements described in section
256b(a)(1) of this title and master agreements described in section 8126(a) of title 38.
(1) Basic rebate for single source drugs and innovator multiple
source drugs
(A) In general
Except as provided in paragraph (2), the amount of the rebate specified in this subsection for a rebate
period (as defined in subsection (k)(8) of this section) with respect to each dosage form and strength of a
single source drug or an innovator multiple source drug shall be equal to the product of -
(i) the total number of units of each dosage form and strength paid for under the State plan in the rebate
period (as reported by the State); and
(ii) subject to subparagraph (B)(ii), the greater of -
(I) the difference between the average manufacturer price and the best price (as defined in
subparagraph (C)) for the dosage form and strength of the drug, or
(II) the minimum rebate percentage (specified in subparagraph (B)(i)) of such average manufacturer
price, for the rebate period.
(2) Additional rebate for single source and innovator multiple source drugs
(A) In general
The amount of the rebate specified in this subsection for a rebate period, with respect to each dosage
form and strength of a single source drug or an innovator multiple source drug, shall be increased by an
amount equal to the product of -
(i) the total number of units of such dosage form and strength dispensed after December 31, 1990, for
which payment was made under the State plan for the rebate period; and
(ii) the amount (if any) by which -
(I) the average manufacturer price for the dosage form and strength of the drug for the period, exceeds
(II) the average manufacturer price for such dosage form and strength for the calendar quarter
beginning July 1, 1990 (without regard to whether or not the drug has been sold or transferred to an
entity, including a division or subsidiary of the manufacturer, after the first day of such quarter),
increased by the percentage by which the consumer price index for all urban consumers (United States
city average) for the month before the month in which the rebate period begins exceeds such index for
September 1990
.
(B) Treatment of subsequently approved drugs
In the case of a covered outpatient drug approved by the Food and Drug Administration after October 1,
1990, clause (ii)(II) of subparagraph (A) shall be applied by substituting “the first full calendar quarter after
the day on which the drug was first marketed” for “the calendar quarter beginning July 1, 1990” and “the
month prior to the first month of the first full calendar quarter after the day on which the drug was first
marketed” for “September 1990”.
(A) In general
The amount of the rebate paid to a State for a rebate period with respect to each dosage form and
strength of covered outpatient drugs (other than single source drugs and innovator multiple source drugs)
shall be equal to the product of -
(i) the applicable percentage (as described in subparagraph (B)) of the average manufacturer price for the
dosage form and strength for the rebate period, and
(ii) the total number of units of such dosage form and strength dispensed after December 31, 1990, for
which payment was made under the State plan for the rebate period.
(A) A State may subject to prior authorization any covered outpatient drug. Any such prior authorization
program shall comply with the requirements of paragraph (5).
(B) A State may exclude or otherwise restrict coverage of a covered outpatient drug if -
(i) the prescribed use is not for a medically accepted indication (as defined in subsection (k)(6) of this
section);
(ii) the drug is contained in the list referred to in paragraph (2);
(iii) the drug is subject to such restrictions pursuant to an agreement between a manufacturer and a State
authorized by the Secretary under subsection (a)(1) of this section or in effect pursuant to subsection
(a)(4) of this section; or
(iv) the State has excluded coverage of the drug from its formulary established in accordance with
paragraph (4).
(A) Agents when used for anorexia, weight loss, or weight gain.
(B) Agents when used to promote fertility.
(C) Agents when used for cosmetic purposes or hair growth.
(D) Agents when used for the symptomatic relief of cough and colds.
(E) Agents when used to promote smoking cessation.
(F) Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.
(G) Nonprescription drugs.
(H) Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that
associated tests or monitoring services be purchased exclusively from the manufacturer or its designee.
(I) Barbiturates.
(J) Benzodiazepines.
(A) The formulary is developed by a committee consisting of physicians, pharmacists, and other
appropriate individuals appointed by the Governor of the State (or, at the option of the State, the State’s
drug use review board established under subsection (g)(3) of this section).
(B) Except as provided in subparagraph (C), the formulary includes the covered outpatient drugs of any
manufacturer which has entered into and complies with an agreement under subsection (a) of this section
(other than any drug excluded from coverage or otherwise restricted under paragraph (2)).
(C) A covered outpatient drug may be excluded with respect to the treatment of a specific disease or
condition for an identified population (if any) only if, based on the drug’s labeling (or, in the case of a drug
the prescribed use of which is not approved under the Federal Food, Drug, and Cosmetic Act
(21 U.S.C. 301 et seq.) but is a medically accepted indication, based on information from the appropriate
compendia described in subsection (k)(6) of this section), the excluded drug does not have a significant,
clinically meaningful therapeutic advantage in terms of safety, effectiveness, or clinical outcome of such
treatment for such population over other drugs included in the formulary and there is a written explanation
(available to the public) of the basis for the exclusion.
(D) The State plan permits coverage of a drug excluded from the formulary (other than any drug excluded
from coverage or otherwise restricted under paragraph (2)) pursuant to a prior authorization program that
is consistent with paragraph (5).
(E) The formulary meets such other requirements as the Secretary may impose in order to achieve
program savings consistent with protecting the health of program beneficiaries. A prior authorization
program established by a State under paragraph (5) is not a formulary subject to the requirements of this
paragraph.
(A) provides response by telephone or other telecommunication device within 24 hours of a request for
prior authorization; and
(B) except with respect to the drugs on the list referred to in paragraph (2), provides for the dispensing of
at least 72-hour supply of a covered outpatient prescription drug in an emergency situation (as defined by
the Secretary).
(1) In general
During the period beginning on January 1, 1991, and ending on
December 31, 1994 –
(A) a State may not reduce the payment limits established by regulation under this subchapter or any
limitation described in paragraph (3) with respect to the ingredient cost of a covered outpatient drug or the
dispensing fee for such a drug below the limits in effect as of January 1, 1991, and
(B) except as provided in paragraph (2), the Secretary may not modify by regulation the formula
established under sections 447.331 through 447.334 of title 42, Code of Federal Regulations, in effect on
November 5, 1990, to reduce the limits described in subparagraph (A).
(1) Repealed. Pub. L. 103-66, title XIII, Sec. 13602(a)(1), Aug. 10, 1993, 107 Stat. 613
(1) In general
(A) In order to meet the requirement of section 1396b(i)(10)(B) of this title, a State shall provide, by not
later than January 1, 1993, for a drug use review program described in paragraph (2) for covered
outpatient drugs in order to assure that prescriptions (i) are appropriate, (ii) are medically necessary, and
(iii) are not likely to result in adverse medical results. The program shall be designed to educate
physicians and pharmacists to identify and reduce the frequency of patterns of fraud, abuse, gross
overuse, or inappropriate or medically unnecessary care, among physicians, pharmacists, and patients,
or associated with specific drugs or groups of drugs, as well as potential and actual severe adverse
reactions to drugs including education on therapeutic appropriateness, overutilization and underutilization,
(B) The program shall assess data on drug use against predetermined standards, consistent with the
following:
(i) compendia which shall consist of the following:
(I) American Hospital Formulary Service Drug Information;
(II) United States Pharmacopeia-Drug Information; 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 State
an amount equal to 75 per centum of so much of the sums expended by the State plan during calendar
years 1991 through 1993 as the Secretary determines is attributable to the statewide adoption of a drug
use review program which conforms to the requirements of this subsection.
(D) States shall not be required to perform additional drug use reviews with respect to drugs dispensed to
residents of nursing facilities which are in compliance with the drug regimen review procedures
prescribed by the Secretary for such facilities in regulations implementing section 1396r of this title,
currently at section 483.60 of title 42, Code of Federal Regulations.
Nothing in this clause shall be construed as requiring a pharmacist to provide consultation when
an individual receiving benefits under this subchapter or caregiver of such individual refuses such
consultation.
(A) Establishment
Each State shall provide for the establishment of a drug use review board (hereinafter referred to as the
“DUR Board”) either directly or through a contract with a private organization.
(B) Membership
The membership of the DUR Board shall include health care professionals who have recognized
knowledge and expertise in one or more of the following:
(i) The clinically appropriate prescribing of covered outpatient drugs.
(ii) The clinically appropriate dispensing and monitoring of covered outpatient drugs.
(iii) Drug use review, evaluation, and intervention.
(iv) Medical quality assurance.
The membership of the DUR Board shall be made up at least 1/3 but no more than 51 percent licensed
and actively practicing physicians and at least 1/3 * * * (FOOTNOTE 5) licensed and actively practicing
pharmacists.
(FOOTNOTE 5) So in original.
(C) Activities
The 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 or
individuals identified in the course of retrospective drug use reviews performed under this subsection.
Intervention programs shall include, in appropriate instances, at least:
(I) information dissemination sufficient to ensure the ready availability to physicians and pharmacists in
the State of information concerning its duties, powers, and basis for its standards;
(II) written, oral, or electronic reminders containing patient-specific or drug-specific (or both) information
and suggested changes in prescribing or dispensing practices, communicated in a manner designed to
ensure the privacy of patient-related information;
(III) use of face-to-face discussions between health care professionals who are experts in rational drug
therapy and selected prescribers and pharmacists who have been targeted for educational
intervention, including discussion of optimal prescribing, dispensing, or pharmacy care practices, and
follow-up face-to-face discussions; and
(IV) intensified review or monitoring of selected prescribers or dispensers. The Board shall re-evaluate
interventions after an appropriate period of time to determine if the intervention improved the quality of
drug therapy, to evaluate the success of the interventions and make modifications as necessary.
(1) In general
In accordance with chapter 35 of title 44 (relating to coordination of Federal information policy), the Secretary
shall encourage each State agency to establish, as its principal means of processing claims for covered
outpatient drugs under this subchapter, a point-of-sale electronic claims management system, for the purpose of
performing on-line, real time eligibility verifications, claims data capture, adjudication of claims, and assisting
pharmacists (and other authorized persons) in applying for and receiving payment.
(2) Encouragement
In order to carry out paragraph (1) -
(A) for calendar quarters during fiscal years 1991 and 1992, expenditures under the State plan
attributable to development of a system described in paragraph (1) shall receive Federal financial
participation under section 1396b(a)(3)(A)(i) of this title (at a matching rate of 90 percent) if the State
acquires, through applicable competitive procurement process in the State, the most cost-effective
telecommunications network and automatic data processing services and equipment; and
(B) the Secretary may permit, in the procurement described in subparagraph (A) in the application of part
433 of title 42, Code of Federal Regulations, and parts 95, 205, and 307 of title 45, Code of Federal
Regulations, the substitution of the State’s request for proposal in competitive procurement for advance
planning and implementation documents otherwise required.
(1) In general
Not later than May 1 of each year the Secretary shall transmit to the Committee on Finance of the Senate, the
Committee on Energy and Commerce of the House of Representatives, and the Committees on Aging of the
Senate and the House of Representatives a report on the (FOOTNOTE 7) operation of this section in the
preceding fiscal year.
(FOOTNOTE 7) So in original.
(2) Details
Each report shall include information on –
(A) ingredient costs paid under this subchapter for single source drugs, multiple source drugs, and
nonprescription covered outpatient drugs;
(B) the total value of rebates received and number of manufacturers providing such rebates;
(C) how the size of such rebates compare with the size or (FOOTNOTE 8) rebates offered to other
purchasers 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 this
subchapter.
(1) Covered outpatient drugs dispensed by * * * (FOOTNOTE 7) Health Maintenance Organizations, including
those organizations that contract under section 1396b(m) of this title, are not subject to the requirements of this
section.
(2) The State plan shall provide that a hospital (providing medical assistance under such plan) that dispenses
covered outpatient drugs using drug formulary systems, and bills the plan no more than the hospital’s purchasing
costs for covered outpatient drugs (as determined under the State plan) shall not be subject to the requirements
of this section.
(3) Nothing in this subsection shall be construed as providing that amounts for covered outpatient drugs paid by
the institutions described in this subsection should not be taken into account for purposes of determining the best
price as described in subsection (C) of this section.
(k) Definitions
In this section -
(A) of those drugs which are treated as prescribed drugs for purposes of section 1396d(a)(12) of this title,
a drug which may be dispensed only upon prescription (except as provided in paragraph (5)), and -
(i) which is approved for safety and effectiveness as a prescription drug under section 505 or 507 of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355, 357) or which is approved under section 505(j) of
such Act (21 U.S.C. 355(j));
(ii)(I) which was commercially used or sold in the United States before October 10, 1962, or which is
identical, similar, or related (within the meaning of section 310.6(b)(1) of title 21 of the Code of Federal
Regulations) to such a drug, and (II) which has not been the subject of a final determination by the
Secretary that it is a “new drug” (within the meaning of section 201(p) of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 321(p))) or an action brought by the Secretary under section 301, 302(a), or
304(a) of such Act (21 U.S.C. 331, 332(a), 334(a)) to enforce section 502(f) or 505(a) of such Act (21
U.S.C. 352(f), 355(a)); or
(iii)(I) which is described in section 107(C)(3) of the Drug Amendments of 1962 and for which the
Secretary has determined there is a compelling justification for its medical need, or is identical, similar, or
related (within the meaning of section 310.6(b)(1) of title 21 of the Code of Federal Regulations) to such a
drug, and (II) for which the Secretary has not issued a notice of an opportunity for a hearing under section
505(e) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355(e)) on a proposed order of the
Secretary to withdraw approval of an application for such drug under such section because the Secretary
has determined that the drug is less than effective for some or all conditions of use prescribed,
recommended, or suggested in its labeling; and
(C) insulin certified under section 506 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 356).
