Pharmaceutical Benefits Under State Medical Assistance Programs, 2007

Pharmaceutical Benefits
Under State Medical

Assistance Programs
2007
Published by the
National Pharmaceutical Council, Inc.
1894 Preston White Drive
Reston, VA 20191-5433
©2007
by the National Pharmaceutical Council
This compilation of data on State Medical Assistance Programs (Title XIX) presents a general
overview of the characteristics of State programs, together with detailed information on the
pharmaceutical benefits provided. The data collection effort covers all States with Medicaid programs
and the District of Columbia.
Information for this compilation was acquired from multiple sources, including a survey of Medicaid
prescription drug programs administered for the National Pharmaceutical Council by United
BioSource Corporation with assistance from Total Compensation Solutions. Additional assistance
was provided by StateScape and Hmetrix. While we have checked all secondary data in the book for
consistency relative to the original source, we have not validated the original data reported by the
Centers for Medicare and Medicaid Services (CMS) and other organizations.
The data in this compilation were compiled under the direction of David Goldenberg, Ph.D., with
assistance from Errica Philpott, Steven Heath, Stanley Weintraub, Edward Steinhouse, J.D., Elizabeth
Segall, Vishal Gupta, and Michael Sanky of United BioSource Corporation. Paul Gavejian, Michael
Steele, and Matthew Leach of Total Compensation Solutions prepared and conducted the 2007 survey.
George Chalissery and Hmetrix were responsible for aggregating the data on number of prescriptions
and drug expenditures by therapeutic category. David Schulz at StateScape provided updated
information on State officials, State professional societies, and State pharmaceutical assistance
programs. As always, Gary Persinger and Kimberly Westrich of the National Pharmaceutical Council
provided valuable input and support.
National Pharmaceutical Council Pharmaceutical Benefits 2007
TABLE OF CONTENTS
SECTION 1: INTRODUCTION .......................................................................................................... 1-1
SECTION 2: THE MEDICAID PROGRAM ..................................................................................... 2-1

Medicaid Program Overview .................................................................................................... 2-3
- Total Medicaid Eligibles by Maintenance Assistance Status, 2004 ........................ 2-11
- Total Medicaid Eligibles by Age Group, 2004........................................................ 2-12
- Total Medicaid Eligibles by Gender, 2004.............................................................. 2-13
- Total Medicaid Eligibles by Race/Ethnicity 2004................................................... 2-14
- Total Medicaid Eligibles by Basis of Eligibility, 2004 ........................................... 2-15
- Total Medicaid Eligibles per 1000 Population, 2004 .............................................. 2-16
- Total Net U.S. Medical Assistance Expenditures by Type of Service,
FY 2004 and FY 2005 ............................................................................................. 2-17
- Federal Medical Assistance Percentages (FMAP), FY 2007 and FY 2008 ............ 2-18
- Medicaid Total Net Expenditures and Eligibles, 2004 ............................................ 2-19
- Total Medicaid Program Expenditures, 2005 .......................................................... 2-20
- Total SCHIP Enrollment, 2005 ............................................................................... 2-21
- Total SCHIP Enrollment, 2006 ............................................................................... 2-22
- Total SCHIP Expenditures, 2005 ............................................................................ 2-23
- Total Medicaid/Medicare Dual Eligibles by Dual Eligibility Type, 2004 .............. 2-24
- Total Medicaid Medical Vendor Payments and Dual Eligibility Status, 2004 ....... 2-26
Medicaid Managed Care Enrollment ................................................................................... 2-29
- Medicaid Managed Care Enrollment, As of June 30, 2006..................................... 2-31
- Pharmaceutical Benefits Under Managed Care Plans ............................................. 2-32
- Medicaid Managed Care Enrollment Trends, 2001-2006 ....................................... 2-33
- Medicaid Managed Care Plan Type, As of June 30, 2006 ...................................... 2-34
- Medicaid Managed Enrollment by Plan Type, As of June 30, 2006 ....................... 2-35
- Medicaid Managed Care Enrollment by Payment Arrangement,
As of June 30, 2006 ................................................................................................. 2-36
Medicaid Managed Care Waivers .......................................................................................... 2-37
- Section 1915(b) and 1115 Waivers ......................................................................... 2-39
SECTION 3: STATE CHARACTERISTICS .................................................................................... 3-1

- Age Demographics, 2006 .......................................................................................... 3-5
- Race Demographics, 2006 ......................................................................................... 3-6
- Hispanic Demographics, 2006 ................................................................................... 3-7
- Insurance Status-Populations, 2006........................................................................... 3-8
- Insurance Status-Percentages, 2006 .......................................................................... 3-9
- Poverty Status-Populations, 2006 ............................................................................ 3-10
- Poverty Status-Percentages, 2006............................................................................ 3-11
- Employment Status, 2006 ........................................................................................ 3-12
- Medicaid/Medicare Certified Facilities, 2006 ......................................................... 3-13
- Licensed Pharmacies, As of June 30, 2006 ............................................................. 3-14
- Physicians, 2005 ...................................................................................................... 3-16
- Other Providers, 2004/2006 ..................................................................................... 3-17
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SECTION 4: PHARMACY PROGRAM CHARACTERISTICS..................................................... 4-1

The Medicaid Drug Program.................................................................................................... 4-3
- Drug Expenditures Trends, 2004-2005 ..................................................................... 4-5
- Ranking Based on Drug Expenditures, 2004-2005 ................................................... 4-6
- Drugs as a Percentage of Total Net Expenditures, 2005 ........................................... 4-7
- Drugs as a Percentage of Total Net Expenditures, 2003-2005 .................................. 4-8
- Drug Expenditures by Category, 2004 ...................................................................... 4-9
- Prescriptions Processed by Category, 2004............................................................. 4-11
- Medicaid Average Cost per Prescription, 2004 ....................................................... 4-13
- Drug Expenditures by Category, 2005 .................................................................... 4-14
- Drug Expenditures by Category, 2006 .................................................................... 4-19
Medicaid Drug Rebates ........................................................................................................... 4-24
- Medicaid Drug Rebates, 2005 ................................................................................. 4-25
- Medicaid Drug Rebate Trends, 2001-2005 ............................................................. 4-26
- Medicaid Drug Rebate Trends, Annual Percent Change, 2000-2005 ..................... 4-27
- Rebates as a Percent of Drug Expenditures, 2005 ................................................... 4-28
Medicaid Drug Coverage ........................................................................................................ 4-29
- Pharmacy Advisory Committees ............................................................................. 4-31
- Pharmacy Benefit Design – Coverage ..................................................................... 4-32
- Coverage of Injectables ........................................................................................... 4-35
- Coverage of Vaccines and Unit Dose ...................................................................... 4-36
- Coverage of Over-the-Counter Medications ........................................................... 4-37
- Prior Authorization Process and Procedures ........................................................... 4-39
- Prior Authorization .................................................................................................. 4-42
- Drug Utilization Review .......................................................................................... 4-45
- Prescribing/Dispensing Limits ................................................................................ 4-46
Pharmacy Payment and Patient Cost Sharing ...................................................................... 4-47
- Pharmacy Payment and Patient Cost Sharing.......................................................... 4-48
- Maximum Allowable Cost (MAC) Programs.......................................................... 4-49
- Mandatory Substitution ........................................................................................... 4-50
- Counseling Requirements and Payment for Cognitive Services ............................. 4-51
- Prescription Price Updating ..................................................................................... 4-52
SECTION 5: STATE PHARMACY PROGRAM PROFILES ......................................................... 5-1
SECTION 6: STATE PHARMACY ASSISTANCE PROGRAMS .................................................. 6-1
APPENDIXES
Appendix A: State and Federal Medicaid Contacts .................................................................... A-1
Appendix B: Medicaid Program Statistics – CMS MSIS Tables ................................................B-1
Appendix C: Medicaid Rebate Law.............................................................................................C-1
Appendix D: Federal Upper Limits for Multiple Source Products ............................................. D-1
Appendix E: Glossary .................................................................................................................. E-1
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Section 1:
Introduction
1-1
1-2
INTRODUCTION
The 2007 edition of Pharmaceutical Benefits Under State Medical Assistance Programs marks the 41st
year that the National Pharmaceutical Council (NPC) has compiled and published one of the largest
sources of information on pharmacy programs within the State Medical Assistance Programs (Title
XIX) and expanded pharmacy programs for the elderly and disabled. Due to the hard work of a skilled
team and countless contributors, the “Medicaid Compilation” has become a standard reference and
invaluable resource in government offices, research libraries, consultancies, the pharmaceutical
industry, numerous businesses, and policy organizations.
The data used to create each edition of the Compilation are assembled from numerous sources. The
Compilation incorporates information on each State pharmacy program from an annual NPC survey of
State Medicaid program administrators and pharmacy consultants, statistics from the Centers for
Medicare and Medicaid Services (CMS), and information from other Federal agencies and
organizations.
In order to give a better understanding of the content of the “Medicaid Compilation,” the information
contained in this version of the book is summarized below by section:
! Section 2: Contains an overview of the Medicaid program (which is current at press time and
has not been revised to reflect any future changes that may result from the Deficit Reduction
Act), details about Medicaid managed care enrollment, including a breakdown by plan type
and enrollment by plan type, and a synopsis of 1915(b) waivers and 1115 demonstrations.
! Section 3: Consists of sociodemographic statistics, by age, race, insurance, income, and

employment, for the fifty States and the District of Columbia. Additionally, a description of
the Medicaid certified facilities in each State, including the number of hospitals, skilled
nursing facilities, and intermediate care facilities for the mentally retarded (ICFs-MR), home
health agencies, and rural health clinics are presented.
! Section 4: Provides Medicaid pharmacy program characteristics, drawn largely from the 2007
NPC annual survey of State pharmacy program administrators. In addition, this section
provides Medicaid eligibility statistics from CMS for fiscal year 2004 and program
expenditure data for fiscal year 2005. Medicaid pharmacy programs are characterized by
estimates of total expenditures, drug payments, drug benefit design, and pharmacy payment
and patient cost sharing.
! Section 5: Contains detailed profiles of the States’ Medicaid pharmacy programs. This
section contains a description of medical assistance benefits and eligibles, drug payments and
recipients, benefit design, pharmacy payment and patient cost sharing, use of managed care,
and State contacts.
! Section 6: Profiles State pharmaceutical assistance programs.

The book also contains a series of appendices. Appendix A features a list of State contacts and CMS
Medicaid program personnel. Appendix B provides a national level summary on total Medicaid
program recipients by type of service for FY 2004 and data on total number of drug recipients for each
State and the nation as a whole for the period 1998-2004. Appendix C provides the current Medicaid
drug rebate law (which is current at press time and has not been revised to reflect any future
changes that may result from the Deficit Reduction Act). Appendix D contains the list of CMS
upper limits on multiple source products. Appendix E is a glossary and list of acronyms.
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As we continue to update and discover data, we are able to improve the Compilation with new tables
and sources that we believe enhance its overall significance to the user. These new tables and sources
include:
! Data on Medicaid eligibles by gender and race/ethnicity;

! Total SCHIP enrollment by State;
! Information on the number of Medicaid/Medicare dual eligibles and Medicaid medical vendor
payments for dual eligibles by State.
NPC gratefully acknowledges the cooperation and assistance of the many State and Federal program
officials and their staffs. With their cooperation, we were able to achieve a 90 percent response rate to
the 2007 Survey. Unfortunately, not all States were able to submit revised/updated information. In
such instances, we have incorporated the most recently available data from other sources. However,
for these States, much of the information may reflect data that have been presented in previous
versions of the Compilation.
We would also like to thank United BioSource Corporation and their subcontractors, Total
Compensation Solutions, Hmetrix, and StateScape, for administering the survey and compiling
important parts of the information on State pharmacy programs. We hope you continue to find the
information contained in this compilation useful and, as always, we welcome your suggestions and
comments.
Gary Persinger
Vice President, Health Care Systems
National Pharmaceutical Council
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Section 2:
The Medicaid Program
2-1
2-2
MEDICAID PROGRAM OVERVIEW

Medicaid (Title XIX of the Federal Social Security Act) is a Federal-State funded program of national
health assistance that provides health care coverage to certain individuals and families with low-
incomes and resources. The 50 States, the District of Columbia, and Puerto Rico, Guam, Virgin
Islands, American Samoa, and Northern Mariana Islands each operate medical assistance programs
according to State or territorial rules and criteria that vary within a broad framework of Federal
guidelines.
MEDICAID ELIGIBILITY
Medicaid Eligibility: Medicaid is a “means tested program for low-income individuals.” To qualify,
a Medicaid recipient must not have “income” or “resources” that exceed the applicable limits
prescribed in the law and regulations.
Every State, in order to receive Federal funding under Title XIX, must provide Medicaid benefits to
certain “categorically needy” persons. These are the “mandatory” categorically needy. In addition,
the State has the option of providing Medicaid benefits to certain additional categories of persons.
These are the “optional” categorically needy. An additional category of Medicaid recipients that a
State may choose to include in its program is the “medically needy.”
Mandatory Categorically Needy: There are numerous and detailed categories under which the
“categorically needy” may qualify for Medicaid benefits. The principal categories of the mandatory
categorically needy are:
! Low-income families with children;
! Recipients of Supplemental Security Income (SSI) for the Aged, Blind, and Disabled
(this includes disabled children);
! Individuals qualified for adoption assistance agreements or foster care maintenance
payments under Title IV-E of the Social Security Act;
! Qualified pregnant women;
! Newborn children of Medicaid-eligible women;
! Various categories of low-income children; and
! Certain low-income Medicare beneficiaries.
Optional Categorically Needy: These are groups of individuals who meet the characteristics of the
mandatory groups, but the eligibility criteria are somewhat more liberally defined. For example, in
determining their incomes and resources, they are allowed to exclude certain kinds of income. The
“optional categorically needy” include individuals who are aged, blind, disabled, caretaker relatives,
and pregnant women who meet the SSI income and resources requirements but are not receiving SSI
cash payments.
Medically Needy: The “medically needy” are those individuals who meet the definitional
requirements described above, except that their income or resources exceed the limitations applicable
to the categorically needy. These individuals can “spend down” to qualify. That is, they can deduct
their medical bills from their income and resources until they meet the applicable income and
resources requirements. Their Medicaid benefits can then begin.
Special Categories: The Medicaid statute also authorizes limited Medicaid benefits to special
categories of individuals. In general, these are individuals whose income and resources would
otherwise be too high to qualify for full Medicaid benefits under the regular provisions.
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For example, a “Qualified Medicare Beneficiary” (QMB) is an individual who qualifies for Medicare
Part A, whose income does not exceed 100 percent of the Federal poverty level, and whose resources
do not exceed twice the SSI resource-eligibility standard. Medicaid coverage of QMBs is limited to
payment of their Medicare cost-sharing charges, such as the Medicare premiums, coinsurance, and
co-payment amounts.
Non-Eligibles: A State can include in its Medicaid program individuals who do not meet the statutory
eligibility criteria. However, the State must pay the full costs for these individuals. There are no
Federal matching payments.
MEDICAID SERVICES
Title XIX lists the many types of medical care that a State may select for inclusion into its Medicaid
State Plan, thus qualifying for Federal matching payments. However, the law requires that certain
basic benefits must be available to all “categorically needy” recipients. These services include:
! Inpatient and outpatient hospital services;
! Physician services;
! Medical and surgical dental services;
! Laboratory and X-ray services;
! Nursing facility services (for persons 21 years of age or older);
! Early and periodic screening, diagnostic, and treatment (EPSDT) services for children
under age 21;
! Family planning services and supplies;
! Home health services for persons eligible for nursing facility services;
! Rural health clinic services and any other ambulatory services offered by a rural health
clinic that are otherwise covered under the State Plan;
! Nurse-midwife services (to the extent authorized under State law);
! Pediatric and family nurse practitioners services; and
! Federally-qualified health center (FQHC) services and any other ambulatory services
offered by an FQHC that are otherwise covered under the State Plan.
If a State chooses to include the “medically needy” population, the State Plan must provide, as a
minimum, the following services:
! Prenatal care and delivery services for pregnant women;
! Ambulatory services to individuals under age 18 and individuals entitled to institutional
services;
! Home health services to individuals entitled to nursing facility services; and
! If the State Plan includes services either in institutions for mental diseases or in
intermediate care facilities for the mentally retarded (ICFs/MR), it must offer medically
needy groups certain specified services provided to the categorically needy.
States may also receive Federal funding if they elect to provide other optional services. The most
commonly covered optional services under the Medicaid program include:
! Clinic services;
! Services of ICFs/MR;
! Nursing facility services (children under 21 years old);
! Prescribed drugs;
! Optometrist services and eyeglasses;
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! TB-related services for TB infected persons;

! Prosthetic devices; and
! Dental services.
States may provide home and community-based care waiver services to certain individuals who are
eligible for Medicaid. The services to be provided to these persons may include case management,
personal care services, respite care services, adult day health services, homemaker/home health aide,
habilitation, and other services requested by the State and approved by CMS.
CHARACTERISTICS OF BENEFITS PROVIDED
Inpatient Hospital Services

Inpatient hospital services are those ordinarily furnished in a hospital for the care and treatment of
inpatients. The facility is one maintained primarily for the care and treatment of patients with
disorders other than mental diseases. There are several general Federal limitations on inpatient
hospital services that apply to all States with Medicaid programs (42 CFR 440.10):
! The facility must be licensed or formally approved as a hospital by an officially
designated authority for State standard setting;
! The facility must meet the requirements for participation in Medicare as a hospital;
! The care and treatment of inpatients must be under the direction of a physician or dentist;
! The facility must have in effect an approved utilization review plan, applicable to all
Medicaid patients, unless a waiver has been granted by the Secretary of Health and
Human Services, because the State’s own utilization review procedures are adequate; and
! A peer review organization (PRO) may satisfy these requirements.
In addition to the Federal limitations, each State may impose further limitations on inpatient hospital
services.
Outpatient Hospital Services

Outpatient hospital services refer to preventive, diagnostic, therapeutic, rehabilitative, or palliative
services provided to an outpatient. Three Federal limitations are imposed on these services, though
States are free to specify other limits on outpatient hospital services and many have chosen to do so.
! The services must be provided under the direction of a physician or dentist;
! The facility must be licensed or formally approved as a hospital by an officially
designated authority for State standard setting; and
! The facility must meet the requirements for participation in Medicare as a hospital.
Rural Health Clinic Services

Rural health clinic (RHC) services are a mandatory service for the categorically needy. Each RHC is
required to have a nurse practitioner (NP) or physician’s assistant (PA) on its staff. Therefore, a
clinic can be certified to participate in the Medicaid program only if State law permits the delivery of
primary care by an NP or PA.
Services in RHCs must be provided by a physician or by a PA, NP, nurse-midwife, or other
specialized nurse practitioner. Services and supplies are furnished as “incident to” the professional
services of such a practitioner are also covered. Part-time or intermittent visiting nurse services and
related medical supplies are provided if the RHC is located in an area which the Department of Health
and Human Services (DHHS) has determined has a shortage of home health agencies, the services are
2-5
furnished by nurses employed by the RHC, and the services are furnished to a homebound recipient
under a written plan of treatment.
Other Laboratory and X-Ray Services

Other laboratory and X-ray services are professional and technical laboratory and radiological
services. These services must be:
! Ordered and provided by or under the direction of a physician or other licensed
practitioner of the healing arts within the scope of his or her practice, as defined by State
law, or ordered and billed by a physician but provided by an independent laboratory;
! Provided in an office or similar facility other than a hospital inpatient or outpatient
department or clinic;
! Provided by a laboratory that meets the requirements for participation in Medicare; and
! In addition, the States can place limitations on “other laboratory and X-ray services.”
Nursing Facility Services

Nursing facility (NF) services are provided to individuals age 21 or older. They do not include
services provided in institutions for mental diseases. These services must be needed on a daily basis
and must be provided in an inpatient facility. Federal regulations require that the services be:
! Provided by a facility or a distinct part of a facility that is certified to meet the
requirements for participation in the Medicaid program as a NF; and
! Ordered by and furnished under the direction of a physician.
Early and Periodic Screening, Diagnostic and Treatment Services

Early and periodic screening, diagnostic and treatment (EPSDT) refers to screening and diagnostic
services to determine physical or mental defects in recipients under age 21, as well as health care,
treatment and other measures to correct or ameliorate any defects and chronic conditions discovered
(42 CFR 440.40(b)). Certain basic screening and treatment services must be provided by each State
as a minimum (42 CFR 441.56). These services include:
Screening:
! Comprehensive health and developmental history screening;
! Comprehensive unclothed physical examination;
! Appropriate vision testing;
! Appropriate hearing testing;
! Appropriate laboratory tests; and
! Dental screening services furnished by direct referral to a dentist for children beginning
at 3 years of age.
Diagnosis and Treatment:
In addition to any diagnostic and treatment services included in the State Medicaid Plan, the State
must provide to eligible EPSDT recipients the following services, the need for which is indicated by
screening, even if the services are not included in the Plan:
! Diagnosis of and treatment for defects in vision and hearing, including eyeglasses and
hearing aids;
! Dental care, at as early an age as necessary, needed for relief of pain and infections,
restoration of teeth and maintenance of dental health; and
2-6
! Appropriate immunizations. (If it is determined at the time of screening that

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

Federal Requirements: States are required to provide family planning services and supplies to
individuals of childbearing age (including minors who can be considered to be sexually active) who
are eligible under the State Medicaid Plan and who desire such services and supplies. Specifically,
family planning services must be made available to categorically needy Medicaid recipients, and the
State has the option of furnishing these services to the medically needy.
Defined: The term “family planning services” is not defined in the law or in regulations. However,
the Senate Report accompanying the law stresses Congress’ intent of placing emphasis on the
provision of services to “aid those who voluntarily choose not to risk an initial pregnancy,” as well as
those families with children who desire to control family size. In keeping with Congressional intent,
the State may choose to include in its definition of Medicaid family planning services only those
services which either prevent or delay pregnancy, or the State may more broadly define the term to
include services for the treatment of infertility. However, the Medicaid definition must be consistent
with overall State policy and regulation regarding the provision of family planning services.
The State is free to determine the specific services and supplies that will be covered as Medicaid
family planning services as long as those services are sufficient in amount, duration, and scope to
reasonably achieve their purpose. It must also establish procedures for identifying individuals who
are sexually active and eligible for family planning services.
Federal Matching Payments: Federal Financial Participation (FFP) is available at the “enhanced”
rate of 90 percent for the cost of family planning services. These include counseling services and
patient education, examination and treatment by medical professionals in accordance with applicable
State requirements, laboratory examinations and tests, medically approved methods, procedures,
pharmaceutical supplies and devices to prevent conception, and infertility services, including
sterilization reversals.
FFP at the enhanced rate of 90 percent is also available for the cost of a sterilization if a properly
completed sterilization informed consent form, in accordance with the requirements of 42 CFR Part
441, Subpart F, is submitted to the State prior to payment of the claim.
FFP at the 90 percent rate is not available for the cost of a hysterectomy or for the costs related to
other procedures performed for medical reasons, such as removal of an intrauterine device due to
infection. Only items and procedures clearly provided or performed for family planning purposes
may be matched at the 90 percent rate. Transportation to a family planning service is not eligible for
the 90 percent match. Transportation must be claimed as either an administrative cost or a State Plan
service, in accordance with the State’s approved Medicaid State Plan.
Abortions: Abortions may not be claimed as a family planning service. For more than 20 years,
Congressional restrictions have been placed on appropriated funds for DHHS programs that fund
abortions. FFP is available only in expenditures for an abortion when a physician has found, and so
certified in writing to the Medicaid agency, that on the basis of his/her professional judgment, the life
of the mother would be endangered if the fetus were carried to term. The certification must contain
the name and address of the patient. Congress has prohibited the use of Federal funds for victims of
rape or incest.
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Voluntary Sterilizations: FFP is available in expenditures for the sterilization of an individual only if
she is at least age 21, has voluntarily given informed consent in accordance with Medicaid
regulations, and is not a mentally incompetent individual.
Physicians’ Services
Physicians’ services are covered, whether provided in the office, the patient’s home, a hospital, a
nursing facility, or elsewhere. Such services must be within the physicians’ scope of practice of
medicine or osteopathy as defined by State law, and by or under the personal supervision of an
individual licensed under State law to practice medicine or osteopathy.
Prescribed Drugs
Prescribed drugs are simple or compound substances or mixtures of substances prescribed for the
cure, mitigation, or prevention of disease, or for health maintenance, which are prescribed by a
physician or other licensed practitioner of the healing arts within the scope of their professional
practice, as defined and limited by Federal and State law (42 CFR 440.120). The drugs must be
dispensed by licensed authorized practitioners on a written prescription that is recorded and
maintained in the pharmacist’s or the practitioner’s records.
Home Health Services

Home health services are provided to a recipient at his or her place of residence. This does not
include a hospital, nursing facility, or (ordinarily) an ICF/MR. Services provided must be on
physicians’ orders as part of a written plan of care that is reviewed by the physician every 60 days.
Home health services include three mandatory services (part-time nursing, home health aide, medical
supplies and equipment) and four optional services (physical therapy, occupational therapy, speech
pathology, and audiology services) (42 CFR 440.70). These services are defined as follows:
! Part-Time Nursing: Nursing that is provided on a part-time or intermittent basis by a
home health agency. If there is no home health agency in the area, services may be
provided by a registered nurse who is currently licensed to practice in the State, receives
written orders from the patient’s physician, documents the care and services provided,
and has had orientation to acceptable clinical and administrative record keeping from a
health department nurse.
! Home Health Aide: Home health aide services provided by a home health agency.
! Medical Supplies and Equipment: Medical supplies, equipment, and appliances that are
suitable for use in the home.
! Physical Therapy (PT), Occupational Therapy (OT), Speech Pathology and Audiology
Services: PT, OT, speech and hearing services provided by a home health agency or a
facility licensed by the State to provide medical rehabilitation.
! Home health services are provided to categorically needy recipients age 21 and over and
to those under 21 only if the State Plan provides SNF services for them.
Personal Support Services
Personal support services consist of a variety of services including personal care, targeted case
management, home and community-based care for functionally disabled elderly, rehabilitative
services, hospice services, and nurse-midwife, nurse practitioner, and private duty nursing. Details of
some of these services are provided below:
1. Personal Care Services: Services provided to an individual who is not an inpatient or
resident of a hospital, nursing facility, intermediate care facility for the mentally
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retarded, or institution for mental disease. Services are authorized by a physician in

accordance with a treatment plan, are provided by a qualified individual who is not a
member of the recipient’s family, and are furnished in a home or (at the State’s
option) in another location.
2. Rehabilitative Services: These services include any medical or remedial service
recommended by a physician or other licensed practitioner of the healing arts within
the scope of State law. Services are for the maximum reduction of physical or mental
disability and restoration of a recipient to their best possible functional level.
3. Hospice Services: Hospice services can be received in a hospice facility or elsewhere.
Services are provided to terminally ill individuals by an authorized hospice program
under a written plan established and reviewed by the attending physician, medical
director or physician designee of the program, and an interdisciplinary group.
Nurse-Midwife Services
Nurse-midwife services are those concerned with management of the care of mothers and newborns
throughout the maternity cycle. The Omnibus Budget Reconciliation Act of 1980 required that
payment be made providing for nurse-midwife services to categorically needy recipients (42 CFR
440.165). These provisions require States to provide coverage for nurse-midwife services to the
extent that the nurse-midwife is authorized to practice under State law or regulation. The statute also
requires that States offer direct reimbursement to nurse-midwives as one of the payment options.
Nurse-midwives must be registered nurses who are either certified by an organization recognized by
the Secretary of DHHS or who have completed a program of study and clinical experience that has
been approved by the Secretary.
Pediatric Nurse Practitioner and Family Nurse Practitioner Services

The Omnibus Budget Reconciliation Act of 1989 provides for the availability and accessibility of
services furnished by a certified pediatric nurse practitioner (CPNP) or a certified family nurse
practitioner (CFNP) to Medicaid recipients. These provisions require that services be covered to the
extent that the CPNPs or CFNPs are authorized to practice under State law or regulation, regardless of
whether they are supervised by or associated with a physician or other health care provider. States
are required to offer direct payment to CPNPs and CFNPs as one of their payment options.
CPNP and CFNP certification requirements include a current license to practice as a registered nurse
in the State, meet the applicable State requirements for qualification of pediatric nurse practitioners or
family nurse practitioners, and be currently certified by the American Nurses’ Association as a
pediatric nurse practitioner or a family nurse practitioner.
Federally Qualified Health Center and Other Ambulatory Services

Medicaid programs must offer Federally Qualified Health Center (FQHC) services and other
ambulatory services offered by an FQHC under the provisions of the Omnibus Budget Reconciliation
Act of 1989. The definition of FQHC services is the same as that of the services provided by rural
health clinics (RHC). FQHC services include physician services, services provided by physician
assistants, nurse practitioners, clinical psychologists, clinical social workers, and services and
supplies incident to services normally covered if furnished by a physician or if incident to a
physician’s services.
FQHCs are facilities or programs more commonly known as Community Health Centers, Migrant
Health Centers, and Health Care for the Homeless. These centers may qualify as providers of service
under Medicaid, under the following conditions:
2-9
! The facility receives a grant under sections 329, 330, or 340 of the Public Health Service
Act;
! The Health Resources and Services Administration (HRSA) recommends, and the DHHS
Secretary determines, that the facility meets the requirements of the grant; or
! The Secretary determines that a facility may qualify through waivers of the requirements.
Such a waiver cannot exceed two years.
AMOUNT AND DURATION OF SERVICES

Within broad Federal guidelines and certain limitations, States may determine the amount and
duration of services offered under their Medicaid programs. Federal regulations require that the
amount and/or duration of each type of medical and remedial care and services furnished under a
State’s program must be specified in the State Plan, and that these types of care and services must be
sufficient in amount, duration, and scope to “reasonably achieve” their purpose. States are required to
provide Medicaid coverage for comparable amounts, duration, and scope of service to all
“categorically needy” and categorically-related eligible persons.
Each State Plan must include a description of the methods that will be used to assure that the medical
and remedial care and services delivered are of high quality, as well as a description of the standards
established by the State to assure high quality care. The regulations also require that the fee
structures developed must result in participation of a sufficient number of providers so that eligible
persons can receive the medical care and services included in the Plan, at least to the extent that these
are available to the general population. The law further requires that services provided under the Plan
be available throughout the State. Recipients are to have freedom of choice with regard to where they
receive their care, including an option to obtain their care through organizations that provide services
or arrange for their availability on a prepayment basis, such as health maintenance organizations.
MEDICAID PAYMENT FOR SERVICES

The Medicaid program operates on the basis of a division of responsibilities between the Federal
government and the States with the Federal government paying States for a portion of State medical
expenditures and administrative costs. Funding for the program is shared between the two bodies,
with the Federal government matching State health care provider reimbursements at an authorized
rate, depending on the State’s per capita income (see the Federal Medical Assistance Percentage
(FMAP) table, page 2-18).
The FMAP is based upon the State’s per capita income; if a State’s per capita income is equal to or
greater than the national average, the Federal share is 50%. If a State’s per capita income is below the
national average, the Federal share is increased.
The percentages apply to State expenditures for assistance payments and medical services. Federal
statute provides separate Federal matching amounts for administrative costs. Cost sharing for
administrative expenditures vary with the services, i.e., 75% for training, 90% for designing,
developing or installing mechanized claims processing and information retrieval, etc. (Federal
Medicaid Law (Section 1903(a)(2) et seq.)).
In 2004, the Medicaid program enrolled 57.6 million eligible individuals with vendor payments for
medical care services totaling $257.7 billion. The vendor payments reported in the 2004 MSIS
Report do not include Disproportionate Share Hospital (DSH), Medicare premium payments made by
State Medicaid programs, and other Medicaid program expenditures. The CMS-64 Report, which
does include such expenditures, shows total net expenditures for 2004 of over $280 billion. When
administrative costs are added to total net expenditures, total Medicaid program expenditures in 2004
were $295.3 billion. For FY 2005, total program expenditures, including those for administration,
were $314.7 billion.
2-10
Total Medicaid Eligibles by Maintenance Assistance Status, 20041
Receiving
Total Cash Medically Poverty 1115 MAS
State Eligibles Assistance Needy Related Other Demonstration Unknown
National Total 57,575,692 20,559,445 3,313,195 17,654,820 9,855,899 6,191,305 1,028
Alabama 918,304 274,597 0 473,394 37,592 132,721 0
Alaska 127,779 50,610 0 66,090 11,079 0 0
Arizona 1,394,378 550,709 0 362,701 269,001 211,967 0
Arkansas 700,038 155,522 12,329 300,605 51,721 179,861 0
California 10,619,361 4,724,483 788,296 609,272 2,133,527 2,363,781 2
Colorado 524,760 315,452 0 150,395 58,911 0 2
Connecticut 508,387 82,602 26,014 105,479 294,292 0 0
Delaware 166,604 79,976 0 15,415 43,402 27,811 0
District of Columbia 160,304 86,349 36,611 28,192 9,152 0 0
Florida 2,867,361 1,224,666 106,007 1,080,601 450,243 5,843 1
Georgia 1,759,654 614,889 10,091 833,942 300,732 0 0
Hawaii 223,417 109,093 3,168 51,898 16,745 42,479 34
Idaho 220,535 58,719 0 127,270 34,546 0 0
Illinois 2,264,567 267,908 443,451 1,174,697 134,026 244,485 0
Indiana 982,131 383,104 0 362,910 236,117 0 0
Iowa 399,710 159,714 11,347 130,176 98,473 0 0
Kansas 344,006 131,391 7,356 144,451 60,808 0 0
Kentucky 833,511 389,105 31,828 334,449 78,129 0 0
Louisiana 1,112,345 357,850 13,564 627,371 113,560 0 0
Maine 306,397 58,110 4,171 134,809 79,104 30,203 0
Maryland 845,145 217,098 97,901 350,903 48,168 131,075 0
Massachusetts 1,156,690 314,997 20,511 454,852 135,831 230,499 0
Michigan 1,770,258 466,725 119,909 559,893 524,071 99,621 39
Minnesota 736,476 415,749 26,565 76,547 102,361 115,254 0
Mississippi 785,105 336,988 0 388,839 31,443 27,758 77
Missouri 1,205,751 721,856 0 155,389 198,035 130,471 0
Montana 113,073 48,927 8,897 31,172 24,075 0 2
Nebraska 260,865 67,774 25,254 129,813 37,411 0 613
Nevada 256,841 151,831 0 57,208 47,802 0 0
New Hampshire 134,216 25,945 12,390 66,034 29,847 0 0
New Jersey 988,602 387,466 5,472 381,705 144,339 69,620 0
New Mexico 511,778 199,408 0 199,847 96,967 15,555 1
New York 4,888,941 2,015,032 947,008 677,568 115,119 1,134,214 0
North Carolina 1,526,268 587,054 45,245 779,887 114,082 0 0
North Dakota 74,996 31,543 12,437 13,706 17,310 0 0
Ohio 1,996,065 433,986 0 418,532 1,143,547 0 0
Oklahoma 683,702 184,415 1 444,337 54,949 0 0
Oregon 590,236 178,155 0 168,164 142,621 101,043 253
Pennsylvania 1,890,061 789,183 107,058 637,420 356,400 0 0
Rhode Island 216,052 79,077 4,309 35,939 53,129 43,598 0
South Carolina 990,658 298,965 0 437,149 195,881 58,663 0
South Dakota 124,032 42,396 0 54,045 27,591 0 0
Tennessee 1,619,941 620,026 206,875 294,071 190,654 308,311 4
Texas 3,878,183 853,265 80,981 2,293,200 650,737 0 0
Utah 295,299 98,214 6,292 105,088 62,486 23,219 0
Vermont 163,595 28,197 14,418 50,260 16,350 54,370 0
Virginia 821,256 148,124 10,190 512,062 143,818 7,062 0
Washington 1,195,703 292,146 20,155 382,563 379,282 121,557 0
West Virginia 373,373 121,122 7,504 200,322 44,425 0 0
Wisconsin 971,210 309,474 39,590 145,519 196,363 280,264 0
Wyoming 77,772 19,458 0 38,669 19,645 0 0
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
Source: CMS, MSIS Report, FY 2004.
2-11
Total Medicaid Eligibles by Age Group, 20041
65 Years and
State Total Eligibles <20 Years 21-64 Years Older Age Unknown
National Total 57,575,692 31,265,163 20,283,550 5,917,484 109,495
Alabama 918,304 486,702 308,866 122,736 0
Alaska 127,779 86,867 33,310 7,602 0
Arizona 1,394,378 715,813 591,870 86,694 1
Arkansas 700,038 420,164 216,520 63,354 0
California 10,619,361 4,952,527 4,764,288 902,525 21
Colorado 524,760 318,605 154,316 51,243 596
Connecticut 508,387 270,566 173,412 64,409 0
Delaware 166,604 82,813 71,492 12,299 0
District of Columbia 160,304 86,818 59,313 14,172 1
Florida 2,867,361 1,644,182 849,036 373,858 285
Georgia 1,759,654 1,114,125 477,959 167,568 2
Hawaii 223,417 110,593 90,064 22,760 0
Idaho 220,535 153,818 53,317 13,400 0
Illinois 2,264,567 1,264,313 627,877 372,369 8
Indiana 982,131 615,708 286,060 80,363 0
Iowa 399,710 228,781 129,581 41,347 1
Kansas 344,006 213,480 97,034 33,492 0
Kentucky 833,511 458,162 282,237 93,085 27
Louisiana 1,112,345 745,594 257,619 109,132 0
Maine 306,397 127,609 144,358 34,428 2
Maryland 845,145 491,203 273,958 79,966 18
Massachusetts 1,156,690 515,616 500,166 140,908 0
Michigan 1,770,258 1,015,405 621,511 133,155 187
Minnesota 736,476 398,610 247,866 89,998 2
Mississippi 785,105 464,734 224,639 95,732 0
Missouri 1,205,751 685,309 419,250 101,188 4
Montana 113,073 65,145 37,477 10,449 2
Nebraska 260,865 164,407 66,519 23,798 6,141
Nevada 256,841 153,307 79,591 23,840 103
New Hampshire 134,216 83,667 36,429 14,115 5
New Jersey 988,602 550,025 295,518 143,059 0
New Mexico 511,778 327,093 151,993 32,692 0
New York 4,888,941 2,112,705 2,174,386 499,842 102,008
North Carolina 1,526,268 860,015 486,217 180,034 2
North Dakota 74,996 39,981 25,360 9,655 0
Ohio 1,996,065 1,139,998 696,688 159,379 0
Oklahoma 683,702 461,685 156,642 65,375 0
Oregon 590,236 289,485 250,518 50,226 7
Pennsylvania 1,890,061 1,013,149 655,551 221,360 1
Rhode Island 216,052 108,448 82,724 24,880 0
South Carolina 990,658 543,494 305,375 141,789 0
South Dakota 124,032 81,288 30,439 12,305 0
Tennessee 1,619,941 747,263 696,060 176,618 0
Texas 3,878,183 2,672,469 801,061 404,632 21
Utah 295,299 175,777 105,137 14,382 3
Vermont 163,595 73,901 68,340 21,354 0
Virginia 821,256 496,821 222,230 102,188 17
Washington 1,195,703 712,093 399,316 84,293 1
West Virginia 373,373 200,481 138,974 33,918 0
Wisconsin 971,210 472,173 344,956 154,054 27
Wyoming 77,772 52,176 20,130 5,464 2
1
2-12
Total Medicaid Eligibles by Gender, 20041