(C) Dental services, except that drugs for which the State plan authorizes direct reimbursement to the
dispensing dentist are covered outpatient drugs.
(F) Nursing facility services and services provided by an intermediate care facility for the mentally
retarded.
(5) Manufacturer
The term “manufacturer” means any entity which is engaged in -
(A) the production, preparation, propagation, compounding, conversion, or processing of prescription drug
products, either directly or indirectly by extraction from substances of natural origin, or independently by
means of chemical synthesis, or by a combination of extraction and chemical synthesis, or
(B) in the packaging, repackaging, labeling, relabeling, or distribution of prescription drug products. Such
term does not include a wholesale distributor of drugs or a retail pharmacy licensed under State law.
(7) Multiple source drug; innovator multiple source drug; noninnovator multiple source drug; single source drug
(A) Defined
(i) Multiple source drug
The term “multiple source drug” means, with respect to a rebate period, a covered outpatient drug (not
including any drug described in paragraph (5)) for which there are 2 or more drug products which -
(I) are rated as therapeutically equivalent (under the Food and Drug Administration’s most recent
publication of “Approved Drug Products with Therapeutic Equivalence Evaluations”),
(II) except as provided in subparagraph (B), are pharmaceutically equivalent and bioequivalent, as
defined in subparagraph (C) and as determined by the Food and Drug Administration, and
(III) are sold or marketed in the State during the period.
(ii) Innovator multiple source drug The term “innovator multiple source drug” means a multiple source
drug that was originally marketed under an original new drug application approved by the Food and Drug
Administration.
(iii) Noninnovator multiple source drug
The term “noninnovator multiple source drug” means a multiple source drug that is not an innovator
multiple source drug.
(iv) Single source drug
The term “single source drug” means a covered outpatient drug which is produced or distributed under an
original new drug application approved by the Food and Drug Administration, including a drug product
marketed by any cross-licensed producers or distributers (FOOTNOTE 01) operating under the new drug
application.
(FOOTNOTE 01) So in original. Probably should be “distributors”.
(B) Exception
Subparagraph (A)(i)(II) shall not apply if the Food and Drug Administration changes by regulation the
requirement that, for purposes of the publication described in subparagraph (A)(i)(I), in order for drug
products to be rated as therapeutically equivalent, they must be pharmaceutically equivalent and
bioequivalent, as defined in subparagraph (C).
(C) Definitions
For purposes of this paragraph -
(i) drug products are pharmaceuutically (FOOTNOTE 11) equivalent if the products contain identical
amounts of the same active drug ingredient in the same dosage form and meet compendial or other
applicable standards of strength, quality, purity, and identity;
(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 they
do present such a problem, they are shown to meet an appropriate standard of bioequivalence; and
(iii) a drug product is considered to be sold or marketed in a State if it appears in a published national
listing of average wholesale prices selected by the Secretary, provided that the listed product is generally
available to the public through retail pharmacies in that State.
• 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), 107
Stat. 613.)
• REFTEXT-
REFERENCES IN TEXT
Section 107(C)(3) of the Drug Amendments of 1962, referred to in subsec. (k)(2)(A)(iii)(I), is section 107(c)(3) of
Pub. L. 87-781 which is set out in an Effective Date of 1962 Amendment note under section 321 of Title 21, Food
and Drugs. The Federal Food, Drug, and Cosmetic Act, referred to in subsecs. (d)(4)(C) and (k)(6), is act June
25, 1938, ch. 675, 52 Stat. 1040, as amended, which is classified generally to chapter 9 (Sec. 301 et seq.) of Title
21. For complete classification of this Act to the Code, see section 301 of Title 21 and Tables.
• MISC2-
PRIOR PROVISIONS
A prior section 1927 of act Aug. 14, 1935, was renumbered section 1928 and is classified to section 1396s of this
title.
AMENDMENTS
1993 - Subsec. (b)(1)(A). Pub. L. 103-66, Sec. 13602(a)(2)(A)(i)(II), which directed amendment of subpar. (A) by
substituting “dispensed after December 31, 1990, for which payment was made under the State plan for such
period” for “dispensed under the plan during the quarter (or other period as the Secretary may specify)”, was
executed by making the substitution for “dispensed under the plan during the quarter (or such other period as the
Secretary 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 schedule
specified by the Secretary)”. Subsec. (b)(2)(A). Pub. L. 103-66, Sec. 13602(a)(2)(A)(ii), substituted “each rebate
period” for “each calendar quarter” and “units of each dosage form and strength and package size” for “dosage
units”, 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 of
rebate for certain drugs. Pub. L. 103-18 substituted “such drug, except that for the calendar quarter beginning
after September 30, 1992, and before January 1, 1993, the amount of the rebate may not exceed 50 percent of
such 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 financial
participation in certain cases, and (f)(1) relating to reductions in pharmacy reimbursement limits, and struck out
par. 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 “rebate
period” for “calendar quarter” and inserted before period at end “, after deducting customary prompt pay
discounts”. Subsec. (k)(3). Pub. L. 103-66, Sec. 13602(a)(2)(B)(ii)(III), in concluding provisions, substituted “for
which a National Drug Code number is not required by the Food and Drug Administration or a drug or biological
used” for “which is used” and inserted at end “Any drug, biological product, or insulin excluded from the definition
of such term as a result of this paragraph shall be treated as a covered outpatient drug for purposes of
determining the best price (as defined in subsection (C)(1)(C) of this section) for such drug, biological product, or
insulin.”
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 Congress
because 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 the
compendia described in subsection (g)(1)(B)(i) of this section.” for “, which appears in peer-reviewed medical
literature or which is accepted by one or more of the following compendia: the American Hospital Formulary
Service-Drug Information, the American Medical Association Drug Evaluations, and the United States
Pharmacopeia-Drug Information.”
Subsec. (k)(7)(A)(i). Pub. L. 103-66, Sec. 13602(a)(2)(B)(iv), substituted “rebate period” for “calendar quarter” in
introductory 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 the
requirements of paragraph (5) (with respect to drugs purchased by a covered entity on or after the first day of the
first month that begins after November 4, 1992) and paragraph (6)” 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 the
Secretary of Veterans Affairs described in subsection (a)(6)(A)(ii) of this section” for “this paragraph”, “Secretary
or the Secretary of Veterans Affairs” for “Secretary”, and “except - “ and cls. (i) to (iii) for “except as the Secretary
determines to be necessary to carry out this section and to permit the Comptroller General to review the
information provided.”
Subsec. (b)(4)(B)(ii). Pub. L. 102-585, Sec. 601(b)(4)(i), (ii), substituted “the calendar quarter beginning at least
60 days” for “such period” and “the manufacturer provides notice to the Secretary.” for “of the notice as the
Secretary 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 reflect
the 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 under
section 1741 of title 38, the Department of Defense, the Public Health Service, or a covered entity described in
subsection (a)(5)(B) of this section, any prices charged under the Federal Supply Schedule of the General
Services Administration, or any prices used under a State pharmaceutical assistance program, and excluding” for
“(excluding”.
• CHANGE-
CHANGE OF NAME
Committee on Energy and Commerce of House of Representatives treated as referring to Committee on
Commerce of House of Representatives by section 1(a) of Pub. L. 104-14, set out as a note preceding section 21
of Title 2, The Congress. Committees on Aging of the Senate and House of Representatives probably mean the
Special Committee on Aging of the Senate and the Select Committee on Aging of the House of Representatives
which was abolished on Jan. 5, 1993, by House Resolution No. 5, One Hundred Third Congress.
• MISC4-
were required to pay rebates under subsec. (C) of this section, Secretary’s best estimate, on State-by-State and
national aggregate basis, of total amount of rebates paid under subsec. (C) of this section and percentages of
such total amounts attributable to rebates paid under pars. (1) to (3) of subsec. (C) of this section, limited
consideration to drugs which are considered significant expenditures under medicaid program, and contained
requirements for initial report.
DEMONSTRATION PROJECTS TO EVALUATE EFFICIENCY AND
COST-EFFECTIVENESS OF PROSPECTIVE DRUG UTILIZATION REVIEW
Section 4401(C) of title IV of Pub. L. 101-508 directed Secretary of Health and Human Services to establish
statewide demonstration projects to evaluate efficiency and cost-effectiveness of prospective drug utilization
review and to evaluate impact on quality of care and cost-effectiveness of paying pharmacists under this
subchapter whether or not drugs were dispensed for drug use review services, with two reports to be submitted to
Congress, 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; REPORT
Section 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, other
institutional 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 and
the 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 under
this section (enacting this section, amending sections 1396a, 1396b, and 1396s of this title, and enacting
provisions 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 review
required under this section, and
“(iii) the efficiency of mechanisms used by these institutions for billing and receiving payment for covered
outpatient 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 Human
Services (hereafter in this section referred to as the ‘Secretary’), the Committee on Finance of the Senate, the
Committee on Energy and Commerce of the House of Representatives, and the Committees on Aging of the
Senate and the House of Representatives on the study conducted under subparagraph (A).
“(2) Report on drug pricing. - The Comptroller General shall submit to the Secretary, the Committee on Finance of
the Senate, the Committee on Energy and Commerce (now Committee on Commerce) of the House of
Representatives, and the Committees on Aging of the Senate and House of Representatives (see Change of
Name note above) a report on changes in prices charged by manufacturers for prescription drugs to the
Department of Veterans Affairs, other Federal programs, hospital pharmacies, and other purchasing groups and
managed care plans.
“(3) Study on prior approval procedures. -
“(A) The Secretary, acting in consultation with the Comptroller General, shall study prior approval procedures
utilized by State medical assistance programs conducted under title XIX of the Social Security Act (this
subchapter), including -
“(i) the appeals provisions under such programs; and
“(ii) the effects of such procedures on beneficiary and provider access to medications covered under such
programs.
“(B) By not later than December 31, 1991, the Secretary and the Comptroller General 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 the Senate and the House of Representatives on the results of the study
conducted under subparagraph (A) and shall make recommendations with respect to which procedures are
appropriate 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 under
each State medical assistance programs conducted under title XIX of the Social Security Act; and (ii) the extent to
which reimbursement rates under such programs have an effect on beneficiary access to medications covered
and 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 the
Senate 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 the
relationship between State medical assistance plans and Federal and State acquisition and reimbursement
policies 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 of
this Act (Nov. 5, 1990).”
• SECREF-
Appendix D:
HCFA Upper Limits for
Multiple Source Products
The following list of multiple source drugs meets the criteria set forth in 42 CFR 447.332 and §1927(e) of the
Social Security Act, as amended by OBRA 1993. The development of the current Federal Upper Limit (FUL)
listing has been accomplished by computer. Payments for multiple source drugs identified and listed in the
accompanying addendum must not exceed, in the aggregate, payment levels determined by applying to each drug
entity a reasonable dispensing fee (established by the State and specified in the State plan), plus an amount based
on the limit per unit which 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 of
drugs. 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 names
are included in the FUL listing provided to the State agencies in electronic media format. The FUL price list is in
Microsoft Word format at http://www.hcfa/gov/medicaid/drug10.htm.
In accordance with current policy, Federal financial participation will not be provided for any drug on the FUL
listing for which the FDA has issued a notice of an opportunity for a hearing as a result of the Drug Efficacy
Study and Implementation (DESI) program and which has been found to be less than effective or is identical,
related, or similar (IRS) to the DESI drug. The DESI drug is identified by the Food and Drug Administration or
reported 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.