State Total Eligibles Female Male Gender Uknown
National Total 57,575,692 34,103,950 23,358,176 113,566
Alabama 918,304 583,874 328,483 5,947
Alaska 127,779 70,590 57,186 3
Arizona 1,394,378 776,189 618,187 2
Arkansas 700,038 438,854 259,490 1,694
California 10,619,361 6,717,525 3,901,818 18
Colorado 524,760 311,442 213,318 0
Connecticut 508,387 302,193 206,194 0
Delaware 166,604 99,238 67,366 0
District of Columbia 160,304 95,541 64,763 0
Florida 2,867,361 1,667,537 1,198,228 1,596
Georgia 1,759,654 1,047,589 712,045 20
Hawaii 223,417 120,313 103,104 0
Idaho 220,535 124,512 96,023 0
Illinois 2,264,567 1,369,106 895,461 0
Indiana 982,131 579,693 402,438 0
Iowa 399,710 231,250 168,460 0
Kansas 344,006 198,114 145,875 17
Kentucky 833,511 482,166 351,341 4
Louisiana 1,112,345 638,257 473,953 135
Maine 306,397 168,041 138,128 228
Maryland 845,145 504,615 340,530 0
Massachusetts 1,156,690 670,140 486,550 0
Michigan 1,770,258 990,908 779,350 0
Minnesota 736,476 423,705 312,771 0
Mississippi 785,105 459,776 303,168 22,161
Missouri 1,205,751 699,762 505,986 3
Montana 113,073 65,006 48,067 0
Nebraska 260,865 144,612 109,958 6,295
Nevada 256,841 149,663 106,502 676
New Hampshire 134,216 77,792 56,424 0
New Jersey 988,602 590,954 397,648 0
New Mexico 511,778 302,577 209,183 18
New York 4,888,941 2,737,167 2,077,827 73,947
North Carolina 1,526,268 918,374 607,894 0
North Dakota 74,996 44,346 30,649 1
Ohio 1,996,065 1,158,583 837,480 2
Oklahoma 683,702 396,931 286,771 0
Oregon 590,236 333,855 256,381 0
Pennsylvania 1,890,061 1,098,948 791,113 0
Rhode Island 216,052 126,918 89,134 0
South Carolina 990,658 618,978 371,558 122
South Dakota 124,032 70,279 53,753 0
Tennessee 1,619,941 940,866 679,075 0
Texas 3,878,183 2,231,241 1,646,853 89
Utah 295,299 170,827 124,024 448
Vermont 163,595 90,456 73,139 0
Virginia 821,256 484,984 336,234 38
Washington 1,195,703 722,913 472,741 49
West Virginia 373,373 213,109 160,264 0
Wisconsin 971,210 599,461 371,749 0
Wyoming 77,772 44,180 33,539 53
1
2-13
Total Medicaid Eligibles by Race/Ethnicity, 20041
American
Indian/
Total Black/African Alaska Hispanic or
State Eligibles White American Native Asian Latino Other
National Total 57,575,692 24,963,746 13,320,983 833,800 1,502,416 12,533,000 4,421,747
Alabama 918,304 428,801 436,679 2,577 4,240 20,835 25,172
Alaska 127,779 54,040 6,635 47,359 6,523 4,699 8,523
Arizona 1,394,378 485,844 80,073 153,888 17,422 623,427 33,724
Arkansas 700,038 438,290 209,923 5,599 6,669 33,852 5,705
California 10,619,361 2,249,008 976,625 45,748 515,864 5,787,987 1,044,129
Colorado 524,760 243,850 41,584 4,881 6,779 197,336 30,330
Connecticut 508,387 236,498 110,945 986 11,860 147,891 207
Delaware 166,604 72,159 70,292 344 2,521 21,285 3
District of Columbia 160,304 2,697 139,053 47 1,375 12,765 4,367
Florida 2,867,361 1,054,831 844,911 2,904 23,431 714,828 226,456
Georgia 1,759,654 749,052 855,834 1,492 22,350 26,314 104,612
Hawaii 223,417 52,040 3,555 662 68,483 8,157 90,520
Idaho 220,535 196,567 2,086 5,521 1,181 14,841 339
Illinois 2,264,567 963,463 810,940 4,355 54,523 402,105 29,181
Indiana 982,131 669,291 218,553 620 4,009 79,022 10,636
Iowa 399,710 263,799 28,786 1,874 3,559 14,385 87,307
Kansas 344,006 219,138 54,265 4,665 4,454 34 61,450
Kentucky 833,511 672,499 103,601 432 2,920 17,859 36,200
Louisiana 1,112,345 407,018 619,087 2,915 6,173 8,984 68,168
Maine 306,397 291,537 7,123 3,924 2,761 1,052 0
Maryland 845,145 279,384 442,491 1,575 24,435 65,393 31,867
Massachusetts 1,156,690 590,847 126,942 2,895 38,633 188,707 208,666
Michigan 1,770,258 1,016,738 601,030 9,332 26,120 97,695 19,343
Minnesota 736,476 441,501 118,215 28,246 46,631 702 101,181
Mississippi 785,105 263,644 436,995 2,961 3,972 6,636 70,897
Missouri 1,205,751 849,802 298,472 4,006 8,483 62 44,926
Montana 113,073 81,551 1,005 26,408 472 3,629 8
Nebraska 260,865 172,392 33,260 9,073 2,825 97 43,218
Nevada 256,841 120,628 48,411 3,722 8,269 57,862 17,949
New Hampshire 134,216 121,971 2,678 160 1,048 4,691 3,668
New Jersey 988,602 371,025 307,191 3,700 20,609 175,870 110,207
New Mexico 511,778 126,902 10,899 96,357 2,889 264,030 10,701
New York 4,888,941 1,753,381 1,154,965 82,849 286,679 663,942 947,125
North Carolina 1,526,268 668,841 609,834 25,149 14,506 77,777 130,161
North Dakota 74,996 52,578 1,419 16,389 270 0 4,340
Ohio 1,996,065 1,329,951 589,261 2,113 13,587 60,185 968
Oklahoma 683,702 422,119 107,827 87,102 6,837 0 59,817
Oregon 590,236 415,236 25,900 14,440 17,272 109,713 7,675
Pennsylvania 1,890,061 1,126,287 500,438 2,364 36,286 138,164 86,522
Rhode Island 216,052 89,736 18,433 415 5,073 39,218 63,177
South Carolina 990,658 405,429 483,878 1,589 3,126 25,604 71,032
South Dakota 124,032 75,349 2,994 41,959 714 2,660 356
Tennessee 1,619,941 1,060,363 450,537 2,623 3,938 41,376 61,104
Texas 3,878,183 1,012,711 709,856 14,497 56,696 2,045,169 39,254
Utah 295,299 214,958 5,969 10,629 8,844 52,331 2,568
Vermont 163,595 93,595 1,300 245 406 303 67,746
Virginia 821,256 368,434 366,039 1,349 21,394 59,191 4,849
Washington 1,195,703 728,888 71,648 30,407 49,394 162,553 152,813
West Virginia 373,373 352,864 19,798 132 541 30 8
Wisconsin 971,210 544,950 151,348 14,461 25,093 50,166 185,192
Wyoming 77,772 61,269 1,400 5,860 277 1,586 7,380
1
2-14
Total Medicaid Eligibles by Basis of Eligibility, 20041
Blind/ Foster Care BCCA BOE

State Total Eligibles Aged Disabled Children Adults Children Women Unknown
National Total 57,575,692 5,193,457 8,607,606 27,822,746 14,996,502 933,167 21,095 1,119
Alabama 918,304 101,352 200,452 440,345 168,436 7,329 390 0
Alaska 127,779 6,922 13,512 76,972 27,667 2,582 124 0
Arizona 1,394,378 72,649 122,720 629,761 559,106 10,142 0 0
Arkansas 700,038 62,814 104,425 353,398 172,705 6,290 405 1
California 10,619,361 728,023 1,077,016 4,197,060 4,459,060 151,411 6,719 72
Colorado 524,760 50,337 75,675 268,565 111,221 18,795 145 22
Connecticut 508,387 63,877 62,120 267,669 108,622 5,923 176 0
Delaware 166,604 11,767 19,583 70,818 62,502 1,887 47 0
District of Columbia 160,304 10,182 31,484 74,527 39,378 4,733 0 0
Florida 2,867,361 317,508 523,045 1,443,986 535,405 47,208 209 0
Georgia 1,759,654 139,709 286,385 999,537 307,160 24,095 2,768 0
Hawaii 223,417 21,895 24,652 95,465 74,509 6,829 33 34
Idaho 220,535 13,308 29,872 140,678 34,084 2,593 0 0
Illinois 2,264,567 327,080 318,285 1,136,989 406,351 75,383 479 0
Indiana 982,131 79,895 137,907 568,530 181,330 14,194 275 0
Iowa 399,710 40,769 65,980 200,711 80,485 11,765 0 0
Kansas 344,006 33,335 56,935 180,665 59,598 13,366 107 0
Kentucky 833,511 69,892 224,670 398,929 128,504 11,154 362 0
Louisiana 1,112,345 108,627 186,351 675,676 131,361 9,671 659 0
Maine 306,397 33,718 48,646 117,347 102,894 3,649 143 0
Maryland 845,145 69,551 130,721 447,242 179,869 17,762 0 0
Massachusetts 1,156,690 112,075 259,840 465,839 318,230 706 0 0
Michigan 1,770,258 106,402 312,142 884,365 426,113 41,197 0 39
Minnesota 736,476 70,095 102,786 366,718 187,411 9,112 354 0
Mississippi 785,105 87,741 162,816 411,035 119,450 3,830 156 77
Missouri 1,205,751 99,152 177,494 626,072 275,730 26,787 516 0
Montana 113,073 9,473 18,402 57,569 23,537 3,939 151 2
Nebraska 260,865 23,242 31,834 144,091 49,216 11,546 323 613
Nevada 256,841 22,583 37,674 135,058 54,477 6,884 165 0
New Hampshire 134,216 14,012 17,985 80,561 19,016 2,642 0 0
New Jersey 988,602 112,082 185,698 473,060 191,757 25,807 198 0
New Mexico 511,778 24,675 57,173 305,869 119,484 4,267 309 1
New York 4,888,941 397,538 709,473 2,040,128 1,675,009 66,076 717 0
North Carolina 1,526,268 179,264 259,130 775,630 294,293 17,951 0 0
North Dakota 74,996 9,584 10,035 35,795 17,593 1,989 0 0
Ohio 1,996,065 149,438 319,238 1,035,824 456,477 35,088 0 0
Oklahoma 683,702 61,009 92,692 424,017 90,375 15,609 0 0
Oregon 590,236 48,243 73,796 248,776 202,172 16,779 217 253
Pennsylvania 1,890,061 220,305 433,865 853,680 329,213 51,908 1,090 0
Rhode Island 216,052 21,087 41,471 92,598 55,180 5,413 303 0
South Carolina 990,658 135,935 140,610 473,857 229,827 10,267 162 0
South Dakota 124,032 10,157 17,190 74,201 20,296 2,144 44 0
Tennessee 1,619,941 129,763 356,551 686,560 428,684 17,678 700 5
Texas 3,878,183 400,780 434,149 2,450,210 552,169 40,029 846 0
Utah 295,299 13,497 31,962 156,407 85,648 7,503 282 0
Vermont 163,595 19,737 20,397 66,487 54,179 2,722 73 0
Virginia 821,256 99,048 147,556 447,154 112,523 14,639 336 0
Washington 1,195,703 83,989 158,555 609,444 325,868 17,847 0 0
West Virginia 373,373 30,492 99,269 174,862 61,337 6,704 709 0
Wisconsin 971,210 133,435 148,475 395,235 277,098 16,698 269 0
Wyoming 77,772 5,414 8,912 46,774 13,893 2,645 134 0
1
Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.
2-15
Total Medicaid Eligibles Per 1000 Population, 20041
Total State Total Eligibles per

State Population Eligibles 1000 Population
National Total 293,655,404 57,575,692 196.1
Alabama 4,530,182 918,304 202.7
Alaska 655,435 127,779 195.0
Arizona 5,743,834 1,394,378 242.8
Arkansas 2,752,629 700,038 254.3
California 35,893,799 10,619,361 295.9
Colorado 4,601,403 524,760 114.0
Connecticut 3,503,604 508,387 145.1
Delaware 830,364 166,604 200.6
District of Columbia 553,523 160,304 289.6
Florida 17,397,161 2,867,361 164.8
Georgia 8,829,383 1,759,654 199.3
Hawaii 1,262,840 223,417 176.9
Idaho 1,393,262 220,535 158.3
Illinois 12,713,634 2,264,567 178.1
Indiana 6,237,569 982,131 157.5
Iowa 2,954,451 399,710 135.3
Kansas 2,735,502 344,006 125.8
Kentucky 4,145,922 833,511 201.0
Louisiana 4,515,770 1,112,345 246.3
Maine 1,317,253 306,397 232.6
Maryland 5,558,058 845,145 152.1
Massachusetts 6,416,505 1,156,690 180.3
Michigan 10,112,620 1,770,258 175.1
Minnesota 5,100,958 736,476 144.4
Mississippi 2,902,966 785,105 270.4
Missouri 5,754,618 1,205,751 209.5
Montana 926,865 113,073 122.0
Nebraska 1,747,214 260,865 149.3
Nevada 2,334,771 256,841 110.0
New Hampshire 1,299,500 134,216 103.3
New Jersey 8,698,879 988,602 113.6
New Mexico 1,903,289 511,778 268.9
New York 19,227,088 4,888,941 254.3
North Carolina 8,541,221 1,526,268 178.7
North Dakota 634,366 74,996 118.2
Ohio 11,459,011 1,996,065 174.2
Oklahoma 3,523,553 683,702 194.0
Oregon 3,594,586 590,236 164.2
Pennsylvania 12,406,292 1,890,061 152.3
Rhode Island 1,080,632 216,052 199.9
South Carolina 4,198,068 990,658 236.0
South Dakota 770,883 124,032 160.9
Tennessee 5,900,962 1,619,941 274.5
Texas 22,490,022 3,878,183 172.4
Utah 2,389,039 295,299 123.6
Vermont 621,394 163,595 263.3
Virginia 7,459,827 821,256 110.1
Washington 6,203,788 1,195,703 192.7
West Virginia 1,815,354 373,373 205.7
Wisconsin 5,509,026 971,210 176.3
Wyoming 506,529 77,772 153.5
1
Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.
Source: U.S. Department of Commerce, Bureau of the Census, 2004; CMS, MSIS Report, FY 2004.
2-16
Total Net U.S. Medical Assistance Expenditures
by Type of Service, FY 2004 & FY 2005
Percent Percent Percent

Service FY 2005 FY 2004
of Total of Total Change
Inpatient Acute Care Hospital $55,502,233,756 18.52% $53,369,218,290 19.01% 4.00%
Nursing Facility $46,361,761,383 15.47% $46,500,694,515 16.56% -0.30%
Pharmaceuticals $43,077,457,835 14.38% $40,065,314,592 14.27% 7.52%
HCBS Waivers $23,354,604,979 7.79% $21,765,416,501 7.75% 7.30%
ICF-Mentally Retarded $12,524,696,098 4.18% $12,132,969,504 4.32% 3.23%
Hospital Outpatient $12,337,463,061 4.12% $11,615,651,583 4.14% 6.21%
Physicians $10,141,677,696 3.38% $9,689,801,589 3.45% 4.66%
Personal Care Services $9,439,267,997 3.15% $8,237,712,957 2.93% 14.59%
Clinic* $9,015,530,077 3.01% $8,141,919,807 2.90% 10.73%
Inpatient Mental Health Hospital $8,216,467,960 2.74% $7,658,041,454 2.73% 7.29%
Home Health Care $3,569,443,730 1.19% $3,445,105,331 1.23% 3.61%
Dental $3,384,483,853 1.13% $3,112,152,041 1.11% 8.75%
Other Practitioners $2,217,963,102 0.74% $2,001,837,788 0.71% 10.80%
Lab/X-ray $1,273,909,924 0.43% $1,170,828,366 0.42% 8.80%
EPSDT $1,075,932,247 0.36% $1,045,523,675 0.37% 2.91%
Other** $58,166,915,121 19.41% $50,819,666,983 18.10% 14.46%
Total Expenditures $299,659,808,819 100%‡ $280,771,854,976 100% ‡ 6.73%
‡ Values may not add to 100% due to rounding. American Samoa, Guam, N. Mariana Islands, Puerto Rico, and Virgin Islands
excluded.
* Clinic includes clinics, FQHCs, and rural health clinics.
** Other includes hospice, other care services, payments to managed care organizations, etc.
Source: CMS, CMS-64 Report, FY 2004 and FY 2005.
2-17
Federal Medical Assistance Percentage (FMAP),

FY 2007 and FY 2008
2007 Enhanced 2008 Enhanced
State 2007 FMAP FMAP* 2008 FMAP FMAP*
Alabama 68.85% 78.20% 67.62% 77.33%
Alaska 57.58% 70.31% 52.48% 66.74%
Arizona 66.47% 76.53% 66.20% 76.34%
Arkansas 73.37% 81.36% 72.94% 81.06%
California 50.00% 65.00% 50.00% 65.00%
Colorado 50.00% 65.00% 50.00% 65.00%
Connecticut 50.00% 65.00% 50.00% 65.00%
Delaware 50.00% 65.00% 50.00% 65.00%
District of Columbia** 70.00% 79.00% 70.00% 79.00%
Florida 58.76% 71.13% 56.83% 69.78%
Georgia 61.97% 73.38% 63.10% 74.17%
Hawaii 57.55% 70.29% 56.50% 69.55%
Idaho 70.36% 79.25% 69.87% 78.91%
Illinois 50.00% 65.00% 50.00% 65.00%
Indiana 62.61% 73.83% 62.69% 73.88%
Iowa 61.98% 73.39% 61.73% 73.21%
Kansas 60.25% 72.18% 59.43% 71.60%
Kentucky 69.58% 78.71% 69.78% 78.85%
Louisiana 69.69% 78.78% 72.47% 80.73%
Maine 63.27% 74.29% 63.31% 74.32%
Maryland 50.00% 65.00% 50.00% 65.00%
Massachusetts 50.00% 65.00% 50.00% 65.00%
Michigan 56.38% 69.47% 58.10% 70.67%
Minnesota 50.00% 65.00% 50.00% 65.00%
Mississippi 75.89% 83.12% 76.29% 83.40%
Missouri 61.60% 73.12% 62.42% 73.69%
Montana 69.11% 78.38% 68.53% 77.97%
Nebraska 57.93% 70.55% 58.02% 70.61%
Nevada 53.93% 67.75% 52.64% 66.85%
New Hampshire 50.00% 65.00% 50.00% 65.00%
New Jersey 50.00% 65.00% 50.00% 65.00%
New Mexico 71.93% 80.35% 71.04% 79.73%
New York 50.00% 65.00% 50.00% 65.00%
North Carolina 64.52% 75.16% 64.05% 74.84%
North Dakota 64.72% 75.30% 63.75% 74.63%
Ohio 59.66% 71.76% 60.79% 72.55%
Oklahoma 68.14% 77.70% 67.10% 76.97%
Oregon 61.07% 72.75% 60.86% 72.60%
Pennsylvania 54.39% 68.07% 54.08% 67.86%
Rhode Island 52.35% 66.65% 52.51% 66.76%
South Carolina 69.54% 78.68% 69.79% 78.85%
South Dakota 62.92% 74.04% 60.03% 72.02%
Tennessee 63.65% 74.56% 63.71% 74.60%
Texas 60.78% 72.55% 60.53% 72.37%
Utah 70.14% 79.10% 71.63% 80.14%
Vermont 58.93% 71.25% 59.03% 71.32%
Virginia 50.00% 65.00% 50.00% 65.00%
Washington 50.12% 65.08% 51.52% 66.06%
West Virginia 72.82% 80.97% 74.25% 81.98%
Wisconsin 57.47% 70.23% 57.62% 70.33%
Wyoming 52.91% 67.04% 50.00% 65.00%
* The “Enhanced Federal Medical Assistance Percentages” are for use in State Children’s Health Insurance Program under Title XXI, and for some or all
of children’s medical assistance under Medicaid sections 1905(u)(2) and 1905(u)(3).
** The values for the District of Columbia in the table were set for the state plan under titles XIX and XXI and for capitation payments and DSH
allotments under those titles. For other purposes, including programs remaining in Title IV of the Act the Percentage for the District of Columbia is
50.00%.
Source: Federal Register, May 15, 2006, Vol. 71, No. 93, pages 28041-28042, and November 30, 2006, Vol. 71, No. 230, pages 69209-69211.
2-18
Medicaid Total Net Expenditures and Eligibles, 2004
Total Net Medical Total Average

1
State Assistance Expenditures Eligibles Per Eligible
National Total 280,771,854,976 57,575,692 $4,877
Alabama 3,636,777,895 918,304 $3,960
Alaska 884,037,863 127,779 $6,918
Arizona 4,933,111,255 1,394,378 $3,538
Arkansas 2,585,068,063 700,038 $3,693
California 30,677,337,285 10,619,361 $2,889
Colorado 2,648,577,338 524,760 $5,047
Connecticut 3,875,748,955 508,387 $7,624
Delaware 792,028,808 166,604 $4,754
District of Columbia 1,116,037,028 160,304 $6,962
Florida 12,789,934,905 2,867,361 $4,461
Georgia 7,044,051,167 1,759,654 $4,003
Hawaii 907,974,098 223,417 $4,064
Idaho 938,680,696 220,535 $4,256
Illinois 9,991,310,983 2,264,567 $4,412
Indiana 4,889,329,727 982,131 $4,978
Iowa 2,239,281,593 399,710 $5,602
Kansas 1,782,435,217 344,006 $5,181
Kentucky 4,086,404,587 833,511 $4,903
Louisiana 4,933,031,400 1,112,345 $4,435
Maine 2,021,194,249 306,397 $6,597
Maryland 4,586,430,658 845,145 $5,427
Massachusetts 8,725,068,052 1,156,690 $7,543
Michigan 8,224,940,371 1,770,258 $4,646
Minnesota 5,550,210,439 736,476 $7,536
Mississippi 3,284,724,191 785,105 $4,184
Missouri 6,082,476,995 1,205,751 $5,045
Montana 666,602,722 113,073 $5,895
Nebraska 1,430,800,678 260,865 $5,485
Nevada 1,037,927,527 256,841 $4,041
New Hampshire 1,148,626,371 134,216 $8,558
New Jersey 7,928,423,533 988,602 $8,020
New Mexico 2,212,810,008 511,778 $4,324
New York 40,978,466,799 4,888,941 $8,382
North Carolina 7,945,585,983 1,526,268 $5,206
North Dakota 479,677,381 74,996 $6,396
Ohio 11,550,492,206 1,996,065 $5,787
Oklahoma 2,500,517,344 683,702 $3,657
Oregon 2,596,299,977 590,236 $4,399
Pennsylvania 14,088,449,923 1,890,061 $7,454
Rhode Island 1,646,343,632 216,052 $7,620
South Carolina 3,848,423,641 990,658 $3,885
South Dakota 561,562,642 124,032 $4,528
Tennessee 7,029,807,190 1,619,941 $4,340
Texas 16,077,695,030 3,878,183 $4,146
Utah 1,235,552,901 295,299 $4,184
Vermont 798,758,992 163,595 $4,883
Virginia 3,825,216,022 821,256 $4,658
Washington 5,243,560,705 1,195,703 $4,385
West Virginia 1,937,298,997 373,373 $5,189
Wisconsin 4,410,918,293 971,210 $4,542
Wyoming 365,832,661 77,772 $4,704
1
Source: CMS, CMS-64 Report, FY 2004 and CMS-MSIS Report, FY 2004.
2-19
Total Medicaid Program Expenditures, 2005
Total Net Medical Administrative Total Program

State Assistance Expenditures Expenditures Expenditures
National Total $299,659,808,819 $15,068,079,406 $314,727,888,225
Alabama $3,837,473,614 $87,376,814 $3,924,850,428
Alaska $983,488,511 $70,733,046 $1,054,221,557
Arizona $5,725,919,558 $183,453,394 $5,909,372,952
Arkansas $2,809,920,508 $110,188,017 $2,920,108,525
California $33,662,911,379 $3,103,635,656 $36,766,547,035
Colorado $2,796,729,720 $120,319,778 $2,917,049,498
Connecticut $4,027,599,803 $148,734,067 $4,176,333,870
Delaware $868,667,588 $54,603,382 $923,270,970
District of Columbia $1,254,159,659 $63,312,168 $1,317,471,827
Florida $13,218,246,322 $658,687,998 $13,876,934,320
Georgia $7,333,266,041 $407,426,231 $7,740,692,272
Hawaii $1,033,126,200 $65,725,548 $1,098,851,748
Idaho $1,008,634,738 $63,181,574 $1,071,816,312
Illinois $10,785,542,795 $590,108,980 $11,375,651,775
Indiana $5,234,229,575 $246,067,710 $5,480,297,285
Iowa $2,376,772,384 $103,762,462 $2,480,534,846
Kansas $1,967,790,699 $122,828,846 $2,090,619,545
Kentucky $4,253,083,096 $125,336,656 $4,378,419,752
Louisiana $5,313,395,456 $161,949,822 $5,475,345,278
Maine $2,242,388,876 $80,066,998 $2,322,455,874
Maryland $5,136,302,340 $297,871,779 $5,434,174,119
Massachusetts $9,556,863,877 $403,706,704 $9,960,570,581
Michigan $8,656,266,850 $389,937,793 $9,046,204,643
Minnesota $5,528,371,422 $319,075,173 $5,847,446,595
Mississippi $3,342,615,012 $95,654,946 $3,438,269,958
Missouri $6,528,988,350 $298,709,983 $6,827,698,333
Montana $696,069,297 $40,452,839 $736,522,136
Nebraska $1,377,175,781 $93,856,052 $1,471,031,833
Nevada $1,184,065,213 $66,180,415 $1,250,245,628
New Hampshire $1,244,582,951 $57,418,911 $1,302,001,862
New Jersey $7,508,874,058 $461,298,321 $7,970,172,379
New Mexico $2,363,669,655 $82,478,622 $2,446,148,277
New York $42,752,347,265 $1,299,681,010 $44,052,028,275
North Carolina $8,844,879,833 $464,447,476 $9,309,327,309
North Dakota $508,464,760 $21,344,898 $529,809,658
Ohio $11,572,449,325 $342,550,662 $11,914,999,987
Oklahoma $2,712,779,961 $161,029,370 $2,873,809,331
Oregon $2,810,667,717 $252,091,973 $3,062,759,690
Pennsylvania $15,786,514,016 $702,907,573 $16,489,421,589
Rhode Island $1,671,398,242 $82,385,970 $1,753,784,212
South Carolina $4,068,509,449 $129,160,005 $4,197,669,454
South Dakota $608,250,647 $24,507,634 $632,758,281
Tennessee $7,557,403,733 $501,249,768 $8,058,653,501
Texas $17,264,066,130 $662,460,980 $17,926,527,110
Utah $1,341,242,046 $105,012,245 $1,446,254,291
Vermont $859,483,644 $58,665,386 $918,149,030
Virginia $4,425,080,633 $259,286,946 $4,684,367,579
Washington $5,700,850,706 $505,104,188 $6,205,954,894
West Virginia $2,161,356,254 $87,988,910 $2,249,345,164
Wisconsin $4,751,656,671 $204,535,435 $4,956,192,106
Wyoming $405,216,459 $29,528,292 $434,744,751
Source: CMS, CMS-64 Report, FY 2005.
2-20
Total SCHIP Enrollment, 2005*

Medicaid SCHIP Non-Medicaid SCHIP Total SCHIP Adults Enrolled in SCHIP
State Enrollment Enrollment Enrollment Demonstrations
National Total 1,738,270 4,412,945 6,151,215 644,569
Alabama - 81,856 81,856 -
Alaska 22,322 - 22,322 -
Arizona - 88,005 88,005 113,621
Arkansas - 1,214 1,214 -
California** 181,017 1,042,458 1,223,475 -
Colorado - 59,530 59,530 1,575
Connecticut - 22,289 22,289 -
Delaware 150 10,204 10,354 -
District of Columbia 6,631 - 6,631 -
Florida 1,942 382,859 384,801 -
Georgia - 306,733 306,733 -
Hawaii 20,602 - 20,602 -
Idaho 18,639 3,200 21,839 135
Illinois 120,582 160,850 281,432 175,994
Indiana 93,666 35,878 129,544 -
Iowa 16,453 30,109 46,562 -
Kansas - 47,323 47,323 -
Kentucky 41,180 22,548 63,728 -
Louisiana 146,347 - 146,347 -
Maine 21,806 8,848 30,654 -
Maryland 106,471 13,845 120,316 -
Massachusetts 119,268 43,411 162,679 -
Michigan 33,965 55,292 89,257 101,283
Minnesota 107 4,969 5,076 35,011
Mississippi - 79,352 79,352 -
Missouri 115,355 - 115,355 -
Montana - 15,841 15,841 -
Nebraska 44,706 - 44,706 -
Nevada - 39,316 39,316 -
New Hampshire 707 11,185 11,892 -
New Jersey 43,435 86,156 129,591 66,827
New Mexico 24,310 - 24,310 5,780
New York NR 618,973 618,973 -
North Carolina - 196,181 196,181 -
North Dakota 1,936 3,789 5,725 -
Ohio 216,495 - 216,495 -
Oklahoma 108,100 - 108,100 -
Oregon - 52,722 52,722 11,366
Pennsylvania - 179,807 179,807 -
Rhode Island 25,609 1,535 27,144 24,169
South Carolina 80,646 - 80,646 -
South Dakota 10,843 3,195 14,038 -
Tennessee - - - -
Texas - 526,406 526,406 -
Utah - 43,931 43,931 -
Vermont - 6,614 6,614 -
Virginia 57,815 66,240 124,055 -
Washington - 15,547 15,547 -
West Virginia - 38,614 38,614 -
Wisconsin 57,165 - 57,165 108,808
Wyoming - 6,120 6,120 -
*The data displayed in this table were compiled from the CMS website at
http://www.cms.hhs.gov/NationalSCHIPPolicy/downloads/FY2005AnnualEnrollmentReport.pdf.
Column and row values do not always sum to totals.
** California reported aggregate enrollment for unborn children via email.
NR- State has not reported data via the Statistical Enrollment Data System (SEDS).
Source: CMS, SCHIP Annual Enrollment Report 2005.
2-21
Total SCHIP Enrollment, 2006*

Medicaid SCHIP Non-Medicaid SCHIP Total SCHIP Adults Enrolled in SCHIP
State Enrollment Enrollment Enrollment Demonstrations
National Total 1,932,667 4,691,485 6,624,152 700,596
Alabama - 84,257 84,257 -
Alaska 22,227 - 22,227 -
Arizona - 96,669 96,669 109,738
Arkansas - 3,440 3,440 -
California 214,216 1,177,189 1,391,405 -
Colorado - 69,997 69,997 2,625
Connecticut - 23,110 23,110 -
Delaware 172 10,579 10,751 -
District of Columbia 6,332 - 6,332 -
Florida 1,877 301,718 303,595 -
Georgia - 343,690 343,690 -
Hawaii 22,031 - 22,031 -
Idaho 17,858 6,869 24,727 382
Illinois 139,565 177,216 316,781 211,114
Indiana 97,213 36,483 133,696 -
Iowa 17,756 31,819 49,575 -
Kansas - 48,934 48,934 -
Kentucky 41,943 22,918 64,861 -
Louisiana 142,389 - 142,389 -
Maine 22,167 8,947 31,114 -
Maryland 112,123 23,911 136,034 -
Massachusetts 126,120 64,520 190,640 -
Michigan 61,214 57,287 118,501 101,919
Minnesota 97 5,246 5,343 34,313
Mississippi - 83,359 83,359 -
Missouri 106,577 - 106,577 -
Montana - 17,304 17,304 -
Nebraska 44,981 - 44,981 -
Nevada - 39,317 39,317 -
New Hampshire 671 11,722 12,393 -
New Jersey 42,482 78,402 120,884 88,606
New Mexico 25,155 - 25,155 5,787
New York 51,576 636,786 688,362 -
North Carolina 53,180 194,811 247,991 -
North Dakota 1,889 4,429 6,318 -
Ohio 218,529 - 218,529 -
Oklahoma 116,012 - 116,012 -
Oregon - 59,039 59,039 13,750
Pennsylvania - 188,765 188,765 -
Rhode Island 24,028 1,464 25,492 21,125
South Carolina 68,870 - 68,870 -
South Dakota 11,254 3,330 14,584 -
Tennessee - - - -
Texas - 585,461 585,461 -
Utah - 51,967 51,967 -
Vermont - 6,314 6,314 -
Virginia 65,536 71,646 137,182 939
Washington - 15,000 15,000 -
West Virginia - 39,855 39,855 -
Wisconsin 56,627 - 56,627 110,298
Wyoming - 7,715 7,715 -
*The data displayed in this table were compiled from the CMS website at http://www.cms.hhs.gov/NationalSCHIPPolicy/
SCHIPER/list.asp.
Column and row values do not always sum to totals.
Source: CMS, SCHIP Annual Enrollment Report 2006 (Revised March 2007).
2-22
Total SCHIP Expenditures, 2005
Medicaid SCHIP Non-Medicaid SCHIP Total SCHIP

State Expenditures Expenditures Expenditures
National Total $1,957,501,616 $5,274,003,241 $7,231,504,857
Alabama $0 $100,725,496 $100,725,496
Alaska $32,720,132 $2,003,640 $34,723,772
Arizona $0 $256,444,257 $256,444,257
Arkansas $63,137,114 $13,530,687 $76,667,801
California $235,868,466 $965,714,137 $1,201,582,603
Colorado $0 $59,499,505 $59,499,505
Connecticut $487 $31,568,327 $31,568,814
Delaware $254,987 $9,569,305 $9,824,292
District of Columbia $8,915,304 $512,014 $9,427,318
Florida $5,225,829 $337,355,275 $342,581,104
Georgia $0 $278,810,644 $278,810,644
Hawaii $17,074,156 $1,287,336 $18,361,492
Idaho $16,700,064 $4,196,828 $20,896,892
Illinois $52,747,363 $441,330,244 $494,077,607
Indiana $73,979,126 $28,865,771 $102,844,897
Iowa $17,071,268 $37,644,726 $54,715,994
Kansas $0 $59,331,747 $59,331,747
Kentucky $63,321,377 $26,622,400 $89,943,777
Louisiana $125,937,574 $11,921,047 $137,858,621
Maine $19,272,547 $8,001,526 $27,274,073
Maryland $160,616,680 $27,633,244 $188,249,924
Massachusetts $116,585,007 $71,264,347 $187,849,354
Michigan $30,507,986 $216,526,269 $247,034,255
Minnesota $0 $110,072,609 $110,072,609
Mississippi $0 $133,948,150 $133,948,150
Missouri $118,305,367 $3,504,111 $121,809,478
Montana $0 $15,919,915 $15,919,915
Nebraska $46,497,218 $964,276 $47,461,494
Nevada $0 $38,439,249 $38,439,249
New Hampshire $577,504 $9,253,754 $9,831,258
New Jersey $53,751,037 $261,552,917 $315,303,954
New Mexico $24,153,109 $538,391 $24,691,500
New York $165,754,958 $392,007,001 $557,761,959
North Carolina $0 $283,039,101 $283,039,101
North Dakota $5,379,032 $5,302,888 $10,681,920
Ohio $234,450,124 $5,653,230 $240,103,354
Oklahoma $78,138,283 $1,749,250 $79,887,533
Oregon $0 $53,025,345 $53,025,345
Pennsylvania $0 $208,143,654 $208,143,654
Rhode Island $34,991,476 $46,875,741 $81,867,217
South Carolina $68,047,065 $4,596,131 $72,643,196
South Dakota $11,264,792 $4,323,769 $15,588,561
Tennessee $0 $0 $0
Texas $0 $396,131,832 $396,131,832
Utah $0 $35,638,694 $35,638,694
Vermont $0 $5,083,497 $5,083,497
Virginia $47,020,947 $75,760,728 $122,781,675
Washington $0 $50,982,193 $50,982,193
West Virginia $0 $40,421,152 $40,421,152
Wisconsin $29,235,237 $92,585,572 $121,820,809
Wyoming $0 $8,131,319 $8,131,319
Source: CMS, CMS-64 Report, 2005.
2-23
Total Medicaid/Medicare Dual Eligibles by Dual Eligibility Type, 20041
Not a QMB/
State All Eligibles Dual Eligible QMB Only Medicaid SLMB Only
National Total 57,575,692 49,361,011 523,829 4,530,864 422,973
Alabama 918,304 728,680 47,835 85,461 24,539
Alaska 127,779 116,512 3 8,170 148
Arizona 1,394,378 1,269,306 1,218 65,203 11,268
Arkansas 700,038 596,512 23,518 73,501 1,880
California 10,619,361 9,541,090 8,175 954,783 5,224
Colorado 524,760 450,709 8,157 9,125 4,142
Connecticut 508,387 413,315 7,523 44,610 4,071
Delaware 166,604 146,445 4,953 6,404 4,241
District of Columbia 160,304 140,933 69 13,361 962
Florida 2,867,361 2,347,199 34,756 333,640 44,766
Georgia 1,759,654 1,505,647 58,508 14,974 27,953
Hawaii 223,417 194,383 83 24,032 1,874
Idaho 220,535 197,631 3,363 11,105 0
Illinois 2,264,567 1,918,663 10,696 145,179 2,724
Indiana 982,131 845,259 9,807 73,969 7,190
Iowa 399,710 326,949 4,723 31,242 3,573
Kansas 344,006 286,012 5,343 29,169 3,303
Kentucky 833,511 676,706 30,554 85,767 11,446
Louisiana 1,112,345 948,819 30,737 106,564 16,851
Maine 306,397 246,169 1,205 28,966 5,509
Maryland 845,145 710,870 16,373 47,416 6,330
Massachusetts 1,156,690 928,406 194 92,740 16,809
Michigan 1,770,258 1,563,692 1,516 52,670 7,120
Minnesota 736,476 616,061 2,289 63,342 5,460
Mississippi 785,105 634,520 1,267 42,979 2,079
Missouri 1,205,751 1,033,623 5,183 71,830 3,841
Montana 113,073 94,901 536 11,057 0
Nebraska 260,865 221,958 0 23,823 2,296
Nevada 256,841 219,552 9,532 19,578 4,648
New Hampshire 134,216 111,012 2,118 5,773 1,353
New Jersey 988,602 805,847 0 138,578 20,062
New Mexico 511,778 465,072 12,660 29,225 0
New York 4,888,941 4,249,119 2,690 330,088 1,231
North Carolina 1,526,268 1,234,899 602 201,784 29,149
North Dakota 74,996 60,174 1,176 1,216 818
Ohio 1,996,065 1,739,767 26,484 123,336 13,209
Oklahoma 683,702 586,738 0 81,155 9,734
Oregon 590,236 510,214 11,052 32,249 6,462
Pennsylvania 1,890,061 1,551,971 692 218,444 24,471
Rhode Island 216,052 177,531 609 18,815 2,223
South Carolina 990,658 856,853 0 76,944 6,238
South Dakota 124,032 105,696 2,958 9,724 1,506
Tennessee 1,619,941 1,311,747 13,332 132,679 11,220
Texas 3,878,183 3,391,054 71,506 275,155 36,114
Utah 295,299 270,361 317 14,353 927
Vermont 163,595 133,320 189 10,003 497
Virginia 821,256 666,656 20,455 91,721 14,559
Washington 1,195,703 1,068,860 10,380 87,970 7,598
West Virginia 373,373 312,397 12,948 0 0
Wisconsin 971,210 762,708 3,938 78,127 4,595
Wyoming 77,772 68,493 1,607 2,865 760
1
QMB Only = Qualified Medicare Beneficiaries Without Other Medicaid
QMB/ Medicaid = QMBs With Full Medicaid
SLMB Only = Specified Low-Income Beneficiaries Without Other Medicaid
2-24
Total Medicaid/Medicare Dual Eligibles by Dual Eligibility Type, 2004

(Con’t)1
SLMB/
State Medicaid QDWI QI(1) QI(2) Other
National Total 225,355 78 218,908 570 2,292,104
Alabama 4,074 0 14,239 2 13,474
Alaska 0 0 0 0 2,946
Arizona 0 0 9,439 0 37,944
Arkansas 0 31 4,593 3 0
California 0 5 3,376 0 106,708
Colorado 5 0 1,789 1 50,832
Connecticut 6,249 0 6,993 0 25,626
Delaware 0 0 1 0 4,560
District of Columbia 744 0 376 7 3,852
Florida 20,765 0 27,691 0 58,544
Georgia 2,623 3 13,774 0 136,172
Hawaii 0 0 0 0 3,045
Idaho 0 0 0 0 8,436
Illinois 22,529 0 13,474 0 151,302
Indiana 13,577 2 4,115 0 28,212
Iowa 7,600 0 1,766 0 23,857
Kansas 1,528 0 1,314 0 17,337
Kentucky 4,322 1 5,038 0 19,677
Louisiana 100 1 9,245 14 14
Maine 1,792 2 2,788 484 19,482
Maryland 0 0 2,430 0 61,726
Massachusetts 0 0 0 0 118,541
Michigan 8,216 3 3,073 10 133,958
Minnesota 11,291 0 2,465 0 35,568
Mississippi 14,612 1 801 0 88,846
Missouri 11,258 0 266 0 79,750
Montana 0 0 0 0 6,579
Nebraska 0 1 0 0 12,787
Nevada 1,398 0 2,098 3 32
New Hampshire 902 3 565 0 12,490
New Jersey 0 0 8,660 0 15,455
New Mexico 0 0 0 0 4,821
New York 5,550 0 1,657 1 298,605
North Carolina 6,134 0 13,199 0 40,501
North Dakota 190 0 322 0 11,100
Ohio 38 0 6,101 0 87,130
Oklahoma 1,246 0 4,788 41 0
Oregon 5,377 0 3,303 0 21,579
Pennsylvania 16,962 0 14,169 0 63,352
Rhode Island 0 0 1,459 0 15,415
South Carolina 0 1 3,980 2 46,640
South Dakota 1,044 0 655 2 2,447
Tennessee 24,412 0 0 0 126,551
Texas 14,966 0 18,387 0 71,001
Utah 1,551 0 496 0 7,294
Vermont 854 0 0 0 18,732
Virginia 0 24 5,359 0 22,482
Washington 1,852 0 3,557 0 15,486
West Virginia 0 0 0 0 48,028
Wisconsin 7,911 0 747 0 113,184
Wyoming 3,683 0 360 0 4
1
SLMB/Medicaid = SLMBs with full Medicaid
QDWI = Qualified Disabled and Working Individuals
QI 1 = Qualifying Individuals (1)
Other = Other Dual Eligibles, Dual Category Unknown, and Dual Status Unknown
2-25
Total Medicaid Medical Vendor Payments and Dual Eligibility Status,