Acebutolol Hydrochloride
Eq 200 mg base, Capsule, Oral 100 $0.4613 B
Eq 400 mg base, Capsule, Oral 100 0.6713 B
Acetazolamide
125 mg, Tablet, Oral 100 0.0760 B
250 mg, Tablet, Oral 100 0.2565 B
Acetylcysteine
10%, Solution, Inhalation 4 ml 0.8060 B
10%, Solution, Inhalation 10 ml 0.7640 R
20%, Solution, Inhalation 4 ml 0.9710 B
20%, Solution, Inhalation 10 ml 0.9290 R
Acyclovir
200 mg, Capsule, Oral 100 0.3530 B
400 mg, Tablet, Oral 100 0.7050 R
800 mg, Tablet, Oral 100 1.2160 B
Albuterol Sulfate
Eq 0.5% base, Solution, Inhalation 20 ml 0.3330 R
Eq 2 mg base/5 ml, Syrup, Oral 480 ml 0.0350 B
Eq 2 mg base, Tablet, Oral 100 0.0380 B
Eq 4 mg base, Tablet, Oral 100 0.0550 B
Allopurinol
100 mg, Tablet, Oral 100 0.0510 B
300 mg, Tablet, Oral 100 0.1198 B
Alprazolam
0.25 mg, Tablet, Oral 100 0.0560 B
0.5 mg, Tablet, Oral 100 0.0690 B
1 mg, Tablet, Oral 100 0.0920 B
Amantadine Hydrochloride
100 mg, Capsule, Oral 100 0.1572 R
50 mg/5 ml, Syrup, Oral 480 ml 0.0720 R
Aminophylline
100 mg, Tablet, Oral 100 0.0278 R
200 mg, Tablet, Oral 1000 0.0390 R
Amiodarone Hydrochloride
200 mg, Tablet, Oral 500 1.8912 R
Amitriptyline Hydrochloride
10 mg, Tablet, Oral 100 0.0315 B
25 mg, Tablet, Oral 100 0.0330 R
50 mg, Tablet, Oral 100 0.0400 B
75 mg, Tablet, Oral 100 0.0592 B
100 mg, Tablet, Oral 100 0.0760 R
150 mg, Tablet, Oral 100 0.1800 B
Amoxapine
25 mg, Tablet, Oral 100 0.3524 B
50 mg, Tablet, Oral 100 0.5426 B
100 mg, Tablet, Oral 100 0.9300 B
150 mg, Tablet, Oral 30 1.5475 B
Amoxicillin
250 mg, Capsule, Oral 100 0.0636 R
500 mg, Capsule, Oral 100 0.1270 B
125 mg/5 ml, Powder for reconstitution, Oral 100 0.0210 B
125 mg/5 ml, Powder for reconstitution, Oral 150 0.0119 B
250 mg/5 ml, Powder for reconstitution, Oral 100 0.0218 B
250 mg/5 ml, Powder for reconstitution, Oral 150 0.0210 B
250 mg, Tablet, Chewable, Oral 100 0.1600 B
Ampicillin/Ampicillin Trihydrate
250 mg, Capsule, Oral 100 0.0850 B
500 mg, Capsule, Oral 100 0.1115 B
Aspirin; Carisoprodol
325 mg; 200 mg, Tablet, Oral 100 0.5960 R
Atenolol
25 mg, Tablet, Oral 100 0.0460 B
100 mg, Tablet, Oral 100 0.0672 B
Atenolol; Chlorthalidone
50 mg; 25 mg, Tablet, Oral 100 0.2550 B
100 mg; 25 mg, Tablet, Oral 100 0.3730 B
Baclofen
10 mg, Tablet, Oral 100 0.0899 B
20 mg, Tablet, Oral 100 0.1688 R
Benzonatate
100 mg, Capsule, Oral 100 0.3899 B
Benztropine Mesylate
0.5 mg, Tablet, Oral 100 0.0360 B
1 mg, Tablet, Oral 100 0.0380 B
2 mg, Tablet, Oral 100 0.0430 B
Betamethasone Dipropionate
Eq 0.05% base, Cream, Topical 15 gm 0.2130 B
Eq 0.05% base, Cream, Topical 45 gm 0.1313 B
Eq 0.05% base, Lotion, Topical 60 ml 0.1440 B
Eq 0.05% base, Ointment, Topical 15 gm 0.3350 B
Eq 0.05% base, Ointment, Topical 45 gm 0.2230 B
Betamethasone Valerate
Eq 0.1% base, Cream, Topical 15 gm 0.1130 B
Eq 0.1% base, Cream, Topical 45 gm 0.0750 B
Eq 0.1% base, Lotion, Topical 60 ml 0.1088 B
Bumetanide
0.5 mg, Tablet, Oral 100 0.1613 R
1 mg, Tablet, Oral 100 0.2810 B
2 mg, Tablet, Oral 100 0.3675 R
Captopril
12.5 mg, Tablet, Oral 100 0.0480 B
25 mg, Tablet, Oral 100 0.0560 B
50 mg, Tablet, Oral 100 0.1180 B
100 mg, Tablet, Oral 100 0.2020 M
Captolpril; Hydrochlorothiazide
25 mg; 15 mg, Tablet, Oral 100 0.2313 R
25 mg; 25 mg, Tablet, Oral 100 0.2313 R
50 mg; 15 mg, Tablet, Oral 100 0.3629 R
50 mg; 25 mg, Tablet, Oral 100 0.3629 R
Carbamazepine
200 mg, Tablet, Oral 100 0.1500 R
Carbidopa; Levodopa
10 mg; 100 mg, Tablet, Oral 100 0.1971 B
25 mg; 100 mg, Tablet, Oral 100 0.2127 B
25 mg; 250 mg, Tablet, Oral 100 0.2513 B
Carisoprodol
350 mg, Tablet, Oral 100 0.3743 B
Cefaclor
Eq 250 mg base, Capsule, Oral 100 0.9290 B
Eq 500 mg base, Capsule, Oral 100 1.7990 B
Eq 125 mg base/5 ml,
Powder for reconstitution, Oral 150 0.1320 R
Eq 187 mg base/5 ml,
Powder for reconstitution, Oral 100 0.2000 R
Eq 250 mg base/5 ml,
Powder for reconstitution, Oral 150 0.2440 B
Eq 375 mg base/5 ml,
Powder for reconstitution, Oral 100 0.3660 B
Cephalexin
Eq 250 mg base, Capsule, Oral 100 0.1700 B
Eq 500 mg base, Capsule, Oral 100 0.2150 B
Eq 125 mg base/5 ml,
Powder for reconstitution, Oral 200 0.0310 B
Eq 250 mg base/5 ml,
Powder for reconstitution, Oral 100 0.0510 B
Eq 250 mg base/5 ml,
Powder for reconstitution, Oral 200 0.0450 B
Chlordiazepoxide Hydrochloride
10 mg, Capsule, Oral 100 0.0950 B
25 mg, Capsule, Oral 100 0.1090 B
Chlorhexidine Gluconate
0.12%, Solution, Dental 480 ml 0.0150 B
Chlorpheniramine Maleate
4 mg, Tablet, Oral 100 0.0100 M
Chlorpropamide
100 mg, Tablet, Oral 100 0.1840 B
250 mg, Tablet, Oral 100 0.3885 R
Chlorthalidone
25 mg, Tablet, Oral 100 0.0510 B
50 mg, Tablet, Oral 100 0.0560 B
Cholestyramine
Eq 4 gm Resin/Packet, Powder, Oral 60 pk 0.9004 B
Cimetidine
200 mg, Tablet, Oral 100 0.1238 B
300 mg, Tablet, Oral 100 0.1080 R
400 mg, Tablet, Oral 100 0.1178 R
800 mg, Tablet, Oral 100 0.3261 B
Cimetidine Hydrochloride
Eq 1% Base, Solution, Topical 30 ml 0.1140 B
Clemastine Fumarate
2.68 mg, Tablet, Oral 100 0.3572 R
Clindamycin Hydrochloride
Eq 150 mg Base, Capsule, Oral 100 0.9230 B
Clindamycin Phosphate
Eq 1% base, Solution, Topical 30 ml 0.2095 B
Eq 1% base, Solution, Topical 60 ml 0.3150 R
Clomipramine Hydrochloride
25 mg, Capsule, Oral 100 0.3750 B
50 mg, Capsule, Oral 100 0.4985 B
75 mg, Capsule, Oral 100 0.6464 R
Clonazepam
0.5 mg, Tablet, Oral 100 0.2760 B
1 mg, Tablet, Oral 100 0.3210 B
2 mg, Tablet, Oral 100 0.4390 B
Clonidine Hydrochloride
0.1 mg, Tablet, Oral 100 0.0900 B
0.2 mg, Tablet, Oral 100 0.1275 B
0.3 mg, Tablet, Oral 100 0.1650 B
Clorazepate Dipotassium
3.75 mg, Tablet, Oral 100 0.8351 R
7.5 mg, Tablet, Oral 100 1.0388 B
15 mg, Tablet, Oral 100 1.4094 R
Cyclobenzaprine Hydrochloride
10 mg, Tablet, Oral 100 0.0910 B
Cyclopentolate Hydrochloride
1%, Solution/Drops, Ophthalmic 15 ml 0.4810 B
Desipramine Hydrochloride
25 mg, Tablet, Oral 100 0.0675 R
50 mg, Tablet, Oral 100 0.0825 B
75 mg, Tablet, Oral 100 0.0900 R
100 mg, Tablet, Oral 100 0.4370 R
Desonide
0.05%, Ointment, Topical 15 gm 0.5840 B
0.05%, Ointment, Topical 50 gm 0.4077 B
Desoximetasone
0.25%, Cream, Topical 15 gm 0.8130 B
Dexamethasone
0.5 mg/5 ml, Elixir, Oral 240 ml 0.0400 B
Diazepam
2 mg, Tablet, Oral 100 0.0300 B
5 mg, Tablet, Oral 100 0.0320 B
10 mg, Tablet, Oral 100 0.0420 B
Diclofenac Potassiuim
50 mg, Tablet, Oral 100 0.8630 B
Diclofenac Sodium
50 mg, Tablet, Delayed Release, Oral 100 0.4748 B
75 mg, Tablet, Delayed Release, Oral 100 0.6560 R
Dicyclomine Hydrochloride
10 mg, Capsule, Oral 100 0.1223 B
20 mg, Tablet, Oral 100 0.1428 M
Diflunisal
500 mg, Tablet, Oral 60 0.4750 B
Diltiazem Hydrochloride
30 mg, Tablet, Oral 100 0.1160 B
60 mg, Tablet, Oral 100 0.1810 B
90 mg, Tablet, Oral 100 0.2180 B
120 mg, Tablet, Oral 100 0.3520 B
Diphenhydramine Hydrochloride
25 mg, Capsule, Oral 100 0.0250 B
12.5 mg/5 ml, Elixir, Oral 480 ml 0.0080 B
Dipivefrin Hydrochloride
0.1%, Solution/Drops, Ophthalmic 5 ml 0.8700 B
0.1%, Solution/Drops, Ophthalmic 10 ml 0.6360 B
0.1%, Solution/Drops, Ophthalmic 15 ml 0.7280 B
Dipyridamole
75 mg, Tablet, Oral 100 0.0770 B
Doxepin Hydrochloride
Eq 10 mg base, Capsule, Oral 100 0.1720 B
Eq 25 mg base, Capsule, Oral 100 0.1820 B
Eq 75 mg base, Capsule, Oral 100 0.1290 B
Eq 100 mg base, Capsule, Oral 100 0.3830 B
Eq 10 mg base/ml, Concentrate, Oral 120 ml 0.1144 B
Doxycycline Hyclate
Eq 50 mg base, Capsule, Oral 50 0.0819 B
Eq 100 mg base, Capsule, Oral 50 0.1050 B
Eq 100 mg base, Tablet, Oral 50 0.0953 B
Erythromycin
250 mg, Capsule, Delayed Released Pellets, Oral 100 0.1890 B
2%, Solution, Topical 60 ml 0.0650 B
Erythromycin Ethylsuccinate
Eq 200 mg base/5 ml, Suspension, Oral 480 ml 0.0340 B
Estazolam
1 mg, Tablet, Oral 100 0.5954 B
2 mg, Tablet, Oral 100 0.6563 B
Estradiol
0.5 mg, Tablet, Oral 100 0.1793 B
1 mg, Tablet, Oral 100 0.2205 B
2 mg, Tablet, Oral 100 0.3060 B
Estropipate
0.75 mg, Tablet, Oral 100 0.3453 R
1.5 mg, Tablet, Oral 100 0.3614 B
Etodolac
200 mg, Capsule, Oral 100 0.4800 B
300 mg, Capsule, Oral 100 0.5100 B
400 mg, Tablet, Oral 100 0.3450 B
500 mg, Tablet, Oral 100 1.0032 R
Fenoprofen Calcium
Eq 600 mg base, Tablet, Oral 100 0.2990 B
Fluocinolone Acetonide
0.01%, Solution, Topical 60 ml 0.1170 B
Fluocinonide
0.05%, Cream, Topical 15 gm 0.1880 B
0.05%, Cream, Topical 30 gm 0.1439 B
0.05%, Cream, Topical 60 gm 0.1187 B
0.05%, Solution, Topical 60 ml 0.2640 B
Fluorometholone
0.1%, Suspension/Drops, Ophthalmic 5 ml 1.6590 R
0.1%, Suspension/Drops, Ophthalmic 10 ml 1.1835 R
0.1%, Suspension/Drops, Ophthalmic 15 ml 0.8950 B
Fluphenazine Hydrochloride
1 mg, Tablet, Oral 100 0.2120 R
2.5 mg, Tablet, Oral 100 0.2775 B
5 mg, Tablet, Oral 100 0.3675 B
10 mg, Tablet, Oral 100 0.4760 R
Flurazepam Hydrochloride
15 mg, Capsule, Oral 100 0.0656 B
30 mg, Capsule, Oral 100 0.0830 R
Flurbiprofen
100 mg, Tablet, Oral 100 0.3680 B
Folic Acid
1 mg, Tablet, Oral 100 0.0460 B
Furosemide
10 mg/ml, Solution, Oral 60 ml 0.1300 B
10 mg/ml, Solution, Oral 120 ml 0.0893 B
20 mg, Tablet, Oral 100 0.0420 B
40 mg, Tablet, Oral 100 0.0440 R
80 mg, Tablet, Oral 100 0.0710 B
Gentamicin Sulfate
Eq 0.1% Base, Ointment, Topical 15 gm 0.1740 B
Eq 0.3% Base, Ointment, Ophthalmic 3.5 gm 2.6786 B
Eq 0.3% Base, Solution/Drops, Ophthalmic 5 ml 0.4890 B
Eq 0.3% Base, Solution/Drops, Ophthalmic 15 ml 0.2560 B
Glipizide
5 mg, Tablet, Oral 100 0.0650 R
10 mg, Tablet, Oral 100 0.0937 B
Glyburide
1.5 mg, Tablet, Oral 100 0.2550 R
3 mg, Tablet, Oral 100 0.3204 R
6 mg, Tablet, Oral 100 0.8471 R
Griseofulvin, Ultramicrocrystalline
125 mg, Tablet, Oral 100 0.3743 B
250 mg, Tablet, Oral 100 0.5093 B
330 mg, Tablet, Oral 100 0.6690 B
Guanabenz Acetate
Eq 4 mg base, Tablet, Oral 100 0.3675 R
Eq 8 mg base, Tablet, Oral 100 0.5625 R
Guanfacine Hydrochloride
Eq 1 mg base, Tablet, Oral 100 0.5250 B
Eq 2 mg base, Tablet, Oral 100 0.7200 B
Haloperidol
0.5 mg, Tablet, Oral 100 0.0360 B
1 mg, Tablet, Oral 100 0.0400 R
2 mg, Tablet, Oral 100 0.0440 B
5 mg, Tablet, Oral 100 0.0570 R
10 mg, Tablet, Oral 100 0.0770 B
Haloperidol Lactate
Eq 2 mg Base/ml, Concentrate, Oral 120 ml 0.1500 B
Hydralazine Hydrochloride
10 mg, Tablet, Oral 100 0.0350 B
25 mg, Tablet, Oral 100 0.0450 B
Hydrochlorothiazide; Spironolactone
25 mg; 25 mg, Tablet, Oral 100 0.3225 B
Hydrochlorothiazide; Triamterene
25 mg; 37.5 mg, Capsule, Oral 100 0.3181 B
25 mg; 50 mg, Capsule, Oral 100 0.1130 B
25 mg; 37.5 mg, Tablet, Oral 100 0.2438 R
50 mg; 75 mg, Tablet, Oral 100 0.0530 B
Hydrocortisone
0.5%, Cream, Topical, 30 gm 0.0380 B
2.5%, Cream, Topical 20 gm 0.1814 B