20041
Not a QMB/
State All Eligibles Dual Eligible QMB Only Medicaid SLMB Only
National Total $257,748,435,309 $144,060,399,677 $674,272,018 $56,786,668,933 $206,068,714
Alabama $3,856,624,429 $1,583,302,687 $36,749,661 $929,411,242 $1,573,886
Alaska $904,557,756 $663,584,562 $50 $149,413,298 $50,137
Arizona $3,888,008,156 $2,909,704,375 $1,584,011 $534,628,409 $4,780
Arkansas $2,358,152,529 $1,350,469,421 $57,154,274 $915,494,564 $725,502
California $27,443,631,984 $16,304,359,930 $21,496,160 $7,740,241,914 $13,682,863
Colorado $2,398,974,577 $1,286,651,222 $4,283,211 $142,693,310 $741,802
Connecticut $3,695,687,112 $1,469,760,511 $7,250,195 $1,264,098,742 $1,680,201
Delaware $800,099,395 $501,603,593 $6,803,439 $116,053,504 $1,713,717
District of Columbia $1,269,371,462 $829,880,668 $113,203 $227,411,616 $683,302
Florida $12,834,434,692 $6,641,965,601 $35,492,107 $3,225,433,405 $32,372,233
Georgia $6,944,469,214 $4,098,833,748 $214,976,658 $441,370,014 $29,692,794
Hawaii $861,761,796 $518,366,411 $88,437 $230,605,032 $648,386
Idaho $990,209,718 $619,521,602 $3,076,663 $168,770,815 $0
Illinois $10,796,139,208 $5,303,760,742 $13,232,916 $1,966,589,869 $1,259,504
Indiana $4,342,598,411 $2,402,498,613 $2,744,506 $1,122,154,376 $889,850
Iowa $2,205,524,237 $1,091,095,702 $5,193,230 $607,709,124 $1,269,105
Kansas $1,860,136,019 $924,679,742 $2,276,944 $496,868,464 $622,265
Kentucky $3,923,759,382 $2,528,984,869 $17,532,058 $919,880,290 $2,522,976
Louisiana $4,039,097,496 $2,545,291,686 $22,136,367 $1,354,365,543 $2,775,625
Maine $2,366,282,600 $1,528,843,247 $1,160,637 $396,767,238 $2,099,865
Maryland $4,594,329,962 $3,033,677,426 $66,508,717 $657,797,458 $11,835,875
Massachusetts $7,776,024,456 $4,061,810,608 $663,361 $1,400,612,956 $10,560,083
Michigan $7,696,785,150 $4,297,053,142 $3,973,840 $635,854,939 $5,884,410
Minnesota $4,575,111,805 $2,448,893,343 $2,340,154 $1,226,049,464 $1,905,268
Mississippi $3,312,060,122 $1,583,259,507 $1,963,380 $189,216,764 $1,966,640
Missouri $4,886,664,657 $2,770,860,385 $2,320,950 $892,257,766 $1,021,268
Montana $584,752,191 $318,938,763 $155,884 $140,284,879 $0
Nebraska $1,345,629,686 $641,628,543 $0 $159,993,203 $714,427
Nevada $805,569,471 $528,799,835 $5,868,888 $222,445,442 $938,586
New Hampshire $822,246,561 $399,394,534 $5,972,314 $93,798,742 $238,693
New Jersey $6,622,936,246 $3,181,378,756 $0 $3,073,182,618 $4,199,969
New Mexico $2,277,653,128 $1,482,024,017 $11,886,973 $444,946,387 $0
New York $37,273,255,429 $19,968,508,658 $430,297 $7,347,226,694 $462,361
North Carolina $7,388,008,367 $4,298,480,752 $395,516 $2,286,938,831 $13,442,116
North Dakota $477,445,701 $186,722,991 $848,147 $12,779,336 $208,728
Ohio $11,374,733,796 $6,206,561,478 $41,391,910 $2,626,016,848 $19,396,257
Oklahoma $2,335,120,746 $1,388,345,408 $0 $909,763,650 $5,344,419
Oregon $2,152,757,267 $1,353,044,525 $6,574,936 $367,790,027 $1,314,492
Pennsylvania $10,055,362,936 $5,575,969,238 $966,185 $2,188,796,043 $7,151,983
Rhode Island $1,530,945,956 $829,656,968 $116,863 $206,084,602 $851,843
South Carolina $4,014,695,264 $2,003,846,419 $0 $674,288,402 $1,167,982
South Dakota $579,796,034 $332,820,680 $3,800,749 $159,328,824 $327,405
Tennessee $6,971,053,079 $4,340,458,251 $7,006,782 $1,323,392,378 $5,293,080
Texas $13,214,404,197 $8,735,684,016 $16,400,930 $2,757,643,652 $3,637,188
Utah $1,355,982,016 $701,877,088 $140,906 $180,264,103 $267,120
Vermont $744,334,990 $437,944,801 $600,107 $98,598,023 $1,695,821
Virginia $3,574,171,786 $1,995,983,802 $13,611,074 $1,058,514,158 $2,750,176
Washington $4,930,041,261 $2,698,245,965 $10,910,399 $1,293,379,059 $3,759,628
West Virginia $2,019,557,347 $982,282,005 $9,001,749 $0 $0
Wisconsin $4,314,127,932 $1,959,115,766 $5,646,769 $1,175,320,659 $4,696,389
Wyoming $363,357,597 $213,973,075 $1,429,511 $34,142,257 $27,714
1
QMB Only = Qualified Medicare Beneficiaries Without Other Medicaid
QMB/ Medicaid = QMBs With Full Medicaid
SLMB Only = Specified Low-Income Beneficiaries Without Other Medicaid
2-26
Total Medicaid Medical Vendor Payments and Dual Eligibility Status,

2004 (Con’t)1
SLMB/
State Medicaid QDWI QI (1) QI (2) Other
National Total $4,307,421,421 $243,359 $217,035,370 $153,285 $51,496,172,532
Alabama $122,139,141 $0 $5,661,187 $79,664 $1,177,706,961
Alaska $0 $0 $0 $0 $91,509,709
Arizona $0 $0 $0 $0 $442,086,581
Arkansas $0 $219,793 $946,387 $0 $33,142,588
California $0 $68 $1,963,877 $0 $3,361,887,172
Colorado $5,963 $0 $203,923 $0 $964,395,146
Connecticut $225,520,619 $0 $540,863 $0 $726,835,981
Delaware $0 $0 $0 $0 $173,925,142
District of Columbia $10,852,595 $0 $980,889 $0 $199,449,189
Florida $451,995,102 $0 $49,787,717 $0 $2,397,388,527
Georgia $58,121,538 $0 $4,848,443 $0 $2,096,626,019
Hawaii $0 $0 $0 $0 $112,053,530
Idaho $0 $0 $0 $0 $198,840,638
Illinois $363,664,994 $0 $86,368,096 $0 $3,061,263,087
Indiana $220,274,012 $0 $832,418 $0 $593,204,636
Iowa $141,284,567 $0 $535,775 $0 $358,436,734
Kansas $16,654,868 $0 $264,421 $0 $418,769,315
Kentucky $111,728,632 $6 $871,349 $0 $342,239,202
Louisiana $1,475,519 $0 $784,091 $0 $112,268,665
Maine $38,238,724 $1,006 $1,324,604 $2,035 $397,845,244
Maryland $0 $0 $1,801,891 $0 $822,708,595
Massachusetts $0 $0 $0 $0 $2,302,377,448
Michigan $167,773,217 $12,517 $4,973,315 $65,437 $2,581,194,333
Minnesota $223,013,200 $0 $806,762 $0 $672,103,614
Mississippi $61,632,145 $887 $528,046 $0 $1,473,492,753
Missouri $144,113,748 $0 $185,166 $0 $1,075,905,374
Montana $0 $0 $0 $0 $125,372,665
Nebraska $0 $0 $0 $0 $543,293,513
Nevada $29,887,741 $0 $492,586 $0 $17,136,393
New Hampshire $16,311,953 $0 $87,587 $0 $306,442,738
New Jersey $0 $0 $1,488,796 $0 $362,686,107
New Mexico $0 $0 $0 $0 $338,795,751
New York $174,249,724 $0 $27,250,325 $3,820 $9,755,123,550
North Carolina $168,238,567 $0 $4,773,427 $0 $615,739,158
North Dakota $2,401,884 $0 $28,722 $0 $274,455,893
Ohio $308,828 $0 $8,773,647 $0 $2,472,284,828
Oklahoma $17,184,163 $0 $590,267 $2,209 $13,890,630
Oregon $93,177,180 $0 $423,435 $0 $330,432,672
Pennsylvania $474,498,156 $0 $3,469,894 $0 $1,804,511,437
Rhode Island $0 $0 $289,060 $0 $493,946,620
South Carolina $0 $292 $798,598 $0 $1,334,593,571
South Dakota $26,692,103 $0 $133,490 $120 $56,692,663
Tennessee $233,115,834 $0 $0 $0 $1,061,786,754
Texas $374,700,130 $0 $1,280,943 $0 $1,325,057,338
Utah $31,409,379 $0 $229,963 $0 $441,793,457
Vermont $5,002,198 $0 $0 $0 $200,494,040
Virginia $0 $8,790 $1,618,639 $0 $501,685,147
Washington $12,335,080 $0 $847,399 $0 $910,563,731
West Virginia $0 $0 $0 $0 $1,028,273,593
Wisconsin $177,580,212 $0 $206,046 $0 $991,562,091
Wyoming $111,839,705 $0 $43,326 $0 $1,902,009
1
SLMB/Medicaid = SLMBs with full Medicaid
QDWI = Qualified Disabled and Working Individuals
Other = Other Dual Eligibles, Dual Category Unknown, and Dual Status Unknown
Source: CMS, MSIS Report, FY 2004
2-27
2-28
MEDICAID MANAGED CARE ENROLLMENT
Since 1981, when Congress authorized States to implement Section 1915(b) and Section 1115
Medicaid waivers to increase access to managed care and test innovative health care financing and
delivery options, enrollment in Medicaid managed care has grown considerably, although the trend
appears to be leveling off. Since 1993, managed care enrollment has increased from 14.4% to over
65% of total Medicaid enrollment. In 2006, 65.3% of all Medicaid beneficiaries were enrolled in
some type of managed care program. As of June 30, 2006, all but two States (Alaska and Wyoming)
were enrolling Medicaid beneficiaries in some type of managed care plan.
Figure 2-1: Managed Care Enrollment as a Percentage of Total Medicaid Enrollment*

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2006. DHHS, CMS, Center for Medicaid
& State Operations. *Includes data for Puerto Rico. **Approximated numbers for 1995. Total Medicaid population was
provided by the Office of the Actuary, which used CMS 2082 data to calculate average Medicaid enrollees over 1995. The
managed care population differs from the 11,619,929 reported in the 1995 report as the number represented enrollment of some
beneficiaries in more than one plan.
TYPES OF MEDICAID MANAGED CARE PLANS
Medicaid managed care beneficiaries can be enrolled in one of five basic Medicaid managed care
plans:
! Health Insuring Organization (HIO): an entity that provides for or arranges for the
provision of care and contracts on a prepaid capitated risk basis to provide a
comprehensive set of services.
! Commercial Managed Care Organization (Com-MCO): a Com-MCO is a health
maintenance organization with a contract under §1876 or a Medicare+Choice
organization, a provider sponsored organization or any other private or public
organization, which meets the requirements of §1902(w). They provide
comprehensive services to commercial and/or Medicare enrollees, as well as
Medicaid enrollees.
! Medicaid-only Managed Care Organization (Mcaid-MCO): an MCO that
provides comprehensive services to Medicaid beneficiaries, but not commercial or
Medicare enrollees.
! Prepaid Inpatient Health Plan (PIHP): an entity that provides less than
comprehensive services on an at-risk basis or one that provides any benefit package
on a non-risk or other than State reimbursement Plan basis; and provides, arranges
for or otherwise has responsibility for the provision of any inpatient hospital or
institutional services.
! Prepaid Ambulatory Health Plan (PAHP): a prepaid ambulatory health plan that
provides less than comprehensive services on an at-risk or other than State Plan
reimbursement basis, and does not provide, arranges for, or otherwise has
responsibility for the provision of any inpatient hospital or institutional services.
! Primary Care Case Management (PCCM): a provider (usually a physician,
physician group practice, or an entity employing or having other arrangements with
such physicians, but sometimes also including nurse practitioners, nurse-midwives,
or physician assistants) who contracts to locate, coordinate, and monitor covered
2-29
primary care (and sometimes additional services). This category includes those
PIHPs that act as PCCMs.
! Program for All-Inclusive Care for the Elderly (PACE): a program that provides
prepaid, capitated comprehensive health care services to the frail elderly.
! “Other” Managed Care Arrangement: An entity where the plan is not considered
a PCCM, PIHP, PAHP, Comprehensive MCO, Medicaid-only MCO, HIO, or PACE.
The most utilized of these plans are Comprehensive MCOs and Prepaid Health Plans.
Table 2-1: Medicaid Managed Care Plans
Number of Number of Enrollees

Plans
Health Insuring Organization (HIO) 4 517,537
Commercial Managed Care Organization (COM-MCO) 177 9,936,268
Medicaid-Only Managed Care Organization (Mcaid-MCO) 133 9,362,928
Primary Care Case Management (PCCM) 33 6,467,252
Prepaid Inpatient Health Plan (PIHP) 109 8,244,584
Prepaid Ambulatory Health Plan (PAHP) 43 5,752,996
Program of All-Inclusive Care for the Elderly (PACE) 35 12,500
Other 11 2,509,586
Total 545 42,803,651*
*This table provides duplicated figures by plan type. The total number of enrollees includes 12,973,245 individuals who were
enrolled in more than one managed care plan. It also includes individuals enrolled in State health care reform programs that
expand eligibility beyond traditional Medicaid eligibility standards.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2006. DHHS, CMS, Center for Medicaid
& State Operations.
The following tables provide an overview of Medicaid managed care enrollment at the State level.
2-30
Medicaid Managed Care Enrollment, As of June 30, 2006
Rank Based on
Medicaid Medicaid Managed Percent in Percent in
State Enrollment Care Enrollment Managed Care Managed Care
National Total 45,652,642 29,830,406 65.34%
Alabama 785,949 497,539 63.30% 38
Alaska 100,720 0 0.00% 51
Arizona 977,094 875,492 89.60% 9
Arkansas 635,065 527,233 83.02% 16
California 6,508,528 3,276,440 50.34% 44
Colorado 391,227 372,046 95.10% 6
Connecticut 395,624 299,052 75.59% 22
Delaware 144,619 110,601 76.48% 21
District of Columbia 137,517 93,182 67.76% 29
Florida 2,276,597 1,491,020 65.49% 33
Georgia 1,321,564 1,290,814 97.67% 4
Hawaii 203,345 162,650 79.99% 20
Idaho 171,795 139,875 81.42% 18
Illinois 1,929,200 140,100 7.26% 50
Indiana 839,101 604,891 72.09% 24
Iowa 329,637 285,163 86.51% 12
Kansas 283,383 161,600 57.03% 42
Kentucky 706,903 652,935 92.37% 7
Louisiana 969,193 689,609 71.15% 25
Maine 243,487 162,397 66.70% 31
Maryland 700,431 489,988 69.96% 26
Massachusetts 1,037,978 627,241 60.43% 41
Michigan 1,523,390 1,292,524 84.85% 15
Minnesota 583,564 371,429 63.65% 37
Mississippi 570,178 58,189 10.21% 49
Missouri 830,262 826,394 99.53% 2
Montana 82,832 55,382 66.86% 30
Nebraska 210,235 169,982 80.85% 19
Nevada 172,274 141,936 82.39% 17
New Hampshire 111,559 83,529 74.87% 23
New Jersey 858,177 595,626 69.41% 27
New Mexico 400,835 261,318 65.19% 34
New York 4,208,629 2,572,242 61.12% 40
North Carolina 1,299,624 843,441 64.90% 35
North Dakota 54,063 30,069 55.62% 43
Ohio 1,749,120 698,049 39.91% 47
Oklahoma 556,068 477,677 85.90% 14
Oregon 408,932 369,447 90.34% 8
Pennsylvania 1,816,812 1,568,237 86.32% 13
Puerto Rico 930,989 907,236 97.45% 5
Rhode Island 181,483 119,483 65.84% 32
South Carolina 690,391 139,412 20.19% 48
South Dakota 101,006 99,240 98.25% 3
Tennessee 1,190,407 1,190,407 100.00% 1
Texas 2,767,930 1,897,394 68.55% 28
Utah 208,501 181,173 86.89% 10
Vermont 133,466 86,347 64.70% 36
Virgin Islands 5,262 0 0.00% 51
Virginia 704,739 445,560 63.22% 39
Washington 990,321 858,052 86.64% 11
West Virginia 296,831 137,457 46.31% 46
Wisconsin 863,145 403,306 46.73% 45
Wyoming 62,660 0 0.00% 51
State Medicaid enrollment includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility
standards. This table provides unduplicated figures for Medicaid Enrollment and Managed Care Enrollment by State for a single point in time. These
values differ significantly (i.e., are lower than) unduplicated annual counts of enrollees over the entire year.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2006. DHHS, CMS, Center for Medicaid & State Operations.
2-31
Pharmaceutical Benefits Under Managed Care Plans

Where do managed care recipients receive pharmacy Special requirements
State benefits? (State, Managed Care Plan, Both) for pharmacy benefits in managed care?
Alabama State N/A
Alaska N/A N/A
Arizona Managed Care Plan Contractual
Arkansas State N/A
California Both Statutes, regulations, guidelines, contractual
Colorado Managed Care Plan None
Connecticut Managed Care Plan Contractual
Delaware State N/A
District of Columbia Managed Care Plan Contractual
Florida Managed Care Plan Statutes
Georgia Managed Care Plan Contractual
Hawaii Managed Care Plan (except dental) Guidelines
Idaho N/A N/A
Illinois State N/A
Indiana Managed Care Plan Statutes
Iowa State N/A
Kansas Managed Care Plan (except hemophilia drugs) Statutes, regulations, guidelines, contractual
Kentucky Both Contractual
Louisiana N/A N/A
Maine State N/A
Maryland Both Regulations, guidelines
Massachusetts Both Contractual
Michigan Managed Care Plan with partial carve outs (antipsychotics Guidelines, contractual
and HIV retrovirals)
Minnesota Both Regulations, contractual
Mississippi N/A N/A
Missouri Both Regulations, guidelines
Montana N/A N/A
Nebraska State N/A
Nevada Managed Care Plan None
New Hampshire N/A N/A
New Jersey Both Contractual
New Mexico Managed Care Plan Regulations, contractual
New York State N/A
North Carolina State N/A
North Dakota N/A N/A
Ohio Managed Care Plan Guidelines
Oklahoma N/A N/A
Oregon Both Contractual
Pennsylvania Both Contractual
Rhode Island Managed Care Plan Regulations
South Carolina Managed Care Plan Guidelines, contractual
South Dakota N/A N/A
Tennessee State N/A
Texas State N/A
Utah State N/A
Vermont N/A N/A
Virginia Managed Care Plan Contractual
Washington Both Contractual
West Virginia State N/A
Wisconsin Both Contractual
Wyoming N/A N/A
“N/A” indicates Not Applicable.

Sources: As reported by State drug program administrators in the 2007 NPC Survey.
2-32
Medicaid Managed Care Enrollment Trends, 2001-2006

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

Commercial Medicaid-only
State HIO MCO MCO PCCM PIHP PAHP PACE Other
National Total 4 177 133 33 109 43 35 11
Alabama 0 0 0 1 2 0 0 0
Alaska 0 0 0 0 0 0 0 1
Arizona 0 0 25 0 1 0 0 0
Arkansas 0 0 0 1 0 1 0 0
California 4 24 2 0 1 13 4 1
Colorado 0 0 2 1 6 0 1 0
Connecticut 0 2 2 0 0 0 0 0
Delaware 0 0 1 0 0 0 0 1
District of Columbia 0 0 3 0 1 0 0 0
Florida 0 13 1 1 3 5 1 2
Georgia 0 0 1 1 1 1 0 0
Hawaii 0 2 1 0 2 0 0 1
Idaho 0 0 0 1 0 0 0 0
Illinois 0 1 2 0 0 0 0 0
Indiana 0 0 5 1 0 0 0 0
Iowa 0 1 0 1 1 0 0 0
Kansas 0 0 1 1 0 0 1 0
Kentucky 0 0 1 1 0 1 0 0
Louisiana 0 0 0 1 0 0 0 0
Maine 0 0 0 1 0 0 0 0
Maryland 0 0 7 0 0 0 1 0
Massachusetts 0 2 2 1 1 0 6 0
Michigan 0 4 11 0 18 0 1 0
Minnesota 0 6 3 0 0 0 0 0
Mississippi 0 0 0 0 0 1 0 0
Missouri 0 3 4 0 0 1 1 0
Montana 0 0 0 1 0 0 0 0
Nebraska 0 1 0 1 0 0 0 1
Nevada 0 2 0 0 0 1 0 0
New Hampshire 0 0 0 0 0 1 0 0
New Jersey 0 2 3 0 0 0 0 0
New Mexico 0 2 1 0 1 0 1 0
New York 0 20 19 4 12 1 4 1
North Carolina 0 1 0 2 2 0 0 0
North Dakota 0 0 1 1 0 0 0 0
Ohio 0 0 8 0 0 0 2 0
Oklahoma 0 0 0 1 0 2 0 0
Oregon 0 2 11 1 9 8 1 1
Pennsylvania 0 11 0 1 28 1 4 0
Puerto Rico 0 15 0 0 2 0 0 0
Rhode Island 0 2 1 0 0 0 1 0
South Carolina 0 0 2 1 0 2 1 0
South Dakota 0 0 0 1 0 1 0 0
Tennessee 0 4 4 0 2 0 1 2
Texas 0 8 2 2 1 0 2 0
Utah 0 0 0 1 12 1 0 0
Vermont 0 0 1 0 0 0 0 0
Virgin Islands 0 0 0 0 0 0 0 0
Virginia 0 5 2 1 0 1 0 0
Washington 0 7 1 1 1 1 1 0
West Virginia 0 3 0 1 0 0 0 0
Wisconsin 0 34 3 0 2 0 1 0
Wyoming 0 0 0 0 0 0 0 0
HIO=Health Insuring Organization; Commercial MCO=Commercial Managed Care Organization; Medicaid-only MCO=Medicaid-only
Managed Care Organization; PCCM=Primary Care Case Management; PIHP=Prepaid Inpatient Health Plan; PAHP=Prepaid Ambulatory Health
Plans; PACE=Program for All-Inclusive Care for the Elderly.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2006. DHHS, CMS, Center for Medicaid & State
Operations.
2-34
Medicaid Managed Care Enrollment by Plan Type,

As of June 30, 2006
Commercial Medicaid-
State HIO MCO only MCO PCCM PIHP PAHP PACE Other
National Total 517,537 9,936,268 9,362,928 6,467,252 8,244,584 5,752,996 12,500 2,509,586
Alabama 0 0 0 410,881 497,539 0 0 0
Alaska 0 0 0 0 0 0 0 97,353
Arizona 0 0 875,492 0 87,664 0 0 0
Arkansas 0 0 0 519,839 0 439,126 0 0
California 517,537 2,686,811 49,380 0 144 374,093 1,826 5,192
Colorado 0 0 80,927 39,749 346,064 0 980 0
Connecticut 0 209,554 89,498 0 0 0 0 0
Delaware 0 0 98,837 0 0 0 0 11,210
District of Columbia 0 0 89,912 0 3,270 0 0 0
Florida 0 546,410 203,769 676,185 192,302 349,100 121 67
Georgia 0 0 579,001 498,188 2,461 1,290,814 0 0
Hawaii 0 110,864 50,101 0 1,569 0 0 2,129
Idaho 0 0 0 139,875 0 0 0 0
Illinois 0 80,400 59,700 0 0 0 0 0
Indiana 0 0 537,496 67,395 0 0 0 0
Iowa 0 5,156 0 138,373 285,163 0 0 0
Kansas 0 0 79,234 82,181 0 0 185 0
Kentucky 0 0 141,691 304,444 0 652,935 0 0
Louisiana 0 0 0 689,609 0 0 0 0
Maine 0 0 0 162,397 0 0 0 0
Maryland 0 0 489,838 0 0 0 150 0
Massachusetts 0 120,949 238,188 268,104 289,406 0 1,388 0
Michigan 0 258,774 670,032 0 1,292,524 0 225 0
Minnesota 0 344,528 26,901 0 0 0 0 0
Mississippi 0 0 0 0 0 58,189 0 0
Missouri 0 99,950 253,265 0 0 473,017 162 0
Montana 0 0 0 55,382 0 0 0 0
Nebraska 0 31,221 0 38,308 0 0 0 169,982
Nevada 0 79,981 0 0 0 141,936 0 0
New Hampshire 0 0 0 0 0 83,529 0 0
New Jersey 0 213,835 381,791 0 0 0 0 0
New Mexico 0 186,144 58,025 0 261,318 0 271 0
New York 0 777,335 1,745,273 17,827 13,231 6,580 2,545 9,451
North Carolina 0 7,374 0 818,685 63,347 0 0 0
North Dakota 0 0 785 29,284 0 0 0 0
Ohio 0 0 697,475 0 0 0 574 0
Oklahoma 0 0 0 6,347 0 843,846 0 0
Oregon 0 27,136 247,479 10,102 335,216 362,937 623 357,734
Pennsylvania 0 1,109,313 0 296,066 1,190,693 33,127 958 0
Puerto Rico 0 907,236 0 0 776,121 0 0 0
Rhode Island 0 48,077 71,378 0 0 0 28 0
South Carolina 0 0 79,580 49,942 0 9,564 353 0
South Dakota 0 0 0 74,957 0 99,240 0 0
Tennessee 0 390,611 799,796 0 1,190,407 0 296 1,856,468
Texas 0 524,947 342,216 939,681 307,645 0 907 0
Utah 0 0 0 46,336 249,811 151,305 0 0
Vermont 0 0 86,347 0 0 0 0 0
Virgin Islands 0 0 0 0 0 0 0 0
Virginia 0 267,564 116,837 61,159 0 320,338 0 0
Washington 0 465,874 19,464 3,794 858,052 63,320 226 0
West Virginia 0 137,457 0 22,162 0 0 0 0
Wisconsin 0 298,767 103,220 0 637 0 682 0
Wyoming 0 0 0 0 0 0 0 0
* This table provides duplicated figures that include enrollees receiving comprehensive and limited benefits. Total number
of enrollees includes those who were enrolled in more than one managed care plan. Figures also include individuals
enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards.
Operations.
2-35
Medicaid Managed Care Enrollment by Payment Arrangement,

As of June 30, 2006*
Fee-For- Physician FFS/Some
Service Risk –Based Non-Risk Services Administrative Risk-Based
State (FFS) Capitation Capitation Capitation Services Fee Capitation Other
National Total 7,088,452 32,018,214 1,426,172 9,413 1,856,468 307,645 97,287
Alabama 410,881 497,539 - - - - -
Alaska 97,353** - - - - - -
Arizona - 963,156 - - - - -
Arkansas 519,839 439,126 - - - - -
California - 3,634,983 - - - - -
Colorado 39,749 415,484 12,487 - - - -
Connecticut - 299,052 - - - - -
Delaware 11,210** 98,837 - - - - -
District of Columbia - 93,182 - - - - -
Florida 694,266 1,129,024 62,213** - - - 82,451
Georgia 498,188 1,872,276 - - - - -
Hawaii - 164,663** - - - - -
Idaho 139,875 - - - - - -
Illinois - 140,100 - - - - -
Indiana 67,395 537,496 - - - - -
Iowa 138,373 290,319 - - - - -
Kansas 82,181 79,419 - - - - -
Kentucky 304,444 794,626 - - - - -
Louisiana 689,609 - - - - - -
Maine 162,397 - - - - - -
Maryland - 489,988 - - - - -
Massachusetts 268,104 649,931 - - - - -
Michigan - 2,221,555 - - - - -
Minnesota - 371,429 - - - - -
Mississippi - 58,189 - - - - -
Missouri - 826,394 - - - - -
Montana 55,382 - - - - - -
Nebraska 208,290** 31,221 - - - - -
Nevada - 221,917 - - - - -
New Hampshire - - 83,529 - - - -
New Jersey - 595,626 - - - - -
New Mexico - 505,758 - - - - -
New York 5,850 2,566,392** - - - - -
North Carolina 818,685 70,721 - - - - -
North Dakota 29,284 785 - - - - -
Ohio - 698,049 - - - - -
Oklahoma - 843,846 6,347 - - - -
Oregon 367,836** 973,391 - - - - -
Pennsylvania 296,066 2,334,091 - - - - -
Puerto Rico - 1,683,357 - - - - -
Rhode Island - 119,483 - - - - -
South Carolina 49,942 80,084 - 9,413 - - -
South Dakota 74,957 99,240 - - - - -
Tennessee - 1,190,703 1,190,407 - 1,856,468** - -
Texas 924,845 868,070 - - - 307,645 14,836
Utah 46,336 329,927 71,189 - - - -
Vermont - 86,347 - - - - -
Virginia 61,159 704,739 - - - - -
Washington 3,794 1,406,936 - - - - -
West Virginia 22,162 137,457 - - - - -
Wisconsin - 403,306 - - - - -
Wyoming - - - - - - -
*Individual State totals may not sum to total managed care enrollment (pages 2-29 and 2-31) because State totals include individuals enrolled in
more than one plan type, including dental, mental, and long-term care.
**Includes managed care entities whose structure is “other” and not considered a PCCM, MCO, PIHP, PAHP, or PACE.
Operation.
2-36
MEDICAID MANAGED CARE WAIVERS

In 1981, Congress authorized States to implement Section 1915(b) and Section 1115 Medicaid
waivers to increase access to managed care and test innovative health care financing and delivery
options. The U.S. Department of Health and Human Services (DHHS) granted these waivers to allow
States to “waive” certain Medicaid requirements in Sections 1902 and 1903 of the Social Security Act
and “mandate” enrollment of Medicaid eligibles in managed care programs.
SECTION 1915(b) “FREEDOM OF CHOICE” WAIVERS
Section 1915(b) waivers are granted to give States the authority to conduct Medicaid programs
outside of the scope of the Medicaid statute, allowing them to waive freedom of choice, statewide
access to care, and comparability requirements under Section 1902 of the Social Security Act. With a
1915(b) waiver, a State can require mandatory enrollment of Medicaid recipients in managed care
plans. Section 1915(b) waivers can also allow a State to create a “carveout” delivery system for
specialty care, e.g., a Managed Behavioral Health Care Plan. Section 1915(b) waivers cannot
negatively impact beneficiary access or quality of care of services, and must be cost-effective (i.e.,
cost must be less than the Medicaid program would cost without the waiver). Section 1915(b)
waivers are typically limited to a targeted geographical area or population, are approved for an initial
period of two years, and can be renewed on an ongoing basis if the State reapplies.
Four options for 1915(b) waivers exist; each is governed by a different subsection(s) of Section
1915(b);
! Paragraph (b)(1) - Case Management: States are allowed to implement case management
systems which can be as simple as requiring each beneficiary to choose a primary care
provider or as comprehensive as mandating enrollment in a prepaid health plan. The
Balanced Budget Act of 1997 also gave States the option to enroll certain beneficiaries
into managed care via a State Plan Amendment.
! Paragraph (b)(2) - Central Broker: Localities are allowed to act as a central broker in
assisting Medicaid eligibles in selecting among competing health care plans, if such a
restriction does not substantially impair access to medically necessary services of
adequate quality.
! Paragraph (b)(3) - Shared Cost Saving: States are allowed to share (through provision of
additional services) cost savings (resulting from use by the recipient of more cost-
effective medical care) with recipients of medical assistance under the State Plan.
! Paragraph (b)(4) - Restrict Providers: States can limit the number of providers of certain
services. These waivers are sometimes referred to as selective contracting waivers and
are gaining in popularity. For example, some approved 1915(b)(4) waivers include
programs to restrict the number of providers of transportation services, organ transplants,
and inpatient obstetrical care.
Although Section 1915(b) waivers allow States to increase access to managed care plans, States are still
limited under Federal regulations and cannot use them to serve beneficiaries beyond Medicaid State Plan
Eligibility or change their benefits package. In order to expand their Medicaid programs even further
than under Section 1915(b) waivers, States apply for Section 1115 research and demonstration waivers.
2-37
SECTION 1115 RESEARCH AND DEMONSTRATION WAIVERS
Section 1115 research and demonstration waivers release States from standard Medicaid
requirements, allowing them the flexibility to test substantially new ideas of policy merit. Along with
Section 1915(b) waivers, Section 1115 waivers allow States to waive freedom of choice, statewide
access to care, and comparability requirements. However, a Section 1115 waiver also allows States
to provide new and additional services, test new payment methods, offer benefits to new and
expanded populations, and contract with managed care organizations that do not meet the necessary
criteria of Section 1903 of the Social Security Act.
To receive approval of a Section 1115 waiver, States submit a proposal to CMS for discussion and
review. Once operational, States allow formal evaluations of the research and public policy value of
the programs and to demonstrate that their programs do not exceed costs, which would have
otherwise occurred under traditional Medicaid programs (i.e., States must demonstrate budget
neutrality). Section 1115 waivers are usually granted for a five-year period and each State must
submit a request for continuation. For example, Arizona has operated its program under a Section
1115 waiver for over 20 years. The Benefits Improvement and Protection Act (BIPA) of 2000
streamlined the process for States to submit requests for and receive extensions of Section 1115
demonstration waivers.
PHARMACY PLUS DEMONSTRATIONS UNDER SECTION 1115 AUTHORITY
Section 1115 demonstration authority may be used to extend pharmacy coverage to certain low-
income elderly and disabled individuals who are not otherwise eligible for Medicaid. This type of
Section 1115 waiver program is commonly referred to as “Pharmacy Plus.” Its purpose is to provide
a subsidized pharmacy benefit that is intended to assist individuals in maintaining their healthy status
and avoid spending down to Medicaid income and asset eligibility levels. The waivers will test how
provision of a pharmacy benefit to a non-Medicaid covered population will affect Medicaid costs,
utilization and future eligibility trends.
2-38
Section 1915(b) and 1115 Waivers
Date Originally
State Official Program Name Waiver Authority
Approved
Alabama Alabama Patient 1st 1915(b) 1915(b) 10/02/1996
Alabama Alabama Family Planning 1115 1115 07/01/2000
Alabama Alabama Hurricane Katrina Relief Program 1115 Katrina 09/22/2005
Alaska Alaska Denali KidCare 1115 1115 09/24/2004
Alaska Alaska Non Emergency Transportation 1915b 1915(b) 11/18/2005
Arizona Arizona Health Care Cost Containment System 1115 07/13/1982
Arizona Arizona HIFA 1115 1115 HIFA 12/12/2001
Arizona Arizona Hurricane Katrina Relief 1115 Katrina 03/06/2006
Arkansas Arkansas Independent Choices 1115 11/22/2000
Arkansas Arkansas RX Senior Care 1115 1115 Pending
Arkansas Arkansas ARKidsB 1115 1115 08/19/1997
Arkansas Primary Care Physician Program

Arkansas 1915(b) 06/11/1993
1915(b)
Arkansas Non Emergency Transportation Waiver

Arkansas 1915(b) 02/19/1998
1915(b)
Arkansas Arkansas TEFRA 1115 10/17/2002
Arkansas Independent Choices - Cash and

Arkansas 1115 10/9/1998
Counseling
Arkansas Arkansas Hurricane Katrina Relief Program 1115 Katrina 09/28/2005
Arkansas Arkansas Family Planning 1115 1115 Family Planning 06/18/1996
Arkansas Arkansas Safety Net Benefit Program HIFA 1115 1115 03/03/2006
California California Parental Coverage Expansion 1115 HIFA 01/25/2002
California California In Home Supportive Services (IHSS) 1115 7/31/2004
California California Geographic Managed Care Sacramento 1915(b) 11/22/1996
California California Two Plan Model 1915(b) 10/17/1998
California Medi-Cal Hospital Uninsured Care

California 1115 08/24/2005
1115 Waiver
California - ICF/DD-CN (Intermediate Care

California 1915(b) 08/17/2001
Facility/Developmentally Disabled..)
Specialty Mental Health Service Consolidation

California 1915(b) 11/16/2000
- Medi-Cal
Medicaid Demonstration Project for Los

California 1115 04/15/1996
Angeles County
California Family Planning, Access, Care and
California 1115 12/01/1999
Treatment (PACT) 1115
Source: CMS, Medicaid Waivers and Demonstrations List, www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/MWDL/list.asp
2-39
Section 1915(b) and 1115 Waivers (Cont.)
Date Originally
Approved
California California Health Insuring Organizations (HIOs) 1915(b) 07/10/2003
California California Health Plan of San Mateo 1915(b) 12/30/1987
California California CalOPTIMA 1915(b) 10/01/1995
California Fee For Service Managed Care

California 1915(b) 02/28/1997
Network
California California Health San Diego 1915(b) 10/07/1998
California California Selective Provider Contracting1915(b) 1915(b) 07/21/1982
California Solano Partnership Health Plan

California 1915(b) 05/01/1994
1915(b)
California Children's Services and Sacramento

California 1915(b) 08/13/2003
Dental Geographic Managed Care
California Santa Barbara Health Initiative

California 1915(b) 01/01/1987
1915(b)
California Primary Care Case Management

California 1915(b) 12/20/1982
1915(b)
California California Central Coast Alliance for Health 1915(b) 01/01/1996
California California Hurricane Katrina Relief Program 1115 Katrina 12/07/2005
Colorado Colorado Family Planning 1115 1115 withdrawn
Colorado Community Mental Health Services Program 1915(b) 03/06/1998
Colorado Consumer Directed Attendant Support

Colorado 1115 08/10/2001
Project
Colorado Adult Prenatal Coverage in CHP+

Colorado HIFA 1115 09/27/2002
HIFA
Connecticut Connecticut Medicaid Transfer of Assets Reform 1115 pending
Connecticut Connecticut ConnPACE Program Rx 1115 pending
Connecticut Connecticut HUSKY Plan Part A 1915(b) 07/20/1995
Delaware Delaware Pharmacy Assistance Program 1115 1115 Disapproved
Delaware Delaware Healthy Adult Program HIFA 1115 Disapproved
Delaware Delaware Diamond State Health Plan 1115 1115 05/17/1995
District of Columbia District of Columbia 1115 for Childless Adults 1115 03/07/2002
D.C. Program to Enhance Mediciad Access for

District of Columbia 1115 01/19/2001
Low-Income HIV-Infected Individuals
District of Columbia DC Coverage Initiative HIFA 1115 Pending
District of Columbia Hurricane Katrina Relief

District of Columbia 1115 Katrina 09/28/2005
Program
2-40
Section 1915(b) and 1115 Waivers (cont.)
Date Originally
Approved
Florida Coordinated Non Emergency

Florida 1915(b) 06/07/2001
Transportation 1915(b)
Florida Managed Care Waiver (Medipass)

Florida 1915(b) 01/1990
1915(b)
Florida Florida Family Planning 1115 1115 08/23/1998
Alzheimer's Medicaid Home and Community

Florida 1915(b)(c) 02/19/2004
Based Waiver Program
Florida Comprehensive Adult Day Health Care

Florida 1915(b)(c) 03/18/2003
Program
Florida Florida Consumer Directed Care Plus 1115 10/09/1998
Florida Statewide Inpatient Psychiatric Program

Florida 1915(b) 06/08/2001
(SIPP)
Florida Program for All Inclusive Care for

Florida 1115 N/A
Children 1115
Florida Florida Medicaid Reform 1115 1115 10/19/2005
Florida Florida MEDS-ADS 115 115 11/22/2005
Florida Florida Eligibility Privatization 1115 1115 Pending
Florida Florida Hurricane Katrina Relief Program 1115 Katrina 09/23/2005
Georgia Georgia Better Health Care Program 1915(b) 1915(b) 07/14/1993
Georgia HIV/AIDS 1115 N/A
MH/MR Preadmission Screening and Resident

Georgia 1915(b) 04/01/1994
Review (PASRR) Program
Georgia Georgia Non Emergency Transportation 1915(b) 1915(b) 09/08/1999
Georgia Georgia Hurricane Katrina Relief Program 1115 Katrina 09/28/2005
Hawaii Hawaii Prescription Plus 1115 1115 Disapproved
Hawaii Hawaii QUEST 1115 1115 07/16/1993
Idaho Idaho Access Card 1115 Waiver 1115 11/04/2004
Idaho Idaho Healthy Connections 1915(b) Waiver 1915(b) 09/17/1993
Idaho Idaho Hurricane Katrina Relief Program 1115 Katrina 09/27/2005
Illinois Illinois KidCare Parent Coverage HIFA 1115 HIFA 10/13/2002
Precription Drug Benefit for Illinois' Low

Illinois 1115 Pharmacy 01/28/2002
Income Seniors 1115
Illinois Illinois Family Planning 1115 1115 Family Planning 06/23/2003
Indiana Healthy Indiana Plan (HIP) 1115 Pending
Indiana Indiana Hoosier Healthwise 1915(b) 1915(b) 09/13/1993
2-41
Date Originally
Approved
Indiana Indiana Hurricane Katrina Relief Program 1115 Katrina 10/21/2005
Indiana Indiana Family Planning 1115 Demonstration 1115 Family Planning Pending
Iowa Iowa Family Planning 1115 01/10/2006
Iowa IowaCare 1115 1115 06/30/2005
Iowa Iowa Plan 1915(b) 12/09/1998
Kansas Kansas Managed Care Program 1915(b) 1915(b) 6/24/1998
Kansas Children & Family Services Behavioral

Kansas 1915(b) 5/27/2005
and Rehabilitative Treatment Services Waiver
Kentucky Non Emergency Medical

Kentucky 1915(b) 02/01/1996
Transportation Program
Kentucky Kentucky Health Care Partnership 1115 1115 12/09/1993
Louisiana Louisiana Community Care Statewide 1915(b) 1915(b) 06/29/1998
Louisiana Louisiana Models of Excellence Waiver 1915(b) 1915(b) 11/11/2002
Louisiana Louisiana HIFA 1115 withdrawn
Louisiana Louisiana Hurricane Katrina Relief Program 1115 Katrina 11/10/2005
Louisiana Louisiana Family Planning Waiver 1115 1115 Family Planning 06/06/2006
Maine MaineCare for Childless Adults HIFA 1115 1115 09/13/2002
Maine Maine - HIV/AIDS 1115 02/24/2000
Maryland Maryland Health Choice 1115 1115 10/30/1996
Maryland Maryland Funding for Pregnant Women 1115 1115 Pending
Maryland Maryland Community Choice 1115 N/A
Maryland Maryland Hurricane Katrina Relief Program 1115 Katrina 11/10/2005
Massachusetts Massachusetts MassHealth 1115 1115 04/24/1995
Massachusetts Massachusetts Family Planning 1115 Under Review
Massachusetts MA Community First 1115 N/A
Michigan Michigan EPIC Ex 1115 1115 Pharmacy 12/12/2005
Michigan Comprehensive Health Care Program

Michigan 1915(b) 10/10/1996
1915 (b)
Michigan Michigan Adult Benefits Waiver HIFA 1115 HIFA 01/16/2004
Michigan Specialty Services and Supports

Michigan 1915(b)(c) 06/26/1998
Waiver Program
Michigan Michigan Modernizing Medicaid 1115 Pending
Michigan Plan First! Family Planning Program

Michigan 1115 Family Planning 03/01/2006
1115
2-42
Date Originally
Approved
Minnesota Minnesota HIFA 1115 1115 HIFA Inactive
Minnesota Prepaid Medical Assistance Project

Minnesota 1115 04/27/1995
Plus
Consolidated Chemical Dependency Treatment

Minnesota 1915(b) 01/01/1988
Fund (CCDTF)
Minnesota Minnesota Senior Care Project 1915(b) 06/3020/05
Minnesota Minnesota Katrina Relief 1115 Katrina N/A
Minnesota Minnesota Care SCHIP 1115 1115 06/13/2001
Minnesota Minnesota Family Planning Project 1115 06/20/2004
Mississippi Non Emergency Transportation

Mississippi 1915(b) 04/11/2003
1915(b)
Mississippi Mississippi Family Planning 1115 1115 01/31/2003
Mississippi Healthier Mississippi 1115 09/10/2004
Mississippi Mississippi Hurricane Katrina Relief Program 1115 Katrina 09/28/2005
Missouri Missouri Managed Care Plus 1915(b) 1915(b) 10/01/1995
Missouri Missouri Family Planning 1115 Waiver 1115 Family Planning Under Review
Missouri Missouri Managed Care Plus (MC+) 1115 1115 04/29/1998
Montana Montana Passport to Health 1915(b) 1915(b) 08/31/1993
Montana Montana Basic Medicaid for Able Bodied Adults 1115 01/30/2004
Montana Montana Katrina Relief Program 1115 Katrina 03/20/2006
Nebraska Health Connection MH/SA Waiver 1915(b) 07/01/1995
Nevada Nevada Non Emergency Transportation 1915(b) 1915(b) 06/22/2004
Nevada Nevada Hurricane Katrina Relief Program 1115 Katrina 11/23/2005
Nevada Nevada HIFA 1115 1115 11/02/2006
New Hampshire New Hampshire Disease Management 1915(b) 1915(b) Pending
New Hampshire New Hampshire Granite Care Select 1915(b) 6/26/2007
New Jersey Family Coverage Under SCHIP for

New Jersey 1115 SCHIP 01/18/2001
Families and Program Coverage
New Jersey New Jersey Care 2000+ 1915(b) 11/2/1999
New Jersey Personal Preference Program

New Jersey 1115 10/9/1998
(Cash/Counseling)
New Mexico New Mexico 1115 HIFA 1115 HIFA 08/23/2002
New Mexico New Mexico Family Planning 1115 Family Planning 08/01/1997
2-43
Date Originally
Approved
New Mexico New Mexico SCHIP Waiver 1115 SCHIP 01/11/1999
New Mexico New Mexico Salud 1915(b) 1915(b) 07/01/1997
New Mexico NM Behavioral Health Waiver 1915(b) 06/24/2005
New York New York Partnership Plan 1115 07/15/1997
New York Non Emergency Transportation

New York 1915(b) 01/17/1996
Program 1915 b
New York Federal-State Health Reform

New York 1115 09/29/2006
Partnership (FSHRP)
North Carolina ACCESS HealthCare Connection

North Carolina 1915(b) 01/01/1991
1915(b)
North Carolina North Carolina Family Planning 1115 1115 Family Planning 11/05/2004
North Carolina - Piedmont Behavioral Health

North Carolina 1915(b)(c) 10/06/2004
Care
North Carolina North Carolina Katrina Waiver 1115 Katrina 02/17/2006
Ohio Ohio PremierCare 1915(b) 1915(b) 05/23/2001
Ohio Ohio Hurricane Katrina Relief Program 1115 Katrina 12/07/2005
Oklahoma Oklahoma Non Emergency Transportation 1915(b) 06/02/2004
Oklahoma Oklahoma SoonerCare 1115 1115 10/12/1995
Oklahoma Oklahoma SoonerCare Family Planning 1115 Family Planning 11/05/2004
Oregon Oregon Non Emergency Transportation 1915(b) 1915(b) 09/01/1994
Oregon Oregon Family Planning 1115 1115 Family Planning 10/01/1998
Oregon Oregon Health Plan 1115 HIFA 10/15/2002
Oregon OR Independent Choices 1115 11/22/00
Oregon Oregon Hurricane Katrina Relief Waiver 1115 Katrina 03/06/2006
Pennsylvania Pennsylvania Access Plus 1915(b) 1915(b) 12/03/2004
Pennsylvania Pennsylvania Health Choices 1915(b) 1915(b) 07/31/2002
Pennsylvania PA Family Planning Waiver 1115 1115 Family Planning 5/11/2007
Pennsylvania Lancaster County Health Plan

Pennsylvania 1915(b) N/A
1915(b)
Rhode Island Rhode Island RIteCare 1115 1115 11/01/1993
Rhode Island Rhode Island Rx + 1115 1115 Pending
Rhode Island Rhode Island Katrina Waiver 1115 Katrina 02/17/2006
Prescription Drug Benefit for South Carolina's

South Carolina 1115 Pharmacy 07/30/2002
Low Income Seniors
2-44
Date Originally
Approved
South Carolina South Carolina Health Connections 1115 1115 Pending
South Carolina South Carolina Hurricane Katrina Relief 1115 Katrina 10/20/2005
South Carolina South Carolina Family Planning Demonstration FP 1115 N/A
South Dakota South Dakota PRIME 1915(b) 1915(b) 03/26/1996
Tennessee Tennessee TennCare 1115 1115 05/30/2002
Tennessee TennCare for Medicaid Medicare

Tennessee 1915(b) 06/28/2002
Duals 1915(b)
Tennessee Tennessee Hurricane Katrina Relief Program 1115 Katrina 10/06/2005
Texas Texas PsychMed 1115 1115 Inactive
Texas Texas LoneStar Select I 1915(b) 1915(b) 07/01/1994
Texas Access Reform STAR MMC Consolidated

Texas 1915(b) 08/10/2001
1915(b)
Texas LoneStar Select II Contracting Program 1915(b) 1915(b) 03/10/1995
Texas Texas NorthStar Behavioral Health 1915(b) 09/07/1999
Texas Texas Star+Plus 1915(b) 01/30/1998
Texas Texas Disease Management 1915(b) 08/9/2005
Texas Texas 3 Share HIFA Demonstration 1115 HIFA Pending
Texas Texas Family Planning 1115 1115 Family Planning 12/21/2006
Texas Tex Kat Program 1115 Katrina 09/15/2005
Texas Texas SCHIP Cost Share 1115 1115 Pending
Utah Utah Primary Care Network PCN 1115 1115 02/08/2002
Utah Non-Emergency Transportation Waiver

Utah 1915(b) 09/19/2000
1915(b)
Home Health Services for San Juan & Grand

Utah 1915(b) N/A
Counties
Utah Utah - Prepaid Mental Health Plan 1915(b) 12/20/2001
Utah Choice of Health Care Delivery Program

Utah 1915(b) 03/23/1982
1915(b)
Utah Utah Katrina Relief Program 1115 Katrina 03/20/2006
Vermont Vermont Health Access Plan 1115 1115 07/28/1995
Vermont VT Long-Term Care Plan 1115 06/13/2005
Vermont Vermont Global Commitment to Healthcare 1115 09/27/2005
Virginia Viriginia Family Planning 1115 1115 Family Planning 07/22/2002
Virginia Virginia Medallion I 1915(b) 1915(b) 12/23/1991
2-45
Date Originally
Approved
Virginia Virginia Medallion II 1915(b) 1915(b) 09/28/1998
Virginia Non Emergency Transportation Waiver

Virginia 1915(b) 08/23/2005
1915(b)
Virginia Virginia FAMIS MOMS 1115 HIFA 06/30/2005
Virginia Virginia Katrina Relief Program 1115 Katrina 03/20/2006
Washington Washington Healthy Options 1915(b) 1915(b) 10/01/1993
Washington Washington Premium Proposal 1115 1115 02/13/2004
Washington Selective Hospital Contracting

Washington 1915(b) 04/01/1988
Program 1915(b)
Washington Washington Mental Health 1915(b) 03/01/2002
Washington Washington Disease Management 1915(b) 03/03/2003
Washington Washington Family Planning 1115 1115 Family Planning 03/06/2001
West Virginia West Virginia Mountain Health Trust 1915(b) 1915(b) 04/29/1996
West Virginia Physician Assured Access System

West Virginia 1915(b) 06/01/1992
PAAS 1915(b)
West Virginia West Virginia Dental and Vision Waiver 1115 Pending
Wisconsin Wisconsin Family Planning 1115 1115 Family Planning 06/14/2002
Wisconsin Wisconsin Badger Care 1115 1115 01/22/1999
Wisconsin Allied Services for Healthy Foster

Wisconsin 1915(b) 07/01/2004
Children 1915(b)
Wisconsin Wisconsin Family Care Concurrent b/c Waiver 1915(b)(c) 06/01/2001
Wisconsin Wisconsin Hurricane Katrina Relief Program 1115 Katrina 03/24/2006
Wyoming Wyoming Katrina Waiver 1115 Katrina 02/17/2006
Wyoming WY Family Planning 1115 Demonstration 1115 Family Planning Pending
Wyoming WY HIFA Demonstration 1115 HIFA Pending
2-46
Section 3:
State Characteristics
3-1
3-2
STATE CHARACTERISTICS
Presented in Section 3 of the Compilation is State-by-State information on several topics. The
Section begins with a series of tables showing select State demographic characteristics including
age composition and racial/Hispanic status. Next, insurance coverage, poverty status,
employment, and income data for each State are presented. The final group of tables show select
components of each State’s health care system including Medicare and Medicaid certified
facilities (hospitals, SNFs, ICFs/MR, home health agencies, and rural health clinics), licensed
pharmacies, and health manpower (physicians, Registered Nurses, and pharmacists).
The data in Section 3 have been compiled from a myriad of sources. These include:
! CMS
! The U.S. Bureau of the Census
! The Bureau of Labor Statistics (BLS)
! The Health Resources and Services Administration (HRSA)
! The National Association of Boards of Pharmacy
Because of the unevenness with which the various government agencies and other organizations
have released updated information, we have carefully reviewed all possible information sources
and made judgments on which data to present. In the final analysis, we have included those data
that, in our opinion, best reflect the factors and characteristics on which we have reported.
However, certain limitations in the different sources have resulted in some inconsistencies among
the tables. The following examples illustrate this problem.
The table showing the age distribution of the population is derived from the 2006 American
Community Survey conducted by the U.S. Bureau of the Census. Unfortunately, individuals
residing in “group quarters” are not included in this survey. Hence, the total population figure
(and the corresponding figures for each State) presented in this table is inconsistent with the
population total in the table showing insurance status.
The data on insurance status was compiled from the Current Population Survey, 2006 Annual
Social and Economic Supplement, a collaborative effort by the Census Bureau and BLS. Hence,
the estimates on the number of Medicare and Medicaid beneficiaries differ slightly from those
published by CMS. In addition, more detailed data on poverty, also compiled from the 2006
Annual Social and Economic Supplement to the Current Population Survey, have been included in
this year’s Compilation.
HRSA’s Bureau of Health Professions, National Center for Health Workforce Analysis is
responsible for compiling the Area Resource File (ARF), an important annual data file for
researchers, planners, policymakers, and others seeking information on the health professions
workforce, health care facilities, health care utilization and expenditures, etc. at a variety of
geographic levels. Physician data come from the 2007 ARF. Nursing data come from HRSA’s
2004 National Sample Survey of Registered Nurses, the most comprehensive source of statistics
on individuals with active registered nurse licenses in the U.S., whether or not they are currently
employed in nursing.
Despite the limitations confronted while compiling these statistics, we believe that the data
presented in Section 3 provide a useful and meaningful picture of State characteristics. Users of
the Compilation are urged to carefully read the source information and notes at the bottom of each
table in order to understand the limitations of the data contained therein.
3-3
3-4
Age Demographics, 2006*

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

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

National Total 299,398,484 44,321,038 14.8%
Alabama 4,599,030 113,890 2.5%
Alaska 670,053 37,548 5.6%
Arizona 6,166,318 1,803,378 29.2%
Arkansas 2,810,872 141,053 5.0%
California 36,457,549 13,074,156 35.9%
Colorado 4,753,377 934,413 19.7%
Connecticut 3,504,809 391,935 11.2%
Delaware 853,476 53,835 6.3%
District of Columbia 581,530 47,774 8.2%
Florida 18,089,888 3,646,499 20.2%
Georgia 9,363,941 703,246 7.5%
Hawaii 1,285,498 99,663 7.8%
Idaho 1,466,465 138,870 9.5%
Illinois 12,831,970 1,886,933 14.7%
Indiana 6,313,520 300,857 4.8%
Iowa 2,982,085 114,700 3.8%
Kansas 2,764,075 237,426 8.6%
Kentucky 4,206,074 85,938 2.0%
Louisiana 4,287,768 124,481 2.9%
Maine 1,321,574 13,529 1.0%
Maryland 5,615,727 337,341 6.0%
Massachusetts 6,437,193 511,014 7.9%
Michigan 10,095,643 393,281 3.9%
Minnesota 5,167,101 196,135 3.8%
Mississippi 2,910,540 53,381 1.8%
Missouri 5,842,713 164,194 2.8%
Montana 944,632 23,818 2.5%
Nebraska 1,768,331 130,304 7.4%
Nevada 2,495,529 610,052 24.4%
New Hampshire 1,314,895 29,872 2.3%
New Jersey 8,724,560 1,364,696 15.6%
New Mexico 1,954,599 860,688 44.0%
New York 19,306,183 3,139,456 16.3%
North Carolina 8,856,505 593,896 6.7%
North Dakota 635,867 10,637 1.7%
Ohio 11,478,006 267,750 2.3%
Oklahoma 3,579,212 247,450 6.9%
Oregon 3,700,758 379,038 10.2%
Pennsylvania 12,440,621 526,976 4.2%
Rhode Island 1,067,610 117,701 11.0%
South Carolina 4,321,249 151,289 3.5%
South Dakota 781,919 16,773 2.1%
Tennessee 6,038,803 194,706 3.2%
Texas 23,507,783 8,385,139 35.7%
Utah 2,550,063 286,113 11.2%
Vermont 623,908 7,135 1.1%
Virginia 7,642,884 479,530 6.3%
Washington 6,395,798 581,357 9.1%
West Virginia 1,818,470 16,767 0.9%
Wisconsin 5,556,506 258,696 4.7%
Wyoming 515,004 35,729 6.9%
This information was taken from the 2006 American Community Survey conducted by the U.S. Bureau of The Census. The information
provided is limited to the household population and excludes the population living in institutions, college dormitories, and other group
quarters. This accounts for the difference in the estimates of the U.S. population from this source compared to other estimates presented
by the U.S. Census. The data are based on a sample and are subject to sampling variability. Data based on twelve monthly samples
during 2006.
Source: U.S. Department of Commerce, Bureau of the Census, 2006 Population Estimates.
3-7
Insurance Status - Populations, 2006*
Total Medicaid Medicare Military Privately Not

State Population Population Population Insurance Insured Insured
National Total 296,824,000 38,281,000 40,343,000 10,547,000 201,690,000 46,995,000
Alabama 4,532,000 614,000 683,000 220,000 3,107,000 689,000
Alaska 659,000 80,000 58,000 91,000 428,000 109,000
Arizona 6,269,000 1,012,000 796,000 266,000 3,770,000 1,311,000
Arkansas 2,758,000 422,000 413,000 136,000 1,662,000 521,000
California 36,208,000 5,775,000 3,998,000 940,000 22,758,000 6,791,000
Colorado 4,803,000 421,000 496,000 190,000 3,392,000 826,000
Connecticut 3,462,000 406,000 499,000 92,000 2,639,000 325,000
Delaware 862,000 82,000 130,000 42,000 637,000 105,000
District of Columbia 569,000 117,000 65,000 12,000 381,000 66,000
Florida 18,062,000 1,791,000 3,083,000 984,000 11,318,000 3,828,000
Georgia 9,347,000 1,152,000 986,000 546,000 6,083,000 1,659,000
Hawaii 1,255,000 133,000 170,000 121,000 937,000 110,000
Idaho 1,475,000 172,000 200,000 56,000 1,019,000 227,000
Illinois 12,644,000 1,381,000 1,562,000 202,000 9,209,000 1,776,000
Indiana 6,337,000 643,000 826,000 184,000 4,773,000 748,000
Iowa 2,919,000 413,000 432,000 82,000 2,215,000 307,000
Kansas 2,723,000 320,000 405,000 90,000 2,033,000 335,000
Kentucky 4,106,000 602,000 602,000 159,000 2,738,000 639,000
Louisiana 4,212,000 659,000 659,000 98,000 2,468,000 921,000
Maine 1,315,000 236,000 236,000 68,000 929,000 122,000
Maryland 5,613,000 473,000 473,000 245,000 4,212,000 776,000
Massachusetts 6,335,000 827,000 827,000 84,000 4,685,000 657,000
Michigan 9,970,000 1,311,000 1,311,000 157,000 7,447,000 1,043,000
Minnesota 6,149,000 602,000 696,000 125,000 4,021,000 475,000
Mississippi 2,892,000 497,000 425,000 132,000 1,712,000 600,000
Missouri 5,800,000 677,000 949,000 173,000 4,114,000 772,000
Montana 931,000 108,000 138,000 48,000 630,000 160,000
Nebraska 1,767,000 152,000 235,000 117,000 1,326,000 217,000
Nevada 2,535,000 174,000 334,000 101,000 1,684,000 496,000
New Hampshire 1,309,000 88,000 183,000 42,000 918,000 150,000
New Jersey 8,660,000 676,000 1,126,000 85,000 6,364,000 1,341,000
New Mexico 1,943,000 308,000 273,000 114,000 1,081,000 445,000
New York 19,040,000 3,542,000 2,756,000 190,000 2,649,000 2,662,000
North Carolina 8,851,000 1,190,000 1,270,000 344,000 5,714,000 1,585,000
North Dakota 617,000 54,000 82,000 20,000 473,000 75,000
Ohio 11,319,000 1,596,000 1,591,000 348,000 8,339,000 1,138,000
Oklahoma 3,492,000 443,000 518,000 273,000 2,145,000 661,000
Oregon 3,715,000 401,000 506,000 106,000 2,534,000 665,000
Pennsylvania 12,345,000 1,473,000 1,986,000 164,000 9,275,000 1,203,000
Rhode Island 1,054,000 222,000 150,000 28,000 774,000 91,000
South Carolina 4,226,000 600,000 647,000 234,000 2,747,000 672,000
South Dakota 770,000 82,000 120,000 52,000 568,000 91,000
Tennessee 5,920,000 816,000 917,000 390,000 3,920,000 809,000
Texas 23,236,000 2,826,000 2,830,000 792,000 13,770,000 5,704,000
Utah 2,537,000 235,000 241,000 73,000 1,825,000 442,000
Vermont 620,000 115,000 89,000 18,000 442,000 63,000
Virginia 7,538,000 564,000 908,000 790,000 5,432,000 1,006,000
Washington 6,318,000 797,000 825,000 463,000 4,592,000 746,000
West Virginia 1,814,000 313,000 341,000 81,000 1,161,000 245,000
Wisconsin 5,476,000 643,000 722,000 144,000 4,224,000 481,000
Wyoming 516,000 46,000 79,000 32,000 378,000 75,000
*The sum of rows may be greater than the total State population because individuals may have dual coverage and appear in
more than one category.
Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2007 Annual Social and Economic
Supplement.
3-8
Insurance Status - Percentages, 2006*
% Covered by % Covered by
Total % Covered by % Covered by Military Private
State Population Medicaid Medicare Insurance Insurance % Not Insured
National Total 296,824,000 12.9% 13.6% 3.6% 67.9% 15.8%
Alabama 4,532,000 13.5% 15.1% 4.9% 68.6% 15.2%
Alaska 659,000 12.1% 8.8% 13.8% 64.9% 16.5%
Arizona 6,269,000 16.1% 12.7% 4.2% 60.1% 20.9%
Arkansas 2,758,000 15.3% 15.0% 4.9% 60.3% 18.9%
California 36,208,000 15.9% 11.0% 2.6% 62.9% 18.8%
Colorado 4,803,000 8.8% 10.3% 4.0% 70.6% 17.2%
Connecticut 3,462,000 11.7% 14.4% 2.7% 76.2% 9.4%
Delaware 862,000 9.5% 15.1% 4.9% 73.9% 12.2%
District of Columbia 569,000 20.6% 11.4% 2.1% 67.0% 11.6%
Florida 18,062,000 9.9% 17.1% 5.4% 62.7% 21.2%
Georgia 9,347,000 12.3% 10.5% 5.8% 65.1% 17.7%
Hawaii 1,255,000 10.6% 13.5% 9.6% 74.7% 8.8%
Idaho 1,475,000 11.7% 13.6% 3.8% 69.1% 15.4%
Illinois 12,644,000 10.9% 12.4% 1.6% 72.8% 14.0%
Indiana 6,337,000 10.1% 13.0% 2.9% 75.3% 11.8%
Iowa 2,919,000 14.1% 14.8% 2.8% 75.9% 10.5%
Kansas 2,723,000 11.8% 14.9% 3.3% 74.7% 12.3%
Kentucky 4,106,000 14.7% 14.7% 3.9% 66.7% 15.6%
Louisiana 4,212,000 15.6% 15.6% 2.3% 58.6% 21.9%
Maine 1,315,000 17.9% 17.9% 5.2% 70.6% 9.3%
Maryland 5,613,000 8.4% 8.4% 4.4% 75.0% 13.8%
Massachusetts 6,335,000 13.1% 13.1% 1.3% 74.0% 10.4%
Michigan 9,970,000 13.1% 13.1% 1.6% 74.7% 10.5%
Minnesota 6,149,000 9.8% 11.3% 2.0% 65.4% 7.7%
Mississippi 2,892,000 17.2% 14.7% 4.6% 59.2% 20.7%
Missouri 5,800,000 11.7% 16.4% 3.0% 70.9% 13.3%
Montana 931,000 11.6% 14.8% 5.2% 67.7% 17.2%
Nebraska 1,767,000 8.6% 13.3% 6.6% 75.0% 12.3%
Nevada 2,535,000 6.9% 13.2% 4.0% 66.4% 19.6%
New Hampshire 1,309,000 6.7% 14.0% 3.2% 70.1% 11.5%
New Jersey 8,660,000 7.8% 13.0% 1.0% 73.5% 15.5%
New Mexico 1,943,000 15.9% 14.1% 5.9% 55.6% 22.9%
New York 19,040,000 18.6% 14.5% 1.0% 13.9% 14.0%
North Carolina 8,851,000 13.4% 14.3% 3.9% 64.6% 17.9%
North Dakota 617,000 8.8% 13.3% 3.2% 76.7% 12.2%
Ohio 11,319,000 14.1% 14.1% 3.1% 73.7% 10.1%
Oklahoma 3,492,000 12.7% 14.8% 7.8% 61.4% 18.9%
Oregon 3,715,000 10.8% 13.6% 2.9% 68.2% 17.9%
Pennsylvania 12,345,000 11.9% 16.1% 1.3% 75.1% 9.7%
Rhode Island 1,054,000 21.1% 14.2% 2.7% 73.4% 8.6%
South Carolina 4,226,000 14.2% 15.3% 5.5% 65.0% 15.9%
South Dakota 77,000 10.6% 15.6% 6.8% 73.7% 11.8%
Tennessee 5,920,000 13.8% 15.5% 6.6% 66.2% 13.7%
Texas 23,236,000 12.2% 12.2% 3.4% 59.3% 24.5%
Utah 2,537,000 9.3% 9.5% 2.9% 71.9% 17.4%
Vermont 620,000 18.5% 14.4% 2.9% 71.3% 10.2%
Virginia 7,538,000 7.5% 12.0% 10.5% 72.1% 13.3%
Washington 6,318,000 12.6% 13.1% 7.3% 72.7% 11.8%
West Virginia 1,814,000 17.3% 18.8% 4.5% 64.0% 13.5%
Wisconsin 5,476,000 11.7% 13.2% 2.6% 77.1% 8.8%
Wyoming 516,000 8.9% 15.3% 6.2% 73.3% 14.5%
*The sum of rows may be greater than the total State population because individuals may have dual coverage and appear in
more than one category.
Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2007 Annual Social and Economic
Supplement.
3-9
Poverty Status - Populations, 2006
Population Population Population Population

Total Below 100% Below 135% Below 150% Below 200%
State Population FPL* FPL* FPL* FPL*
National Total 296,450,000 36,460,000 54,190,000 63,117,000 90,469,000
Alabama 4,532,000 650,000 970,000 1,103,000 1,571,000
Alaska 658,000 58,000 91,000 114,000 167,000
Arizona 6,256,000 902,000 1,372,000 1,555,000 2,274,000
Arkansas 2,748,000 487,000 717,000 831,000 1,169,000
California 36,160,000 4,427,000 6,885,000 8,125,000 11,639,000
Colorado 4,797,000 466,000 714,000 844,000 1,234,000
Connecticut 3,457,000 275,000 422,000 485,000 735,000
Delaware 858,000 80,000 108,000 136,000 214,000
District of Columbia 569,000 104,000 129,000 146,000 193,000
Florida 18,029,000 2,068,000 3,271,000 3,842,000 5,601,000
Georgia 9,334,000 1,172,000 1,712,000 2,086,000 2,831,000
Hawaii 1,254,000 116,000 180,000 215,000 300,000
Idaho 1,472,000 141,000 262,000 313,000 479,000
Illinois 12,633,000 1,338,000 1,966,000 2,378,000 3,428,000
Indiana 6,334,000 674,000 979,000 1,151,000 1,747,000
Iowa 2,913,000 301,000 456,000 564,000 810,000
Kansas 2,719,000 349,000 478,000 568,000 793,000
Kentucky 4,106,000 690,000 972,000 1,111,000 1,499,000
Louisiana 4,206,000 713,000 1,026,000 1,200,000 1,595,000
Maine 1,313,000 134,000 213,000 252,000 381,000
Maryland 5,607,000 469,000 676,000 758,000 1,103,000
Massachusetts 6,324,000 758,000 1,021,000 1,144,000 1,641,000
Michigan 9,953,000 1,323,000 1,856,000 2,112,000 2,884,000
Minnesota 5,415,000 422,000 673,000 781,000 1,204,000
Mississippi 2,887,000 596,000 793,000 925,000 1,296,000
Missouri 5,797,000 659,000 1,018,000 1,189,000 1,800,000
Montana 930,000 125,000 195,000 209,000 310,000
Nebraska 1,765,000 180,000 276,000 320,000 484,000
Nevada 2,530,000 241,000 372,000 471,000 740,000
New Hampshire 1,308,000 71,000 129,000 155,000 250,000
New Jersey 8,650,000 762,000 1,092,000 1,249,000 1,791,000
New Mexico 1,939,000 328,000 450,000 514,000 726,000
New York 19,021,000 2,668,000 3,763,000 4,364,000 6,072,000
North Carolina 8,847,000 1,225,000 1,758,000 2,123,000 3,132,000
North Dakota 615,000 70,000 97,000 114,000 176,000
Ohio 11,297,000 1,371,000 2,037,000 2,257,000 3,257,000
Oklahoma 3,489,000 531,000 834,000 949,000 1,309,000
Oregon 3,705,000 439,000 671,000 776,000 1,133,000
Pennsylvania 12,326,000 1,397,000 1,950,000 2,261,000 3,302,000
Rhode Island 1,054,000 110,000 164,000 187,000 266,000
South Carolina 4,224,000 474,000 819,000 980,000 1,486,000
South Dakota 770,000 82,000 129,000 158,000 238,000
Tennessee 5,916,000 879,000 1,297,000 1,499,000 204,000
Texas 23,208,000 3,816,000 5,543,000 6,281,000 8,734,000
Utah 2,536,000 235,000 391,000 477,000 778,000
Vermont 618,000 48,000 82,000 96,000 142,000
Virginia 7,532,000 651,000 971,000 1,195,000 1,819,000
Washington 6,310,000 502,000 880,000 1,001,000 1,522,000
West Virginia 1,810,000 277,000 414,000 469,000 673,000
Wisconsin 5,471,000 555,000 842,000 992,000 1,425,000
Wyoming 516,000 51,000 75,000 86,000 141,000
*FPL- Federal Poverty Level
Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2007 Annual Social and
Economic Supplement.
3-10
Poverty Status - Percentages, 2006
Percent Percent Percent Percent

Total Below 100% Below 135% Below 150% Below 200%
State Population FPL* FPL* FPL* FPL*
National Total 296,450,000 12.3% 18.3% 21.3% 30.5%
Alabama 4,532,000 14.3% 21.4% 24.3% 34.7%
Alaska 658,000 8.8% 13.8% 17.3% 25.4%
Arizona 6,256,000 14.4% 21.9% 24.9% 36.3%
Arkansas 2,748,000 17.7% 26.1% 30.2% 42.5%
California 36,160,000 12.2% 19.0% 22.5% 32.2%
Colorado 4,797,000 9.7% 14.9% 17.6% 25.7%
Connecticut 3,457,000 8.0% 12.2% 14.0% 21.3%
Delaware 858,000 9.3% 12.6% 15.9% 24.9%
District of Columbia 569,000 18.3% 22.7% 25.7% 33.9%
Florida 18,029,000 11.5% 18.1% 21.3% 31.1%
Georgia 9,334,000 12.6% 18.3% 22.3% 30.3%
Hawaii 1,254,000 9.3% 14.4% 17.1% 23.9%
Idaho 1,472,000 9.6% 17.8% 21.3% 32.5%
Illinois 12,633,000 10.6% 15.6% 18.8% 27.1%
Indiana 6,334,000 10.6% 15.5% 18.2% 27.6%
Iowa 2,913,000 10.3% 15.7% 19.4% 27.8%
Kansas 2,719,000 12.8% 17.6% 20.9% 29.2%
Kentucky 4,106,000 16.8% 23.7% 27.1% 36.5%
Louisiana 4,206,000 17.0% 24.4% 28.5% 37.9%
Maine 1,313,000 10.2% 16.2% 19.2% 29.0%
Maryland 5,607,000 8.4% 12.1% 13.5% 19.7%
Massachusetts 6,324,000 12.0% 16.1% 18.1% 25.9%
Michigan 9,953,000 13.3% 18.6% 21.2% 29.0%
Minnesota 5,415,000 7.8% 12.4% 14.4% 22.2%
Mississippi 2,887,000 20.6% 27.5% 32.0% 44.9%
Missouri 5,797,000 11.4% 17.6% 20.5% 31.1%
Montana 930,000 13.4% 21.0% 22.5% 33.3%
Nebraska 1,765,000 10.2% 15.6% 18.1% 27.4%
Nevada 2,530,000 9.5% 14.7% 18.6% 29.2%
New Hampshire 1,308,000 5.4% 9.9% 11.9% 19.1%
New Jersey 8,650,000 8.8% 12.6% 14.4% 20.7%
New Mexico 1,939,000 16.9% 23.2% 26.5% 37.4%
New York 19,021,000 14.0% 19.8% 22.9% 31.9%
North Carolina 8,847,000 13.8% 19.9% 24.0% 35.4%
North Dakota 615,000 11.4% 15.8% 18.5% 28.6%
Ohio 11,297,000 12.1% 18.0% 20.0% 28.8%
Oklahoma 3,489,000 15.2% 23.9% 27.2% 37.5%
Oregon 3,705,000 11.8% 18.1% 20.9% 30.6%
Pennsylvania 12,326,000 11.3% 15.8% 18.3% 26.8%
Rhode Island 1,054,000 10.4% 15.6% 17.7% 25.2%
South Carolina 4,224,000 11.2% 19.4% 23.2% 35.2%
South Dakota 770,000 10.6% 16.8% 20.5% 30.9%
Tennessee 5,916,000 14.9% 21.9% 25.3% 3.4%
Texas 23,208,000 16.4% 23.9% 27.1% 37.6%
Utah 2,536,000 9.3% 15.4% 18.8% 30.7%
Vermont 618,000 7.8% 13.3% 15.5% 23.0%
Virginia 7,532,000 8.6% 12.9% 15.9% 24.2%
Washington 6,310,000 8.0% 13.9% 15.9% 24.1%
West Virginia 1,810,000 15.3% 22.9% 25.9% 37.2%
Wisconsin 5,471,000 10.1% 15.4% 18.1% 26.0%
Wyoming 516,000 9.9% 14.5% 16.7% 27.3%
*FPL- Federal Poverty Level
Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2007 Annual Social and
Economic Supplement.
3-11
Employment Status, 2006*
Total Civilian Population Unemployment

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

State Hospitals Facilities Facilities Agencies Clinics
National Total 6,016 15,047 6,444 8,955 3,689
Alabama 128 228 6 145 65
Alaska 24 15 0 16 0
Arizona 100 134 12 83 13
Arkansas 105 214 41 174 66
California 419 1,202 1,141 682 255
Colorado 92 193 3 137 47
Connecticut 45 244 120 86 0
Delaware 11 39 2 19 0
District of Columbia 14 19 112 24 0
Florida 237 678 105 791 149
Georgia 179 355 11 101 99
Hawaii 27 44 18 14 2
Idaho 49 75 65 50 0
Illinois 212 699 312 488 226
Indiana 158 493 530 206 54
Iowa 125 414 141 80 139
Kansas 159 267 31 135 186
Kentucky 120 292 9 104 131
Louisiana 233 290 520 222 94
Maine 45 113 20 29 41
Maryland 64 227 4 49 0
Massachusetts 114 440 6 125 1
Michigan 179 403 1 383 162
Minnesota 145 384 218 213 87
Mississippi 115 168 13 56 152
Missouri 142 486 18 169 320
Montana 64 92 1 36 43
Nebraska 96 195 4 71 120
Nevada 45 46 9 69 6
New Hampshire 30 73 1 36 15
New Jersey 108 365 9 49 0
New Mexico 52 67 42 68 12
New York 242 655 580 188 0
North Carolina 135 419 332 169 100
North Dakota 49 83 67 25 64
Ohio 220 946 433 472 12
Oklahoma 156 283 87 212 40
Oregon 59 121 1 57 0
Pennsylvania 238 711 210 320 56
Rhode Island 15 87 5 21 0
South Carolina 78 174 93 69 100
South Dakota 66 93 1 43 60
Tennessee 152 302 83 139 58
Texas 544 1,075 875 1,790 327
Utah 49 85 15 69 17
Vermont 15 40 2 12 18
Virginia 113 258 34 184 56
Washington 10 234 14 59 170
West Virginia 66 122 66 61 62
Wisconsin 144 372 19 128 47
Wyoming 29 33 2 27 17
Sources: OSCAR Report 10. Facility Counts: Active Providers. CMS, Center for Medicaid and State Operations, August 1,
2007 (hospitals and rural health clinics); http://www.cms.hhs.gov/HealthPlanRepFileData/05_Inst.asp (SNF and ICF-MR);
http://www.medicare.gov/Download/DownloadDB.asp (Home Health Compare).
3-13
Licensed Pharmacies, As of June 30, 2006*
Hospital/ Independent Out-of-State or

Total Institutional Community Chain Pharmacies Non-Resident
State Pharmacies Pharmacies Pharmacies (Four or More) Pharmacies
National Total 85,300 7,655 17,250 16,591 15,059
Alabama 1,915 164 697 617 437
Alaska 118 20 (G) 218
Arizona 1,626 97 126 879 436
Arkansas 1,213 177 252
California 7,120 583 293
Colorado 908 398
Connecticut 651 (D) 51(D) 182 (D) 469 (D) 373 (D)
Delaware 550 13 25 147 365
District of Columbia 131 14 53 64 0
Florida 6,841 (F) 1,945 (O) (O) 419
Georgia 3,689 205 (M) (M)
Hawaii 220 212
Idaho 744 59 259 (A, E) 286
Illinois 3,077 234 2,668 (A) (A) 296
Indiana 1,396 437
Iowa 1,301 130 (F) 790 (A, F) (A) 358
Kansas 837 176 341 283 434
Kentucky 1,687 (P) 143 571 490 402
Louisiana 1,568 202 681 430 226
Maine 306 42 309
Maryland 1,581 (H) 86 (R) 352 726 368
Massachusetts 1,089 (I) 250 740 0
Michigan 2,547 150
Minnesota 1,601 249 584 987 373
Mississippi 962 130 220
Missouri 1,788 (J) 113 240 533 418
Montana 322 89 139 94 302
Nebraska 498 174 (K)
Nevada 836 268
New Hampshire 295 33 40 202 345
New Jersey 2,026
New Mexico 750 61 136 168 136
New York 4,812 470 (N) 2,211 2,124 331
North Carolina 2,215 (F) 174 590 1,048 341
North Dakota 629 47 150 39 369
Ohio 3,068 (L) 235 556 1,599 406
Oklahoma 1,550 168 (D) 930 (A) (A) 452
Oregon 1,196 124 448 624 469
Pennsylvania 3,244 0
Rhode Island 188 23 38 5 327
South Carolina 1,198 470
South Dakota 612 45 133 90 344
Tennessee 1,999 454 550 874 83
Texas 6,116 (B) 599 1,767 2,457 370
Utah 786 132 412 (A) (A) 342
Vermont 363 18 154 133 211
Virginia 1,600 509
Washington 1,378 120 (C) 1,177 769 383
West Virginia 572 (I) 393
Wisconsin 3,409 (Q) 0
Wyoming 140 (F) 30 354
*Figures reported reflect number of pharmacies licensed by state boards of pharmacy. Individual columns will not sum to
total. Total includes other pharmacies not specified in the four practice settings. Blanks indicate that information was not
available.
Source: 2007 National Association of Boards of Pharmacy, Survey of Pharmacy Law.
3-14
LEGEND
A — Chains included in independent community pharmacies figure.