2.5%, Cream, Topical 30 gm 0.1820 B
1%, Lotion, Topical 120 ml 0.0640 B
Hydroxychloroquine Sulfate
200 mg, Tablet, Oral 100 0.8540 B
Hydroxyurea
500 mg, Capsule, Oral 100 1.1666 B
Hydroxyzine Hydrochloride
10 mg/5 ml, Syrup, Oral 480 ml 0.0370 B
10 mg, Tablet, Oral 100 0.0248 B
25 mg, Tablet, Oral 100 0.0347 B
50 mg, Tablet, Oral 100 0.0450 R
Hydroxyzine Pamoate
Eq 25 mg HCL, Capsule, Oral 100 0.0794 B
Eq 50 mg HCL, Capsule, Oral 100 0.1013 R
Eq 100 mg HCL, Capsule, Oral 100 0.2710 B
Ibuprofen
400 mg, Tablet, Oral 100 0.0640 B
600 mg, Tablet, Oral 100 0.0740 R
800 mg, Tablet, Oral 100 0.1070 B
Imipramine Hydrochloride
10 mg, Tablet, Oral 100 0.1557 R
25 mg, Tablet, Oral 100 0.1880 R
50 mg, Tablet, Oral 100 0.2290 R
Indapamide
1.25 mg, Tablet, Oral 100 0.1780 B
2.5 mg, Tablet, Oral 100 0.2080 B
Indomethacin
25 mg, Capsule, Oral 100 0.0440 B
50 mg, Capsule, Oral 100 0.0501 B
Isoniazid
300 mg, Tablet, Oral 100 0.0548 B
Isosorbide Dinitrate
5 mg, Tablet, Oral 100 0.0242 B
10 mg, Tablet, Oral 100 0.0280 B
20 mg, Tablet, Oral 100 0.0248 B
5 mg, Tablet, Sublingual 100 0.0300 R
Isosorbide Mononitrate
10 mg, Tablet, Oral 100 0.6110 R
20 mg, Tablet, Oral 100 0.4950 B
Ketoconazole
200 mg, Tablet, Oral 100 2.7645 B
Ketoprofen
50 mg, Capsule, Oral 100 0.4750 B
Ketorolac Tromethamine
10 mg, Tablet, Oral 100 0.6374 B
Labetalol Hydrochloride
100 mg, Tablet, Oral 100 0.4670 B
200 mg, Tablet, Oral 100 0.6620 B
300 mg, Tablet, Oral 100 0.8810 B
Lactulose
10 gm/15 ml, Solution, Oral 480 ml 0.0219 B
Levobunolol Hydrochloride
0.25%, Solution/Drops, Ophthalmic 10 ml 1.2749 B
0.5%, Solution/Drops, Ophthalmic 5 ml 1.3950 R
0.5%, Solution/Drops, Ophthalmic 10 ml 1.4930 B
0.5%, Solution/Drops, Ophthalmic 15 ml 1.4190 R
Lidocaine Hydrochloride
2%, Solution, Oral 100 ml 0.0278 M
Lindane
1%, Shampoo, Topical 480 ml 0.1660 B
Loperamide Hydrochloride
2 mg, Capsule, Oral 100 0.1500 B
Lorazepam
0.5 mg, Tablet, Oral 100 0.4350 B
1 mg, Tablet, Oral 100 0.5718 B
2 mg, Tablet, Oral 100 0.8480 B
Meclizine Hydrochloride
12.5 mg, Tablet, Oral 100 0.0370 B
25 mg, Tablet, Oral 100 0.0390 B
Medroxyprogesterone Acetate
5 mg, Tablet, Oral 100 0.2250 B
Megestrol Acetate
20 mg, Tablet, Oral 100 0.5000 R
40 mg, Tablet, Oral 100 0.8000 B
Meprobamate
200 mg, Tablet, Oral 100 0.1080 B
400 mg, Tablet, Oral 100 0.1580 R
Methazolamide
25 mg, Tablet, Oral 100 0.3260 B
50 mg, Tablet, Oral 100 0.5000 B
Methocarbamol
500 mg, Tablet, Oral 100 0.1350 B
750 mg, Tablet, Oral 100 0.1710 B
Methyclothiazide
5 mg, Tablet, Oral 100 0.3689 B
Methyldopa
250 mg, Tablet, Oral 100 0.1013 B
500 mg, Tablet, Oral 100 0.1800 B
Methylphenidate Hydrochloride
5 mg, Tablet, Oral 100 0.3020 B
10 mg, Tablet, Oral 100 0.4224 B
20 mg, Tablet, Oral 100 0.6180 B
Methylprednisolone
4 mg, Tablet, Oral 100 0.4658 R
Metoclopramide Hydrochloride
Eq 5 mg base/5 ml, Solution, Oral 480 ml 0.0155 B
Eq 5 mg base, Tablet, Oral 100 0.1200 B
Eq 10 mg base, Tablet, Oral 100 0.0195 R
Metoprolol Tartrate
50 mg, Tablet, Oral 100 0.1060 B
100 mg, Tablet, Oral 100 0.1290 B
Metronidazole
250 mg, Tablet, Oral 100 0.0640 B
500 mg, Tablet, Oral 100 0.1350 B
Mexiletine Hydrochloride
150 mg, Capsule, Oral 100 0.6452 B
200 mg, Capsule, Oral 100 0.7784 R
250 mg, Capsule, Oral 100 0.8568 R
Minocycline Hydrochloride
Eq 50 mg base, Capsule, Oral 100 0.5020 B
Eq 100 mg base, Capsule, Oral 50 0.7875 B
Minoxidil
2.5 mg, Tablet, Oral 100 0.3170 B
10 mg, Tablet, Oral 100 0.6970 B
Nadolol
20 mg, Tablet, Oral 100 0.4650 B
40 mg, Tablet, Oral 100 0.5780 B
120 mg, Tablet, Oral 100 1.1220 B
160 mg, Tablet, Oral 100 1.1540 B
Naphazoline Hydrochloride
0.1%, Solution/Drops, Ophthalmic 15 ml 0.3140 R
Naproxen
250 mg, Tablet, Oral 100 0.1035 B
375 mg, Tablet, Oral 100 0.1335 B
500 mg, Tablet, Oral 100 0.1628 B
375 mg, Tablet, Delayed Release, Oral 100 0.6450 B
500 mg, Tablet, Delayed Release, Oral 100 0.9750 B
Naproxen Sodium
Eq 250 mg base, Tablet, Oral 100 0.1670 R
Eq 500 mg base, Tablet, Oral 100 0.2070 B
Niacin
500 mg, Tablet, Oral 100 0.0390 R
Nicardipine Hydrochloride
20 mg, Capsule, Oral 100 0.3380 B
30 mg, Capsule, Oral 100 0.4050 B
Nifedipine
20 mg, Capsule, Oral 100 0.2470 B
Nitrofurantoin, Macrocrystalline
50 mg, Capsule, Oral 100 0.5040 R
100 mg, Capsule, Oral 100 0.7425 B
Nortriptyline Hydrochloride
Eq 10 mg base, Capsule, Oral 100 0.1020 B
Eq 25 mg base, Capsule, Oral 100 0.1580 R
Eq 50 mg base, Capsule, Oral 100 0.1720 B
Eq 75 mg base, Capsule, Oral 100 0.2204 B
Nystatin
100,000 units/gm, Cream, Topical 15 gm 0.0900 R
100,000 units/gm, Cream, Topical 30 gm 0.0760 B
100,000 units/ml, Suspension, Oral 60 ml 0.0620 B
100,000 units/ml, Suspension, Oral 480 ml 0.0425 R
500,000 units, Tablet, Oral 100 0.3563 B
Oxazepam
10 mg, Capsule, Oral 100 0.3100 R
15 mg, Capsule, Oral 100 0.5160 B
30 mg, Capsule, Oral 100 1.1200 B
Oxybutynin Chloride
5 mg, Tablet, Oral 100 0.1650 B
Penicillin V Potassium
Eq 125 mg base/5 ml, Powder for reconstitution, Oral 200 ml 0.0120 B
Eq 250 mg base/5 ml, Powder for reconstitution, Oral 100 ml 0.0220 B
Eq 250 mg base/5 ml, Powder for reconstitution, Oral 200 ml 0.0170 B
Eq 250 mg base, Tablet, Oral 100 0.0491 B
Eq 500 mg base, Tablet, Oral 100 0.0800 B
Pentoxifylline
400 mg, Tablet, Extended Release, Oral 100 0.3150 B
Perphenazine
2 mg, Tablet, Oral 100 0.2550 B
4 mg, Tablet, Oral 100 0.3150 B
8 mg, Tablet, Oral 100 0.4290 R
16 mg, Tablet, Oral 100 0.6000 B
Pindolol
5 mg, Tablet, Oral 100 0.1540 B
10 mg, Tablet, Oral 100 0.1970 B
Piroxicam
10 mg, Capsule, Oral 100 0.1090 B
20 mg, Capsule, Oral 100 0.1480 B
Potassium Chloride
8 mEq, Tablet, Extended Release, Oral 100 0.0773 R
Prazosin Hydrochloride
Eq 1 mg base, Capsule, Oral 100 0.0580 B
Eq 2 mg base, Capsule, Oral 100 0.0790 R
Eq 5 mg base, Capsule, Oral 100 0.1380 R
Prednisolone
15 mg/5 ml, Syrup, Oral 240 ml 0.2580 B
15 mg/5 ml, Syrup, Oral 480 ml 0.2090 B
Prednisolone Acetate
1%, Suspension/Drops, Ophthalmic 5 ml 1.8900 B
1%, Suspension/Drops, Ophthalmic 10 ml 1.6200 B
Prednisone
5 mg, Tablet, Oral 100 0.0332 B
10 mg, Tablet, Oral 100 0.0550 B
20 mg, Tablet, Oral 100 0.0760 B
Primidone
250 mg, Tablet, Oral 100 0.3610 B
Probenecid
500 mg, Tablet, Oral 100 0.7060 B
Procainamide Hydrochloride
500 mg, Tablet, Extended Release, Oral 100 0.2460 B
Prochlorperazine Maleate
Eq 5 mg base, Tablet, Oral 100 0.3986 R
Eq 10 mg base, Tablet, Oral 100 0.5766 B
Promethazine Hydrochloride
6.25 mg/5 ml, Syrup, Oral 120 ml 0.0219 B
6.25 mg/5 ml, Syrup, Oral 480 ml 0.0079 B
Proparacaine Hydrochloride
0.5%, Solution/Drops, Ophthalmic 15 ml 0.4990 B
Propoxyphene Hydrochloride
65 mg, Capsule, Oral 100 0.1350 B
Propranolol Hydrochloride
10 mg, Tablet, Oral 100 0.0500 B
20 mg, Tablet, Oral 100 0.0410 B
40 mg, Tablet, Oral 100 0.0490 B
80 mg, Tablet, Oral 100 0.0530 B
Quinidine Gluconate
324 mg, Tablet, Extended Release, Oral 100 0.4200 R
Ranitidine Hydrochloride
Eq 150 mg base, Tablet, Oral, 100 0.3410 B
Eq 300 mg base, Tablet, Oral 100 0.6830 B
Selegiline Hydrochloride
5 mg, Tablet, Oral 60 0.8230 R
Selenium Sulfide
2.5%, Lotion/Shampoo, Topical 120 ml 0.0350 B
Spironolactone
25 mg, Tablet, Oral 100 0.3000 B
Sucralfate
1 gm, Tablet, Oral 100 0.3690 B
Sulfacetamide Sodium
10%, Ointment, Ophthalmic 3.5 gm 1.4530 M
10%, Solution/Drops, Opthalmic 15 ml 0.1240 B
Sulfamethoxazole; Trimethoprim
200 mg/5 ml; 40 mg/5 ml, Suspension, Oral 480 ml 0.0230 B
400 mg; 80 mg, Tablet, Oral 100 0.1325 B
800 mg; 160 mg, Tablet, Oral 100 0.2070 B
Sulfasalazine
500 mg, Tablet, Oral 100 0.1403 R
Sulindac
150 mg, Tablet, Oral 100 0.2138 R
200 mg, Tablet, Oral 100 0.3500 B
Temazepam
15 mg, Capsule, Oral 100 0.1300 B
30 mg, Capsule, Oral 100 0.1560 B
Tetracycline Hydrochloride
500 mg, Capsule, Oral 100 0.0650 B
Theophylline
80 mg/15 ml, Elixir, Oral 480 ml 0.0070 B
100 mg, Tablet, Extended Release, Oral 100 0.0710 B
200 mg, Tablet, Extended Release, Oral 100 0.0940 B
300 mg, Tablet, Extended Release, Oral 100 0.1070 R
450 mg, Tablet, Extended Release, Oral 100 0.2700 B
Thioridazine Hydrochloride
100 mg/ml, Concentrate, Oral 120 ml 0.2376 B
10 mg, Tablet, Oral 100 0.0939 R
25 mg, Tablet, Oral 100 0.1103 R
50 mg, Tablet, Oral 100 0.1760 B
100 mg, Tablet, Oral 100 0.2324 R
Thiothixene
1 mg, Capsule, Oral 100 0.0890 B
2 mg, Capsule, Oral 100 0.1190 B
5 mg, Capsule, Oral 100 0.1690 B
10 mg, Capsule, Oral 100 0.2289 B
Timolol Maleate
Eq 0.25% base, Solution/Drops, Ophthalmic 5 ml 0.7500 B
Eq 0.25% base, Solution/Drops, Ophthalmic 10 ml 0.7970 B
Eq 0.25% base, Solution/Drops, Ophthalmic 15 ml 0.7500 B
Eq 0.5% base, Solution/Drops, Ophthalmic 5 ml 1.4070 B
Eq 0.5% base, Solution/Drops, Ophthalmic 10 ml 1.0310 B
Eq 0.5% base, Solution/Drops, Ophthalmic 15 ml 1.0000 B
5 mg, Tablet, Oral 100 0.1538 B
10 mg, Tablet, Oral 100 0.2138 B
Tobramycin
0.3%, Solution/Drops, Ophthalmic 5 ml 0.7680 B
Tolazamide
250 mg, Tablet, Oral 100 0.1038 B
500 mg, Tablet, Oral 100 0.2480 B
Tolmetin Sodium
Eq 400 mg base, Capsule, Oral 100 0.7280 B
Eq 600 mg base, Tablet, Oral 100 0.9098 R
Trazodone Hydrochloride
50 mg, Tablet, Oral 100 0.0640 B
100 mg, Tablet, Oral 100 0.0952 R
150 mg, Tablet, Oral 100 0.4280 B
Triamcinolone Acetonide
0.025%, Cream, Topical 15 gm 0.0950 R
0.025%, Cream, Topical 454 gm 0.0132 B
0.1%, Cream, Topical 15 gm 0.0810 B
0.1%, Cream, Topical 80 gm 0.0420 B
0.1%, Cream, Topical 454 gm 0.0295 R
0.5%, Cream, Topical 15 gm 0.1889 B
0.1%, Lotion, Topical 60 ml 0.1215 B
0.1%, Ointment, Topical 15 gm 0.0810 B
0.1%, Ointment, Topical 80 gm 0.0502 B
0.1%, Ointment, Topical 454 gm 0.0381 B
0.1%, Paste, Dental 5 gm 0.8250 B
Triazolam
0.125 mg, Tablet, Oral 100 0.4000 R
Trifluoperazine Hydrochloride
Eq 1 mg base, Tablet, Oral 100 0.2433 B
Eq 2 mg base, Tablet, Oral 100 0.3552 B
Eq 5 mg base, Tablet, Oral 100 0.4271 B
Eq 10 mg base, Tablet, Oral 100 0.5400 B
Trimethoprim
100 mg, Tablet, Oral 100 0.1553 B
Tropicamide
0.5%, Solution/Drops, Ophthalmic 15 ml 0.6550 B
1%, Solution/Drops, Ophthalmic 15 ml 0.7000 B
Valproic Acid
250 mg, Capsule, Oral 100 0.2100 B
250 mg/5 ml, Syrup, Oral 480 ml 0.0670 B
Verapamil Hydrochloride
120 mg, Capsule, Extended Release, Oral 100 0.8250 B
180 mg, Capsule, Extended Release, Oral 100 0.8700 B
240 mg, Capsule, Extended Release, Oral 100 0.9900 B
40 mg, Tablet, Oral 100 0.1840 R
80 mg, Tablet, Oral 100 0.0620 B
120 mg, Tablet, Oral 100 0.0860 B
180 mg, Tablet, Extended Release, Oral 100 0.2352 B
240 mg, Tablet, Extended Release, Oral 100 0.2175 B
Warfarin Sodium
1 mg, Tablet, Oral 100 0.4361 B