B — Also licenses 923 nuclear, public health, clinic, ambulatory surgical center, and HMO pharmacies.
C — Includes 121 hospital, 35 nursing home, 19 home infusion, 7 nuclear, 42 HMO, and 18 other pharmacies.
D — Approximately.
E — Plus 28 limited service and 75 parenteral admixture pharmacies.
F — In-state.
G — Drug rooms.
H — Total includes other areas not listed: clinic, correctional, HMO, nursing home, IV, nuclear, research, and other.
105 pharmacies have waiver (specialty permits) Board issued 735 distributor permits.
I — Total also includes home IV and mail-order pharmacies.
J — Includes the following pharmacy categories: 9 long-term care, 3 home health, 10 radiopharmaceutical, 2 renal
dialysis, 2 sterile pharmaceuticals, 2 consultant pharmacy, 0 medical gas, 0 shared services, and 357 with multiple
classes.
K — Nebraska licenses out-of-state pharmacies.
L — Includes 272 nuclear, clinic, fluid therapy, mail-order, specialty, and pharmacies serving nursing homes only.
M — 2,202 (2,165 independent and chain pharmacies, 14 nuclear pharmacies, 18 prison pharmacies, 5 clinic
pharmacies, and 2 pharmacy schools).
N — 15 nuclear pharmacies.
O — For Florida, 4,477 are primarily community pharmacies but cannot be broken down by chain or independent.
P — Includes 9 charitable pharmacies.
Q — As of May 15, 2006.
R — Includes HMO clinics, Home Health, and Hospitals.
3-15
Physicians, 2005
Primary Care
Office Based Physicians Percent
Physicians Physicians Physicians (Non-Federal, Office Based
(Non-Federal, Per 1,000 (Non-Federal, Percent Patient Care, Physicians
State Patient Care) Population Patient Care) Office Based Office Based)* Primary Care
National Total 690,592 2.3 554,482 80% 287,322 42%
Alabama 8,802 1.9 7,288 83% 3,953 45%
Alaska 1,286 1.9 1,181 92% 851 66%
Arizona 10,962 1.8 9,522 87% 4,756 43%
Arkansas 5,102 1.8 4,257 83% 2,668 52%
California 82,591 2.3 70,273 85% 36,665 44%
Colorado 10,653 2.3 9,155 86% 5,050 47%
Connecticut 10,989 3.1 8,424 77% 3,650 33%
Delaware 1,863 2.2 1,514 81% 749 40%
District of Columbia 3,395 5.8 2,240 66% 899 26%
Florida 38,575 2.2 33,796 88% 15,809 41%
Georgia 17,583 1.9 14,921 85% 7,976 45%
Hawaii 3,380 2.7 2,922 86% 1,539 46%
Idaho 2,237 1.6 2,086 93% 1,340 60%
Illinois 30,715 2.4 23,408 76% 12,575 41%
Indiana 12,249 1.8 10,218 83% 5,877 48%
Iowa 4,838 1.6 3,894 80% 2,463 51%
Kansas 5,431 2.0 4,486 83% 2,679 49%
Kentucky 8,645 2.1 7,248 84% 3,941 46%
Louisiana 10,332 2.3 8,257 80% 4,120 40%
Maine 3,145 2.4 2,656 84% 1,561 50%
Maryland 18,222 3.3 14,215 78% 6,403 35%
Massachusetts 24,236 3.8 17,485 72% 7,544 31%
Michigan 21,522 2.1 16,210 75% 8,726 41%
Minnesota 12,938 2.5 10,386 80% 6,938 54%
Mississippi 4,618 1.6 3,855 83% 2,162 47%
Missouri 12,242 2.1 9,400 77% 4,562 37%
Montana 1,904 2.0 1,763 93% 1,071 56%
Nebraska 3,772 2.1 2,996 79% 1,929 51%
Nevada 4,089 1.7 3,721 91% 1,923 47%
New Hampshire 3,084 2.4 2,594 84% 1,449 47%
New Jersey 23,821 2.7 18,868 79% 8,342 35%
New Mexico 3,941 2.0 3,259 83% 1,992 51%
New York 64,498 3.3 44,677 69% 19,534 30%
North Carolina 19,195 2.2 15,760 82% 8,494 44%
North Dakota 1,377 2.2 1,160 84% 768 56%
Ohio 26,420 2.3 20,203 76% 10,637 40%
Oklahoma 5,405 1.5 4,514 84% 2,508 46%
Oregon 8,575 2.4 7,449 87% 4,245 50%
Pennsylvania 31,516 2.5 23,548 75% 11,102 35%
Rhode Island 3,363 3.1 2,478 74% 1,142 34%
South Carolina 8,804 2.1 7,255 82% 4,087 46%
South Dakota 1,501 1.9 1,327 88% 835 56%
Tennessee 14,031 2.4 11,710 83% 6,182 44%
Texas 42,896 1.9 35,459 83% 18,666 44%
Utah 4,609 1.9 3,805 83% 2,075 45%
Vermont 1,961 3.2 1,479 75% 932 48%
Virginia 17,556 2.3 14,363 82% 7,948 45%
Washington 14,458 2.3 12,462 86% 7,526 52%
West Virginia 3,666 2.0 2,860 78% 1,588 43%
Wisconsin 12,730 2.3 10,688 84% 6,376 50%
Wyoming 869 1.7 787 91% 515 59%
*Primary care physicians include General Practice, General Family Practice, General Internal Medicine, Ob-Gyn, and General Pediatrics.
Source: USDHHS, HRSA, Bureau of Health Professions, National Center for Health Workforce Information & Analysis, Area Resource File,
June 2007.
3-16
Other Providers, 2004/2006
# FTE # FTE
Registered Registered Nurses* Pharmacists** Pharmacists**
State Nurses* per 1,000 population (Licensed by State) per 1,000 population
National Total 2,056,960 7.0 372,032 1.2
Alabama 31,736 7.0 7,596 1.7
Alaska 5,839 8.9 660 1.0
Arizona 35,036 5.7 7,672 1.2
Arkansas 18,318 6.7 3,920 1.4
California 175,183 4.9 33,922 0.9
Colorado 29,268 6.4 5,807 1.2
Connecticut 26,698 7.6 4,637 1.3
Delaware 7,194 8.7 1,479 1.7
District of Columbia 10,194 17.6 1,341 2.3
Florida 117,447 6.8 21,540 1.2
Georgia 58,910 6.6 11,284 1.2
Hawaii 7,978 6.3 1,660 1.3
Idaho 7,401 5.3 1,722 1.2
Illinois 95,490 7.5 14,458 1.1
Indiana 46,677 7.5 8,481 1.3
Iowa 27,451 9.3 5,156 1.7
Kansas 21,328 7.8 3,709 1.3
Kentucky 33,435 8.1 5,713 1.4
Louisiana 32,183 7.2 6,375 1.5
Maine 12,799 9.7 1,546 1.2
Maryland 39,725 7.2 7,820 1.4
Massachusetts 59,337 9.2 9,902 1.5
Michigan 70,630 7.0 11,322 1.1
Minnesota 40,454 7.9 6,484 1.3
Mississippi 21,768 7.5 3,483 1.2
Missouri 49,174 8.5 7,486 1.3
Montana 6,520 7.0 1,639 1.7
Nebraska 15,990 9.2 3,004 1.7
Nevada 12,733 5.5 8,475 3.4
New Hampshire 13,669 10.5 2,073 1.6
New Jersey 59,691 6.9 13,927 1.6
New Mexico 11,811 6.2 2,379 1.2
New York 148,653 7.7 19,798 1.0
North Carolina 68,030 8.0 10,494 1.2
North Dakota 6,391 10.1 2,122 3.3
Ohio 93,830 8.2 15,185 1.3
Oklahoma 21,651 6.1 4,953 1.4
Oregon 24,459 6.8 4,125 1.1
Pennsylvania 106,912 8.6 18,707 1.5
Rhode Island 9,133 8.5 1,906 1.8
South Carolina 26,921 6.4 5,824 1.3
South Dakota 7,857 10.2 1,504 1.9
Tennessee 48,252 8.2 7,588 1.3
Texas 129,442 5.7 22,723 1.0
Utah 13,056 5.4 2,358 0.9
Vermont 5,006 8.1 885 1.4
Virginia 47,904 6.4 9,142 1.2
Washington 38,740 6.2 7,541 1.2
West Virginia 14,125 7.8 3,024 1.7
Wisconsin 40,954 7.4 6,433 1.2
Wyoming 3,577 7.1 1,048 2.0
*FTE- Full-time equivalent employees as of 2004. Excludes 4,261 RNs for whom full-time/part-time status is unknown.
**As of June 30, 2006
Source: USDHHS, HRSA, Bureau of Health Professions, National Center for Health Workforce Information & Analysis, 2004 National
Sample Survey of Registered Nurses. 2007 National Association of Boards of Pharmacy, Survey of Pharmacy Law.
3-17
3-18
Section 4:
Pharmacy Program
Characteristics
4-1
4-2
THE MEDICAID DRUG PROGRAM
The Medicaid program defines prescribed drugs as simple or compound substances or mixtures of
substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance,
which are prescribed by a physician or other licensed practitioner of the healing arts within the scope
of their professional practice (42 CFR 440.120). The drugs must be dispensed by licensed authorized
practitioners on a written prescription that is recorded and maintained in the pharmacist’s or the
practitioner’s records.
MEDICAID PRESCRIPTION DRUG REIMBURSEMENT
On July 31, 1987, CMS published a notice of the final rule for limits on payments for drugs in the
Medicaid program. The regulations adopted in the rule became effective October 29, 1987 (52 FR
28648). In this final rule, CMS attempted to (1) respond to public comments on the NPRM (51 FR
2956); (2) provide maximum flexibility to the States in their administration of the Medicaid program;
(3) provide responsible but not burdensome Federal oversight of the Medicaid program; and (4) take
advantage of savings in the marketplace for multiple-source drugs.
To accomplish this, CMS adopted a Federal upper limit standard for certain multiple-source drugs,
based on application of a specific formula. The upper limit for other drugs is similar, in that it retains
the estimated acquisition cost (EAC) as the upper limit standard that State agencies must meet.
However, this standard is applied on an aggregate basis rather than on a prescription-specific basis.
State agencies are therefore encouraged to exercise maximum flexibility in establishing their own
payment methods (see the Federal Register, Vol. 52, No. 147, Friday, July 31, 1987, page 28648).
Multiple-Source Drugs
A multiple-source drug is one that is marketed or sold by two or more manufacturers or labelers, or a
drug marketed or sold by the same manufacturer or labeler under two or more different proprietary
names or under a proprietary name and without such a name.
A specific upper limit for a multiple-source drug may be established if the following requirements are
met:
! All of the formulations of the drug approved by the Food and Drug Administration (FDA) have
been evaluated as therapeutically equivalent in the current edition of the publication, Approved
Drug Products with Therapeutically Equivalent Evaluations; and
! At least three suppliers list the drug (which is classified by the FDA as Category A in its
publication) in the current editions of published compendia of cost information for drugs
available for sale nationally.
The upper limit for a multi-source drug for which a specific limit has been established does not apply
if a physician certifies in his or her own handwriting that a specific brand is “medically necessary” for
a particular recipient.
The handwritten phrase “brand necessary,” “medically necessary,” or “brand medically necessary”
must appear on the face of the prescription. The rule specifically states that a check-off box on a
prescription form is not acceptable, but it does not address the use of two-line prescription forms.
4-3
The formula to be used in calculating the aggregate upper limit of payment for certain multiple-source
drugs will be 150% of the least costly therapeutic equivalent that can be purchased by pharmacists in
quantities of 100 tablets or capsules (or if the drug is not commonly available in quantities of 100, the
package size commonly listed), or in the case of liquids, the commonly listed size, plus a reasonable
dispensing fee.
Other Drugs
A drug described as an “other drug” is (1) a brand name drug certified as medically necessary by the
physician, (2) a multiple-source drug not subject to the 150% formula; or (3) a single-source drug.
Payments for these drugs must not exceed, in the aggregate, payment levels determined by applying
the lower of:
! Estimated acquisition cost (EAC) plus reasonable dispensing fees; or

! The provider’s usual and customary charges to the general public.
States may continue to use their existing EAC program, or adopt another method, as long as their
aggregate expenditures do not exceed what would have been paid under EAC principles.
Other Requirements
The rule requires States to submit a State plan that describes their payment methods for prescribed
drugs. The rule does not prescribe a preferred payment method, as long as the State’s aggregate
spending in each category is equal to or below the upper limit requirements. States are also required
to submit assurances to CMS that the requirements are met.
The rule does not prescribe a preferred payment method for the States, but gives States the flexibility
to determine how they will pay for prescription drugs under Medicaid. As long as the State’s
aggregate spending is at or below the amount derived from the formula, the State is free to maintain
its current payment program or adopt other methods. States can alter payment rates for individual
drugs, balancing payment increases for certain products with payment decreases for other drugs so
that, in the aggregate, the program does not exceed the established limit. With the establishment of
upper limit payment maximums, some States may alter their current payment methods to comply with
the established limits.
State programs vary, depending upon whether or not State maximum allowable cost (MAC) programs
cover the same drugs listed by CMS. States with established MAC programs may be unaffected if
their MAC rates are already low, or they may have to make certain adjustments in their MAC levels
to meet the Federal aggregate expenditure limits. States without MAC programs may develop a new
payment method to increase the use of lower cost generic drug products in order to stay within the
upper payment limits, or may simply adopt CMS’ formula for listed drug products.
DRUG RECIPIENTS
Drug recipients are defined as individuals who received drugs, not as everyone eligible to receive
drugs. Today, all 50 States and the District of Columbia cover drugs under the Medicaid program.
4-4
Drug Expenditures Trends, 2004-2005*
State 2004 2005 % Change 2004-2005

National Total $40,065,314,592 $43,077,457,835 7.5%
Alabama $594,477,767 $606,578,572 2.0%
Alaska $115,273,427 $127,315,710 10.5%
Arizona $5,367,723 $5,486,350 2.2%
Arkansas $380,446,105 $419,350,865 10.2%
California $4,817,590,501 $5,187,275,034 7.7%
Colorado $264,117,222 $285,371,981 8.1%
Connecticut $448,164,399 $496,715,211 10.9%
Delaware $122,552,631 $122,026,857 -0.4%
District of Columbia $106,453,411 $105,948,589 -0.5%
Florida $2,472,756,351 $2,503,151,114 1.2%
Georgia $1,213,833,584 $1,184,915,057 -2.9%
Hawaii $117,149,907 $119,852,050 2.3%
Idaho $153,351,334 $168,780,832 10.1%
Illinois $1,751,647,987 $1,716,361,486 -2.0%
Indiana $703,941,201 $751,525,376 6.8%
Iowa $371,927,390 $412,274,229 10.9%
Kansas $274,203,278 $296,283,292 8.1%
Kentucky $802,700,636 $794,519,116 -1.0%
Louisiana $944,175,123 $1,082,597,269 14.7%
Maine $281,693,429 $282,039,741 0.1%
Maryland $490,288,888 $578,238,275 17.9%
Massachusetts $987,294,716 $1,067,378,270 8.1%
Michigan $874,729,802 $965,368,582 10.4%
Minnesota $394,600,158 $441,908,835 12.0%
Mississippi $668,097,090 $665,504,688 -0.4%
Missouri $1,119,655,471 $1,246,144,317 11.3%
Montana $99,334,048 $105,154,540 5.9%
Nebraska $231,317,773 $228,576,569 -1.2%
Nevada $127,920,160 $134,564,289 5.2%
New Hampshire $128,552,504 $133,253,555 3.7%
New Jersey $1,016,646,964 $1,158,553,486 14.0%
New Mexico $117,451,186 $116,252,520 -1.0%
New York $4,782,579,851 $5,253,655,620 9.9%
North Carolina $1,575,005,070 $1,790,399,967 13.7%
North Dakota $59,722,091 $64,157,312 7.4%
Ohio $1,819,580,108 $1,981,230,721 8.9%
Oklahoma $416,314,217 $500,420,840 20.2%
Oregon $245,180,310 $261,373,083 6.6%
Pennsylvania $952,341,486 $1,009,804,038 6.0%
Rhode Island $166,067,772 $173,884,102 4.7%
South Carolina $673,035,838 $716,694,085 6.5%
South Dakota $81,936,507 $88,963,445 8.6%
Tennessee $2,196,066,176 $2,344,351,015 6.8%
Texas $2,202,097,688 $2,416,879,360 9.8%
Utah $192,093,154 $221,854,365 15.5%
Vermont $160,039,523 $184,730,219 15.4%
Virginia $582,093,270 $634,701,038 9.0%
Washington $649,265,744 $682,553,233 5.1%
West Virginia $376,426,405 $431,614,161 14.7%
Wisconsin $684,912,153 $759,682,514 10.9%
Wyoming $52,845,063 $51,242,060 -3.0%
*Rebates have not been subtracted from these figures.
4-5
Ranking Based on Drug Expenditures, 2004-2005*
% of 2005 National
2005 2005 Medicaid Drug 2004 2004
State Payments Ranking Expenditures Payments Ranking
National Total $43,077,457,835 $40,065,314,592
New York $5,253,655,620 1 12.2% $4,782,579,851 2
California $5,187,275,034 2 12.0% $4,817,590,501 1
Florida $2,503,151,114 3 5.8% $2,472,756,351 3
Texas $2,416,879,360 4 5.6% $2,202,097,688 4
Tennessee $2,344,351,015 5 5.4% $2,196,066,176 5
Ohio $1,981,230,721 6 4.6% $1,819,580,108 6
North Carolina $1,790,399,967 7 4.2% $1,575,005,070 8
Illinois $1,716,361,486 8 4.0% $1,751,647,987 7
Missouri $1,246,144,317 9 2.9% $1,119,655,471 10
Georgia $1,184,915,057 10 2.8% $1,213,833,584 9
New Jersey $1,158,553,486 11 2.7% $1,016,646,964 11
Louisiana $1,082,597,269 12 2.5% $944,175,123 13
Massachusetts $1,067,378,270 13 2.5% $987,294,716 14
Pennsylvania $1,009,804,038 14 2.3% $952,341,486 12
Michigan $965,368,582 15 2.2% $874,729,802 15
Kentucky $794,519,116 16 1.8% $802,700,636 16
Wisconsin $759,682,514 17 1.8% $684,912,153 18
Indiana $751,525,376 18 1.7% $703,941,201 17
South Carolina $716,694,085 19 1.7% $673,035,838 19
Washington $682,553,233 20 1.6% $649,265,744 21
Mississippi $665,504,688 21 1.5% $668,097,090 20
Virginia $634,701,038 22 1.5% $582,093,270 23
Alabama $606,578,572 23 1.4% $594,477,767 22
Maryland $578,238,275 24 1.3% $490,288,888 24
Oklahoma $500,420,840 25 1.2% $416,314,217 26
Connecticut $496,715,211 26 1.2% $448,164,399 25
Minnesota $441,908,835 27 1.0% $394,600,158 27
West Virginia $431,614,161 28 1.0% $376,426,405 29
Arkansas $419,350,865 29 1.0% $380,446,105 28
Iowa $412,274,229 30 1.0% $371,927,390 30
Kansas $296,283,292 31 0.7% $274,203,278 33
Colorado $285,371,981 32 0.7% $264,117,222 31
Maine $282,039,741 33 0.7% $281,693,429 32
Oregon $261,373,083 34 0.6% $245,180,310 34
Nebraska $228,576,569 35 0.5% $231,317,773 35
Utah $221,854,365 36 0.5% $192,093,154 36
Vermont $184,730,219 37 0.4% $160,039,523 38
Rhode Island $173,884,102 38 0.4% $166,067,772 37
Idaho $168,780,832 39 0.4% $153,351,334 39
Nevada $134,564,289 40 0.3% $127,920,160 41
New Hampshire $133,253,555 41 0.3% $128,552,504 40
Alaska $127,315,710 42 0.3% $115,273,427 43
Delaware $122,026,857 43 0.3% $122,552,631 45
Hawaii $119,852,050 44 0.3% $117,149,907 44
New Mexico $116,252,520 45 0.3% $117,451,186 42
District of Columbia $105,948,589 46 0.2% $106,453,411 46
Montana $105,154,540 47 0.2% $99,334,048 47
South Dakota $88,963,445 48 0.2% $81,936,507 48
North Dakota $64,157,312 49 0.1% $59,722,091 49
Wyoming $51,242,060 50 0.1% $52,845,063 50
Arizona $5,486,350 51 0.0% $5,367,723 51
4-6
Drugs as a Percentage of Total Net Expenditures, 2005
Total Medicaid
Net Medical Assistance Total Drug % of Total
State Expenditures Expenditures* Net Expenditures
National Total $299,659,808,819 $43,077,457,835 14.4%
Alabama $3,837,473,614 $606,578,572 15.8%
Alaska $983,488,511 $127,315,710 12.9%
Arizona $5,725,919,558 $5,486,350 0.1%
Arkansas $2,809,920,508 $419,350,865 14.9%
California $33,662,911,379 $5,187,275,034 15.4%
Colorado $2,796,729,720 $285,371,981 10.2%
Connecticut $4,027,599,803 $496,715,211 12.3%
Delaware $868,667,588 $122,026,857 14.0%
District of Columbia $1,254,159,659 $105,948,589 8.4%
Florida $13,218,246,322 $2,503,151,114 18.9%
Georgia $7,333,266,041 $1,184,915,057 16.2%
Hawaii $1,033,126,200 $119,852,050 11.6%
Idaho $1,008,634,738 $168,780,832 16.7%
Illinois $10,785,542,795 $1,716,361,486 15.9%
Indiana $5,234,229,575 $751,525,376 14.4%
Iowa $2,376,772,384 $412,274,229 17.3%
Kansas $1,967,790,699 $296,283,292 15.1%
Kentucky $4,253,083,096 $794,519,116 18.7%
Louisiana $5,313,395,456 $1,082,597,269 20.4%
Maine $2,242,388,876 $282,039,741 12.6%
Maryland $5,136,302,340 $578,238,275 11.3%
Massachusetts $9,556,863,877 $1,067,378,270 11.2%
Michigan $8,656,266,850 $965,368,582 11.2%
Minnesota $5,528,371,422 $441,908,835 8.0%
Mississippi $3,342,615,012 $665,504,688 19.9%
Missouri $6,528,988,350 $1,246,144,317 19.1%
Montana $696,069,297 $105,154,540 15.1%
Nebraska $1,377,175,781 $228,576,569 16.6%
Nevada $1,184,065,213 $134,564,289 11.4%
New Hampshire $1,244,582,951 $133,253,555 10.7%
New Jersey $7,508,874,058 $1,158,553,486 15.4%
New Mexico $2,363,669,655 $116,252,520 4.9%
New York $42,752,347,265 $5,253,655,620 12.3%
North Carolina $8,844,879,833 $1,790,399,967 20.2%
North Dakota $508,464,760 $64,157,312 12.6%
Ohio $11,572,449,325 $1,981,230,721 17.1%
Oklahoma $2,712,779,961 $500,420,840 18.4%
Oregon $2,810,667,717 $261,373,083 9.3%
Pennsylvania $15,786,514,016 $1,009,804,038 6.4%
Rhode Island $1,671,398,242 $173,884,102 10.4%
South Carolina $4,068,509,449 $716,694,085 17.6%
South Dakota $608,250,647 $88,963,445 14.6%
Tennessee $7,557,403,733 $2,344,351,015 31.0%
Texas $17,264,066,130 $2,416,879,360 14.0%
Utah $1,341,242,046 $221,854,365 16.5%
Vermont $859,483,644 $184,730,219 21.5%
Virginia $4,425,080,633 $634,701,038 14.3%
Washington $5,700,850,706 $682,553,233 12.0%
West Virginia $2,161,356,254 $431,614,161 20.0%
Wisconsin $4,751,656,671 $759,682,514 16.0%
Wyoming $405,216,459 $51,242,060 12.6%
4-7
Drugs as a Percentage of Total Net Expenditures, 2003-2005*
State 2003 2004 2005

National Total 13.0% 14.3% 14.4%
Alabama 15.4% 16.3% 15.8%
Alaska 11.4% 13.0% 12.9%
Arizona 0.1% 0.1% 0.1%
Arkansas 13.3% 14.7% 14.9%
California 14.0% 15.7% 15.4%
Colorado 8.8% 10.0% 10.2%
Connecticut 11.5% 11.6% 12.3%
Delaware 15.3% 15.5% 14.0%
District of Columbia 7.6% 9.5% 8.4%
Florida 18.4% 19.3% 18.9%
Georgia 17.0% 17.2% 16.2%
Hawaii 12.7% 12.9% 11.6%
Idaho 16.3% 16.3% 16.7%
Illinois 15.9% 17.5% 15.9%
Indiana 14.7% 14.4% 14.4%
Iowa 15.5% 16.6% 17.3%
Kansas 13.0% 15.4% 15.1%
Kentucky 18.5% 19.6% 18.7%
Louisiana 18.7% 19.1% 20.4%
Maine 15.1% 13.9% 12.6%
Maryland 9.9% 10.7% 11.3%
Massachusetts 12.3% 11.3% 11.2%
Michigan 9.5% 10.6% 11.2%
Minnesota 7.5% 7.1% 8.0%
Mississippi 19.9% 20.3% 19.9%
Missouri 17.0% 18.4% 19.1%
Montana 15.6% 14.9% 15.1%
Nebraska 15.9% 16.2% 16.6%
Nevada 10.5% 12.3% 11.4%
New Hampshire 12.3% 11.2% 10.7%
New Jersey 9.8% 12.8% 15.4%
New Mexico 4.3% 5.3% 4.9%
New York 10.6% 11.7% 12.3%
North Carolina 18.3% 19.8% 20.2%
North Dakota 12.2% 12.5% 12.6%
Ohio 14.9% 15.8% 17.1%
Oklahoma 13.0% 16.6% 18.4%
Oregon 9.8% 9.4% 9.3%
Pennsylvania 6.2% 6.8% 6.4%
Rhode Island 9.8% 10.1% 10.4%
South Carolina 16.0% 17.5% 17.6%
South Dakota 13.3% 14.6% 14.6%
Tennessee 20.1% 31.2% 31.0%
Texas 12.5% 13.7% 14.0%
Utah 14.9% 15.5% 16.5%
Vermont 18.1% 20.0% 21.5%
Virginia 14.4% 15.2% 14.3%
Washington 11.9% 12.4% 12.0%
West Virginia 18.6% 19.4% 20.0%
Wisconsin 12.4% 15.5% 16.0%
Wyoming 14.6% 14.4% 12.6%
*Percentages are based on figures that have not had rebates subtracted from them.
Source: CMS, CMS-64 Report, FY 2003 - FY 2005.
4-8
Drug Expenditures by Category, 2004
Hormones and
Central Nervous Cardiovascular Anti-Infective Gastrointestinal Synthetic
State System Drugs Drugs Agents Drugs Substitutes
National Total $13,300,359,808 $3,969,414,844 $3,648,306,434 $2,469,562,269 $3,274,866,917
Alabama $208,760,996 $69,043,166 $60,931,002 $35,879,041 $62,771,380
Alaska $47,912,513 $9,505,258 $10,076,774 $10,087,697 $9,000,355
Arizona*
Arkansas $155,702,637 $38,171,834 $41,975,653 $19,069,811 $43,560,568
California $1,610,536,923 $630,157,032 $421,979,467 $378,449,383 $493,683,362
Colorado $122,978,421 $26,900,240 $22,474,930 $14,187,562 $25,233,231
Connecticut $198,383,506 $50,937,823 $36,772,205 $36,272,702 $32,042,343
Delaware $41,021,683 $11,732,238 $17,612,565 $3,126,934 $11,315,099
District of Columbia $26,670,897 $12,520,390 $23,179,899 $2,643,629 $6,592,102
Florida $747,292,514 $270,773,916 $363,341,806 $198,477,510 $191,344,602
Georgia $407,156,598 $120,487,467 $147,835,763 $55,381,643 $116,295,273
Hawaii $43,073,550 $17,937,928 $8,511,363 $4,330,362 $11,541,866
Idaho $71,352,803 $11,207,631 $10,474,850 $8,530,670 $14,690,005
Illinois**
Indiana $329,400,563 $63,864,597 $51,774,597 $37,105,204 $65,429,310
Iowa $180,751,055 $32,264,220 $30,515,629 $22,760,834 $34,717,131
Kansas $130,448,685 $23,299,032 $19,290,087 $22,768,014 $23,256,463
Kentucky $299,579,345 $89,039,723 $73,109,907 $41,944,307 $83,980,921
Louisiana $289,784,312 $93,920,065 $115,974,399 $64,822,495 $80,944,494
Maine $119,962,268 $28,225,919 $19,041,538 $28,918,551 $27,272,891
Maryland $223,828,886 $59,018,665 $40,017,606 $33,385,048 $32,668,403
Massachusetts $437,346,870 $94,472,294 $93,663,246 $72,171,009 $80,120,349
Michigan $447,139,945 $81,118,326 $45,939,633 $46,444,308 $69,242,799
Minnesota $203,255,537 $24,499,964 $22,934,171 $29,259,476 $28,421,319
Mississippi $210,940,132 $101,240,783 $68,988,274 $36,686,079 $66,591,404
Missouri $471,964,290 $115,900,356 $95,050,827 $40,690,835 $105,701,660
Montana $45,102,777 $7,459,968 $6,150,907 $5,131,898 $8,361,839
Nebraska $105,213,526 $21,345,302 $17,889,099 $9,481,172 $22,289,480
Nevada $54,004,427 $11,892,140 $11,024,517 $4,638,057 $9,828,218
New Hampshire $64,375,785 $10,219,677 $6,549,308 $8,369,457 $11,012,547
New Jersey $341,505,598 $126,475,891 $110,144,283 $79,960,008 $75,482,040
New Mexico**
New York $1,477,360,243 $547,267,499 $733,035,427 $346,610,504 $425,428,586
North Carolina $543,405,555 $175,726,290 $140,877,989 $157,859,974 $139,958,047
North Dakota $29,044,762 $5,398,111 $3,944,563 $2,884,297 $5,367,993
Ohio $755,434,684 $184,869,267 $156,813,358 $122,914,780 $166,743,130
Oklahoma $172,393,633 $36,570,700 $41,689,442 $20,604,328 $41,918,694
Oregon $147,403,531 $15,273,079 $10,964,664 $8,939,913 $16,522,989
Pennsylvania $404,913,210 $110,273,064 $64,274,505 $96,565,142 $85,279,878
Rhode Island $71,998,124 $21,461,519 $11,163,274 $14,165,053 $13,220,350
South Carolina $241,712,165 $102,316,506 $71,166,206 $29,469,037 $78,905,290
South Dakota $35,494,580 $5,758,477 $7,020,500 $7,328,902 $7,696,219
Tennessee**
Texas $750,907,166 $229,611,591 $239,350,204 $128,549,116 $221,602,731
Utah $90,793,203 $13,103,636 $13,704,039 $14,269,056 $16,005,029
Vermont $20,380,595 $4,923,113 $3,924,394 $2,831,497 $4,837,757
Virginia $216,282,993 $74,189,057 $44,188,648 $52,170,367 $49,166,042
Washington $215,060,401 $51,783,776 $36,951,943 $44,456,162 $47,672,718
West Virginia $148,004,350 $45,398,113 $30,465,631 $22,502,144 $39,328,691
Wisconsin $321,759,763 $88,777,279 $41,226,534 $43,727,866 $66,809,859
Wyoming $22,563,808 $3,081,922 $4,320,808 $2,740,435 $5,011,460
* Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
** Data not reported for Illinois, New Mexico and Tennessee due to inconsistencies.
Source: CMS, State Drug Utilization Data, FY 2004.
4-9
Drug Expenditures by Category, 2004 (Con't.)
Unclassified Blood
Therapeutic Autonomic Formulation and
State Agents Drugs Coagulation Other Totals
National Average $1,268,709,776 $1,504,382,071 $1,780,432,781 $4,539,258,679 $35,755,293,579
Alabama $19,815,936 $28,276,590 $30,130,751 $93,636,378 $609,245,240
Alaska $4,236,261 $4,702,727 $7,297,448 $12,322,584 $115,141,617
Arizona*
Arkansas $15,089,745 $20,212,100 $22,302,405 $53,697,466 $409,782,219
California $154,643,546 $119,405,722 $273,003,668 $461,107,379 $4,542,966,482
Colorado $11,231,161 $14,098,886 $8,493,735 $34,949,118 $280,547,284
Connecticut $13,954,956 $17,727,053 $19,448,788 $48,084,018 $453,623,394
Delaware $4,397,712 $4,948,366 $5,145,925 $15,613,980 $114,914,502
Florida $84,995,587 $102,867,469 $132,999,437 $303,067,303 $2,395,160,144
Georgia $44,108,288 $63,249,138 $60,174,610 $197,123,630 $1,211,812,410
Hawaii $5,706,853 $4,405,121 $7,303,532 $12,792,380 $115,602,955
Idaho $5,947,343 $6,458,100 $3,853,852 $16,587,939 $149,103,193
Illinois**
Indiana $29,725,442 $34,463,246 $61,441,511 $102,961,022 $776,165,492
Iowa $12,417,134 $18,409,947 $10,842,034 $43,851,314 $386,529,298
Kansas $8,849,086 $12,576,734 $9,873,381 $30,332,674 $280,694,156
Kentucky $31,804,260 $53,791,138 $37,300,733 $113,248,663 $823,798,997
Louisiana $30,168,868 $45,859,178 $48,365,184 $157,515,097 $927,354,092
Maine $9,405,074 $11,919,851 $11,623,735 $25,627,824 $281,997,651
Maryland $13,097,536 $13,898,001 $29,865,381 $42,225,645 $488,005,171
Massachusetts $28,219,888 $33,704,489 $38,426,993 $100,869,810 $978,994,948
Michigan $32,181,251 $32,307,939 $55,846,178 $91,605,196 $901,825,575
Minnesota $12,809,076 $14,795,693 $16,753,741 $40,961,946 $393,690,923
Mississippi $22,684,360 $33,882,763 $32,051,245 $89,074,230 $662,139,270
Missouri $38,296,575 $59,234,130 $55,920,224 $149,412,057 $1,132,170,954
Montana $4,261,207 $4,887,086 $3,064,524 $11,854,757 $96,274,963
Nebraska $8,939,346 $11,010,780 $8,419,450 $29,000,045 $233,588,200
Nevada $4,516,008 $5,936,937 $10,643,715 $15,284,714 $127,768,733
New Hampshire $4,110,542 $6,720,017 $2,965,942 $14,653,555 $128,976,830
New Jersey $35,679,895 $43,449,706 $65,546,285 $131,578,491 $1,009,822,197
New Mexico**
New York $182,586,702 $165,350,243 $229,409,543 $639,902,270 $4,746,951,017
North Carolina $54,413,248 $70,605,784 $70,282,003 $218,643,112 $1,571,772,002
North Dakota $2,464,988 $2,861,449 $1,682,198 $7,114,750 $60,763,111
Ohio $56,744,399 $101,205,281 $71,165,315 $240,076,427 $1,855,966,641
Oklahoma $17,396,906 $20,036,410 $23,059,956 $46,342,187 $420,012,256
Oregon $5,860,382 $8,296,626 $9,343,855 $16,214,738 $238,819,777
Pennsylvania $34,783,700 $60,401,478 $70,317,964 $131,016,175 $1,057,825,116
Rhode Island $5,242,264 $7,200,855 $5,771,722 $16,991,501 $167,214,662
South Carolina $26,550,002 $31,574,570 $32,393,334 $100,541,806 $714,628,916
South Dakota $3,172,046 $4,121,980 $3,312,522 $11,246,610 $85,151,836
Tennessee**
Texas $94,573,950 $96,244,690 $100,239,771 $370,863,735 $2,231,942,954
Utah $5,658,786 $7,456,053 $2,766,670 $19,584,825 $183,341,297
Vermont $2,045,354 $2,095,719 $1,828,575 $6,144,343 $49,011,347
Virginia $20,969,064 $28,697,738 $32,941,936 $77,399,118 $596,004,963
Washington $16,555,811 $17,206,755 $10,090,619 $50,041,660 $489,819,845
West Virginia $14,321,406 $17,966,680 $10,815,009 $45,634,292 $374,436,316
Wisconsin $29,817,176 $35,312,820 $30,347,538 $83,348,189 $741,127,024
Wyoming $2,416,229 $2,429,563 $1,440,201 $7,143,649 $51,148,075
4-10
Prescriptions Processed by Category, 2004
Hormones and
National Average 167,888,750 79,371,749 44,019,700 33,525,189 53,642,322
Alabama 3,278,516 1,590,111 1,084,735 611,990 1,133,807
Alaska 584,955 237,819 120,430 111,598 160,090
Arizona*
Arkansas 1,940,172 872,682 789,138 289,294 735,854
California 16,140,871 8,762,370 4,163,569 3,826,736 6,211,702
Colorado 1,869,444 696,456 466,021 264,850 607,516
Connecticut 2,132,602 994,667 265,547 384,063 568,378
Delaware 538,520 208,070 168,827 69,670 179,106
Florida 9,805,117 5,812,626 2,781,099 2,112,140 3,136,531
Georgia 5,909,547 2,729,143 2,417,822 989,503 2,179,471
Hawaii 490,293 336,920 89,324 142,354 176,389
Idaho 842,808 233,923 199,437 115,892 250,988
Illinois**
Indiana 4,392,459 1,552,226 910,144 928,081 1,141,298
Iowa 2,405,468 813,817 573,808 325,830 670,385
Kansas 1,551,388 591,586 353,575 268,149 475,833
Kentucky 4,645,620 2,073,878 1,366,167 1,089,815 1,444,433
Louisiana 3,938,337 1,856,000 1,607,037 642,164 1,335,519
Maine 2,015,551 770,556 347,931 351,711 586,256
Maryland 2,633,151 1,258,463 312,811 371,774 659,700
Massachusetts 5,812,606 2,421,077 974,401 937,398 1,610,341
Michigan 6,282,409 2,321,047 761,712 843,742 1,394,537
Minnesota 2,168,242 621,246 306,388 464,346 510,208
Mississippi 2,825,237 1,954,769 1,072,504 500,967 1,075,376
Missouri 5,780,979 2,584,837 1,255,130 918,442 1,789,360
Montana 579,675 180,716 120,309 95,081 171,680
Nebraska 1,382,247 484,928 375,678 322,118 406,308
Nevada 624,279 272,312 124,908 88,113 179,704
New Hampshire 887,305 249,895 141,013 175,189 203,533
New Jersey 3,964,285 2,369,974 706,224 846,406 1,209,970
New Mexico**
New York 16,651,586 9,648,142 4,963,852 4,298,342 5,976,807
North Carolina 6,812,234 3,684,497 1,937,463 1,455,037 2,452,646
North Dakota 375,058 153,187 83,016 51,875 119,577
Ohio 10,712,189 4,250,302 2,447,799 2,555,093 3,098,614
Oklahoma 2,106,058 749,897 758,715 319,697 648,626
Oregon 2,007,873 459,454 200,114 232,258 376,993
Pennsylvania 5,047,146 2,436,122 967,173 1,126,691 1,584,252
Rhode Island 870,717 346,964 117,378 175,104 206,611
South Carolina 3,143,775 2,208,842 964,823 489,627 1,436,448
South Dakota 422,113 155,469 142,829 75,437 142,546
Tennessee**
Texas 9,555,330 3,325,626 4,684,673 1,690,336 2,849,109
Utah 1,226,270 279,704 293,800 183,928 314,835
Vermont 249,031 100,613 50,198 39,517 78,797
Virginia 3,017,582 1,546,359 583,196 809,102 918,666
Washington 3,266,958 1,315,922 523,389 765,203 934,552
West Virginia 2,294,623 944,174 607,461 373,840 675,911
Wisconsin 4,160,520 2,605,992 663,934 718,305 1,439,276
Wyoming 265,989 69,406 85,112 43,409 76,516
4-11
Prescriptions Processed by Category, 2004 (Con't.)
Unclassified Blood
Alabama 227,396 673,411 262,701 2,682,619 11,545,286
Alaska 36,707 93,014 33,986 256,715 1,635,314
Arizona*
Arkansas 146,838 357,751 139,053 1,361,082 6,631,864
California 1,257,486 2,430,679 1,591,923 9,951,195 54,336,531
Colorado 121,849 351,496 118,012 971,534 5,467,178
Connecticut 147,746 303,980 175,517 992,217 5,964,717
Delaware 39,080 108,626 33,781 350,778 1,696,458
District of Columbia 23,958 48,848 25,167 224,251 1,074,127
Florida 976,550 1,938,542 961,015 6,322,293 33,845,913
Georgia 477,858 1,397,467 489,393 4,840,641 21,430,845
Hawaii 69,406 82,720 47,561 326,396 1,761,363
Idaho 55,809 135,658 42,852 371,928 2,249,295
Illinois**
Indiana 252,246 707,340 331,131 2,723,249 12,938,174
Iowa 136,072 371,056 149,482 1,150,391 6,596,309
Kansas 95,197 248,781 98,869 820,171 4,503,549
Kentucky 350,381 977,033 384,185 3,401,282 15,732,794
Louisiana 329,371 930,317 359,032 3,603,150 14,600,927
Maine 106,289 308,112 90,583 689,442 5,266,431
Maryland 156,801 328,935 219,477 1,081,585 7,022,697
Massachusetts 280,117 804,194 319,206 2,389,395 15,548,735
Michigan 327,833 725,159 456,014 2,494,063 15,606,516
Minnesota 98,537 278,693 99,914 941,974 5,489,548
Mississippi 252,852 540,406 292,655 2,225,936 10,740,702
Missouri 353,492 1,072,302 437,990 3,263,920 17,456,452
Montana 38,232 99,061 26,936 267,472 1,579,162
Nebraska 94,634 238,851 91,552 1,003,496 4,399,812
Nevada 45,535 127,665 45,552 325,019 1,833,087
New Hampshire 40,184 143,511 40,200 449,864 2,330,694
New Jersey 385,643 695,640 382,934 2,702,315 13,263,391
New Mexico**
New York 1,904,657 3,429,346 1,293,585 13,896,087 62,062,404
North Carolina 608,135 1,307,947 511,445 4,906,941 23,676,345
North Dakota 24,720 54,569 26,244 198,945 1,087,191
Ohio 656,535 2,154,127 824,394 7,110,698 33,809,751
Oklahoma 154,964 435,049 97,085 1,096,146 6,366,237
Oregon 54,836 187,056 75,117 566,209 4,159,910
Pennsylvania 347,281 934,426 705,002 3,005,516 16,153,609
Rhode Island 60,429 133,178 58,933 404,984 2,374,298
South Carolina 268,346 597,461 324,087 2,350,308 11,783,717
South Dakota 32,478 74,591 29,661 270,458 1,345,582
Tennessee**
Texas 777,489 2,223,580 657,848 10,093,801 35,857,792
Utah 55,947 175,023 47,561 537,159 3,114,227
Vermont 16,037 42,821 14,114 124,262 715,390
Virginia 242,302 519,649 274,114 2,158,209 10,069,179
Washington 196,331 371,824 152,037 1,540,253 9,066,469
West Virginia 163,120 387,534 134,768 1,212,992 6,794,423
Wisconsin 350,271 654,116 386,065 2,344,346 13,322,825
Wyoming 20,734 47,868 15,911 166,177 791,122
*Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
4-12
Medicaid Average Cost Per Prescription, 2004*
Drug Prescriptions Average

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

**Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
*** Data not reported for Illinois, New Mexico and Tennessee due to inconsistencies.
4-13
Hormones and
National Total $13,733,672,000 $4,409,779,315 $3,795,913,778 $2,700,933,651 $3,549,133,873
Alabama $214,552,130 $73,802,209 $56,724,127 $42,880,640 $62,577,950
Alaska $51,014,894 $11,684,647 $11,472,017 $12,305,340 $10,512,077
Arizona*
Arkansas $170,203,870 $44,199,827 $40,494,234 $25,043,648 $46,474,770
California $1,577,940,461 $682,118,842 $428,390,448 $403,356,229 $462,655,404
Colorado $134,522,019 $31,069,329 $24,334,273 $15,250,451 $29,352,001
Connecticut $207,432,304 $57,960,246 $38,900,924 $40,001,158 $36,536,080
Delaware $37,017,954 $11,410,832 $18,490,842 $3,949,655 $11,869,250
Florida $692,119,817 $297,390,891 $373,470,079 $215,858,221 $219,223,786
Georgia $398,614,954 $126,712,089 $159,154,053 $70,040,037 $128,895,843
Hawaii $44,911,145 $19,251,022 $8,794,470 $3,724,301 $12,795,327
Idaho $71,222,640 $11,532,719 $11,186,208 $8,725,592 $15,618,743
Illinois**
Indiana $323,309,355 $71,032,439 $45,461,298 $43,184,105 $63,929,980
Iowa $198,345,246 $36,978,920 $32,909,189 $21,727,070 $38,930,947
Kansas $139,644,790 $27,725,243 $20,320,128 $26,999,791 $25,896,170
Kentucky $273,903,838 $86,644,725 $68,996,989 $37,610,724 $83,549,039
Louisiana $304,695,909 $104,488,213 $125,903,628 $71,097,667 $88,786,676
Maine $122,675,758 $32,682,598 $19,919,917 $33,336,199 $32,003,288
Maryland $235,878,248 $65,233,868 $44,863,927 $34,062,328 $36,101,160
Massachusetts $438,462,703 $102,324,635 $98,710,494 $79,285,503 $87,437,122
Michigan $465,642,417 $92,298,628 $56,806,194 $62,302,650 $78,582,106
Minnesota $220,614,609 $30,636,546 $24,491,736 $32,874,924 $32,255,840
Mississippi $197,640,832 $95,740,331 $67,825,156 $24,652,569 $65,517,465
Missouri $508,352,069 $140,298,572 $100,989,144 $46,536,754 $122,625,807
Montana $49,313,924 $8,372,267 $6,528,375 $5,224,250 $9,202,773
Nebraska $113,869,878 $24,858,618 $18,368,009 $9,244,009 $24,930,071
Nevada $55,822,280 $13,007,296 $11,236,673 $4,507,500 $10,342,649
New Hampshire $67,832,710 $11,590,852 $6,914,941 $8,439,575 $12,275,482
New Jersey $373,529,060 $150,004,977 $118,893,816 $91,234,292 $89,192,201
New Mexico**
New York $1,552,391,330 $625,561,684 $788,859,153 $361,966,786 $478,979,355
North Carolina $599,486,231 $204,569,508 $152,027,401 $174,448,054 $160,898,618
North Dakota $30,502,365 $5,935,677 $4,170,398 $2,572,846 $5,928,454
Ohio $794,592,304 $206,292,755 $150,805,411 $175,539,234 $188,600,216
Oklahoma $184,266,645 $43,651,603 $45,209,726 $29,227,955 $49,617,242
Oregon $159,525,446 $15,790,550 $9,734,364 $8,507,078 $15,961,846
Pennsylvania $373,905,197 $106,055,869 $57,962,409 $58,189,032 $81,182,254
Rhode Island $74,733,675 $23,064,893 $11,509,528 $15,060,588 $14,161,908
South Carolina $249,532,462 $109,550,871 $76,671,996 $32,671,736 $84,043,918
South Dakota $36,887,007 $6,464,738 $7,362,362 $7,712,871 $8,549,059
Tennessee**
Texas $800,062,681 $262,986,093 $253,264,190 $150,787,827 $248,184,183
Utah $105,497,120 $16,041,107 $15,929,708 $16,032,323 $19,073,269
Vermont $20,138,225 $5,732,917 $4,024,154 $3,872,914 $4,718,765
Virginia $226,513,235 $80,628,883 $43,975,229 $56,436,937 $53,220,641
Washington $293,834,554 $66,578,485 $47,705,204 $48,282,935 $66,030,231
West Virginia $168,731,118 $52,797,324 $33,163,561 $37,055,041 $46,158,335
Wisconsin $319,637,524 $99,102,590 $40,550,320 $42,744,865 $72,772,136
Wyoming $22,596,132 $3,136,315 $4,545,958 $3,158,315 $5,065,005
4-14
Unclassified Blood
National Average $1,531,040,695 $1,596,864,325 $1,998,438,628 $4,775,919,111 $38,091,695,376
Alabama $24,902,512 $26,906,221 $36,933,895 $90,883,496 $630,163,180
Alaska $5,255,423 $5,105,214 $10,059,442 $13,778,167 $131,187,221
Arizona*
Arkansas $18,069,153 $21,417,826 $24,380,875 $54,212,690 $444,496,893
California $192,095,334 $127,816,349 $286,819,093 $429,053,695 $4,590,245,855
Colorado $13,767,441 $15,695,757 $9,426,888 $38,883,092 $312,301,251
Connecticut $17,629,346 $19,935,083 $22,897,258 $53,228,609 $494,521,008
Delaware $5,257,686 $4,200,231 $4,684,696 $15,507,441 $112,388,587
Florida $100,347,671 $108,548,324 $147,058,338 $316,945,389 $2,470,962,516
Georgia $44,594,047 $67,576,711 $63,100,564 $190,863,020 $1,249,551,318
Hawaii $7,371,604 $4,498,000 $8,502,032 $14,156,230 $124,004,131
Idaho $6,945,664 $6,164,709 $4,197,023 $16,715,213 $152,308,511
Illinois**
Indiana $32,440,671 $33,643,946 $76,146,048 $98,359,441 $787,507,283
Iowa $15,643,316 $18,894,992 $12,624,738 $46,233,132 $422,287,550
Kansas $11,255,310 $13,421,479 $11,580,473 $31,179,253 $308,022,637
Kentucky $33,464,592 $50,973,672 $39,967,530 $118,371,796 $793,482,905
Louisiana $34,330,832 $50,106,962 $49,998,356 $161,817,388 $991,225,631
Maine $10,869,487 $13,004,310 $11,795,168 $28,510,727 $304,797,452
Maryland $16,551,728 $15,976,236 $30,127,136 $44,818,569 $523,613,200
Massachusetts $34,273,891 $35,801,824 $47,032,500 $105,604,352 $1,028,933,024
Michigan $39,756,274 $36,295,568 $56,333,032 $96,767,421 $984,784,290
Minnesota $15,548,784 $15,764,632 $21,201,894 $45,413,234 $438,802,199
Mississippi $24,256,906 $27,533,003 $36,366,456 $80,103,307 $619,636,025
Missouri $50,091,418 $62,451,303 $64,889,970 $167,455,537 $1,263,690,574
Montana $5,364,423 $5,053,922 $3,495,037 $12,332,512 $104,887,483
Nebraska $11,022,585 $11,866,646 $8,637,603 $30,919,635 $253,717,054
Nevada $5,367,911 $6,383,591 $9,908,700 $15,563,837 $132,140,437
New Hampshire $4,695,907 $6,840,460 $3,739,775 $15,061,722 $137,391,424
New Jersey $46,846,440 $50,599,505 $74,917,112 $155,552,870 $1,150,770,273
New Mexico**
New York $211,252,457 $172,267,631 $254,109,864 $716,433,091 $5,161,821,351
North Carolina $64,885,022 $81,250,090 $82,523,055 $243,656,396 $1,763,744,375
North Dakota $2,794,304 $3,298,133 $2,034,759 $7,731,194 $64,968,130
Ohio $70,270,337 $105,004,513 $72,270,082 $241,525,465 $2,004,900,317
Oklahoma $22,920,597 $23,558,595 $27,967,206 $53,652,385 $480,071,954
Oregon $6,401,798 $8,281,421 $10,262,503 $16,025,750 $250,490,756
Pennsylvania $36,212,113 $57,971,113 $70,200,216 $120,431,391 $962,109,594
Rhode Island $6,370,996 $7,774,511 $6,421,812 $17,693,234 $176,791,145
South Carolina $31,534,376 $33,911,644 $37,270,088 $102,302,056 $757,489,147
South Dakota $3,662,431 $4,733,561 $2,634,571 $11,629,219 $89,635,819
Tennessee**
Texas $119,441,273 $102,902,689 $128,618,140 $413,010,166 $2,479,257,242
Utah $7,407,843 $8,488,557 $3,037,342 $22,148,801 $213,656,070
Vermont $2,362,088 $2,046,736 $1,752,162 $5,865,446 $50,513,407
Virginia $27,376,114 $30,480,949 $36,095,697 $81,306,462 $636,034,147
Washington $29,815,033 $28,202,835 $32,757,379 $73,385,010 $686,591,666
West Virginia $18,706,956 $21,003,967 $12,706,954 $49,301,388 $439,624,644
Wisconsin $36,029,761 $38,366,790 $34,832,125 $90,896,400 $774,932,511
Wyoming $2,656,659 $2,372,924 $1,262,519 $6,869,243 $51,663,070
4-15
Hormones and
Alabama 3,232,377 1,599,474 1,085,636 644,601 1,122,760
Alaska 610,394 274,332 132,139 126,111 176,203
Arizona*
Arkansas 2,010,056 906,451 797,064 309,713 739,529
California 15,109,303 9,201,039 3,849,081 3,749,245 5,820,996
Colorado 1,951,438 745,356 510,657 273,249 648,137
Connecticut 2,185,526 1,072,706 275,250 415,595 602,431
Delaware 535,501 203,661 174,139 67,245 175,637
Florida 9,722,766 6,174,856 2,848,958 2,205,231 3,383,461
Georgia 5,861,309 2,725,527 2,570,140 1,063,572 2,205,235
Hawaii 497,817 354,399 90,949 148,055 182,372
Idaho 835,517 242,690 217,691 114,922 246,632
Illinois**
Indiana 4,137,565 1,609,777 775,277 928,445 1,085,729
Iowa 2,521,064 894,375 622,769 361,015 699,054
Kansas 1,649,419 629,139 372,469 279,853 496,858
Kentucky 4,528,809 2,032,296 1,355,734 1,065,834 1,394,072
Louisiana 3,983,412 1,923,705 1,710,966 660,789 1,376,986
Maine 2,052,292 816,224 366,491 370,755 612,210
Maryland 2,754,822 1,343,091 338,537 390,093 700,452
Massachusetts 5,765,456 2,489,395 959,958 963,925 1,602,847
Michigan 6,457,330 2,448,637 834,280 930,390 1,452,311
Minnesota 2,257,637 666,445 326,779 484,725 536,286
Mississippi 2,635,134 1,807,777 1,053,455 439,131 1,025,501
Missouri 6,139,842 2,883,016 1,306,399 1,065,719 1,931,857
Montana 591,123 187,570 125,063 99,015 175,685
Nebraska 1,434,507 518,840 397,467 345,237 421,290
Nevada 639,293 287,520 124,591 92,333 182,254
New Hampshire 908,891 263,570 150,385 175,071 214,359
New Jersey 4,090,116 2,590,500 754,730 906,408 1,326,516
New Mexico**
New York 17,070,337 10,354,197 5,146,710 4,479,018 6,335,159
North Carolina 7,141,343 3,954,735 2,052,837 1,533,553 2,577,796
North Dakota 380,673 158,590 92,834 53,868 121,278
Ohio 11,170,571 4,583,729 2,384,308 2,641,502 3,226,628
Oklahoma 2,309,383 819,705 845,779 388,735 715,057
Oregon 1,933,176 415,564 183,974 225,094 325,629
Pennsylvania 4,714,134 2,338,546 894,317 991,202 1,494,551
Rhode Island 891,322 368,066 117,465 179,032 208,483
South Carolina 3,187,298 2,220,303 1,005,899 514,780 1,410,470
South Dakota 428,323 162,233 156,281 79,726 149,127
Tennessee**
Texas 9,880,766 3,466,170 4,998,083 1,758,482 2,951,423
Utah 1,343,038 320,991 335,403 201,063 346,332
Vermont 255,142 110,272 54,629 47,901 73,472
Virginia 3,085,474 1,598,875 604,891 826,757 946,086
Washington 4,180,750 1,740,708 700,145 923,497 1,269,554
West Virginia 2,539,372 1,051,990 657,038 432,186 754,162
Wisconsin 4,231,728 2,748,853 701,823 729,301 1,483,433
Wyoming 268,047 70,672 98,330 46,155 78,849
4-16
Unclassified Blood
Alabama 249,974 694,644 247,378 2,589,866 11,466,710
Alaska 44,674 102,589 37,678 277,212 1,781,332
Arizona*
Arkansas 163,863 367,964 131,600 1,290,170 6,716,410
California 1,481,054 2,462,289 1,580,317 8,783,238 52,036,562
Colorado 133,969 369,963 120,668 983,483 5,736,920
Connecticut 169,312 323,166 182,273 1,025,352 6,251,611
Delaware 44,977 110,129 30,635 334,680 1,676,604
District of Columbia 28,904 53,811 29,464 248,686 1,155,613
Florida 977,582 2,013,218 1,031,348 6,455,672 34,813,092
Georgia 422,757 1,451,034 489,590 4,881,777 21,670,941
Hawaii 78,672 84,267 49,640 335,040 1,821,211
Idaho 59,982 134,853 43,874 380,176 2,276,337
Illinois**
Indiana 246,947 681,706 333,228 2,490,801 12,289,475
Iowa 148,981 392,669 155,720 1,222,532 7,018,179
Kansas 108,372 261,488 100,219 827,685 4,725,502
Kentucky 353,525 983,113 380,345 3,448,554 15,542,282
Louisiana 339,626 996,979 355,880 3,604,383 14,952,726
Maine 109,353 326,020 98,520 723,994 5,475,859
Maryland 181,817 361,515 231,784 1,131,438 7,433,549
Massachusetts 305,702 805,523 322,087 2,384,308 15,599,201
Michigan 362,779 785,156 467,378 2,580,723 16,318,984
Minnesota 107,496 293,020 103,820 987,480 5,763,688
Mississippi 236,774 502,867 272,941 2,015,122 9,988,702
Missouri 415,649 1,165,688 485,404 3,530,175 18,923,749
Montana 41,823 100,203 27,046 272,478 1,620,006
Nebraska 105,789 249,910 96,657 1,056,357 4,626,054
Nevada 49,906 131,855 51,137 330,829 1,889,718
New Hampshire 43,174 133,998 44,477 436,470 2,370,395
New Jersey 442,378 755,398 387,161 2,886,268 14,139,475
New Mexico**
New York 1,947,303 3,592,303 1,119,760 13,203,806 63,248,593
North Carolina 634,829 1,418,575 525,697 5,156,017 24,995,382
North Dakota 26,449 58,191 26,508 201,365 1,119,756
Ohio 728,016 2,253,944 864,499 7,110,606 34,963,803
Oklahoma 201,845 488,102 107,014 1,211,519 7,087,139
Oregon 55,744 168,024 71,831 536,571 3,915,607
Pennsylvania 346,344 874,882 665,002 2,770,224 15,089,202
Rhode Island 68,114 136,714 69,663 414,330 2,453,189
South Carolina 264,171 627,410 325,835 2,358,438 11,914,604
South Dakota 36,195 78,939 30,019 278,381 1,399,224
Tennessee**
Texas 893,880 2,327,948 813,612 10,860,530 37,950,894
Utah 65,825 195,210 49,106 587,937 3,444,905
Vermont 17,037 42,698 15,392 122,725 739,268
Virginia 276,240 538,056 267,360 2,173,778 10,317,517
Washington 248,490 632,589 258,590 2,120,753 12,075,076
West Virginia 193,375 437,372 149,244 1,306,689 7,521,428
Wisconsin 391,320 691,822 405,454 2,396,776 13,780,510
Wyoming 21,452 49,643 15,783 166,797 815,728
4-17

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

*** Data not reported for Illinois, New Mexico and Tennessee due to inconsistencies.
4-18
Hormones and
National Total $7,700,546,892 $1,542,565,701 $2,595,119,847 $1,213,134,157 $2,010,561,660
Alabama $143,746,263 $29,984,767 $46,662,490 $21,266,913 $43,033,435
Alaska $33,241,269 $4,611,581 $9,106,509 $6,283,982 $5,911,697
Arizona*
Arkansas $120,775,180 $14,558,092 $36,126,566 $17,801,495 $32,430,203
California $916,478,860 $224,184,513 $241,260,807 $164,265,390 $268,043,142
Colorado $80,174,650 $10,640,557 $17,869,192 $8,254,254 $17,480,342
Connecticut $74,852,777 $14,141,558 $20,075,685 $12,409,803 $12,872,634
Delaware $32,178,552 $7,543,843 $14,746,762 $5,365,936 $10,516,995
Florida $314,145,818 $75,521,349 $201,686,102 $80,376,193 $99,887,497
Georgia $234,302,560 $51,013,715 $103,749,889 $36,274,747 $72,037,944
Hawaii $23,127,594 $4,865,756 $4,683,872 $2,268,440 $4,455,398
Idaho $47,744,673 $4,337,593 $8,337,967 $5,220,520 $9,941,860
Illinois**
Indiana $119,928,901 $20,040,525 $16,200,880 $16,697,798 $21,212,940
Iowa $114,434,163 $12,557,860 $24,632,339 $11,402,849 $22,151,730
Kansas $75,217,177 $8,386,720 $12,156,381 $11,160,841 $12,551,899
Kentucky $164,544,818 $42,190,381 $52,291,447 $22,139,298 $52,842,763
Louisiana $191,578,852 $42,378,843 $108,767,280 $38,712,365 $58,147,923
Maine $70,513,562 $12,885,929 $13,490,132 $16,817,459 $19,500,312
Maryland $142,829,425 $11,374,011 $24,409,946 $7,410,054 $10,715,505
Massachusetts $206,084,564 $33,334,340 $59,973,952 $21,136,913 $42,721,614
Michigan $247,854,895 $10,371,673 $35,087,371 $15,017,919 $26,345,293
Minnesota $105,365,936 $12,443,620 $15,635,016 $16,383,207 $18,531,175
Mississippi $86,969,491 $19,889,378 $44,854,273 $9,341,908 $27,944,889
Missouri $249,014,975 $47,194,066 $55,666,945 $20,952,104 $58,798,320
Montana $29,830,562 $2,837,818 $4,323,700 $2,683,522 $4,634,992
Nebraska $66,174,725 $7,159,551 $13,216,063 $6,365,731 $13,534,467
Nevada $37,531,155 $4,881,067 $8,565,274 $2,881,887 $6,011,462
New Hampshire $33,169,018 $3,899,765 $4,646,416 $3,966,267 $7,339,516
New Jersey $176,610,382 $42,896,940 $71,187,349 $32,240,506 $38,578,589
New Mexico**
New York $998,122,069 $291,182,550 $648,616,265 $142,047,799 $339,493,318
North Carolina $335,821,426 $63,780,863 $109,302,988 $79,259,159 $90,679,910
North Dakota $14,465,289 $1,408,343 $2,766,567 $1,099,853 $2,681,601
Ohio $448,392,643 $90,909,082 $87,780,976 $114,665,119 $105,983,118
Oklahoma $109,447,270 $13,693,120 $34,117,111 $17,149,198 $32,566,766
Oregon $88,803,635 $4,616,121 $4,863,296 $3,940,110 $7,388,078
Pennsylvania $169,093,547 $33,747,110 $33,888,739 $17,938,067 $39,236,433
Rhode Island $32,360,407 $6,887,360 $6,006,430 $5,967,807 $5,478,297
South Carolina $136,947,640 $28,725,321 $50,035,501 $16,902,273 $44,715,335
South Dakota $20,067,869 $1,665,243 $5,674,689 $3,052,793 $5,086,563
Tennessee**
Texas $561,737,141 $88,326,294 $221,818,603 $78,950,703 $166,489,536
Utah $64,828,269 $6,459,755 $11,025,175 $8,676,963 $11,575,737
Vermont $12,464,283 $1,869,488 $2,991,551 $1,376,888 $2,726,718
Virginia $100,982,471 $16,673,791 $22,178,943 $20,699,036 $20,603,187
Washington $166,564,339 $28,117,648 $26,671,731 $26,572,238 $39,009,489
West Virginia $126,890,388 $29,233,450 $26,190,868 $28,581,250 $31,999,775
Wisconsin $134,454,261 $50,496,502 $22,702,578 $26,968,386 $38,273,699
Wyoming $15,134,561 $1,220,387 $4,088,580 $1,984,576 $3,410,244
4-19
Unclassified Blood
National Average $818,108,654 $744,328,825 $1,198,511,289 $2,853,858,420 $20,676,735,445
Alabama $19,499,211 $14,020,830 $24,879,590 $64,838,385 $407,931,884
Alaska $2,833,646 $2,724,173 $4,641,142 $8,403,128 $77,757,127
Arizona*
Arkansas $14,630,219 $9,786,634 $14,823,473 $39,726,486 $300,658,348
California $82,902,027 $57,519,946 $214,364,933 $233,135,375 $2,402,154,993
Colorado $7,017,156 $6,930,067 $6,937,339 $21,303,692 $176,607,249
Connecticut $5,152,854 $5,172,366 $10,360,664 $22,154,497 $177,192,838
Delaware $4,562,247 $3,003,717 $2,745,930 $11,854,076 $92,518,058
Florida $45,069,196 $42,953,771 $108,702,993 $144,256,944 $1,112,599,863
Georgia $25,326,476 $32,207,168 $36,526,355 $114,072,252 $705,511,106
Hawaii $1,825,446 $1,580,528 $5,982,712 $7,961,557 $56,751,303
Idaho $4,431,676 $3,146,359 $3,448,561 $10,819,832 $97,429,041
Illinois**
Indiana $13,362,647 $9,532,772 $41,859,401 $52,670,361 $311,506,225
Iowa $9,032,101 $9,858,695 $8,347,641 $25,178,243 $237,595,621
Kansas $5,760,622 $5,070,803 $7,947,380 $15,829,567 $154,081,390
Kentucky $20,607,958 $25,954,477 $20,936,142 $76,672,179 $478,179,463
Louisiana $24,255,850 $31,645,989 $30,710,516 $108,336,504 $634,534,122
Maine $5,363,342 $7,564,323 $7,050,279 $16,829,459 $170,014,797
Maryland $4,130,464 $3,515,563 $14,958,326 $12,868,548 $232,211,842
Massachusetts $15,608,493 $12,192,897 $32,019,478 $54,615,766 $477,688,017
Michigan $12,746,756 $7,425,208 $26,752,683 $37,871,620 $419,473,418
Minnesota $8,128,640 $6,806,297 $11,543,947 $27,905,968 $222,743,806
Mississippi $11,501,217 $8,942,660 $18,410,348 $38,724,260 $266,578,424
Missouri $25,134,460 $24,523,450 $34,762,130 $90,597,900 $606,644,350
Montana $2,713,509 $2,296,988 $2,949,472 $6,367,975 $58,638,538
Nebraska $6,162,850 $6,143,913 $6,744,105 $18,490,678 $143,992,083
Nevada $2,985,989 $3,311,541 $5,099,908 $8,817,362 $80,085,645
New Hampshire $2,654,103 $2,696,695 $1,492,142 $7,644,890 $67,508,812
New Jersey $17,350,933 $17,579,775 $29,720,047 $63,453,188 $489,617,709
New Mexico**
New York $124,570,887 $113,576,351 $140,008,671 $486,869,777 $3,284,487,687
North Carolina $38,849,460 $40,131,764 $47,427,452 $153,085,320 $958,338,342
North Dakota $1,262,635 $1,282,869 $1,165,327 $3,848,021 $29,980,505
Ohio $40,677,917 $45,783,580 $38,807,475 $149,124,532 $1,122,124,442
Oklahoma $17,499,026 $13,897,068 $28,462,775 $48,204,260 $315,036,594
Oregon $2,562,224 $3,050,596 $7,180,358 $7,300,034 $129,704,452
Pennsylvania $17,648,555 $17,721,188 $33,582,881 $55,474,673 $418,331,193
Rhode Island $2,190,159 $2,207,954 $3,161,071 $7,312,534 $71,572,019
South Carolina $16,739,759 $16,672,622 $18,679,468 $69,615,830 $399,033,749
South Dakota $2,208,896 $2,133,782 $779,128 $6,082,650 $46,751,613
Tennessee**
Texas $86,087,871 $62,285,205 $73,151,821 $336,580,952 $1,675,428,126
Utah $4,260,105 $4,615,122 $1,259,995 $13,798,586 $126,499,707
Vermont $1,088,566 $875,545 $813,502 $3,574,351 $27,780,892
Virginia $11,094,798 $10,906,018 $13,042,209 $34,907,023 $251,087,476
Washington $14,420,598 $14,078,152 $27,522,310 $39,254,040 $382,210,545
West Virginia $13,923,110 $12,162,474 $6,543,816 $35,977,765 $311,502,896
Wisconsin $18,905,113 $15,882,983 $18,325,654 $47,972,830 $373,982,006
Wyoming $1,774,340 $1,209,484 $814,008 $4,420,946 $34,057,126
4-20
Hormones and
Alabama 2,140,899 626,089 875,200 306,598 639,857
Alaska 400,715 101,198 100,459 60,469 86,118
Arizona*
Arkansas 1,407,588 296,563 715,074 169,241 455,748
California 9,045,439 2,802,484 2,272,797 1,780,218 2,987,599
Colorado 1,069,789 226,303 348,885 113,335 296,045
Connecticut 842,376 248,753 99,701 150,737 172,392
Delaware 474,668 130,858 156,811 59,810 146,347
Florida 4,682,035 1,496,059 1,687,208 736,934 1,247,809
Georgia 3,325,834 1,005,160 1,505,795 477,122 1,072,908
Hawaii 291,116 89,187 40,895 104,963 59,613
Idaho 584,587 91,635 185,790 60,558 139,064
Illinois**
Indiana 1,738,698 418,362 243,969 474,287 310,445
Iowa 1,565,908 286,447 465,216 174,881 337,777
Kansas 875,285 180,285 226,501 103,177 194,544
Kentucky 3,114,057 925,591 1,045,996 717,153 778,443
Louisiana 2,572,304 746,509 1,427,240 324,959 811,707
Maine 1,195,715 287,935 265,162 168,878 328,132
Maryland 1,504,685 238,501 124,899 81,527 177,577
Massachusetts 3,216,404 867,308 583,917 439,162 731,786
Michigan 3,681,581 263,324 419,125 289,437 335,703
Minnesota 1,214,947 247,991 197,012 306,870 240,828
Mississippi 1,227,077 398,210 756,906 138,912 401,681
Missouri 3,293,133 922,232 763,857 523,803 819,297
Montana 356,695 61,087 85,760 55,737 76,651
Nebraska 868,548 143,502 297,662 250,327 189,594
Nevada 414,998 105,097 83,276 46,699 86,000
New Hampshire 504,913 84,574 106,934 93,683 99,823
New Jersey 1,809,268 722,488 350,018 286,848 468,141
New Mexico**
New York 11,966,230 4,698,451 4,045,185 3,073,156 3,954,280
North Carolina 4,261,361 1,174,949 1,581,818 658,914 1,238,184
North Dakota 204,089 35,843 62,089 17,811 46,265
Ohio 6,478,642 1,857,167 1,398,871 1,495,818 1,536,416
Oklahoma 1,468,699 256,625 661,126 180,832 400,746
Oregon 1,114,049 100,201 93,804 152,376 118,415
Pennsylvania 3,120,422 989,450 604,944 515,994 742,156
Rhode Island 444,880 98,040 51,035 79,066 70,050
South Carolina 1,819,565 555,888 726,125 229,727 656,080
South Dakota 242,537 39,570 120,351 33,928 67,594
Tennessee**
Texas 7,148,798 1,140,878 4,049,974 969,390 1,671,886
Utah 873,697 126,180 247,456 115,845 187,596
Vermont 179,815 34,077 41,798 21,819 38,697
Virginia 1,603,379 316,100 310,353 433,665 307,837
Washington 2,600,102 683,471 408,939 621,500 645,765
West Virginia 1,971,453 567,686 537,186 282,285 485,447
Wisconsin 2,106,763 1,363,795 384,407 339,608 704,710
Wyoming 178,587 25,390 79,480 24,756 44,159
4-21
Unclassified Blood
Alabama 168,748 454,060 88,786 1,660,430 6,960,667
Alaska 20,134 62,007 10,788 156,362 998,250
Arizona*
Arkansas 115,553 239,732 31,557 852,224 4,283,280
California 490,423 1,331,965 940,240 5,341,431 26,992,596
Colorado 53,060 198,805 28,935 476,276 2,811,433
Connecticut 35,658 111,426 41,682 367,873 2,070,598
Delaware 34,489 90,999 14,446 258,039 1,366,467
Florida 353,914 942,475 276,286 2,666,541 14,089,261
Georgia 201,071 762,350 180,934 2,630,570 11,161,744
Hawaii 17,075 39,586 18,354 187,607 848,396
Idaho 32,321 86,270 15,178 241,371 1,436,774
Illinois**
Indiana 60,883 224,143 109,361 1,051,010 4,631,158
Iowa 74,570 222,141 47,273 687,138 3,861,351
Kansas 44,893 117,478 23,634 375,721 2,141,518
Kentucky 193,352 607,576 148,184 2,304,238 9,834,590
Louisiana 206,173 675,836 128,269 2,360,905 9,253,902
Maine 46,200 182,939 26,170 360,048 2,861,179
Maryland 29,873 111,830 57,114 292,043 2,618,049
Massachusetts 125,210 383,543 87,330 1,213,739 7,648,399
Michigan 78,102 230,965 109,658 877,786 6,285,681
Minnesota 44,793 147,473 37,259 591,387 3,028,560
Mississippi 100,173 252,461 58,145 1,051,456 4,385,021
Missouri 180,439 558,733 186,344 1,793,995 9,041,833
Montana 18,383 54,971 6,505 130,934 846,723
Nebraska 52,845 145,155 28,543 705,180 2,681,356
Nevada 21,349 76,150 17,695 169,091 1,020,355
New Hampshire 19,261 67,274 12,445 217,324 1,206,231
New Jersey 131,048 299,878 102,911 1,190,262 5,360,862
New Mexico**
New York 991,934 2,542,133 405,051 8,927,090 40,603,510
North Carolina 314,040 827,444 157,782 3,036,909 13,251,401
North Dakota 8,953 28,863 5,480 77,492 486,885
Ohio 345,995 1,153,570 340,786 3,837,740 18,445,005
Oklahoma 138,427 323,674 34,860 708,101 4,173,090
Oregon 17,057 76,252 17,161 285,319 1,974,634
Pennsylvania 159,531 409,135 242,006 1,438,404 8,222,042
Rhode Island 20,348 51,280 21,006 188,706 1,024,411
South Carolina 113,591 357,987 104,118 1,409,132 5,972,213
South Dakota 18,183 43,981 5,486 135,529 707,159
Tennessee**
Texas 611,094 1,640,532 271,786 8,561,048 26,065,386
Utah 30,652 116,790 18,019 365,710 2,081,945
Vermont 7,224 22,715 4,337 73,197 423,679
Virginia 90,846 223,178 82,272 1,109,731 4,477,361
Washington 97,358 359,914 87,068 1,249,585 6,753,702
West Virginia 132,063 314,339 70,166 897,331 5,257,956
Wisconsin 196,115 297,400 170,233 1,146,725 6,709,756
Wyoming 13,303 33,157 4,339 100,058 503,229
4-22

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

4-23
MEDICAID DRUG REBATES
In 1990, Congress considered a number of proposals designed to reduce and control Federal and State
expenditures for prescription drug products provided to Medicaid patients (S.2605, the
Pharmaceutical Access and Prudent Purchasing Act; S.3029, the Medicaid Anti-Discriminatory Drug
Act, sponsored by Senator David Pryor; and H.R.5589, the Medicaid Prescription Drug Fair Access
and Pricing Act, sponsored by Representatives Ron Wyden and Jim Cooper). A vigorous
Congressional debate ensued over which of these approaches to pursue. Several pharmaceutical
manufacturers voluntarily offered rebates to the States in exchange for open access for their products,
while the Pharmaceutical Manufacturers Association proposed a set rebate amount in exchange for
open formularies. Numerous public interest groups offered opinions on the proposals and in some
cases proposals of their own.
The Congressional debate ended in both the House and Senate offering somewhat similar proposals.
During the ensuing Conference between the House and Senate, the Office of Management and Budget
(OMB) argued for the inclusion of several proposals into the provisions in budget bill, the Omnibus
Budget Reconciliation Act of 1990 (OBRA ’90). The resulting Public Law 101-508, enacted
November 5, 1990, required a drug manufacturer to enter into and have in effect a national rebate
agreement with the Secretary of DHHS for States to receive Federal funding for outpatient drugs
dispensed to Medicaid patients. (For a detailed account of the debate and genesis of various
provisions see Robert Betz’s analysis of the Medicaid Best Price Law and its effect on pharmaceutical
manufacturers’ pricing policies.")
The requirement for rebate agreements does not apply to the dispensing of a single-source or
innovator multiple-source drug if the State has determined that the drug is essential, rated 1-A by the
FDA, and prior authorization is obtained for the exception. Existing rebate agreements qualify under
the law if the State agrees to report all rebates to DHHS and the agreement provides for a minimum
aggregate rebate of 10% of the State’s expenditures for the manufacturer’s products.
OBRA ‘90 was amended by the Veterans Health Care Act of 1992 which also required a drug
manufacturer to enter into discount pricing agreements with the Department of Veterans Affairs and
with covered entities funded by the Public Health Service in order to have its drugs covered by
Medicaid. The Medicaid rebate law, as amended, is included as Appendix C.
The drug rebate program is administered by CMS’ Center for Medicaid and State Operations
(CMSO). Currently, the rebate for covered outpatient drugs is as follows:
! For all innovator products, reimbursement requires: (1) a rebate that is the greater of 15.1
percent of the average manufacturer’s price (AMP) or the difference between the AMP and
the manufacturer’s “best price,” and (2) an additional rebate for any price increase for a
product that exceeds the increase in the Consumer Price Index (CPI-U) for all items since the
fall of 1990. AMP is the average price paid by wholesalers for products distributed to the
retail class of trade. The best price is the lowest price offered to any other customer,
excluding Federal Supply Schedule prices, prices to State pharmaceutical assistance
programs, and prices that are nominal in amount, and includes all discounts and rebates.
! For generic drugs (non-innovator drugs), reimbursement requires: a rebate of 11 percent of
each product’s AMP.
"
Robert Betz, “The Medicaid Best Price Law and Its Effect on Pharmaceutical Manufacturer’s Pricing Policies and Behavior for
Name Brand, Outpatient Pharmaceutical Products,” unpubl. Ph.D. dissertation, The George Washington University, May 21,
2000.
4-24
Medicaid Drug Rebates, 2005
Allocation of
State Drug Rebate Monies1 Total Rebates2 Federal Share2
National Total $12,409,442,413 $7,171,923,418
Alabama Medicaid General $145,238,083 $103,232,896
Alaska Medicaid General $27,511,193 $15,840,945
Arizona* - - -
Arkansas Medicaid Drug Budget $93,635,941 $70,052,049
California Medicaid Drug Budget $2,056,515,858 $1,055,322,930
Colorado Medicaid General $74,633,154 $37,746,924
Connecticut General Fund $109,418,487 $54,760,945
Delaware Medicaid General $35,424,633 $18,108,454
District of Columbia General Fund $24,703,979 $17,293,632
Florida Medicaid Drug Budget $728,568,990 $429,549,051
Georgia Medicaid General $336,290,253 $204,764,236
Hawaii General Fund $25,103,501 $14,678,017
Idaho Medicaid General $48,525,397 $34,268,635
Illinois Medicaid Drug Budget $575,457,731 $289,935,647
Indiana General Fund $204,350,287 $128,403,306
Iowa Medicaid Drug Budget $90,050,305 $57,237,973
Kansas Medicaid Drug Budget $93,125,615 $56,998,633
Kentucky General Fund $217,275,788 $151,461,068
Louisiana Medicaid Drug Budget $278,830,912 $198,561,571
Maine General Fund $99,804,572 $64,958,802
Maryland Medicaid Drug Budget $154,069,573 $77,297,337
Massachusetts General Fund $281,523,695 $140,761,848
Michigan Medicaid Drug Budget $325,135,732 $184,773,823
Minnesota General Fund $118,040,245 $59,142,717
Mississippi General Fund $180,055,329 $138,986,927
Missouri Medicaid Drug Budget $300,271,256 $184,397,584
Montana Medicaid General $25,166,744 $18,138,955
Nebraska Medicaid General $68,431,450 $41,009,525
Nevada General Fund $34,103,702 $19,100,049
New Hampshire General Fund $37,566,506 $18,924,184
New Jersey Medicaid Drug Budget $261,578,682 $131,087,744
New Mexico Medicaid General $25,417,996 $18,885,572
New York General Fund $1,300,131,531 $650,065,766
North Carolina Medicaid General $452,693,066 $288,839,970
North Dakota Medicaid Drug Budget $15,334,927 $10,380,570
Ohio Medicaid General $591,916,354 $353,797,769
Oklahoma Medicaid General $103,412,619 $72,740,150
Oregon General Fund $60,464,711 $37,234,839
Pennsylvania Medicaid General $253,722,496 $137,457,156
Rhode Island General Fund $44,671,288 $24,738,960
South Carolina Medicaid Drug Budget $217,001,438 $152,540,481
South Dakota Medicaid Drug Budget $22,083,160 $14,646,662
Tennessee Medicaid General $768,857,139 $498,296,312
Texas Medicaid Drug Budget $736,763,024 $449,541,903
Utah General Fund $39,887,001 $28,627,828
Vermont Health Access Trust Fund $45,054,392 $27,124,381
Virginia Virginia Health Care Fund $174,023,976 $87,234,401
Washington General Fund $176,803,507 $89,333,600
West Virginia Medicaid General $114,327,436 $85,345,432
Wisconsin Medicaid General $202,803,404 $120,383,018
Wyoming Medicaid Drug Budget $13,665,355 $7,912,241
*Does not apply for Arizona. Arizona has a 1115 waiver for which special rules apply.
Sources: 1As reported by State drug program administrators in the 2007 NPC Survey; 2 CMS, CMS-64 Report, FY 2005.
Includes reported state supplemental rebates for AL, CA, FL, GA, HI, IA, ID, IL, KS, KY, LA, ME, MI, MN, NH, NV, OH,
TN, VA, VT, WA, and WV.
4-25
Medicaid Drug Rebate Trends, 2001-2005
State 2001 2002** 2003** 2004** 2005**

National Total $4,948,222,331 $5,917,504,760 $7,008,382,303 $9,652,191,744 $12,409,442,413
Alabama $76,624,463 $84,994,286 $102,784,110 $127,283,554 $145,238,083
Alaska $11,337,883 $14,347,654 $15,060,446 $29,188,871 $27,511,193
Arizona* - - - - -
Arkansas $45,744,406 $56,688,398 $58,097,761 $82,286,907 $93,635,941
California $786,113,991 $946,651,118 $1,207,800,866 $1,611,941,832 $2,056,515,858
Colorado $34,264,574 $39,054,140 $32,446,928 $60,264,706 $74,633,154
Connecticut $61,916,192 $62,627,160 $81,550,711 $96,617,771 $109,418,487
Delaware $17,042,045 $16,990,455 $28,352,506 $25,068,377 $35,424,633
Florida $297,362,792 $353,649,807 $464,880,949 $670,836,774 $728,568,990
Georgia $110,087,285 $205,469,531 $219,238,104 $256,980,634 $336,290,253
Hawaii $14,363,603 $15,267,796 $19,212,047 $27,794,342 $25,103,501
Idaho $18,841,154 $22,939,130 $31,430,642 $30,041,654 $48,525,397
Illinois $170,733,612 $190,316,986 $292,630,625 $469,399,409 $575,457,731
Indiana $103,148,144 $126,512,101 $131,850,261 $177,387,116 $204,350,287
Iowa $42,602,101 $50,092,788 $62,173,583 $84,729,745 $90,050,305
Kansas $39,731,568 $29,755,595 $59,849,370 $65,409,297 $93,125,615
Kentucky $104,759,238 $133,330,557 $124,919,867 $169,285,080 $217,275,788
Louisiana $115,254,842 $113,729,749 $165,904,174 $220,068,423 $278,830,912
Maine $41,847,632 $47,395,300 $68,331,107 $80,173,931 $99,804,572
Maryland $34,263,429 $54,261,949 $77,934,401 $90,642,415 $154,069,573
Massachusetts $180,517,139 $191,118,385 $208,146,240 $277,112,233 $281,523,695
Michigan $111,716,756 $172,522,597 $179,774,542 $246,698,471 $325,135,732
Minnesota $54,548,714 $62,655,474 $54,081,115 $92,188,275 $118,040,245
Mississippi $88,481,567 $115,221,421 $114,233,479 $125,406,134 $180,055,329
Missouri $133,927,028 $147,281,505 $178,620,625 $220,602,904 $300,271,256
Montana $13,359,968 $15,955,235 $17,172,113 $20,783,447 $25,166,744
Nebraska $30,219,685 $47,855,128 $42,766,762 $46,634,148 $68,431,450
Nevada $16,330,579 $13,547,604 $21,078,909 $28,947,187 $34,103,702
New Hampshire $13,934,765 $20,888,707 $27,628,562 $33,253,239 $37,566,506
New Jersey $124,127,231 $127,373,014 $149,040,244 $197,451,860 $261,578,682
New Mexico $12,110,896 $13,274,387 $19,585,223 $24,519,599 $25,417,996
New York $543,984,948 $663,973,100 $598,407,083 $962,452,836 $1,300,131,531
North Carolina $207,551,841 $207,064,443 $260,487,290 $324,686,591 $452,693,066
North Dakota $8,780,182 $11,651,682 $11,369,358 $14,069,176 $15,334,927
Ohio $217,702,350 $263,267,258 $325,329,459 $447,436,396 $591,916,354
Oklahoma $40,177,945 $51,471,649 $59,205,487 $74,198,766 $103,412,619
Oregon $34,991,037 $54,474,938 $65,706,778 $53,842,614 $60,464,711
Pennsylvania $129,265,110 $154,338,235 $149,563,463 $196,449,883 $253,722,496
Rhode Island $21,467,002 $26,213,636 $30,477,726 $38,067,294 $44,671,288
South Carolina $95,438,155 $98,272,773 $119,101,600 $163,587,518 $217,001,438
South Dakota $9,405,933 $12,056,925 $14,808,661 $17,559,898 $22,083,160
Tennessee $102,644,077 $180,613,885 $224,072,761 $492,767,285 $768,857,139
Texas $268,557,241 $305,110,523 $392,292,711 $507,363,520 $736,763,024
Utah $21,949,963 $36,756,960 $25,931,043 $45,818,326 $39,887,001
Vermont $22,045,277 $24,488,863 $28,595,852 $35,983,462 $45,054,392
Virginia $79,484,868 $76,776,155 $112,854,618 $137,924,722 $174,023,976
Washington $91,250,830 $100,874,789 $123,683,508 $148,998,346 $176,803,507
West Virginia $52,402,218 $48,976,536 $69,568,029 $107,509,922 $114,327,436
Wisconsin $79,554,207 $89,226,751 $118,267,026 $162,034,977 $202,803,404
Wyoming $5,809,366 $8,681,912 $6,962,798 $11,929,271 $13,665,355
*Does not apply for Arizona. Arizona has a 1115 waiver for which special rules apply.
**Includes reported state supplemental rebates.
4-26
Medicaid Drug Rebate Trends