2 mg, Tablet, Oral 100 0.4553 B
2.5 mg, Tablet, Oral 100 0.4692 B
3 mg, Tablet, Oral 100 0.4718 R
4 mg, Tablet, Oral 100 0.4724 B
5 mg, Tablet, Oral 100 0.4761 B
6 mg, Tablet, Oral 100 0.6752 R
7.5 mg, Tablet, Oral 100 0.6981 B
10 mg, Tablet, Oral 100 0.7244 B
Appendix E:
Glossary
Term Definition
Access A patient’s ability to obtain medical care. The ease of access is determined by
components such as the availability of medical services and their acceptability
to the patient, the location of health care facilities, transportation, hours of
operation and affordability of care.
Actual Acquisition Cost The pharmacist’s net payment made to purchase a drug product, after taking
into account such items as purchasing allowances, discounts, and rebates.
Actual Charge The amount a physician or other provider actually bills a patient for a
particular medical service, procedure or supply in a specific instance. The
actual charge may differ from the usual, customary, prevailing, and/or
reasonable charge.
Acute Care Medical treatment rendered to individuals whose illnesses or health problems
are of a short-term or episodic nature. Acute care facilities are those hospitals
that mainly serve persons with short-term health problems.
Additional Drug Benefit List A list of pharmaceutical products approved by a health plan and employer for
dispensing in larger quantities than the standards covered under a benefit
package in order to facilitate long-term patient use. The list is subject to
periodic review and modification by the health plan. Also called “drug
maintenance list.”
Administrative Costs The costs incurred by a carrier, such as an insurance company or HMO, for
services such as claims processing, billing and enrollment, and overhead
costs. Administrative costs can be expressed as a percentage of premiums or
on a per member per month basis. Additional costs that are often expressed as
administrative include those related to utilization review, insurance marketing,
medical underwriting, agents’ commissions, premium collection, claims
processing, insurer profit, quality assurance activities, medical libraries and
risk management.
Administrative Services Only (ASO) An insurance arrangement requiring the employer to be at risk for the cost of
health care services provided, while a separate company delivers
administrative services. This is a common arrangement when an employer
sponsors a self-funded health care program.
Adverse Selection A term used to describe a situation in which a health plan disproportionally
enrolls a population that is prone to higher than average utilization of benefits,
thereby driving up costs and increasing financial risk.
Term Definition
Aged For purposes of Medicare enrollment, persons 65 years of age or over are
considered to be aged. Medicaid eligibility is determined on the basis of
financial need for people who meet Supplemental Security Income eligibility
criteria (aged, blind, or disabled individuals) and Aid to Families with
Dependent Children criteria (adults and children). Eligibility determinations
are made for an entire economic unit or “case” (sometimes a family) based on
whether or not one member of a case meets the criteria. For example, an
“aged” case could consist of a 66 year old male and his 63 year old wife. In
contrast, a disabled enrollee could be over 65 years of age. May also be
defined as “Elderly.”
Agency for Health Care Policy and A federal agency under Health and Human Services (HHS) whose purpose is
Research (AHCPR) to enhance the quality and effectiveness of healthcare by funding healthcare
services research, conducting health technology assessments and outcomes
studies, and developing and disseminating clinical practice guidelines.
Aid to Families with Dependent A state-based federal cash assistance program for low-income families. In all
Children (AFDC) states, AFDC recipiency may be used to establish Medicaid eligibility. Now
known as Temporary Assistance to Needy Families (TANF).
Allied Health Personnel Specially trained and licensed (when necessary) health workers other than
physicians, dentists, optometrists, chiropractors, podiatrists and nurses. The
term is sometimes used synonymously with paramedical personnel, all health
workers who perform tasks that must otherwise be performed by a physician,
or health workers who do not usually engage in independent practice.
Allowable Charge The maximum fee that a third party will reimburse a provider for a given
service. An allowable charge may not be the same amount as either a
reasonable or customary charge.
Allowable Costs Charges for services rendered or supplies furnished by a health provider,
which qualify for an insurance reimbursement.
Ambulatory Care All types of health services that are provided on an outpatient basis, in
contrast to services provided in the home or to persons who are inpatients.
While many inpatients may be ambulatory, the term ambulatory care usually
implies that the patient must travel to a location to receive services which do
not require an overnight stay.
Ambulatory Surgery Any minor surgical procedures that can be performed at any type of medical
facility on an outpatient basis, i.e., not requiring an overnight stay.
American National Standards Institute A nonprofit organization that coordinates the development of voluntary
(ANSI) national standards in both the public and private sectors.
Ancillary Charge (1) The fee associated with additional service performed prior to and/or
secondary to a significant procedure. (2) Also referred to as hospital “extras”
or miscellaneous hospital charges. They are supplementary to a hospital’s
daily room and board charge. They include such items as charges for drugs,
medicines and dressings, lab services, x-ray examinations, and use of the
operating room.
Term Definition
Ancillary Services Hospital services other than room, board, and professional services. They
may include X-rays, lab tests, or anesthesia.
Any Willing Provider A requirement that a health insurance plan or a health maintenance
organization (HMO) must sign a contract for the delivery of healthcare
services with any provider in the area that would like to provide such services
to the plan’s or HMO’s enrollees, and can meet the terms of a contract.
Assignee The person to whom the rights to a health insurance policy are assigned, either
in part or in whole, by the original policyholder.
Assignment of Benefits A method under which a claimant requests that his/her benefits under a claim
be paid to some designated person or institution, usually a physician or
hospital.
Average Cost Per Claim The average dollar amount of administrative and/or medical services rendered
for the unit of measure within each expenditure category. The calculation is
$amount / #of units.
Average Manufacturer Price (AMP) The average price paid by wholesalers for products distributed to the retail
class of trade.
Average Wholesale Price (AWP) The published suggested wholesale price of a drug. It is often used by
pharmacies as a cost basis for pricing prescriptions.
Behavioral Health Care Assessment and treatment of mental and/or psychoactive substance abuse
disorders.
Benefit Maximum Specifies a dollar limit for the total reimbursement of health care costs during
a benefit period.
Term Definition
Benefit Package Services an insurer, government agency, or health plan offers to a group or
individual under the terms of a contract.
Best Price For purposes of Medicaid rebate calculations, lowest price paid for a product
by any purchaser other than Federal agencies and state pharmaceutical
assistance programs.
Biological Equivalents Those chemical equivalents which, when administered in the same amounts,
will provide the same biological or physiological availability, as measured by
blood levels, urine levels, etc.
Blue Book (MDBT) The generic name for a widely used pricing guide entitled the American
Druggist First Databank Annual Directory of Pharmaceuticals. Brand name
and generic drugs are listed by product, manufacturer, National Drug or
Universal Price Codes, direct price and average wholesale price (AWP).
Other pricing guides are the Red Book and Medispan’s Pricing Guide.
Cafeteria Plan An employee benefit plan under which all participants are permitted to choose
among two or more benefit options according to their needs and/or ability to
pay. Also called a flexible benefit plan of “flex plan.”
Capitation Fund A fund based on the number of members multiplied by the budgeted or
capitated amount each member pays. Some HMOs, in lieu of reimbursing
physicians on a direct capitation basis, may establish such a fund. Physicians
are then reimbursed on a fee-for-service basis from the capitation fund. The
HMO monitors patient visits for over-utilization; patients exceeding the norm
are notified.
Card Programs The use of a drug benefit identification card which, when presented to a
participating pharmacy by employees or their dependents, usually entitles
them to receive the medication for a copay.
Care Coordinator A primary health care practitioner: (1) who provides primary care services to
an enrollee, (2) who is generally responsible for coordinating the enrollee’s
healthcare, and (3) with whom, other than in an emergency, a patient must
consult to obtain a referral to a specialist provider in order to obtain the
highest level of benefits available under a health plan. Care coordinators are
sometimes called “gatekeepers.”
Term Definition
Case Management (1) A process whereby covered persons with specific health care needs are
identified and a plan designed to efficiently utilize healthcare resources is
formulated and implemented to achieve the optimum patient outcome in the
most cost-effective manner. (2) A utilization management program that assists
the patient in determining the most appropriate and cost-effective treatment
plan. It is used for patients who have prolonged expensive or chronic
conditions, helps determine the treatment location (hospital, or other
institution, or home), and authorizes payment for such care if it is not covered
under the patient’s benefit agreement.
Case Manager An experienced professional (e.g., nurse, doctor or social worker) who works
with patients, providers and insurers to coordinate all services deemed
necessary to provide the patient with a plan of medically necessary and
appropriate health care.
Categorically Needy Under Medicaid, categorically needy causes are aged, blind, or disabled
individuals or families and children who meet financial eligibility
requirements for Aid to Families with Dependent Children, Supplemental
Security Income, or an optional state supplement.
Certificate of Need (CON) A certificate issued by a government body, where required, to an individual or
organization proposing to construct or modify a health facility, acquire major
new medical equipment, or offer a new or different health service. Such
issuance recognizes that a facility or services, when available, will meet the
needs of those for whom it is intended.
Chain Pharmacy One of a group of pharmacies, usually three or more, under the same
management or ownership.
Charity Care Pools The assets of several funds combined to cover health care costs to the poor
and uninsured. The pools are established by organizations such as hospitals
and insurance companies to offset a portion of the cost for providing health
care to the indigent.
Chemical Equivalents Those multiple-source drug products containing identical amounts of the same
active ingredients, in equivalent dosage forms, and meeting existing
physical/chemical standards.
Chronic Care Care and treatment rendered to individuals whose health problems are of a
long-term and continuing nature. Rehabilitation facilities, nursing homes, and
mental hospitals may be considered chronic care facilities.
Claims Administration A carrier function involving the review of health insurance claims submitted
for payment, by individual claim or in the aggregate. Claims administration,
as it relates to professional review programs, is an identification procedure,
screening treatment or charge pattern, for subsequent peer review and
adjudication.
Claims Clearinghouse System A system which allows electronic claims submission through a single source.
Term Definition
Claims Review The method by which an enrollee’s health care service claims are reviewed
before reimbursement is made. The purpose of this monitoring system is to
validate the medical appropriateness of the provided services and to be sure
the cost of the service is not excessive.
Clearinghouse Capability A company capable of submitting electronic and/or paper claims to several
third-party payers.
Clinical Indicator A tool or marker used to monitor and evaluate care to assure desirable
outcomes and to explain or prevent undesirable outcomes.
Clinical Outcome The status of the patient’s health, especially after receipt of medical care
services. Assessment of outcomes may be dependent upon targeted goals,
clinical markers, and the ability to provide objective measurements.
Clinical Practice Guidelines Guidelines that specify the appropriate course(s) of treatment for specified
health conditions.
Closed-Panel HMO Generally offers the services of a relatively limited number of healthcare
providers, e.g., physicians employed by the HMO. Staff- and group-model
HMOs are usually referred to as being in this category.
Coinsurance The portion of covered healthcare costs for which the covered person has a
financial responsibility, usually according to a fixed percentage. Often
coinsurance applies after first meeting a deductible requirement.
Community Rating A method of determining a premium structure that is influenced not by the
expected level of benefit utilization by specific groups, but by expected
utilization by the population as a whole. Most often based on the entire
population of a metropolitan statistical area (MSA). The intent is to spread
risk over a large number of covered lives.
Competitive Medical Plan (CMP) A status granted by the federal government to an organization meeting
specified criteria, enabling that organization to obtain a Medicare risk
contract.
Comprehensive Benefits Plan A variation of the major medical plan which carries copayment requirements,
usually 10-20 percent of all health expenses and deductibles ranging from
$100 to $1,000.
Concurrent Drug Evaluation An electronic assessment of claims at the point of service to detect potential
problems that should be addressed prior to dispensing drugs to patients.
Consolidated Omnibus Reconciliation A federal law that, among other things, requires employers to offer continued
Act (COBRA) health insurance coverage to certain employees and their beneficiaries whose
group health insurance coverage has been terminated.
Consumer Price Index (CPI) A price index constructed monthly by the U.S. Bureau of Labor using retail
prices of goods and services sold in large cities across the country.
Continuous Quality Improvement A formal process of constantly seeking better ways to achieve stated goals.
(CQI)
Term Definition
Continuum of Care A range of clinical services provided to an individual or group, which may
reflect treatment rendered during a single inpatient hospitalization, or care for
multiple conditions over a lifetime. The continuum provides a basis for
analyzing quality, cost and utilization over the long term.
Contract Pharmacy System Pharmaceutical benefit delivery arrangement in which an HMO contracts with
community pharmacies (chain or selected independents) to provide
medications to members. Reimbursement may be by fee-for-service,
capitation, or some other arrangement.
Contributory Program A method of payment for group coverage in which part of the premium is paid
by the employee and part is paid by the employer or union.
Cosmetic Procedures Those procedures which involve physical appearance, but which do not
correct or materially improve a physiological function and are not deemed
medically necessary.
Cost Sharing Any provision of a health insurance policy that requires the insured to pay
some portion of medical expenses. The general term includes deductibles,
copayments, and coinsurance.
Cost Shifting The redistribution of payment sources. Typically, cost shifting occurs when
one payer obtains a discount on provider services, and the providers increase
costs to another payer to make up the difference.
Cost-Based Reimbursement Payment by third party insurers in which the amount is based on the cost to
the provider of delivering services.
Term Definition
Covered Expenses Medical and related costs, experienced by those covered under the policy, that
qualify for reimbursement under terms of the insurance contract.
Covered Services The specific services and supplies for which Medicaid will provide
reimbursement. Covered services under Medicaid consist of a combination of
mandatory and optional services within each state.
Customary Charge The charge a physician or supplier usually bills his patients for furnishing a
particular service or supply is called the customary charge.
Customary, Prevailing, and Reasonable Method of reimbursement which limits payment to the lowest of the
Charges following: physician’s actual charge, physician’s median charge in a recent
prior period (customary), or the 75th percentile of charges in the same time
period (prevailing).
Day Supply Maximum The maximum amount of medication a person may receive at one time,
usually the amount needed for 30 (acute) or 90 (maintenance) days of therapy,
as defined by the drug benefit.
Deductible An amount the insured person must pay before payments for covered services
begin. For example, an insurance plan might require the insured to pay the
first $250 of covered expenses during a calendar year before the insurance
company will begin payment.
Demand The amount of care a population seeks to obtain through the health delivery
system.
Depot Price The price(s) available to any depot of the federal government, for purchase of
drugs from the Manufacturer through the depot system of procurement.
Diagnostic Related Group (DRG) A system of classification for inpatient hospital services based on principal
diagnosis, secondary diagnosis, surgical procedures, age, sex and presence of
complications. This system of classification is used as a financing mechanism
to reimburse hospital and selected other providers for services rendered.
Disability (1) Any condition that results in functional limitations that interfere with an
individual’s ability to perform his/her customary work and which results in
substantial limitation in one of more major life activities. (2) Condition(s) that
prevent or limit an individual’s ability to engage in normal activities. These
may be temporary.
Disability Income Insurance Type of health insurance that periodically pays a disabled subscriber to
replace income lost during the period of disability.
Term Definition
Disease Management An effort to improve patient outcomes and lower costs by organizing managed
care initiatives around patients with a particular disease or condition.
Dispense As Written (DAW) A prescribing directive issued by physicians to indicate that the pharmacy
should not in any way alter a prescription. Such alterations are usually done
in order to substitute a generic drug for the brand-name drug ordered.
Dispensing, Fill or Professional Fee The amount paid to a pharmacy for each prescription, in addition to the
negotiated formula for reimbursing ingredient cost.
Drug Formulary A listing of prescription medications which are preferred for use by a health
plan and which may be dispensed through participating pharmacies to covered
persons. This list is subject to periodic review and modification by the health
plan. A plan that has adopted an “open or voluntary” formulary allows
coverage for both formulary and non-formulary medications. A plan that has
adopted a “closed, select or mandatory” formulary limits coverage to those
drugs in the formulary.
Drug Use Evaluation (DUE) Evaluations of prescribing patterns of prescribers to specifically determine the
appropriateness of drug therapy. There are three forms of DUE: prospective
(before or at the time of prescription dispensing), concurrent (during the
course of drug therapy), and retrospective (after the therapy has been
completed). Same as “Drug Utilization Review.”
Drug Utilization Review (DUR) A quantitative evaluation of prescription drug use, physician prescribing
patterns or patient drug utilization to determine the appropriateness of drug
therapy. Most often focuses on over utilization.
Early and Periodic Screening, The EPSDT program covers screening and diagnostic services to determine
Diagnosis, and Treatment (EPSDT) physical or mental defects in recipients under age 21, as well as health care
and other measures to correct or ameliorate any defects and chronic
conditions discovered.
Electronic Data Interchange (EDI) The computer-to-computer exchange of business or other information. The
data may be in either a standardized or priority format.
Employee Benefits Program Health insurance and other benefits, beyond salaries, offered to employees at
their place of work. The employer typically picks up all or part of the cost of
these benefits.
Employee Retirement Income Security A Federal act passed in 1974, that established new standards and
Act of 1974, Public Law 93-406 reporting/disclosure requirements for employer-funded pension and health
(ERISA) benefit programs. To date, self-funded health benefit plans operating under
ERISA have been held to be exempt from state insurance laws.
Term Definition
Enrollment The total number of covered persons in a health plan. Also refers to the
process by which a health plan signs up groups and individuals for
membership, or the number of enrollees who sign up in any one group.
Estimated Acquisition Cost (EAC) An estimate of the price generally, and currently, paid by providers for a drug
marketed or sold by a particular manufacturer or labeler in the package size
most frequently purchased by providers.
Exclusivity Clause A part of a contract which prohibits physicians from contracting with more
than one health maintenance organization or preferred provider organization.
Experience Rating The process of setting rates based partially or in whole on previous claims
experience and projected required revenues for a future policy year for a
specific group or pool of groups.
Experimental, Investigational or Medical, surgical, psychiatric, substance abuse or other healthcare services,
Unproven Procedures supplies, treatments, procedures, drug therapies or devices that are determined
by the health plan (at the time it makes a determination regarding coverage in
a particular case) to be either: not generally accepted by informed healthcare
professionals in the U.S. as effective in treating the condition, illness or
diagnosis for which their use is proposed; or not proven by scientific evidence
to be effective in treating the condition, illness or diagnosis for which their
use is proposed.
Extended Care Long-term care, ranging from routine assistance for daily activities to
sophisticated medical and nursing care for those needing it. The care, covered
under certain insurance policies, can be provided in homes, day-care centers
or other facilities.
Family Planning Services Any medically approved means, including diagnosis, treatment, drugs,
supplies and devices, and related counseling which are furnished or prescribed
by or under the supervision of a physician for individuals of childbearing age
for purposes of enabling such individuals freely to determine the number or
spacing of their children.
Favorable Selection A tendency for utilization of health services in a population group to be lower
than expected or estimated.
Federally Qualified HMOs HMOs that meet certain federally stipulated provisions aimed at protecting
consumers: e.g., providing a broad range of basic health services, assuring
financial solvency, and monitoring the quality of care. HMOs must apply to
the federal government for qualification. The Office of Prepaid Health Care of
the Health Care Financing Administration (HCFA) administers the process.
Fee Maximum The maximum amount a participating provider may be paid for a specific
healthcare service provided to a covered person under a specific contract.
Sometimes called “fee max.”
Term Definition
Fee Schedule A listing of codes and related services with pre-established payment amounts
that could be percentages of billed charges, flat rates or maximum allowable
amounts.
Fee-for-Service Reimbursement The traditional healthcare payment system, under which physicians and other
providers receive a payment that does not exceed their billed charge for each
unit of service provided. Fees are paid as care is rendered.
First-Dollar Coverage Health policies that pay all or a portion of medical expenses upon enrollment,
without a deductible charge.
Fiscal Agent A contractor that processes or pays vendor claims on behalf of a Medicaid
agency.
Fiscal Intermediary The agent that has contracted with providers of service to process claims for
reimbursement under health care coverage. In addition to handling financial
matters, it may perform other functions such as providing consultative
services or serving as a center for communication with providers and making
audits of providers’ records.
Fiscal Year Any predetermined set of 12 months for which annual accounts are kept. The
Federal Government’s fiscal year extends from Oct. 1 to the following Sept.
30.
Fixed Fee An established “fee” schedule for pharmacy services allowed by certain
government and private third-party programs in lieu of cost-of-doing business
markups.
Free-Standing Hospital Any hospital that is not affiliated with a multihospital system.
Freedom-of-Choice (FOC) Legislation requiring managed care organizations to allow members to choose
providers whether or not they connect with the plans (often coupled with any
willing provider (AWP) legislation).
Generic Drug A chemically equivalent copy of a brand-name drug whose patent has expired.
Drug formulations must be of identical composition with respect to the active
ingredient (i.e., meet official standards of identity, purity, and quality of active
ingredient). Also called generic equivalent.
Global Target A financing method identical to a global budget except that no enforcement
mechanism is used to keep providers and hospitals within budget (i.e.,
providers and hospitals will receive additional funding if their costs exceed
their budgeted payments).
HCFA 1500 A universal form developed by the government agency known as Health Care
Financing Administration (HCFA), for providers of services to bill
professional fees to health carriers.
Term Definition
HCFA Common Procedural Coding A listing of services, procedures and supplies offered by physicians and other
System (HCPCS) providers. HCPCS includes current procedural terminology (CPT) codes,
national alphanumeric codes and local alphanumeric codes. The national
codes are developed by HCFA in order to supplement CPT codes. They
include physician services not included in CPT as well as non-physician
services such as ambulance, physical therapy and durable medical equipment.
The local codes are developed by local Medicare carriers in order to
supplement the national codes. HCPCS codes are 5-digit codes, the first digit
a letter followed by four numbers. HCPCS codes beginning with A through V
are national; those beginning with W through Z are local.