Annual Percent Change, 2000-2005
% Change % Change % Change % Change % Change

State 00-01 01-02 02-03 03-04 04-05
National Total 24.3% 19.6% 18.4% 37.7% 22.22%
Alabama 25.6% 10.9% 20.9% 23.8% 12.36%
Alaska 31.9% 26.5% 5.0% 93.8% -6.10%
Arizona* - - - - -
Arkansas 12.1% 23.9% 2.5% 41.6% 12.12%
California 30.8% 20.4% 27.6% 33.5% 21.62%
Colorado 18.8% 14.0% -16.9% 85.7% 19.25%
Connecticut 25.9% 1.1% 30.2% 18.5% 11.70%
Delaware 23.7% -0.3% 66.9% -11.6% 29.23%
District of Columbia 13.4% 9.6% 32.1% 35.7% 16.97%
Florida 19.6% 18.9% 31.5% 44.3% 7.92%
Georgia 19.8% 86.6% 6.7% 17.2% 23.58%
Hawaii 31.2% 6.3% 25.8% 44.7% -10.72%
Idaho 34.7% 21.8% 37.0% -4.4% 38.09%
Illinois 18.9% 11.5% 53.8% 60.4% 18.43%
Indiana 22.1% 22.7% 4.2% 34.5% 13.19%
Iowa 18.2% 17.6% 24.1% 36.3% 5.91%
Kansas 28.1% -25.1% 101.1% 9.3% 29.76%
Kentucky 11.8% 27.3% -6.3% 35.5% 22.09%
Louisiana 35.9% -1.3% 45.9% 32.6% 21.07%
Maine 32.4% 13.3% 44.2% 17.3% 19.67%
Maryland -18.6% 58.4% 43.6% 16.3% 41.17%
Massachusetts 23.5% 5.9% 8.9% 33.1% 1.57%
Michigan 47.6% 54.4% 4.2% 37.2% 24.12%
Minnesota 26.2% 14.9% -13.7% 70.5% 21.90%
Mississippi 44.4% 30.2% -0.9% 9.8% 30.35%
Missouri 21.7% 10.0% 21.3% 23.5% 26.53%
Montana 21.6% 19.4% 7.6% 21.0% 17.42%
Nebraska -2.5% 58.4% -10.6% 9.0% 31.85%
Nevada 235.8% -17.0% 55.6% 37.3% 15.12%
New Hampshire -7.6% 49.9% 32.3% 20.4% 11.48%
New Jersey 17.6% 2.6% 17.0% 32.5% 24.52%
New Mexico 36.1% 9.6% 47.5% 25.2% 3.53%
New York 15.7% 22.1% -9.9% 60.8% 25.97%
North Carolina 48.2% -0.2% 25.8% 24.6% 28.28%
North Dakota 35.0% 32.7% -2.4% 23.7% 8.25%
Ohio 26.8% 20.9% 23.6% 37.5% 24.41%
Oklahoma 8.2% 28.1% 15.0% 25.3% 28.25%
Oregon 9.2% 55.7% 20.6% -18.1% 10.95%
Pennsylvania 8.6% 19.4% -3.1% 31.3% 22.57%
Rhode Island 11.7% 22.1% 16.3% 24.9% 14.78%
South Carolina 30.6% 3.0% 21.2% 37.4% 24.61%
South Dakota 30.7% 28.2% 22.8% 18.6% 20.48%
Tennessee 148.5% 76.0% 24.1% 119.9% 35.91%
Texas 20.8% 13.6% 28.6% 29.3% 31.14%
Utah 0.3% 67.5% -29.5% 76.7% -14.87%
Vermont 23.4% 11.1% 16.8% 25.8% 20.13%
Virginia 5.1% -3.4% 47.0% 22.2% 20.74%
Washington 30.8% 10.5% 22.6% 20.5% 15.73%
West Virginia 12.1% -6.5% 42.0% 54.5% 5.96%
Wisconsin 19.9% 12.2% 32.5% 37.0% 20.10%
Wyoming 23.1% 49.4% -19.8% 71.3% 12.70%
*Does not apply to Arizona. Arizona has a 1115 waiver for which special rules apply.
4-27
Rebates as a Percent of Drug Expenditures, 2005
Rebates as % Drug
State Drug Expenditures Rebates** Expenditure
National Total $43,077,457,835 $12,409,442,413 28.8%
Alabama $606,578,572 $145,238,083 23.9%
Alaska $127,315,710 $27,511,193 21.6%
Arizona* $5,486,350 - -
Arkansas $419,350,865 $93,635,941 22.3%
California $5,187,275,034 $2,056,515,858 39.6%
Colorado $285,371,981 $74,633,154 26.2%
Connecticut $496,715,211 $109,418,487 22.0%
Delaware $122,026,857 $35,424,633 29.0%
District of Columbia $105,948,589 $24,703,979 23.3%
Florida $2,503,151,114 $728,568,990 29.1%
Georgia $1,184,915,057 $336,290,253 28.4%
Hawaii $119,852,050 $25,103,501 20.9%
Idaho $168,780,832 $48,525,397 28.8%
Illinois $1,716,361,486 $575,457,731 33.5%
Indiana $751,525,376 $204,350,287 27.2%
Iowa $412,274,229 $90,050,305 21.8%
Kansas $296,283,292 $93,125,615 31.4%
Kentucky $794,519,116 $217,275,788 27.3%
Louisiana $1,082,597,269 $278,830,912 25.8%
Maine $282,039,741 $99,804,572 35.4%
Maryland $578,238,275 $154,069,573 26.6%
Massachusetts $1,067,378,270 $281,523,695 26.4%
Michigan $965,368,582 $325,135,732 33.7%
Minnesota $441,908,835 $118,040,245 26.7%
Mississippi $665,504,688 $180,055,329 27.1%
Missouri $1,246,144,317 $300,271,256 24.1%
Montana $105,154,540 $25,166,744 23.9%
Nebraska $228,576,569 $68,431,450 29.9%
Nevada $134,564,289 $34,103,702 25.3%
New Hampshire $133,253,555 $37,566,506 28.2%
New Jersey $1,158,553,486 $261,578,682 22.6%
New Mexico $116,252,520 $25,417,996 21.9%
New York $5,253,655,620 $1,300,131,531 24.7%
North Carolina $1,790,399,967 $452,693,066 25.3%
North Dakota $64,157,312 $15,334,927 23.9%
Ohio $1,981,230,721 $591,916,354 29.9%
Oklahoma $500,420,840 $103,412,619 20.7%
Oregon $261,373,083 $60,464,711 23.1%
Pennsylvania $1,009,804,038 $253,722,496 25.1%
Rhode Island $173,884,102 $44,671,288 25.7%
South Carolina $716,694,085 $217,001,438 30.3%
South Dakota $88,963,445 $22,083,160 24.8%
Tennessee $2,344,351,015 $768,857,139 32.8%
Texas $2,416,879,360 $736,763,024 30.5%
Utah $221,854,365 $39,887,001 18.0%
Vermont $184,730,219 $45,054,392 24.4%
Virginia $634,701,038 $174,023,976 27.4%
Washington $682,553,233 $176,803,507 25.9%
West Virginia $431,614,161 $114,327,436 26.5%
Wisconsin $759,682,514 $202,803,404 26.7%
Wyoming $51,242,060 $13,665,355 26.7%
*Does not apply to Arizona. Arizona has a 1115 waiver for which special rules apply.
**Includes reported State supplemental rebates.
4-28
MEDICAID DRUG COVERAGE
In general, all prescription products sold by a manufacturer that has signed a drug rebate agreement
are covered outpatient drugs reimbursable by Medicaid. A State Medicaid program may require prior
approval before dispensing of any drug product and may design and implement a formulary intended
to limit coverage for specific drugs. Drug formularies and prior authorization programs must meet
specific requirements established in Medicaid law.
A State Medicaid program can restrict coverage for a drug product through a formulary, if based on
official labeling or information in designated official medical compendia, “the excluded drug does not
have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness or
clinical outcome of such treatment” over other drug products, and there is a written explanation
(available to the public) of the basis for the exclusion. However, drug products excluded from the
formulary under these conditions, nevertheless, must be available through prior authorization.
Drugs in certain specific classes may be restricted or excluded from coverage without regard to the
formulary conditions and need not be available through prior authorization. These classes include:
! Drugs used for anorexia, weight gain, fertility, hair growth, cosmetic effect, symptomatic
relief of cough or colds, or for cessation of smoking.
! Vitamins and minerals (except prenatal prescription vitamins and fluoride preparations) or
non-prescription drugs.
! Drugs that require tests or monitoring services to be purchased exclusively from the
manufacturer or his designee.
! Barbiturates or benzodiazepines.
PRIOR AUTHORIZATION
Whether or not a drug product is on a formulary, States may require physicians to request and receive
official permission before a particular product can be dispensed. This procedure is called Prior
Authorization or Prior Approval.
States may not operate prior authorization plans unless the State provides for a response within 24
hours of a request and provides for a 72-hour emergency supply of the medication.
The Congressional intent for the prior authorization provision was not to encourage the use of such
programs, but rather to make them available to the States for the purpose of controlling utilization of
products that have very narrow indications or high abuse potential.
The majority of States report the establishment of prior authorization programs and have plans to
apply prior authorization to a select number of drugs. Some States will do so only after their Drug
Utilization Review (DUR) program has identified areas of therapeutic concern.
DRUG UTILIZATION REVIEW
DUR Program. Each State must establish a Drug Utilization Review (DUR) Program in order to
assure that prescriptions are appropriate, medically necessary, and not likely to result in adverse
medical results. A DUR Program consists of prospective and retrospective components as well as
components to educate physicians and pharmacists on common drug therapy problems.
4-29
Specifically, the program educates physicians and pharmacists how to identify and reduce fraud,
abuse, gross overuse, or inappropriate or medically unnecessary care; potential and actual severe
adverse reactions to drugs, including education on therapeutic appropriateness, overutilization and
underutilization, appropriate use of generic products, therapeutic duplication, drug-disease
contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, drug-
allergy interactions, and clinical abuse or misuse.
The two primary objectives of DUR systems are (1) to improve quality of care; and (2) to assist in
containing health care costs. While there is a general belief that DUR is cost beneficial, it is difficult
to isolate concrete evidence that supports this view. The primary issue facing Medicaid DUR
programs is whether or not the systems currently in place (or envisioned) meet the two objectives
outlined above.
Prospective DUR. Prospective DUR is to be conducted at the point of sale (POS) before delivery of a
medication by the pharmacist to the Medicaid recipient or caregiver. The State is to establish
standards for counseling patients and will require the pharmacist to offer to discuss matters, which, in
the exercise of the pharmacist’s professional judgment are deemed significant, including the
following:
! Name and description of the medication;

! The route of administration, dosage form, dosage, and duration of therapy;
! Special directions and precautions for preparation, administration and use by the patient;
! Common severe side or adverse effects or interactions and therapeutic contraindications that
may be encountered, including their avoidance, and the action required if they occur;
! Techniques for self-monitoring prescription therapy;
! Proper storage;
! Prescription refill information; and
! Action to be taken in the event of a missed dose.
State law must also require pharmacists to make a reasonable effort to obtain, record, and maintain at
least the following information for each Medicaid recipient:
! Name, address, telephone number, date of birth (or age) and gender;
! Individual history where significant, including a disease state or states, known allergies and
drug reactions, and a comprehensive list of medications and relevant devices; and
! Pharmacist comments relevant to the individual’s pharmaceutical therapy.
Retrospective DUR. This activity continuously assesses data on drug use against established
standards, preferably using automated claims processing and information retrieval techniques to
monitor for therapeutic appropriateness, overutilization and underutilization, appropriate use of
generic products, therapeutic duplication, drug-disease contraindications, drug-drug interactions,
incorrect drug dosage or duration of drug treatment, clinical abuse/misuse and, as necessary,
introduce remedial strategies in order to improve the quality of care and to conserve program funds or
personal expenditures. This activity is also intended to identify patterns of fraud, abuse, gross
overuse, or inappropriate of medically unnecessary care among physicians, pharmacists, and
recipients, or with respect to specific drugs or groups of drugs.
State Drug Use Review Board. Each State must provide for the establishment of a DUR board of
health practitioners (one-third to one-half physicians and at least one-third pharmacists) to help
implement the DUR program. Each State must require its DUR board to make annual reports to
DHHS on its activities and on cost savings resulting from the DUR program.
4-30
Pharmacy Advisory Committees

Preferred Product Introduction
State Pharmacy Advisory Committee Meetings
Process
Alabama Pharmacy Advisory Committee Quarterly Introductory letter, Electronic submission
Alaska None - Introductory letter
Arizona* - - Inform health plans directly
Arkansas None - Introductory letter, E-mail Pamela Ford
California Medi-Cal Contract Drug Advisory Comm. Ad Hoc Petition with specific content requirements
Colorado None - Introductory letter
Connecticut DUR Board and P & T Committee advise Quarterly Introductory letter
Delaware DUR Board Bi-Monthly Introductory letter
District of Columbia Pharmacy Services Committee Monthly Introductory letter
Florida None - Introductory letter
Georgia None Quarterly PBM’s quarterly forum
Hawaii DUR Board Quarterly Formulary kit
Idaho None - Mail dossier
Pharm. Subcommittee of Medicaid Introductory letter and manuf. report to First
Illinois Bi-Monthly
Advisory Committee DataBank
Indiana DUR Board Monthly Electronic form
Iowa DUR Board 8 per year Dossier to info@iowamedicaidpdl.com
Kansas None - Introductory letter
Kentucky Pharmacy & Therapeutics Committee Bi-Monthly Introductory letter, Package insert
Louisiana Pharmacy Advisory Committee Semiannually Intro. ltr., Package insert, & FDA approval ltr.
Maine DUR Committee Monthly Introductory letter
Maryland Medicaid Advisory Committee Quarterly Introductory letter
Massachusetts DUR Board Quarterly Introductory letter
Michigan Pharmacy & Therapeutics Committee Quarterly FDB files
Minnesota None - Introductory letter, Contact M.C. Woheltz
Mississippi None - Introductory letter
Missouri Pharmacy Advisory Group Quarterly AMPC format dossier
Montana DUR Board Monthly Introductory letter, Electronic submission
Nebraska DUR Board Bi-Monthly Introductory letter
Nevada DUR Board Quarterly Introductory letter
New Hampshire None - Introductory letter
New Jersey None - Introductory letter
New Mexico None - Introductory letter
New York Pharmacy Advisory Committee Quarterly Introductory letter
North Carolina Pharmacy & Therapeutics Committee Monthly Introductory letter
North Dakota None - Contact First DataBank
Ohio Pharmacy & Therapeutics Committee Quarterly Introductory letter
Oklahoma DUR Board Monthly E-mail to pharmacy@okhca.org
Oregon DUR Board Quarterly Introductory letter
Pennsylvania Pharmacy & Therapeutics Committee Quarterly Introductory letter/e-mail to State agency
Rhode Island None - Introductory letter
South Carolina Medical Care Advisory Committee Quarterly Introductory letter
South Dakota Pharmacy & Therapeutics Committee Ad Hoc Introductory letter
Tennessee* TennCare Pharmacy Advisory Comm. Quarterly Introductory letter
Texas None - State form
Utah DUR Board Monthly Introductory letter
Vermont DUR Board 10 per year Introductory letter
Virginia None - Introductory letter
Washington Drug Evaluation Matrix Team Weekly AMCP format dossier
West Virginia Medical Services Fund Advisory Council Quarterly Introductory letter
Wisconsin None - Introductory letter
Wyoming None - Introductory letter
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2007 NPC Survey.
4-31
Pharmacy Benefit Design - Coverage

State Cosmetics Fertility Drugs Experimental Drugs
Alabama Not Covered Not Covered Not Covered
Alaska Covered with Restrictions Not Covered Not Covered
Arizona* - - -
Arkansas Not Covered Not Covered Not Covered
California Not Covered Not Covered Not Covered
Colorado Not Covered Not Covered Not Covered
Connecticut Not Covered Not Covered Not Covered
Delaware Not Covered Not Covered Not Covered
District of Columbia Not Covered Not Covered Not Covered
Florida Not Covered Not Covered Not Covered
Georgia Not Covered Not Covered Not Covered
Hawaii Not Covered Not Covered Not Covered
Idaho Not Covered Not Covered Not Covered
Illinois Not Covered Not Covered Not Covered
Indiana Not Covered Not Covered Not Covered
Iowa Not Covered Not Covered Not Covered
Kansas Not Covered Not Covered Not Covered
Kentucky Not Covered Not Covered Not Covered
Louisiana Not Covered Not Covered Not Covered
Maine Not Covered Not Covered Not Covered
Maryland Not Covered Not Covered Not Covered
Massachusetts Not Covered Not Covered Not Covered
Michigan Not Covered Not Covered Not Covered
Minnesota Not Covered Not Covered Not Covered
Mississippi Not Covered Not Covered Not Covered
Missouri Not Covered Not Covered Not Covered
Montana Not Covered Not Covered Not Covered
Nebraska Not Covered Not Covered Not Covered
Nevada Not Covered Not Covered Not Covered
New Hampshire Not Covered Not Covered Not Covered
New Jersey Not Covered Not Covered Not Covered
New Mexico Not Covered Not Covered Not Covered
New York Not Covered Not Covered Not Covered
North Carolina Not Covered Not Covered Not Covered
North Dakota Not Covered Not Covered Not Covered
Ohio Not Covered Not Covered Not Covered
Oklahoma Not Covered Not Covered Not Covered
Oregon** Not Covered Not Covered Not Covered
Pennsylvania Not Covered Not Covered Not Covered
Rhode Island Not Covered Not Covered Not Covered
South Carolina Not Covered Not Covered Not Covered
South Dakota Not Covered Not Covered Not Covered
Tennessee Not Covered Not Covered Not Covered
Texas Not Covered Not Covered Not Covered
Utah Not Covered Not Covered Not Covered
Vermont Not Covered Not Covered Not Covered
Virginia Not Covered Not Covered Not Covered
Washington Not Covered Not Covered Not Covered
West Virginia Not Covered Not Covered Not Covered
Wisconsin Not Covered Covered with Restrictions Not Covered
Wyoming Not Covered Not Covered Not Covered
**Subject to the restrictions of the Oregon Health Plan.
PA = Prior Authorization, DME = Durable Medical Equipment, DMS = Durable Medical Supplies
4-32
Pharmacy Benefit Design - Coverage (Con’t)

Disposable Needles for Syringe Combinations Blood Glucose Test
State Prescribed Insulin Insulin Use for Insulin Use Strips
Alabama Covered with Restrictions Covered Covered Covered
Alaska Covered Covered as DME Covered as DME Covered as DME
Arizona* - - - -
Arkansas Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
California Covered Covered Covered Covered
Colorado Covered DME DME DME
Connecticut Covered Covered Covered Covered
Delaware Covered Covered Covered Covered
District of Columbia Covered Covered Covered Covered with Restrictions
Florida Covered Not Covered Not Covered Not Covered
Georgia Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Hawaii Covered Covered as DME Covered as DME Covered as DME
Idaho Covered Covered as DME Covered as DME Covered as DME
Illinois Covered with Restrictions Covered Covered Covered with Restrictions
Indiana Covered Covered Covered Covered
Iowa Covered Not Covered Not Covered Not Covered
Kansas Covered Covered with PA as DME Covered with PA as DME Covered as DME
Kentucky Covered Not Covered Covered Not Covered
Louisiana Covered Covered Covered Covered
Maine Covered Covered Covered Covered
Maryland Covered Covered Covered Covered as DME
Massachusetts Covered Covered with Restrictions Covered with Restrictions Covered with Restrictions
Michigan Covered Covered Covered as DME Covered as DME
Minnesota Covered Covered as DME Covered as DME Covered as DME
Mississippi Covered Not Covered Not Covered Not Covered
Missouri Covered Covered Covered Covered
Montana Covered, PA Required Covered as DME Covered as DME Covered as DME
Nebraska Covered, PA Required Covered as DME Covered as DME Covered as DME
Nevada Covered Covered Covered Covered
New Hampshire Covered Covered Covered Covered
New Jersey Covered Covered Covered Covered
New Mexico Covered Covered Covered Covered
New York Covered Covered Covered Covered
North Carolina Covered Not Covered Not Covered Not Covered
North Dakota Covered Covered Covered Covered
Ohio Covered Covered as DME Covered as DME Covered as DME
Oklahoma Covered Covered as DME Covered as DME Covered as DME
Oregon** Covered Covered as DME Covered as DME Covered as DME
Pennsylvania Covered Covered Covered Covered
Rhode Island Covered Covered Covered Covered as DME
South Carolina Covered Covered Covered Covered as DME
South Dakota Covered Covered Covered Covered
Tennessee Covered Covered Covered Covered
Texas Covered Covered Not Covered Not Covered
Utah Covered Covered Covered Covered
Vermont Covered Covered Covered Covered
Virginia Covered Covered as DME Covered Covered as DME
Washington Covered Covered Covered Covered
West Virginia Covered with Restrictions Covered with Limitations Covered with Limitations Covered
Wisconsin Covered Covered as DMS Covered as DMS Covered as DMS
Wyoming Covered Covered Covered Covered
PA = Prior Authorization, DME = Durable Medical Equipment, DMS = Durable Medical Supplies
4-33
Pharmacy Benefit Design - Coverage (Con’t)

Urine Ketone Total Interdialytic Parenteral
State Test Strips Parenteral Nutrition Nutrition
Alabama Not Covered Covered Covered with Restrictions
Alaska Covered as DME Covered under Home Infusion Covered under Home Infusion
Arizona* - - -
Arkansas Not Covered Not Covered Not Covered
California Covered Covered, PA Required Not Covered
Colorado DME Covered Covered
Connecticut Covered Not Covered Not Covered
Delaware Covered Covered Covered
District of Columbia Not Covered Covered with Restrictions Covered with Restrictions
Florida Not Covered Covered Covered
Georgia Covered with Restrictions Covered, PA Required Covered, PA Required
Hawaii Covered as DME Covered, PA Required Covered, PA Required
Idaho Covered as DME Covered as DME Covered as DME
Illinois Covered Covered Covered
Indiana Covered Covered Covered
Iowa Not Covered Not Covered Not Covered
Kansas Covered as DME Covered with PA as DME Covered with PA as DME
Kentucky Not Covered Covered, PA Required Covered, PA Required
Louisiana Covered Covered as DME Covered as DME
Maine Covered Covered Covered
Maryland Covered as DME Covered Covered with Restrictions
Massachusetts Covered with Restrictions Covered with Restrictions Not Covered
Michigan Covered as DME Covered, PA required Covered
Minnesota Covered as DME Covered Covered
Mississippi Not Covered Covered Not Covered
Missouri Covered Covered Covered
Montana Not Covered Covered, PA Required Covered, PA Required
Nebraska Covered as DME Covered as DME Covered as DME
Nevada Covered Covered as DME Covered as DME
New Hampshire Covered Covered Covered
New Jersey Covered Covered Covered
New Mexico Covered Covered Covered
New York Covered Covered Covered
North Carolina Not Covered Not Covered Not Covered
North Dakota Not Covered Covered Not Covered
Ohio Covered as DME Covered as DME, PA Required Covered as DME, PA Required
Oklahoma Covered as DME Covered with Restrictions N/A
Oregon** Covered as DME Covered, PA Required Covered, PA Required
Pennsylvania Covered Not Covered Not Covered
Rhode Island Covered Covered as DME, PA Required Covered as DME, PA Required
South Carolina Covered as DME Covered as DME Covered as DME
South Dakota Covered Covered, PA Required Covered, PA Required
Tennessee Covered Covered Covered
Texas Not Covered Not Covered Not Covered
Utah Covered Not Covered Not Covered
Vermont Not Covered Covered as DME Not Covered
Virginia Covered as DME Covered Covered
Washington Covered Covered Covered
West Virginia Covered Covered under DME Covered under DME
Wisconsin Covered as DMS Covered Covered
Wyoming Covered Covered as DME Covered as DME
PA= Prior Authorization, DME = Durable Medical Equipment, DMS = Durable Medical Supplies
4-34
Coverage of Injectables
Reimbursement for Non Self-Administered Medicines via
the Prescription Drug Program (PDP) or Physician Payment (PP)
State Physicians Office Home Health Care Extended Care Facility

Alabama PP PDP PDP
Alaska PDP and PP - -
Arizona* - - -
Arkansas PP PDP PDP
California PP PDP and PP PDP
Colorado PP PDP PDP
Connecticut PP PP PP
Delaware PDP and PP - PDP
District of Columbia PP PDP PP
Florida PDP and PP PDP PDP
Georgia PP PDP PDP
Hawaii PDP PDP PDP
Idaho PP PP PP
Illinois PDP and PP PP PP
Indiana PDP and PP PDP and PP PDP and PP
Iowa PDP and PP PDP PDP
Kansas PP PDP PDP
Kentucky PDP and PP PDP PDP
Louisiana PDP and PP - -
Maine PP PDP PDP
Maryland PDP and PP PDP PDP
Massachusetts PDP and PP PDP PDP
Michigan PP PDP PDP
Minnesota PP PP -
Mississippi PP PDP PDP
Missouri PDP PDP PDP
Montana PP PDP and PP PP
Nebraska PP PDP PDP
Nevada PP PDP PDP
New Hampshire PDP and PP PDP and PP PDP and PP
New Jersey PDP and PP PDP and PP PDP and PP
New Mexico PP PP -
New York PP PDP Included in facility rate
North Carolina PP PDP PDP
North Dakota PDP and PP PDP PDP
Ohio PDP and PP - -
Oklahoma PP PDP and PP PDP and PP
Oregon PP PP PDP
Pennsylvania PDP PDP PDP
Rhode Island PDP and PP PDP PDP
South Carolina PP PDP PDP
South Dakota PP PP PP
Tennessee PP PDP PDP
Texas PP PP PP
Utah PP PDP and PP PDP and PP
Vermont PP PP PP
Virginia PP PDP and PP PDP and PP
Washington PP PDP PDP
West Virginia PP PDP PDP
Wisconsin PP PP PP
Wyoming PP PP PP
4-35
Coverage of Vaccines and Unit Dose

State Method for Vaccine Reimbursement ^ Reimbursement for Unit Dose
Alabama VCP Yes
Alaska EPSDT, VCP Yes
Arizona* - -
Arkansas EPSDT, CHIP, VCP No
California VCP No
Colorado EPSDT No
Connecticut CHIP No
Delaware CHIP, VCP No
District of Columbia EPSDT, VCP Yes
Florida VCP Yes
Georgia EPSDT, CHIP, VCP Yes
Hawaii EPSDT, CHIP Yes
Idaho VCP Yes
Illinois VCP No
Indiana VCP Yes
Iowa VCP Yes
Kansas VCP No
Kentucky EPSDT, CHIP, VCP, Pharmacy Program Yes
Louisiana EPSDT, VCP No
Maine EPSDT, VCP, Prescription Drug "Safety Net Program" No
Maryland VCP No
Massachusetts Department of Public Health No
Michigan EPSDT, CHIP, VCP Yes
Minnesota CHIP, VCP Yes
Mississippi VCP Yes
Missouri VCP (Pharmacy Program for adults) Yes
Montana EPSDT, CHIP, VCP Yes
Nebraska VCP No
Nevada EPSDT Yes
New Hampshire EPSDT, CHIP, VCP Yes
New Jersey VCP Yes
Yes – for commercially unit dose
New Mexico EPSDT, CHIP, VCP, Dept. of Health
packaged drugs
New York EPSDT, CHIP, VCP No
North Carolina VCP No
North Dakota EPSDT No
Ohio VCP No
Oklahoma EPSDT, VCP No
Oregon VCP No
Pennsylvania EPSDT, CHIP, VCP No
Rhode Island VCP No
South Carolina VCP Yes
South Dakota EPSDT, CHIP, VCP Yes
Tennessee EPSDT, VCP No
Texas EPSDT, CHIP No
Utah VCP Yes
Vermont VCP Yes
Virginia EPSDT, VCP Yes
Washington EPSDT Yes
West Virginia EPSDT, CHIP, VCP, Physician Payment Program Yes
Wisconsin EPSDT, CHIP, VCP No
Wyoming EPSDT, CHIP, VCP No
^ Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Children Health Insurance Program (CHIP), Vaccines for
Children Program (VCP), or other.
LTC = Long Term Care
4-36
Coverage of Over-the-Counter Medications

Allergy, Asthma,
State and Sinus Analgesics Cough and Cold Smoking Deterrents
Alabama Covered Covered Covered with Restrictions Not Covered
Alaska Not Covered Not Covered Not Covered Covered
Arizona* - - - -
Arkansas Limited Coverage Limited Coverage Limited Coverage Covered with Restrictions
California Partial Coverage, PA Req. Partial Coverage, PA Req. Partial Coverage, PA Req. Partial Coverage, PA Req.
Colorado Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Connecticut Covered Not Covered Covered with Restrictions Not Covered
Delaware Covered Covered Covered Covered with Restrictions
District of Columbia Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Florida Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Georgia Limited Coverage Covered with Restrictions Covered with Restrictions Not Covered
Hawaii Covered Covered Limited Coverage Covered with Restrictions
Idaho Limited Coverage Not Covered Not Covered Not Covered
Illinois Covered with Restrictions Covered with Restrictions Limited Coverage Covered
Indiana Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Iowa Covered Covered Covered Covered
Kansas Covered Covered Covered with Restrictions Covered with Restrictions
Kentucky Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Louisiana Covered with Restrictions Not Covered Not Covered Not Covered
Maine Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Maryland Covered with Restrictions Limited Coverage Not Covered Not Covered
Massachusetts Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Michigan Limited Coverage Limited Coverage Not Covered Covered
Minnesota Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Mississippi Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Missouri Limited Coverage Limited Coverage Limited Coverage Not Covered
Montana Covered with Restrictions Covered with Restrictions Not Covered PA Required
Nebraska Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Nevada Covered Covered Covered Covered
New Hampshire Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered
New Jersey Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered
New Mexico Covered Covered Covered Covered
New York Covered Covered Covered Limited Coverage
North Carolina Covered Not Covered Not Covered Covered
North Dakota Covered with Restrictions Covered Not Covered Covered with Restrictions
Ohio Selective Coverage Selective Coverage Selective Coverage Selective Coverage
Oklahoma Covered with Restrictions Not Covered Not Covered Covered with Restrictions
Oregon Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Pennsylvania Covered Covered with Restrictions Covered with Restrictions Covered
Rhode Island Not Covered Covered Covered Not Covered
South Carolina Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
South Dakota Limited Coverage Not Covered Not Covered Not Covered
Tennessee Covered Covered Not Covered Not Covered
Texas Covered Covered Covered Covered
Utah Limited Coverage Limited Coverage Limited Coverage Separate program
Vermont Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Virginia Covered Covered Covered Covered
Washington Limited Coverage Limited Coverage Limited Coverage Not Covered
West Virginia Limited Coverage Limited Coverage Limited Coverage PA Required
Wisconsin Covered Covered Covered Not Covered
Wyoming Covered Covered Covered Covered with Restrictions
PA= Prior Authorization
4-37
Coverage of Over-the-Counter Medications (Con’t)

Digestive Products
State (non- H2 antagonists) H2 Antagonists Feminine Products Topical Products
Alabama Covered Covered Not Covered Covered
Alaska Not Covered Not Covered Limited Coverage Limited Coverage
Arizona* - - - -
Arkansas Limited Coverage Limited Coverage Limited Coverage Limited Coverage
California Partial Coverage, PA Req. Partial Coverage, PA Req. Partial Coverage, PA Req. Partial Coverage, PA Req.
Colorado Covered with Restrictions Covered with Restrictions Not Covered Not Covered
Connecticut Covered with Restrictions Covered Not Covered Covered
Delaware Covered Covered Covered with Restrictions Covered
District of Columbia Covered with Restrictions Covered with Restrictions Not Covered Covered with Restrictions
Florida Covered with Restrictions Not Covered Covered with Restrictions Not Covered
Georgia Not Covered Covered with Restrictions Not Covered Covered with Restrictions
Hawaii Covered Limited Coverage N/A Limited Coverage
Idaho Covered with Restrictions Not Covered Not Covered Limited Coverage
Illinois Covered Covered with Restrictions Not Covered Covered with Restrictions
Indiana Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Iowa Covered with Restrictions Not Covered Covered Covered
Kansas Covered Covered Covered with Restrictions Covered
Kentucky Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Louisiana Not Covered Not Covered Not Covered Not Covered
Maine Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Maryland Not Covered Covered with Restrictions Not Covered Not Covered
Massachusetts Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Michigan Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Minnesota Limited Coverage Not Covered Covered Limited Coverage
Mississippi Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Missouri Limited Coverage Limited Coverage Not Covered Limited Coverage
Montana Covered Covered Not Covered Not Covered
Nebraska Covered with Restrictions Covered with Restrictions Not Covered Covered with Restrictions
Nevada Covered Covered Not Covered Covered with Restrictions
New Hampshire Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
New Jersey Not Covered Not Covered Not Covered Covered with Restrictions
New Mexico Covered Covered Not Covered Covered
New York Covered Covered Covered Covered
North Carolina Covered Not Covered Not Covered Not Covered
North Dakota Covered Covered Not Covered Covered with Restrictions
Ohio Selective Coverage Selective Coverage Selective Coverage Selective Coverage
Oklahoma Covered with Restrictions Not Covered Not Covered Not Covered
Oregon Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Pennsylvania Covered with Restrictions Covered Not Covered Covered with Restrictions
Rhode Island Not Covered Not Covered Covered Covered
South Carolina Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
South Dakota Not Covered Not Covered Not Covered Not Covered
Tennessee Covered Covered Not Covered Covered
Texas Covered Covered Not Covered Covered
Utah Covered with Restrictions Covered Covered Covered
Vermont Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Virginia Covered Covered Covered Covered
Washington Limited Coverage Limited Coverage Limited Coverage Limited Coverage
West Virginia Limited Coverage Not Covered Limited Coverage Limited Coverage
Wisconsin Covered Not Covered Covered Covered
Wyoming Covered with Restrictions Covered Not Covered Covered
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA= Prior Authorization
4-38
Prior Authorization Process and Procedures

State PA Procedure Prior Authorization Committee Members Meetings
Alabama Yes Pharmacy and Therapeutics Committee 9 Quarterly
Alaska Yes No - -
Arizona* - - - -
Arkansas Yes DUR Board 9 Quarterly
California Yes No - -
Colorado Yes No - -
Connecticut Yes Pharmaceutical and Therapeutics Committee 14 Quarterly
Delaware Yes No - -
District of Columbia Yes No - -
Florida Yes No - -
Georgia Yes No - -
Hawaii Yes Yes 8 N/A
Idaho Yes PA Review Committee 5 Semi-annually
Illinois Yes Committee on Drugs and Therapeutics 12 Min. quarterly
Indiana Yes No - -
Iowa Yes No - -
Kansas Yes DUR Board 9 Bi-monthly
Kentucky Yes Pharmacy and Therapeutics Advisory Committee 14 Bi-monthly
Louisiana Yes Pharmaceutical and Therapeutics Committee 21 Semi-annually
Maine Yes DUR Board 13 9 meetings/yr.
Maryland Yes DUR Board 10 Quarterly
Massachusetts Yes No - -
Michigan Yes No - -
Minnesota Yes Drug Formulary Committee 9 Quarterly
Mississippi Yes Pharmacy and Therapeutics Committee 12 Quarterly
Missouri Yes Prior Authorization Committee 9 Quarterly
Montana Yes DUR Board 10 Monthly
Nebraska Yes No - -
Nevada Yes No - -
New Hampshire Yes Pharmacy and Therapeutics Advisory Committee 13 Quarterly
New Jersey Yes No - -
New Mexico Yes No - -
New York Yes Pharmacy and Therapeutics Committee 18 Quarterly
North Carolina Yes No - -
North Dakota Yes DUR Board 14 Quarterly
Ohio Yes No - -
Oklahoma Yes No - -
Oregon Yes Health Resources Commission 11 Monthly
Pennsylvania Yes Pharmacy and Therapeutics Committee 25 Quarterly
Rhode Island Yes No - -
South Carolina Yes Pharmacy and Therapeutics Committee 14 Quarterly
South Dakota Yes Pharmacy and Therapeutics Committtee 8 5 - 8/yr.
Tennessee Yes No - -
Texas Yes No - -
Utah Yes No - -
Vermont Yes No - -
Virginia Yes Pharmacy and Therapeutics Committee 12 Quarterly
Washington Yes DUR Team and Drug Eval. Matrix Team 8 Daily, weekly
West Virginia Yes Pharmaceutical and Therapeutics Committee 15 3 meetings/yr.
Wisconsin Yes Prior Authorization Advisory Comm. 11 Semi-annually
Wyoming Yes DUR Board 10 Bi-monthly
4-39
Prior Authorization Process and Procedures (Con’t)

State Initiated By: Annual Requests % Approved
Alabama M.D., R.Ph., Pharm. Tech. 420,000 60%
Alaska M.D., R.Ph. (some drugs) 3,700 95%
Arizona* - - -
Arkansas M.D. 415,000 72%
California M.D., R.Ph. 1,800,000 76%
Colorado M.D., M.D.’s Agent 18,000 90%
Connecticut M.D., R.Ph. 37,000 94%
Delaware M.D., R.Ph. 34,000 92%
District of Columbia M.D., R.Ph. 4,800 65%
Florida M.D. 440,000 78%
Georgia M.D., R.Ph. 125,000 72%
Hawaii M.D., R.Ph., Pharm. Tech. 8,000 98%
Idaho M.D., R.Ph., N.P., P.A. 60,000 90%
Illinois M.D., R.Ph. 370,000 70%
Indiana M.D., Other Providers N/A N/A
Iowa M.D. 60,000 60%
Kansas M.D., R.Ph. 4,700 81%
Kentucky M.D., R.Ph. 285,000 58%
Louisiana M.D. 217,000 83%
Maine M.D. 78,000 80%
Maryland M.D., R.Ph. 36,000 99%
Massachusetts M.D., Other Licensed Prescriber N/A N/A
Michigan M.D. 100,000 98%
Minnesota M.D., R.Ph. 17,000 87%
Mississippi M.D. 282,000 20%
Missouri M.D., R.Ph., Other Authorized Prescriber 99,000 60%
Montana M.D., R.Ph., Pharm. Tech. 18,000 74%
Nebraska M.D., R.Ph. 15,000 65%
Nevada M.D. N/A N/A
New Hampshire M.D. 11,700 79%
New Jersey M.D., R.Ph. 715,000 95%
New Mexico M.D. N/A N/A
New York M.D./Ordering Provider 285,000 100%
North Carolina M.D., R.Ph. 23,000 19%
North Dakota M.D., R.Ph., Pharm. Tech. 2,000 60%
Ohio M.D., R.Ph. (sometimes) 133,000 99%
Oklahoma M.D., R.Ph. 168,000 70%
Oregon M.D. 21,400 90%
Pennsylvania M.D. 42,000 75%
Rhode Island M.D. N/A N/A
South Carolina M.D., R.Ph. 60,000 70%
South Dakota M.D., R.Ph. 20,000 20%
Tennessee M.D. 180,000 74%
Texas M.D. 2,500 95%
Utah M.D., R.Ph. 8,000 85%
Vermont M.D., Prescribing Agent 20,566 81%
Virginia M.D., R.Ph. 21,000 84%
Washington R.Ph., Pharm. Tech. N/A N/A
West Virginia M.D., R.Ph., Other Prescribers 131,000 79%
Wisconsin M.D., R.Ph., Pharm. Tech. 182,000 97%
Wyoming M.D., Nurse Pract., R.N. 375 43%
4-40
Prior Authorization Process and Procedures (Con’t)

State Reviewer Review Time Response Vehicle
Alabama M.D., R.N., R.Ph., Pharm. Tech. <8 hours Fax, mail
Alaska R.Ph., Pharm. Tech. 24 hours or less Phone, fax
Arizona* - - -
Arkansas M.D., R.Ph. 1-3 minutes Phone, fax, mail
California R.Ph. One business day Phone, fax
Colorado M.D., R.Ph. 24 hours Phone, fax, mail, e-mail
Connecticut R.Ph., Pharm. Tech. 2 hours Phone, fax, mail
Delaware M.D., R.Ph., R.N, Pharm. Tech. < 1 working day Phone, mail, e-mail
District of Columbia R.Ph. 72 hours Phone, fax
Florida R.Ph., Pharm. Tech. 24 hours Phone, fax, mail, e-mail
Georgia Pharm. Tech. (R.Ph. must review denials) 10 minutes Phone, fax, mail
Hawaii R.Ph., Pharm. Tech. 24 hours Phone, fax, mail
Idaho R.Ph., Pharm. Tech. Immediately to 24 hours Fax
Illinois M.D., R.Ph. 24 hours or less Phone, fax, mail
Indiana Medicaid Director or designee 10 days Phone, letter
Iowa R.Ph. 30 minutes Fax
Kansas R.N. 15-30 minutes Mail
Kentucky R.N., R.Ph. 4-24 hours Phone, fax
Louisiana R.Ph. 3-5 minutes Phone, fax
Maine M.D., R.Ph. 3 hours Fax
Maryland R.Ph., Pharm. Tech. 24 hours Phone, fax
Massachusetts R.Ph. <24 hours Phone, fax, mail
Michigan M.D., R.Ph., Pharm. Tech. <24 hours Phone, fax
Minnesota R.N. Within minutes Phone, mail
Mississippi M.D., R.N., R.Ph., Pharm. Tech. 3 hours Phone, mail
Missouri M.D., R.Ph., R.N., Info. Specialist < 5 minutes Phone, fax
Montana R.Ph., Pharm. Tech. 1-2 minutes Phone, fax, mail
Nebraska R.Ph., Pharm, Tech. 1 business day Phone, fax
Nevada R.Ph., Pharm. Tech. 24 hours Phone
New Hampshire R.Ph., Pharm. Tech. 24 hours or less Phone, fax with written follow-up of denials
New Jersey R.N., R.Ph. 3 minutes Phone, fax, mail
New Mexico R.Ph. <24 hours Phone, fax, mail
New York Call ctr. & voice interactive system Processed during call PA issued to prescriber by phone
North Carolina R.Ph., Pharm. Tech. 24 hours Phone, fax, mail
North Dakota R.Ph. 4 hours Fax, mail
Ohio R.Ph., Pharm. Tech. Immediately to 24 hours Phone, fax
Oklahoma R.Ph., Pharm. Tech, Pharm. Intern 24 hours or less Fax, secure provider website notice
Oregon R.Ph., Pharm. Tech. 24 hours or less Fax
Pennsylvania M.D., R.Ph., Pharm. Tech. 24 hours Phone, mail
Rhode Island R.Ph., Pharm. Tech. <24 hours Phone, fax
South Carolina R.Ph. Minutes to 24 hours Phone, fax, mail
South Dakota M.D., R.N., R.Ph., Pharm. Tech. <8 hours Fax, mail
Tennessee R.Ph. Same day Fax
Texas R.Ph. 24 hours Phone, fax, e-mail
Utah R.N. 24 hours Phone
Vermont M.D., R.Ph., Pharm. Tech, Med. Dir. 24 hours or less Phone, fax
Virginia R.Ph., Pharm. Tech. 24 hours Phone, fax
Washington M.D., R.Ph. 24 hours Phone, fax
West Virginia R.Ph. 3.5 min-2 hours Phone, fax
Wisconsin R.Ph. 24 hours Mail
Wyoming M.D., R.Ph. 14 days Fax
4-41
Prior Authorization
Analgesics,
State Anabolic Steroids Antipyretics, NSAIDs Anorectics
Alabama Covered Covered, PA Required Covered, PA Required
Alaska Covered Covered Not Covered
Arizona* - - -
Arkansas Covered Covered, PA Required Not Covered
California Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Colorado Covered, PA Required Partial Coverage, PA Required Not Covered
Connecticut Covered Covered Not Covered
Delaware Covered Partial Coverage, PA Required Partial Coverage, PA Required
District of Columbia Not Covered Covered Partial Coverage, PA Required
Florida Covered Covered Not Covered
Georgia Covered, PA Required Covered, PA Required Not Covered
Hawaii Covered, PA Required Covered Covered, PA Required
Idaho Not Covered Covered, PA Required Not Covered
Illinois Covered Covered Not Covered
Indiana** N/A N/A Not Covered
Iowa Covered Covered, PA Required Not Covered
Kansas Covered Partial Coverage Partial Coverage
Kentucky Covered, PA Required Covered, PA Required Covered, PA Required
Louisiana Covered Covered, PA Required Partial Coverage
Maine Covered, PA Required Covered, PA Required Covered, PA Required
Maryland*** Covered Covered Not Covered
Massachusetts Covered Partial Coverage, PA Required Not Covered
Michigan Not Covered Covered Not Covered
Minnesota Not Covered Covered Not Covered
Mississippi Covered Covered Not Covered
Missouri Partial Coverage, PA Required Covered Not Covered
Montana Covered Covered, PA Required Not Covered
Nebraska Not Covered Covered, PA Required Not Covered
Nevada Partial Coverage Covered Not Covered
New Hampshire Covered Covered, PA Required Covered, PA Required
New Mexico Covered Covered Covered, PA Required
New York Covered Covered Not Covered
North Carolina Covered Covered, PA Required Not Covered
North Dakota Covered Covered Partial Coverage, PA Required
Ohio Partial Coverage Partial Coverage Not Covered
Oklahoma Not Covered Covered, PA Required Partial Coverage, PA Required
Oregon**** Covered, PA Required Covered Covered, PA Required
Pennsylvania Covered Covered Not Covered
Rhode Island Covered Covered Covered, PA Required
South Carolina Covered Covered Not Covered
South Dakota Covered Covered, PA Required Covered, PA Required
Tennessee Covered Covered, PA Required Not Covered
Texas Covered Covered Covered, PA Required
Utah Covered, PA Required Covered Not Covered
Vermont Covered Covered, PA Required Covered, PA Required
Virginia Covered Partial Coverage, PA Required Covered, PA Required
Washington Covered, PA Required Covered, PA Required Not Covered
West Virginia Covered Covered, PA Required Not Covered
Wisconsin Not Covered Partial Coverage, PA Required Covered
Wyoming Partial Coverage Covered, Some require PA Not Covered
** All coverage in accordance with OBRA'90 and OBRA'93.
***PA required for all drugs not on the preferred drug list.
****Subject to the restrictions of the Oregon Health Plan.
PA = Prior Authorization
4-42
Prior Authorization (Con’t)