Health Care Financing Administration The government agency within the Department of Health and Human Services
(HCFA) which directs the Medicare and Medicaid programs (Titles XVIII and XIX of
the 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 per
month to provide Medicare-eligible Part B medical services to enrolled
members. Members pay premiums to cover the Medicare coinsurance,
deductibles and copayments, plus any additional non-Medicare covered
services that the plan provides. The HCPP does not arrange for Part A
services.
Health Insurance
Financial protection against the medical care costs arising from disease or
accidental bodily injury. Such insurance usually covers all or part of the
medical costs of treating the disease or injury. Insurance may be obtained on
either an individual or a group basis.
Health Insuring Organization (HIO) An entity that provides for or arranges for the provision of care and contracts
on a prepaid capitated risk basis to provide a comprehensive set of services.
Health Maintenance Organizations (1) An entity that provides, offers or arranges for coverage of designated
(HMO’s) health services needed by plan members for a fixed, prepaid premium. There
are four basic models of HMOs: staff model, group model, network model
and individual practice association; (2) Under the federal HMO Act, an entity
must have three characteristics to call itself an HMO: (a) An organized system
for providing healthcare or otherwise assuring healthcare delivery in a
geographic area, (b) An agreed upon set of basic and supplemental health
maintenance and treatment services, and (c) A voluntary enrolled group of
people.
Health Plan An organization that provides a defined set of benefits; this term usually refers
to an HMO-like entity, as opposed to an indemnity insurer.
Health Plan Employer Data and A core set of performance measures to assist employers and other health
Information Set (HEDIS) purchasers in understanding the value of healthcare purchases and evaluating
health plan performance. HEDIS 3.0 is currently used and distributed by
NCQA (National Committee for Quality Assurance).
HMO - Group Model A healthcare model involving contracts with physicians organized as a
partnership, professional corporation, or other association. The health plan
compensates the medical group for contracted services at a negotiated rate,
and that group is responsible for compensating its physicians and contracting
with hospitals for care of their patients.
Term Definition
HMO - Individual Practice Association A healthcare model that contracts with physicians and other community
(IPA) healthcare providers, to provide services in return for a negotiated fee.
Physicians continue in their existing individual or group practices and are
compensated on a per capita, fee schedule, or fee-for-service basis.
HMO - Network Model An HMO type in which the HMO contracts with more than one physician
group, and may contract with single- and multi-specialty groups. The
physician works out of his/her own office. The physician may share in
utilization savings, but does not necessarily provide care exclusively for HMO
members.
HMO - Staff Model A healthcare model that employs physicians to provide healthcare to its
members. All premiums and other revenues accrue to the HMO, which
compensates physicians by salary and incentive programs.
Home Health Agency (HHA) A facility or program licensed, certified or otherwise authorized pursuant to
state and federal laws to provide healthcare services in the home.
Home Health Services Services and items furnished to an individual who is under the care of a
physician by a home health agency or by others under arrangements made by
such agency. Services are furnished under a plan established and periodically
reviewed by a physician. They are provided on a visiting basis in an
individual’s home and include: nursing, physical therapy, dietary, counseling,
and social services; part-time or intermittent skilled nursing care; physical,
occupational, or speech therapy; medical social services, medical supplies and
appliances (other than drugs and biologicals); home health aide services; and
services of interns and residents.
Hospice A program that provides palliative and supportive care for terminally ill
patients and their families, either directly or on a consulting basis with the
patient's physician or another community agency. Originally a medieval name
for a way station for crusaders where they could be replenished, refreshed,
and cared for, hospice is used here for an organized program of care for
people going through life's "last station." The whole family is considered the
unit of care, and care extends through their period of mourning.
Indemnity Insurance An insurance program in which the insured person is reimbursed or the
provider is paid for covered expenses after services are rendered.
Inpatient Hospital Services Items and services furnished to a resident patient of a hospital by the hospital.
May include such items as: bed and board; nursing and related services;
diagnostic and therapeutic services; and medical or surgical services.
Integrated Behavioral Health A carve-out benefit plan that combines independent managed care services
into what is designed as a seamless delivery system for behavioral health
concerns. Components could include employee assistance services, a
telephone counseling triage, utilization management, behavioral health
treatment networks, claims payment, and data management.
Integrated Delivery System A generic term referring to a joint effort of physician/hospital integration for a
variety of purposes. Some models of integration include physician-hospital
organization, group practice without walls, integrated provider organization
and medical foundation.
Term Definition
Intensive Care Skilled nursing services, usually in a hospital, prescribed by a physician for
individuals with serious medical conditions and delivered with the guidance of
a registered nurse.
Intermediate Care Facility (ICF) An institution that is licensed under state law to provide on a regular basis,
health-related care and services to individuals who do not require the degree
of care or treatment which a hospital or skilled nursing facility is designed to
provide. Public institutions for care of the mentally retarded or people with
related conditions are also included in the definition. The distinction between
"health-related care and services" and "room and board" has often proven
difficult to make but is important because ICFs are subject to quite different
regulations and coverage requirements than institutions which do not provide
health-related care and services.
International Classification of Diseases, A listing of diagnoses and identifying codes used by physicians for reporting
9th Edition (Clinical Modification) diagnoses of health plan enrollees. The coding and terminology provide a
(ICD-9-CM) uniform language that can accurately designate primary and secondary
diagnoses and provide for reliable, consistent communications on claim
forms.
Investigational Treatments Medical treatments, including drugs waiting for FDA approval, that are
considered experimental and, therefore, may not be covered by insurance
plans. The definition of experimental currently varies from plan to plan.
Laboratory and Radiological Services Professional and technical laboratory and radiological services ordered by a
licensed practitioner, provided in an office or similar facility (other than a
hospital outpatient department or clinic) or by a qualified lab.
Legend Drug A drug that, by law, can be obtained only by prescription and bears the label,
“Caution: federal law prohibits dispensing without a prescription.” See
“Prescription Medication.”
Lifetime Maximum Benefit A limitation on financial coverage for healthcare for an individual stated by an
insurer. This amount serves as a cap on contractual liability and can be
exceeded only in rare and unusual circumstances.
Long Term Care A set of health care, personal care and social services required by persons
who have lost, or never acquired, some degree of functional capacity (e.g., the
chronically ill, aged, disabled, or retarded) in an institution or at home, on a
long-term basis. The term is often used more narrowly to refer only to long-
term institutional care such as that provided in nursing homes, homes for the
retarded and mental hospitals. Ambulatory services such home health care,
which can also be provided on a long-term basis, are seen as alternatives to
long-term institutional care.
Magnetic Resonance Imaging State-of-the-art machine used as a diagnostic tool, using fields to produce
comprehensive pictures of the anatomy.
Managed Care (1) A system of healthcare delivery that influences utilization and cost of
services and measures performance. The goal is a system that delivers value
by giving people access to high quality, cost-effective healthcare; (2) A
systemized approach which seeks to ensure the provision of the right
healthcare at the right time, place and cost.
Term Definition
Managed Care Organization (MCO) Broad term that encompasses various types of health plans, including Health
Maintenance Organizations (HMOs), Preferred Provider Organizations
(PPOs), Point-of-Service plans (POSs) and Provider-Sponsored Organizations
(PSOs). Often used to refer to a health plan that is similar to an HMO but
which does not have an HMO license and serves only Medicaid beneficiaries.
Mandated Benefits Those benefits which health plans are required by state or federal law to
provide to policyholders and eligible dependents.
Maximum Allowable Cost, or A maximum cost is fixed for which the pharmacist can be reimbursed for
“Reasonable Cost Range” selected products, as identified in a “formulary.”
Maximum Out-of-Pocket Costs The limit on total member copayments, deductibles and coinsurance under a
benefit contract.
Medicaid Buy-In A provision in certain health reform proposals whereby the uninsured would
be allowed to purchase Medicaid coverage by paying premiums on a sliding
scale based on income.
Medicaid Management Information Federally developed guidelines for a computer system designed to achieve
System (MMIS) national standardization of Medicaid claims processing, payment, review and
reporting for all health care claims.
Medical Necessity The evaluation of healthcare services to determine if they are: medically
appropriate and required to meet basic health needs; consistent with the
diagnosis or condition and rendered in a cost-effective manner; and consistent
with national medical practice guidelines regarding type, frequency and
duration of treatment.
Medical Savings Account (MSA) A non-taxable savings account used to cover medical expenses. Based
loosely on the idea of individual retirement accounts.
Medically Needy Under Medicaid, medically needy cases are aged, blind, or disabled
individuals or families and children who are not otherwise eligible for
Medicaid, and whose income resources are above the limits for eligibility as
categorically needy (AFDC or SSI) but are within limits set under the
Medicaid state plan.
Term Definition
Medicare (Part A/Part B) A U.S. health insurance program for people aged 65 and over, for persons
eligible for social security disability payments for two years or longer, and for
certain workers and their dependents who need kidney transplantation or
dialysis. Monies from payroll taxes and premiums from beneficiaries are
deposited in special trust funds for use in meeting the expenses incurred by
the insured. It consists of two separate but coordinated programs: hospital
insurance (Part A) and supplementary medical insurance (Part B).
Medicare Payment Advisory A federal commission established under the Balanced Budget Act of 1997 to
Commission (MedPAC) advise and assist Congress and the Department of Health and Human Services
in maintaining and updating the Medicare prospective payment system.
MedPAC replaces and assumes the responsibilities of the Physician Payment
Review Commission (PPRC) and the Prospective Payment Assessment
Commission (ProPAC).
Medicare Supplemental Insurance A policy guaranteeing that a health plan will pay a policyholder’s coinsurance,
deductible and copayments and will provide additional health plan or non-
Medicare coverage for services up to a predefined benefit limit. In essence,
the product pays for the portion of the cost of services not covered by
Medicare. Also called “Medigap” or “Medicare wrap.”
Modified Fee-for-Service A system in which providers are paid on a fee-for-service basis, with certain
fee maximums for each procedure.
Most Favored Nations Discount or A contractual agreement that stipulates that a vendor must provide to a
Clause particular payor the lowest prices that would be available to any purchaser.
The federal government often invokes most favored nation clauses for
healthcare contracts.
National Committee for Quality A national organization founded in 1979 composed of 14 directors
Assurance (NCQA) representing consumers, purchasers, and providers of managed health care. It
accredits quality assurance programs in prepaid managed health care
organizations, and develops and coordinates programs for assessing the
quality of care and service in the managed care industry, including the HEDIS
quality measures.
National Drug Code (NDC) A national classification system for identification of drugs. Similar to the
Universal Product Code (UPC).
Network Plan A phrase that generally refers to arrangements where providers contract with
payers or a managed care plan to provide services for patients enrolled in the
managed care plan. See “Managed Care.”
Term Definition
Other Practitioners’ Services Health care services of licensed practitioners other than physicians and
dentists.
Out-of-Pocket Costs/Expenses (OOPs) The portion of payments for health services required to be paid by the
enrollee, including copayments, coinsurance and deductibles.
Out-of-Pocket Limit The total payments toward eligible expenses that a covered person funds for
him/herself and/or dependents: i.e., deductibles, copays and coinsurance - as
defined per the contract. Once this limit is reached, benefits will increase to
100% for health services received during the rest of that calendar year. Some
out-of-pocket costs (e.g., mental health, penalties for non-precertification,
etc.) are not eligible for out-of-pocket limits.
Outcome Measures Assessments which gauge the effect or results of treatment for a particular
disease or condition. Outcome measures include such parameters as: the
patient’s perception of restoration of function, quality of life and functional
status, as well as objective measures of mortality, morbidity and health status.
Outcomes Research Studies aimed at measuring the effect of a given product, procedure, or
medical technology on health or costs.
Outpatient Services Outpatient services are medical and other services provided on a non-resident
basis (patients are not admitted to the facility) by a hospital or other qualified
facility, such as a mental health clinic, rural health clinic, mobile X-ray unit,
or freestanding dialysis unit. Such services include outpatient physical therapy
services, diagnostic X-ray and laboratory tests, and X-ray and other radiation
therapy.
Over-the-Counter (OTC) A drug product that does not require a prescription under federal or state law.
Participating Provider A provider who has contracted with the health plan to provide medical
services to covered persons. The provider may be a hospital, pharmacy, other
facility or a physician who has contractually accepted the terms and
conditions as set forth by the health plan.
Patient Health Status Survey Questionnaire used to solicit patient perceptions regarding the state of their
health. Questions may be general and address overall health status with regard
to a specific condition (e.g., an arthritic patient’s ability to make a fist or an
asthmatic patient’s ability to climb a flight of stairs).
Patient Satisfaction Survey Questionnaire used to solicit the perceptions the plan enrollees or patients
have regarding how a health plan meets their medical needs and how the
delivery of care is handled, (e.g., waiting time, access to treatments).
Term Definition
Payer A general term indicating the responsible party for the payment of medical
care service expenses. Payers may be patients, insurance companies,
government agencies, or a combination of these.
Peer Review The evaluation of quality of total healthcare provided, by medical staff with
equivalent training.
Peer Review Organization (PRO) An entity established by the Tax Equity and Fiscal Responsibility Act of 1982
(TERFA) to review quality of care and appropriateness of admissions,
readmissions and discharges for Medicare and Medicaid. These organizations
are held responsible for maintaining and lowering admission rates, and
reducing lengths of stay while insuring against inadequate treatment. Also
known as “Professional Standards Review Organization.”
Pharmacy And Therapeutics (P&T) An organized panel of physicians and pharmacists from varying practice
Committee specialties, who function as an advisory panel to the plan regarding the safe
and effective use of prescription medications. Often compromises the official
organizational line of communication between the medical and pharmacy
components of the health plan. A major function of such a committee is to
develop, manage and administer a drug formulary.
Physician Any doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who is duly
licensed and qualified under the law of jurisdiction in which treatment is
received.
Physician-Hospital Organization A legal entity formed by a hospital and a group of physicians to further mutual
(PHO) interests and to achieve market objectives. A PHO generally combines
physicians and a hospital into a single organization for the purpose of
obtaining payer contracts. Doctors maintain ownership of their practices and
agree to accept managed care patients according to the terms of a professional
service agreement with the PHO. The PHO serves as a collective negotiating
and contracting unit. It is typically owned and governed jointly by a hospital
and shareholder physicians.
Point-Of-Service (POS) Plan A health plan allowing the covered person to choose to receive a service from
a participating or non-participating provider, with different benefit levels
associated with the use of participating providers. POS can be provided in
several ways: an HMO may allow members to obtain limited services from
non-participating providers; an HMO may provide non-participating benefits
through a supplemental major medical policy; a PPO may be used to provide
both participating and non-participating levels of coverage and access; or
various combinations of the above may be used.
Portability Requirement that health plans guarantee continuous coverage without waiting
periods for persons moving between plans.
Term Definition
Pre-Existing Condition (PEC) Any medical condition that has been diagnosed or treated within a specified
period immediately preceding the covered person’s effective date of coverage
under the master group contract.
Preferred Provider Organization A program in which contracts are established with providers of medical care.
(PPO) Providers under such contracts are referred to as preferred providers. Usually,
the benefit contract provides significantly better benefits (fewer copayments)
for services received from preferred providers, thus encouraging covered
persons to use these providers. Covered persons are generally allowed
benefits for non-participating providers’ services, usually on an indemnity
basis with significantly higher copayments. A PPO arrangement can be
insured or self-funded. Providers may be, but are not necessarily, paid on a
discounted fee-for-service basis.
Prepaid Group Practice Plans Organized medical groups of essentially full-time physicians in appropriate
specialties, as well as other professional and subprofessional personnel, who,
for regular compensation, undertake to provide comprehensive care to an
enrolled population for premium payments that are made in advance by the
consumer and/or their employers.
Prepaid Health Plan (PHP) An entity that provides a non-comprehensive set of services on either
capitated risk or non-risk basis or the entity provides comprehensive services
on a non-risk basis.
Prescribed Drugs Prescribed drugs are drugs dispensed by a licensed pharmacist on the
prescription of a practitioner licensed by law to administer such drugs, and
drugs dispensed by a licensed practitioner to his own patients. This item does
not include a practitioner’s drug charges that are not separable from his other
charges, or drugs covered by a hospital bill.
Prescription Medication A drug which has been approved by the Food and Drug Administration and
which can, under federal and state law, be dispensed only pursuant to a
prescription order from a duly licensed prescriber, usually a physician.
Preventive Care Comprehensive care emphasizing priorities for prevention, early detection and
early treatment of conditions, generally including routine physical
examinations, immunization and well person care.
Primary Care Case Management Managed care arrangements where primary care providers receive a per capita
(PCCM) management fee to coordinate a patient's care in addition to reimbursement
(fee-for-service or capitation) for the medical services they provide.
Term Definition
Primary Care Physician (PCP) The primary care practitioner (e.g., internist, family/general practitioner,
pediatrician, and in some cases, OB/Gyn) in managed care organizations who
determines whether the presenting patient needs to see a specialist or requires
other non-routine services. See Care Coordinator.
Prior Authorization The process of obtaining prior approval as to the appropriateness of a service
or medication. Prior authorization does not guarantee coverage.
Prospective Financing Financing for health care services based on prices or budgets determined prior
to the delivery of service. Payments can be per unit of service, per member, or
per time period. In all its forms prospective financing differs from cost-based
reimbursement, under which a provider is paid for costs incurred.
Providers A physician, hospital, group practice, nurse, nursing home, pharmacy or any
individual or group of individuals that provides a healthcare service.
Quality assurance (QA) or quality A formal set of activities to review and affect the quality of services provided.
improvement (QI) Quality assurance includes assessment and corrective actions to remedy any
deficiencies identified in the quality of direct patient, administrative and
support services.
Rate Setting A form of financing under which hospitals or nursing homes are paid prices
that are prospectively determined, generally by a state agency. Prospectively
determined prices may be paid by all payers for all covered services, as in all
payer systems, or by only some payers. The unit of payment can be service,
patient, or time period. See “Prospective Financing.”
Rational Drug Therapy Prescribing the right drug for the right patient, at the right time, in the right
amount, and with due consideration of relative cost.
Reasonable Charge In processing claims for Supplementary Medical Insurance benefits, carriers
use HCFA guidelines to establish the reasonable charge for services rendered.
The reasonable charge is the lowest of: the actual charge billed by the
physician or supplier; the charge the physician or supplier customarily bills
his patients for the same services, and the prevailing charge which most
physicians or suppliers in that locality bill for the same service. Increases in
the physicians’ prevailing charge levels are recognized only to the extent
justified by an index reflecting changes in the costs of practice and in general
earnings.
Reasonable Cost In processing claims for Health Insurance benefits, intermediaries use HCFA
guidelines to determine the reasonable cost incurred by the individual
providers in furnishing covered services to enrollees. The reasonable cost is
based on the actual cost of providing such services, including direct and
indirect costs of providers, excluding any costs that are unnecessary in the
efficient delivery of services covered by the insurance program.
Term Definition
Referral The process of sending a patient from one practitioner to another for health
care services. Health plans may require that designated primary care providers
authorize a referral for coverage of specialty services.
Restrictive Formulary A term often used synonymously with closed formulary. See “Drug
Formulary.”
Retrospective Review Determination of medical necessity and/or appropriate billing practice for
services already rendered.
Risk Responsibility for paying for or otherwise providing a level of health care
services based on an unpredictable need for these services.
Risk Contract (1) An agreement between HCFA and an HMO or competitive medical plan
requiring the HMO to furnish at a minimum all Medicare covered services to
Medicare eligible enrollees for an annually determined, fixed monthly
payment rate from the government and a monthly premium paid by the
enrollee. The HMO is then liable for services regardless of their extent,
expense or degree. (2) An agreement between a provider and payer, or
intermediary, on behalf of a payer, that requires the provider to furnish all
specified services for a specified enrollee for a set fee, usually prepaid, and
for a set period of time (usually one year). The provider is then liable for
services regardless of their extent, expense or degree. Such stated limitations
for such liability are stated in advance and may be subject to reinsurance.
Rural Health Clinic A rural health clinic is an outpatient facility which is primarily engaged in
furnishing physicians’ and other medical and health services, which meets
certain other requirements designed to ensure the health and safety of the
individuals served by the clinic. The clinic must be located in an area that is
not urbanized as defined by the Census Bureau and that is designated by the
Secretary of DHHS either as an area with a shortage of personal health
services, or as a health manpower shortage area, and has filed an agreement
with the Secretary not to charge any individual or other person for items or
services for which such individual is entitled to have payment made by
Medicare, except for the amount of any deductible or coinsurance amount
applicable.
Secondary Care Services provided by medical specialists, such as cardiologists, urologists and
dermatologists, who generally do not have first contact with patients. See also
“Primary Care.”
Section 1115 Waivers Section 1115 of the Social Security Act grants the Secretary of Health and
Human Services broad authority to waive certain laws relating to Medicaid for
the purpose of conducting pilot, experimental or demonstration projects.
Section 1115 demonstration waivers allow states to change provisions of their
Medicaid programs, including: eligibility requirements, the scope of services
available, the freedom to choose a provider, a provider’s choice to participate
in a plan, the method of reimbursing providers, and the statewide application
of the program. Projects typically run three to five years.
Term Definition
Section 1915(b) Waivers Prior to the passage of the Balanced Budget Act (BBA) of 1997, Section
1915(b) freedom-of-choice waivers allowed states to require Medicaid
recipients to enroll in HMOs or other managed care plans in an effort to
control costs. The waivers allowed states to: implement a primary care case-
management system; require Medicaid recipients to choose from a number of
competing health plans; provide additional benefits in exchange for savings
resulting from recipients’ use of cost-effective providers; and limit the
providers from which beneficiaries can receive non-emergency treatment.
Under the BBA, states can enroll recipients into managed care without
applying for 1915(b) waivers.
Sin Taxes Taxes imposed on items considered harmful to public health interests, such as
tobacco and alcohol.
Skilled Nursing Facility (SNF) A facility, either freestanding or part of a hospital, that accepts patients in
need of rehabilitation and medical care that is of a lesser intensity than that
received in a hospital.
Skilled Nursing Facility Services All services furnished to inpatients of, and billed for by, a formally certified
skilled nursing facility that meets standards set by Secretary of DHHS.
State Buy-In The term given to the process by which a state may provide Supplementary
Medical Insurance coverage for its needy eligible persons through an
agreement with the Federal government under which the state pays the
premiums for them.
State Mandated Benefits Laws State laws requiring insurance contracts to provide coverage for certain health
services (e.g., in vitro fertilization) or services provided by certain health care
providers (e.g., audiologists). Self-insureds are exempt from these
requirements. There are over 800 mandates nationwide.
Stop Loss That point at which a third party has reinsurance to protect against the overly
large single claim or the excessively high aggregate claim during a given
period of time. Large employers, who are self-insured, may also purchase
“reinsurance” for stop-loss purposes.
Supplemental Security Income (SSI) A federal cash assistance program for low-income aged, blind and disabled
individuals established by Title XVI of the Social Security Act. States may
use SSI income limits to establish Medicaid eligibility.
Term Definition
Tax Equity and Fiscal Responsibility The federal law which created the current risk and cost contract provisions
Act of 1982 (TEFRA) under which health plans contract with HCFA and which defined the primary
and secondary coverage responsibilities of the Medicare program.
Temporary Assistance to Needy Federal-state welfare program which replaces Aid to Families with Dependent
Families (TANF) Children. Authorized by the 1996 Welfare Reform Act. States may use
TANF to establish Medicaid eligibility.
Therapeutic Alternatives Drug products containing different chemical entities but which should provide
similar treatment effects, the same pharmacological action or chemical effect
when administered to patients in therapeutically equivalent doses.
Therapeutic Substitution Dispensing by a pharmacist of a product different from that which was
prescribed, but which is deemed to be therapeutically equivalent. In most
states such a practice requires the prescribing physician’s authorization before
the substitution may occur. A pharmacy and therapeutics committee (P&T)
most often approves the rationale for therapeutic equivalency prior to such
practice.
Third-Party Administrator (TPA) An independent person or corporate entity (third party) that administers group
benefits, claims and administration for a self-insured company/group. A TPA
does not underwrite the risk.
Third-Party Liability Under Medicaid, third-party liability exists if there is any entity (i.e., other
government programs or insurance) which is or may be liable to pay all or
part of the medical cost or injury, disease, or disability of an applicant or
recipient of Medicaid.
Universal Access The availability of affordable public or private insurance coverage for every
United States citizen or legal resident. There is no guarantee, however, that all
individuals will actually choose to purchase or have the funds to purchase
coverage. See “Universal Coverage.”
Universal Coverage The guaranteed provision of at least basic health care services to every United
States citizen or legal resident. See “Universal Access.”
Usual, Customary and Reasonable A term used to refer to the commonly charged or prevailing fees for health
Charges services within a geographic area. A fee is considered to be reasonable if it
falls within the parameters of the average or commonly charged fee for the
particular service within that specific community.
Utilization The extent to which the members of a covered group use a program or obtain
a particular service, or category of procedures, over a given period of time.
Usually expressed as the number of services used per year or per 100 or 1,000
persons eligible for the service.
Utilization Management (UM) A process of integrating review and case management of services in a
cooperative effort with other parties, including patients, providers, and payers.
Term Definition
Vendor Payments In welfare programs, direct payments are made by the state to providers such
as physicians, pharmacists and health care institutions rather than to the
welfare recipient himself.
Withhold “At-risk” portion of a claim deducted and withheld by the health plan before
payment is made to a participating physician as an incentive for appropriate
utilization and quality of care. This amount – for example, 20% of the claim
– remains within the plan and is credited to the doctor’s account. Can be used
where the plan needs additional funds to pay for claims. The withhold may be
returned to the physician in varying levels which are determined based on
analysis of his/her performance or productivity compared against his/her
peers. Also called “physician contingency reserve (PCR).”
ACRONYMS
POS Point-of-Service
PPO Preferred Provider Organization
PRO Peer Review Organization
ProPAC Prospective Payment Assessment Commission
PT Physical Therapy
QA/QI Quality Assurance/Quality Improvement
RHC Rural Health Clinic
RPH Registered Pharmacist
Rx Pharmaceutical
SFO State Funds Only
SNF Skilled Nursing Facility
SSA Social Security Administration
SSI Supplemental Security Income
SSP State Supplemental Payments
TANF Temporary Assistance for Needy Families
TDOC Total Days of Care
TEFRA Tax Equity & Fiscal Responsibility Act
TPA Third-Party Administrator
TQM Total Quality Management
UCR Usual, Customary and Reasonable
UM Utilization Management
UR Utilization Review
WAC Weighted Average Cost OR Wholesale Acquisition Cost