Anxiolytics, Prescribed
State Antihistamines Sedatives, and Hypnotics Cold Medications
Alabama Covered, PA Required Covered, PA Required Partial Coverage
Alaska Covered Covered Not Covered
Arizona* - - -
Arkansas Covered, PA Required Covered, PA Required Partial Coverage
Colorado Covered Covered Covered, PA Required
Connecticut Covered Covered Covered
Delaware Covered Partial Coverage, PA Required Partial Coverage, PA Required
District of Columbia Covered Covered Covered
Florida Covered Covered Partial Coverage
Georgia Covered, PA Required Partial Coverage, PA Required Partial Coverage
Hawaii Partial Coverage, PA Required Covered Covered, PA Required
Idaho Covered, PA Required Covered, PA Required Covered
Illinois Covered, PA Required Covered Covered
Indiana** N/A N/A N/A
Iowa Covered, PA Required Covered, PA Required Covered
Kansas Covered Covered Partial Coverage
Kentucky Covered, PA Required Covered, PA Required Covered, PA Required
Louisiana Covered, PA Required Covered, PA Required Partial Coverage
Maryland*** Covered Covered Covered
Massachusetts Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage
Michigan Covered Covered Not Covered
Minnesota Covered Covered Covered
Mississippi Covered Covered Partial Coverage
Missouri Covered Covered, PA Required Covered, PA Required
Montana Covered, PA Required Covered, PA Required Covered
Nebraska Covered, PA Required Covered Covered
Nevada Covered Covered Covered
New Hampshire Covered, PA Required Covered, PA Required Covered
New York Covered, PA Required Covered Partial Coverage
North Carolina Covered Covered, PA Required Covered
North Dakota Covered, PA Required Covered Covered
Ohio Partial Coverage Partial Coverage Partial Coverage
Oklahoma Partial Coverage, PA Required Covered, PA Required Not Covered
Oregon*** Covered, PA Required Covered, PA Required Covered
Pennsylvania Covered Covered Partial Coverage
Rhode Island Covered Covered Covered
South Carolina Covered Covered Covered
South Dakota Covered, PA Required Covered Covered
Tennessee Covered, PA Required Covered Not Covered
Texas Covered Covered Covered
Utah Covered, PA Required Covered Partial Coverage
Vermont Covered, PA Required Covered, PA Required Partial Coverage, PA Required
Virginia Partial Coverage, PA Required Partial Coverage, PA Required Covered
Washington Covered Covered, PA Required Covered, PA Required
West Virginia Covered, PA Required Covered, PA Required Partial Coverage, PA Required
Wisconsin Partial Coverage, PA Required Partial Coverage, PA Required Covered
Wyoming Covered, PA Required Partial Coverage Covered
**All coverage in accordance with OBRA ’90 and OBRA ’93.
4-43
Prior Authorization (Con’t)

Miscellaneous Prescribed
State Growth Hormones GI Products Smoking Deterrents
Alabama Covered, PA Required Covered, PA Required Not Covered
Alaska Covered, PA Required Covered Covered, PA Required
Arizona* - - -
Arkansas Covered, PA Required Covered, PA Required Partial Coverage, PA Required
Colorado Covered, PA Required Partial Coverage, PA Required Covered, PA Required
Connecticut Covered Covered Not Covered
Delaware Partial Coverage, PA Required Covered Partial Coverage, PA Required
District of Columbia Covered Covered Covered
Florida Covered, PA Required Covered Covered
Georgia Covered, PA Required Covered, PA Required Not Covered
Hawaii Covered, PA Required Covered Covered, PA Required
Idaho Covered, PA Required Covered, PA Required Not Covered
Illinois Covered Covered Covered
Indiana** Covered, PA Required N/A N/A
Iowa Covered, PA Required Covered, PA Required Partial Coverage
Kansas Covered, PA Required Covered Partial Coverage
Kentucky Covered, PA Required Covered, PA Required Not Covered
Louisiana Covered, PA Required Covered, PA Required Covered
Maryland*** Covered, PA Required Covered Covered
Massachusetts Covered, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Michigan Covered Covered Covered
Minnesota Covered, PA Required Covered Covered
Mississippi Covered Covered Partial Coverage
Missouri Covered, PA Required Covered, PA Required Not Covered
Montana Covered, PA Required Covered, PA Required Covered, PA Required
Nebraska Covered, PA Required Covered, PA Required Not Covered
Nevada Partial Coverage, PA Required Covered Covered
New Hampshire Covered Covered, PA Required Covered
New York Covered, PA Required Partial Coverage, PA Required Covered
North Carolina Covered, PA Required Covered Covered
North Dakota Covered Covered, PA Required Partial Coverage
Ohio Partial Coverage, PA Required Partial Coverage Covered
Oklahoma Covered, PA Required Covered, PA Required Partial Coverage, PA Required
Oregon**** Covered, PA Required Covered, PA Required Covered
Pennsylvania Covered Covered Covered
Rhode Island Covered, PA Required Covered Partial Coverage
South Carolina Covered, PA Required Covered Covered, Some require PA
South Dakota Covered, PA Required Covered, PA Required Covered
Tennessee Covered Covered Not Covered
Texas Covered, PA Required Covered Covered
Utah Covered, PA Required Covered Covered
Vermont Covered, PA Required Covered, PA Required Covered, PA Required
Virginia Covered Partial Coverage, PA Required Covered
Washington Covered, PA Required Covered, PA Required Limited Coverage
West Virginia Covered, PA Required Covered, PA Required Covered, PA Required
Wisconsin Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Wyoming Partial Coverage, PA Required Covered, PA Required on PPIs Covered, PA Required
**All coverage in accordance with OBRA ’90 and OBRA ’93.
4-44
Drug Utilization Review

In-House or PRODUR
State State Contact Telephone Contracted Implemented
Alabama Tiffany Minnifield 334-353-4596 Contracted Jul-96
Alaska Edward Bako, R.Ph. 907-334-2654 Both Jun-95
Arizona* - - - -
Arkansas Pamela Ford, Pharm.D. 501-683-4120 Contracted Mar-97
California J. Kevin Gorospe, Pharm.D. 916-552-9500 Both Aug-95
Colorado Kimberly Eggert 303-866-3176 Contracted Dec-98
Connecticut James Zakszewski, R.Ph. 860-424-5150 Contracted Sep-96
Delaware Cynthia R. Denemark, R.Ph. 302-453-8453 Contracted Feb-94
District of Columbia Carolyn Rachel-Price, R.Ph. 202-442-9078 Contracted Sep-96
Florida Linda Barnes, R.Ph. 850-487-4441 Contracted Jul-93
Georgia Patricia Zeigler-Jeter, R.Ph., M.P.A. 404-656-4044 Contracted Oct-00
Hawaii Kathleen Kang-Kaulupali 808-692-8065 In-House 1997
Idaho Tami Eide, P.D., B.C.P.S., FASHP 208-364-1821 Contracted Jan-98
Illinois Lisa D. Voils 217-782-2570 In-House Jan-93
Indiana DUR Board Secretary 317-232-4307 Contracted Mar-96
Iowa Shelly Larson 515-725-1295 Contracted Jul-97
Kansas Anne S. Ferguson, R.Ph. 785-296-7788 In-House Nov-96
Kentucky Nici Gaines 502-564-7940 In-House 1987
Louisiana Mary J. Terrebonne, Pharm.D. 225-342-9768 Contracted Apr-66
Maine Kim Rackleff 207-622-7153 In-House Dec-95
Maryland Phil Cogan 410-767-5878 Both Jan-93
Massachusetts Paul L. Jeffrey 617-210-5319 Contracted Oct-95
Michigan Medical Services Administration 517-335-5181 Both Jul-00
Minnesota Mary Beth Reinke, Pharm.D., M.S.A. 651-431-2505 In-House Feb-96
Mississippi Paige Black Clayton, Pharm.D. 601-359-5253 Contracted Oct-93
Missouri Tisha A. Honse 573-751-6961 Contracted Feb-93
Montana Mark Eichler, R.Ph., FASCP 406-457-5818 Contracted Sep-94
Nebraska Marcia Mueting 402-420-1500 Contracted Apr-95
Nevada Mary Griffith 775-684-3751 Contracted 2004
New Hampshire Lise C. Farrand, RPh. 603-271-4419 Contracted Jul-95
New Jersey Kaye S. Morrow 609-631-2396 In-House Oct-96
New Mexico John Erb, Pharm.D. 505-827-3129 In-House Oct-93
New York Lydia Kosinski, R.Ph. 518-474-6866 In-House Mar-95
North Carolina Glenda Adams, Pharm.D. 919-855-4300 In-House Oct-96
North Dakota Brendan K. Joyce, Pharm.D., R. Ph. 701-328-4023 In-House Jul-96
Ohio Margaret Scott, R.Ph. 614-466-6420 In-House Feb-00
Oklahoma Ronald Graham, D.Ph. 405-271-6614 Contracted 2000
Oregon Kathy L. Ketchum, R.Ph., M.P.A 503-947-5220 Contracted Mar-94
Pennsylvania Terri Cathers 717-346-8156 In-House Jun-93
Rhode Island Paula Avarista, R.Ph., M.B.A. 401-462-6390 Contracted Dec-94
South Carolina James M. Assey, R.Ph. 803-898-2876 In-House Nov-00
South Dakota Connie Hohn 605-773-5013 In-House 1996
Tennessee Jeffrey G. Stockard, D.Ph. 615-507-6496 Contracted Jul-01
Texas Don Valdes, R.Ph. 512-491-1157 Contracted Feb-95
Utah Tim Morley 801-538-6293 In-House 1994
Vermont Medmetrics Health Partners 802-879-5605 Contracted Nov-93
Virginia Rachel E. Cain, Pharm.D. 804-225-2873 Contracted Jul-94
Washington Nicole Nguyen, Pharm.D. 360-725-1757 In-House Mar-96
West Virginia Vicki M. Cunningham, R.Ph. 304-588-1700 Both Mar-95
Wisconsin Michael Mergener, R.Ph., Ph.D. 608-258-3350 Contracted 2001
Wyoming Aimee Lewis, Pharm.D. 307-766-6750 Contracted Oct-95
PRODUR = Prospective Drug Utilization Review System
4-45
Prescribing/Dispensing Limits
Limits on
State Rx Limits on Number, Quantity, and Refills of Prescriptions
Alabama Yes 5 refills per Rx, 34 day supply per Rx, 4 brand limit per month
Alaska Yes 30 day supply per Rx, maximum number units for 50 classes and 40 narcotics
Arizona* - -
Arkansas Yes 31 day supply per Rx; 3 Rx per month (extension to 6); 5 refills per Rx within 6 months
California Yes 6 Rx per month, maximum 100 day supply for most medications, 3 claims per drug within 75 days
Colorado Yes 30 day quantity supply per Rx; 100 days maint. meds. Other limits may apply
Connecticut Yes 240 units or 30 day supply, 5 refills per RX except 12 month limit on oral contraceptives
Delaware Yes 34 day supply or 100 unit doses per Rx (whichever is greater) or by therapeutic category
District of Columbia Yes 34 day supply per Rx, 3 refills per Rx within 4 mos. Max/min quantities for certain meds
Florida Yes Vary according to the drug
Georgia Yes 34 day supply per Rx; Per Rx limit: $2999.99 (potential override)
Hawaii Yes 30 day supply or 100 unit doses per Rx, maximum quantities for some drugs
Idaho Yes 34 day supply per Rx (with exceptions); 3 cycles of birth control; limits on refills/early refills
Illinois Yes Medically appropriate monthly quantity, 3 brand scripts per month, daily dosage limits
Indiana No -
Iowa Yes Maximum 30 day supply except oral contraceptives (90 days); quantity limits on some drugs
Kansas Yes 31 day supply per Rx, 5 Rx per month, other limitations specific to certain medications
Kentucky Yes 32 day supply, max. 11 refills in 12 months; 93 days/100 units for maint. medication, 4 scripts/mo.
Louisiana Yes Greater of 30 day supply or 100 unit doses; 5 refills per Rx within 6 mos., max. 8 scripts/mo./recipient
Maine Yes 34 day supply (brand), 90 day supply (generic); Max. 11 refills per Rx, 4 brand scripts per month
Maryland Yes 34 day supply/Rx; 100 day supply for maint., max. 11 refills/ Rx, refills not to exceed 360 day supply
Massachusetts Yes 30 day supply, per month limits on some drugs, maximum 5 refills per prescription
Michigan Yes 34 day supply (100 days for maintenance), quantity limits for selected drugs (e.g., sedative hypnotics)
Minnesota Yes 34 day supply, quantity limits for selected drugs (triptans, antiemetics, sedatives pregabalin)
Mississippi Yes 31 day supply; 5 Rx per month (no more than 2 brand); 11 refills maximum
Missouri No -
Montana Yes 34 day supply
Nebraska No -
Nevada Yes 34 day supply per Rx; 100 day supply for maintenance medications. 5 refills within 6 months.
New Hampshire Yes 34 day supply, 90 day supply on maintenance medications, 5 refills within 6 months
New Jersey Yes 34 day supply or 100 unit doses per Rx, 5 refills within 6 months
New Mexico No -
New York Yes 5 refills per Rx; annual limit on number of Rx and OTC drugs avail. (potential override)
North Carolina Yes 34 day supply per Rx, with exceptions; 8 Rx per month with exceptions
North Dakota Yes 34 day supply per Rx
Ohio Yes 34 day supply; 102 day supply for maintenance medications; 5 refills per Rx
Oklahoma Yes 6 Rx (incl. 3 brands) per month (21+; under 21 unlimited), 34 day supply or 100 unit doses per Rx
Oregon Yes 34 day supply (100 days for mail order and maintenance drugs)
Pennsylvania Yes 34 day supply or 100 unit doses per Rx (whichever is greater); 5 refills within 6 mos., 6 Rx per month
Rhode Island Yes 30 day supply per Rx (non-maintenance); 5 refills per Rx
South Carolina Yes 34 day supply w/ unlimited Rx (children); quantity limits on some drugs, 4 Rx per month (adult)
South Dakota Yes Quantity limits that vary by drug
Tennessee Yes Varies by basis of eligibility
Texas Yes 3 Rx per month (unlimited Rx’s for nursing home recipients or those < 21), max 5 refills or 6 months
Utah Yes 31 day supply per Rx, max 5 refills, cumulative limit on specific drugs
Vermont Yes 34 days (102 days for maintenance medications), 5 refills per Rx
Virginia Yes 34 day supply per Rx
Washington Yes 34 day supply per Rx; 2 scripts per month; except antibiotics and schedule drugs, 4 brand cap
West Virginia Yes 34 day supply up to 11 refills, except antibiotics (14 days and 1 refill)
Wisconsin Yes 34 day supply per Rx with exceptions, 5 refills for Schedule III, IV, &V drugs, max.11 refills during
12-month period for non-schedule drugs
Wyoming Yes Quantity limits on some medications as deemed clinically appropriate.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
4-46
PHARMACY PAYMENT AND PATIENT COST SHARING
Medicaid Payment for Outpatient Prescription Drugs. Federal Medicaid regulations prescribe the
principles that apply to State Medicaid programs when they pay a pharmacy for outpatient drugs.
These regulations don’t just indicate the FFP cannot be based on amounts that exceed drug costs as
determined under the federal formula; they indicate the actual method for paying for prescription
drugs.
Medicaid Managed Care Organizations (MCOs). If the recipient is enrolled in a Medicaid managed
care organization, payment is made to the MCO in accordance with its contract with the State
Medicaid agency to the extent the contract covers outpatient prescribed drugs.
Medicaid Payment to Pharmacies. Each State’s Medicaid State Plan must comprehensively describe
its payment for prescription drugs. Its aggregate Medicaid expenditures for “multiple-source drugs”
must not exceed the Federal Upper Limits published by CMS (see Appendix D) and its payment level
for other drugs must not exceed, in the aggregate, the lower of (1) EAC plus a reasonable dispensing
fee, or (2) providers’ charges to the general public.
PATIENT COST SHARING
States are permitted to require certain recipients to share some of the costs of Medicaid by imposing
on them such payments as enrollment fees, premiums, deductibles, coinsurance, copayments, or
similar cost-sharing charges (42 CFR 447.50). For States that impose cost-sharing payments, the
regulations specify the standards and conditions under which States may impose cost-sharing, set
forth minimum amounts and the methods for determining maximum amounts, and describe
limitations on availability that relate to cost-sharing requirements.
With the passage of the Social Security Amendments of 1972, States were empowered to impose
“nominal” cost-sharing requirements on optional Medicaid services for cash assistance recipients, and
on any services for the medically needy. Section 131 of the Tax Equity and Fiscal Responsibility Act
(TEFRA) of 1982 introduced major changes to Medicaid cost-sharing requirements. Under this act,
States may impose a nominal deductible, coinsurance, copayment, or similar charge on both
categorically needy and medically needy persons for any service offered under the State Plan. Public
Law 97-248, TEFRA, has been in effect since October 1982; it prohibits imposition of cost-sharing
on the following:
! Services furnished to individuals under 18 years of age (or up to 21 at State option);
! Pregnancy-related services (or, at State option, any service provided to pregnant women);
! Services provided to certain institutionalized individuals, who are required to spend all of
their income for medical care except for a personal needs allowance;
! Emergency services;
! Family planning services and supplies;
! Services furnished to categorically needy HMO enrollees (or, at State option, services
provided to both categorically needy and medically needy HMO enrollees).
In addition, the law prohibits imposing more than one type of charge on any service.
While emergency services are excluded from cost sharing, States may apply for waivers of nominal
amounts for non-emergency services furnished in hospital emergency rooms. Such a waiver allows
States to impose a copayment amount up to twice the current maximum for such services. Approval
of a waiver request by CMS is based partly on the State’s assurance that recipients will have access to
alternative sources of care.
4-47
Pharmacy Payment and Patient Cost Sharing

State Dispensing Fee Ingredient Reimbursement Basis Copayment
Alabama $5.40 AWP- 10%; WAC+9.2% $0.50 - $3.00
Alaska $3.45-$11.46 AWP-5% $2.00
Arizona* - - -
Arkansas $5.51 ($7.51 non-MAC generics) B: AWP-14%, G: AWP-20% $0.50 - $5.00
California $7.25 ($8.00 for LTC) AWP-17% $1.00
Colorado $4.00; $1.89 Inst. & dispensing physicians AWP-13.5% or direct pricing +18%; AWP-35% B: $3.00, G: $1.00
>25 miles from participating pharmacy (for generics)
Connecticut $3.15 AWP-14% (AAC+8% Factor 8) None
Delaware $3.65 AWP-14%, AWP-16% (LTC) $0.50 - $3.00
District of Columbia $4.50 AWP-10% $1.00
Florida $4.23 AWP-15.4%; WAC+5.75% None
Georgia $4.63 (for profit), $4.33 (non-profit) AWP-11% G/P: $0.50, B/NP: $0.50 - $3.00
Hawaii $4.67 AWP-10.5% None
Idaho $4.94 ($5.54 for unit dose) AWP-12% None
Illinois G: $4.60, B: $3.40 B: AWP-12%, G: AWP-25% B: $3.00
Indiana $4.90 B: AWP-16.0%, G: AWP-20% $3.00
Iowa $4.52 AWP-12% $1.00-$3.00
Kansas $3.40 B: AWP-13%, G: AWP-27%, IV AWP-50%, blood $3.00
AWP-30%
Kentucky B: $4.50, G: $5.00 B: AWP-14%, G: AWP-15% $1.00 - $3.00
Louisiana $4.59 (avg.) to $5.77 AWP-13.5% (AWP-15% for chains) $0.50 - $3.00
Maine $3.35 AWP-15% (Retail), 17% (Spec.), 20% (Mail Order)
$3.00, Max $30/rec/pharm/mo
Maryland $2.69-$4.69 Lowest of :WAC+8%, direct+8%, AWP-12% $3.00 Brand not on PDL,
$1.00 Brand on PDL & generics
Massachusetts $3.50 - $5.00 WAC+5% B: $3.00, G and OTC: $1.00
Michigan $2.50 ($2.75 – LTC) AWP-13.5% (1-4 stores), AWP-15.1% (5+stores) B: $3.00, G: $1.00, ABW: $1.00
Minnesota $3.65 ($0.30 for legend unit dose) AWP-12% (MAC, Specialty Pharm AWP-15%) B: $3.00, G: $1.00
Mississippi $3.91 sole source, $4.91 multisource AWP-12% or WAC/WNU+9% $3.00
Missouri $4.09 - $8.19 AWP-10.43%, WAC+10% $0.50 - $2.00, $5.00 for some 1115
waiver pop.
Montana $2.00 - $4.70, $3.50 out-of-state AWP-15% $1.00 - $5.00, $25 max/mo.
Nebraska $3.27 - $5.00 AWP-11% $2.00
Nevada $4.76 AWP-15% B: $3.00, G: $1.00, (dual eligibles)
New Hampshire $1.75 AWP-16% B: $2.00, G: $1.00
New Jersey $3.70 - $4.07 AWP-12.5% None
New Mexico $3.65 AWP-14% None (except $5.00 for SCHIP and
working disabled)
New York B: $3.50, G: $4.50 B: AWP-14%;, G: AWP-25% B: $3.00, G: $1.00, OTC: $0.50
North Carolina B: $4.00, G: $5.60 AWP-10% $3.00
North Dakota B: $4.60, G: $5.60 Lowest of AWP-10%, WAC+12.5%, FUL, or MAC $3.00 (Brand)
Ohio $3.70 WAC +7%, AWP-14.4% B: $2.00
Oklahoma $4.15 AWP-12.0% $1.00 - $2.00 dep. on Rx cost
Oregon Retail: $3.50, Inst./NF: $3.91 AWP-15% (retail), AWP-11% (inst.) B: $3.00, G: $2.00
Pennsylvania $4.00 ($5.00 for compounds) AWP-14%, WAC+7% B: $3.00, G: $1.00
Rhode Island $3.40 (LTC: $2.85) WAC None
South Carolina $4.05 AWP-10% $3.00
South Dakota $4.75 ($5.55 for unit dose) AWP-10.5% B: $3.00, G: no copay
Tennessee $2.50 AWP-13% Varies by eligibility status
Texas $5.14 AWP-15% or WAC+12%, whichever is lowest None
Utah $3.90 (urban), $4.40 (rural), $1.00 OTC AWP-15% $3.00
Vermont $4.75, $3.65 out-of-state AWP-11.9% $1.00 - $3.00 dep. on Rx Cost
Virginia $4.00 AWP-10.25% B: $3.00, G: $1.00
Washington $4.24-$5.25 (based on annual # of Rx) AWP-14%, AWP-50% (>5 labelers) None
West Virginia $2.50 - $8.25 (+ extra $1.00 for B: AWP-15%, G: AWP-30% $0.50 - $3.00
compounding)
Wisconsin $4.88 (to a maximum $40.11) AWP-13% $1.00-$3.00, max $12/rec/pharm/mo
Wyoming $5.00 AWP-11% G: $1.00, PB: $2.00, NP: $3.00
WAC = Wholesalers Acquisition Cost; AWP = Average Wholesale Price; EAC = Estimated Acquisition Cost; AAC= Actual Acquisition Cost;
G = Generic; B = Brand Name; OP = Outpatient; LTC = Long Term Care; P = Preferred; NP = Non-Preferred; PDL= Preferred Drug List; PB = Preferred
Brand
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions.
4-48
Maximum Allowable Cost (MAC) Programs
Federal State-Specific
Upper Upper Limits
State Limits MAC Override Provisions
Alabama Yes Yes Brand medically necessary
Alaska Yes No Brand medically necessary and reason
Arizona* - - -
Arkansas Yes Yes Brand medically necessary plus MedWatch indicating why generics cannot be dispensed
California Yes Yes Medically necessary and product unavailable at MAC rate
Colorado Yes Yes Brand medically necessary
Connecticut Yes Yes No physician MAC override
Delaware Yes Yes MedWatch form for prior authorization
District of Columbia No No -
Florida Yes Yes Dispense as written plus multi-source brand drug form and prior authorization request
Georgia Yes Yes Brand medically necessary and Georgia Watch form
Hawaii Yes Yes PA plus brand medically necessary or do not substitute on script
Idaho Yes Yes Medically necessary with appropriate documentation
Illinois Yes Yes Prior authorization request by M.D. justifying need for brand
Indiana Yes Yes Brand medically necessary, prior authorization
Iowa Yes Yes Brand medically necessary and PA form
Kansas Yes Yes Prior authorization and MedWatch form
Kentucky Yes Yes Brand necessary, brand medically necessary, plus PA on some drugs
Louisiana Yes Yes Brand necessary, brand medically necessary
Maine Yes Yes Prior authorization
Maryland Yes Yes MedWatch form
Massachusetts Yes Yes Dispense as written and brand medically necessary, plus prior authorization
Michigan Yes Yes Brand medically necessary, plus prior authorization
Minnesota Yes Yes Dispense as written, brand medically necessary, must meet PA criteria
Mississippi Yes No Medically necessary, brand medically necessary, or PA for brand multi-source
Missouri Yes Yes Brand medically necessary, prior authorization and MedWatch form
Montana Yes No Brand necessary, brand required
Nebraska Yes Yes State-specific form
Nevada Yes Yes Dispense as written
New Hampshire Yes Yes Brand medically necessary
New Jersey Yes No Brand medically necessary
New Mexico Yes Yes Medically necessary, brand necessary, brand medically necessary
New York Yes No Prior authorization
North Carolina Yes Yes Brand medically necessary in writing on prescription
North Dakota Yes Yes Dispense as written
Ohio Yes Yes Prior authorization
Oklahoma Yes Yes Brand medically necessary plus prior authorization
Oregon Yes Yes Brand medically necessary plus prior authorization
Pennsylvania Yes Yes Brand medically necessary and prior authorization
Rhode Island No No Brand medically necessary with justification
South Carolina Yes Yes Brand medically necessary w/cert. by prescriber and prior authorization
South Dakota Yes No Prior authorization
Tennessee Yes Yes Dispense as written
Texas Yes Yes Brand necessary, brand medically necessary
Utah Yes Yes Dispense as written, prior approval, plus documentation
Vermont Yes Yes Dispense as written, medically necessary, brand necessary, or DAW 8 (generic not
available)
Virginia Yes Yes Brand necessary in physician’s own handwriting
Washington Yes Yes Brand medically necessary
West Virginia Yes Yes Brand medically necessary
Wisconsin No Yes Brand medically necessary plus prior authorization
Wyoming Yes Yes Brand medically necessary
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions.
4-49
Mandatory Substitution
Incentive Fee for Dispensing of Generic Dispensing of Lowest Cost

State Generic Substitution Multi-Source Required Multi-Source Required
Alabama No Yes No
Alaska No Yes No
Arizona* - - -
Arkansas $2.00 Yes Yes
California No No Yes
Colorado No Yes No
Connecticut No Yes No
Delaware No Yes No
District of Columbia No Yes No
Florida No Yes No
Georgia No Yes No
Hawaii No Yes No
Idaho No Yes No
Illinois No No No
Indiana No Yes Yes
Iowa No No Yes
Kansas No Yes No
Kentucky No Yes Yes
Louisiana No No No
Maine No Yes (preferred generics) Yes
Maryland No Yes No
Massachusetts No Yes No
Michigan No No No
Minnesota No Yes Yes
Mississippi No Yes (if less costly) No
Missouri No Yes Yes
Montana No Yes No
Nebraska No No No
Nevada No Yes Yes
New Hampshire No Yes No
New Jersey No Yes Yes
New Mexico No No Yes
New York $1.00 Yes No
North Carolina $1.60 Yes Yes
North Dakota No Yes No
Ohio No No No
Oklahoma No Yes No
Oregon No Yes No
Pennsylvania No Yes No
Rhode Island No Yes No
South Carolina No Yes Yes
South Dakota No Yes No
Tennessee No Yes Yes
Texas $0.50 Yes No
Utah No Yes No
Vermont No Yes Yes
Virginia No Yes No
Washington No No Yes
West Virginia No Yes No
Wisconsin No Yes No
Wyoming No Yes No
4-50
Counseling Requirements and Payment for Cognitive Services
Medicaid Patient Counseling Medicaid Payment

State Required1 for Cognitive Services2
Alabama Yes No
Alaska Yes No
Arizona Yes -
Arkansas Yes No
California Yes No
Colorado Yes No
Connecticut Yes No
Delaware Yes No
District of Columbia Yes No
Florida Only an offer to counsel is required No
Georgia Yes No
Hawaii Yes, OBRA requirements Yes (emergency contraception)
Idaho Yes No
Illinois Only an offer to counsel is required No
Indiana Only an offer to counsel is required No
Iowa Yes Yes (pharm. case management)
Kansas Yes No
Kentucky Yes No
Louisiana Yes No
Maine Yes No
Maryland Yes No
Massachusetts Only an offer to counsel is required No
Michigan Yes No
Minnesota Yes Yes (patient specific)
Mississippi Yes Yes (diabetes, asthma, coagulation, and lipids)
Missouri Yes (diabetes, asthma, heart failure, depression, sickle cell,
Yes GERD, education)
Montana Yes No
Nebraska Yes No
Nevada Yes No
New Hampshire Yes No
New Jersey Yes No
New Mexico Yes No
New York Yes No
North Carolina Yes Yes (focused risk management reviews)
North Dakota Yes No
Ohio Only an offer to counsel is required No
Oklahoma When applicable/appropriate No
Oregon Yes No
Pennsylvania Yes Yes (tobacco cessation as medical service, not pharmacy)
Rhode Island Only an offer to counsel is required No
South Carolina Yes, HHS Finance Commission
No
Regulation
South Dakota Yes No
Tennessee Yes No
Texas Yes, must post a sign in pharmacy No
Utah Yes No
Vermont Yes No
Virginia Yes No
Washington Yes Yes (emerg. contraceptive counseling, clozaril case management)
West Virginia Only an offer to counsel is required No
Wisconsin Yes Yes
Wyoming Only an offer to counsel is required No
Sources: 12007 National Association of Boards of Pharmacy Law, Survey of Pharmacy Law; 2 As reported by State drug
program administrators in the 2007 NPC Survey.
4-51
Prescription Price Updating
State Contact Telephone Updated

Alabama Stephanie Frawley 334-353-4592 Biweekly
Alaska Dave Campana, R.Ph. 907-334-2425 Weekly
Arizona* - - -
Arkansas First DataBank 650-588-5454 Weekly
California EDS Federal Corp. 916-636-1000 Weekly
Colorado Cathy Traugott, R.Ph., J.D. 303-866-2468 Biweekly
Connecticut Mark Synol 860-255-3886 Weekly
Delaware Cynthia R. Denemark, R.Ph. 302-453-8453 Weekly
District of Columbia Carolyn Rachel-Price, R.Ph. 202-442-9078 As needed
Florida First DataBank 650-588-5454 Weekly
Georgia SXC 630-577-3120 Weekly
Hawaii ACS State Healthcare 800-358-2381 Weekly
Idaho David Mendoza 208-364-1838 Weekly
Illinois Lisa D. Voils 217-782-2570 Weekly
Indiana First DataBank 650-588-5454 Weekly
Iowa Sandy Pranger, R.Ph. 515-725-1272 Weekly
Kansas Margaret Smith 785-296-4753 Weekly
Kentucky Nici Gaines 502-564-7940 Weekly
Louisiana Maggie Vick, Unisys Corp. 225-216-6251 Weekly
Maine Marcia Pykare 207-622-7153 Weekly
Maryland Frank Tetkoski, P.D. 410-767-1460 Weekly
Massachusetts First DataBank 650-588-5454 Weekly
Michigan First Health Service Corp. 800-884-2822 Weekly
Minnesota First DataBank 800-633-3453 Weekly
Mississippi Terri R. Kirby, R.Ph. 601-359-5253 Weekly
Missouri First DataBank 650-588-5454 Weekly
Montana First DataBank 650-588-5454 Weekly
Nebraska Barbara Mart 402-471-9301 Weekly
Nevada First DataBank 650-588-5454 Monthly
New Hampshire Robert Coppola, Pharm.D. 603-224-2083 Weekly
New Jersey First DataBank 650-588-5454 Weekly
New Mexico Julie A. McKeay 505-827-6202 Weekly
New York Carl Cioppa, Pharm.D. 518-474-3209 Monthly
North Carolina Tom D’Andrea, R.Ph., M.B.A. 919-855-4300 Weekly
North Dakota Brendan K. Joyce, Pharm.D., R.Ph. 701-328-4023 Biweekly
Ohio First DataBank 650-588-5454 Monthly
Oklahoma First DataBank 800-633-3453 Weekly
Oregon Debbie L. Bishop 503-945-6291 Biweekly
Pennsylvania Terri Cathers 717-346-8156 Monthly
Rhode Island Paula Avarista, R.Ph., M.B.A. 401-462-6390 Weekly
South Carolina First DataBank 650-588-5454 Weekly
South Dakota Mark Petersen, R.Ph. 605-773-3495 Biweekly
Tennessee First DataBank 650-588-5454 Weekly
Texas Betty Wasko 512-491-1155 Weekly
Utah RaeDell Ashley, R.Ph. 801-538-6495 Biweekly
Vermont Bob Rase 913-451-9466 Monthly
Virginia Keith T. Hayashi 804-225-2773 Weekly
Washington Johnna Ziegler 360-725-1841 Weekly
West Virginia Eric N. Sears, R.Ph. 304-348-3200 Weekly
Wisconsin Carrie L. Gray 608-266-3901 Weekly
Wyoming First DataBank 800-633-3453 Weekly
Source: As reported by State drug program administrators in the 2007 Survey.
4-52
Section 5:
State Pharmacy Program
Profiles
5-1
5-2
Profiles of State Medicaid Drug Programs

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

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

2005 2006
Expenditures Recipients Expenditures Recipients
TOTAL $622,777,164 544,400 $462,845,776 541,235
RECEIVING CASH ASSISTANCE TOTAL $410,969,308 191,182 $318,243,346 168,015

Aged $35,915,708 17,699 $843,942 7,511
Blind/Disabled $353,786,496 138,297 $291,426,026 128,380
Child $3,692,129 10,537 $3,320,992 7,990
Adult $17,574,975 24,649 $22,652,384 24,134
MEDICALLY NEEDY, TOTAL $0 0 $0 0

Aged $0 0 $0 0
Blind/Disabled $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0
POVERTY RELATED, TOTAL $88,675,021 272,673 $111,870,343 301,512

Aged/Blind/Disabled $4,521,741 3,022 $1,636,932 1,719
Child $0 0 $0 0
Adult $81,519,379 254,291 $106,629,875 282,467
BCCA Women $2,633,901 15,360 $3,603,534 17,325
TOTAL OTHER EXPENDITURES/RECIPIENTS* $123,132,834 80,545 $32,732,087 71,708

*Total other expenditures/recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
Total expenditures do not include clawback payments.
Source: Alabama Medicaid Statistical Information System, 2005 and 2006.
Alabama-1
C. ADMINISTRATION
Vaccines: Vaccines reimbursable as part of the
Alabama Medicaid Agency. Vaccines for Children Program.
D. PROVISIONS RELATING TO DRUGS Unit Dose: Unit dose packaging reimbursable.
Benefit Design Formulary/Prior Authorization
Drug Benefit Product Coverage: Products covered: Formulary: Open formulary with preferred drug list.
disposable needles and syringe combinations used for Formulary managed through restrictions on use, prior
insulin; blood glucose test strips; and total parenteral authorization, preferred products, physician profiling,
nutrition. Products covered with restrictions: and academic dealing. Prior authorization required
prescribed insulin and syringe combinations used for for non-preferred drugs. Anti-psychotics and
insulin (on PDL and max units apply); and HIV/AIDs drugs are exempted from the prior
interdialytic parenteral nutrition (cert. of med. authorization requirements. (For additional
necessity on script). Products not covered: cosmetics information see: www.medicaid.alabama.gov)
(except through medical necessity); fertility drugs;
experimental drugs; urine ketone test strips; drugs for Prior Authorization: State currently has a formal
anorexia or weight gain/loss; hair growth products; prior authorization procedure. Prior authorization
and DESI drugs. decisions may be appealed by physician submitting
written notice along with medical documentation
Over-the-Counter Product Coverage: Products (i.e., peer reviewed literature and medical records) to
covered if prescribed by a physician: allergy, asthma the administrative services contractor for physician
and sinus products; analgesics; cough and cold review. The request is forwarded to the contractor’s
preparations (generics only); digestive products; Medical Director and the Agency’s Medical Director
topical products; prenatal vitamins; and hemorrhoidal for review.
products. Products not covered: feminine products;
smoking deterrent products. Prescribing or Dispensing Limitations
Therapeutic Category Coverage: Therapeutic Prescription Refill Limit: maximum of five refills for
categories covered: anablolic steroids; controlled substance, 11 for non-controlled.
anticoagulants; anticonvulsants; anti-psychotics;
chemotherapy agents; contraceptives; and thyroid Monthly Quantity Limit: 34-day supply.
agents. Partial coverage for: prescribed cold
medications. Prior authorization required for: Monthly Prescription Limit: four brand limit.
analgesics, antipyretics, and NSAIDs; anoretics;
antibiotics; antidepressants; antidiabetic agents;
antihistamines; antilipemic agents; anxiolytics;
sedatives, and hypnotics; cardiac drugs; ENT anti-
PRODUR system implemented in July 1996. State
inflammatory agents; estrogens; growth hormones;
currently has a DUR Board with a quarterly review.
hypotensive agents; misc. GI drugs;
sympathominetics (adrenergic); skeletal muscle
relaxants; skin and mucous membrane agents; triptan
agents; respiratory agents; PPIs; platelet aggregation
Dispensing Fee: $5.40 (additional reimbursement for
inhibitors; Alzheimer’s Disease agents; ADHD
compounding).
agents; EENT anti-allergic agents; brand H2
antagonists; intranasal corticosteroids; narcotic
Ingredient Reimbursement Basis: AWP-10%, WAC
analgesics; specialized nutritional supplements;
+ 9.2%.
Retina A; Dipyridamole; Synagis; antihypertensive
agents; antiemetics; Xenical; and Xolair. Therapeutic
Prescription Charge Formula: Medicaid pays for
categories not covered: anoretics; prescribed smoking
prescribed legend and non-legend drugs authorized
deterrents; and OBRA 90 excludables.
under the program based upon and shall not exceed
the lowest of:
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program 1. The Federal Upper Limit or Maximum
when used in extended care facilities and home Allowable Cost (MAC) of the drug plus a
health care, and through physician payment when dispensing fee,
used in physicians’ offices.
Alabama-2
2. The Estimated Acquisition Cost (EAC) of the DUR Contact

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

FDB Contract Administrator
Does not use MCOs to deliver pharmaceutical
501 Dexter Avenue
services to general Medicaid recipients. State does
P.O. Box 5624
have a maternity managed care waiver.
Montgomery, AL 36103-5424
T: 334/353-4592
F. STATE CONTACTS F: 334/353-7014
Email: stephanie.frawley@medicaid.alabama.gov
State Drug Program Administrator
Kelli D. Littlejohn, R.Ph.
Director of Pharmacy Stephanie Frawley
Alabama Medicaid Agency 334/353-4592
501 Dexter Avenue
P.O. Box 5624 Medicaid Drug Rebate Contact
Lynn M. Abrell
T: 334/353-4525
Associate Director Drug Rebate
F: 334/353-5623
E-mail: kelli.littlejohn@medicaid.alabama.gov
501 Dexter Avenue
Internet address: www.medicaid.alabama.gov
P.O. Box 5624
Montgomery AL 36103-5624
Prior Authorization Contact T: 334/242-2326
Kelli D. Littlejohn, R.Ph. F: 334/353-7014
334/353-4525 E-mail: lynn.abrell@medicaid.alabama.gov
Alabama-3
Title XIX Medical Care Advisory Committee

Claims Submission Contact
Jim Carnes
Susan Jones
Pattisue Carrenza
Fiscal Agent Liaison (EDS)
Irene Collins
Louis E. Cottrell, Jr.
501 Dexter Avenue
Joe Decker
P.O. Box 5624
Al Fox
Jean Fulton
T: 334/242-5553
Lawrence F. Gardella
F: 334/242-7014
A.Z. Holloway, M.D.
E-mail: susan.jones@medicaid.alabama.gov
Mike Horsley
John Houston
Medicaid Managed Care Contact
Jolene James
Kelli D. Littlejohn, R.Ph. Louise Jones
334/353-4525 Cary Kuhlman
Linda Lee
Mail Order Pharmacy Program Roosevelt McCorvey, M.D.
Holley Midgley
None J.A. Powell, M.D.
Marsha D. Raulerson, M.D.
Disease Management/Patient Education Steve Shivers
Programs Wilburn Smith, Jr., M.D.
Disease/Medical State: PCCM Page Walley
Program Name: Patient First Donald Williamson, M.D.
Program Manager: Paige Clark, Medical Services
Program Sponsor: Univ. of South Alabama/Alabama Pharmacy and Therapeutics Committee
Dept. of Public Health. A. Z. Holloway, M.D.
Richard Freeman, M.D.
Disease Management Program/Initiative Ben Main, R.Ph.
Contact Lucy Culpepper, M.D.
Kathy Hall W.Thomas Geary, Jr., M.D. (Chair)
Deputy Commissioner Program Administration Vickie Litte, R.P.h.
Alabama Medicaid Agency Sheri Lynn Boston, R.Ph.
501 Dexter Avenue Mary McIntyre, M.D.
PO Box 5624 Lucien Newman, III, M.D.
Montgomery, AL 36103-5624 Joseph Thomas, M.D.
334/242-5007
E-mail: Kathy.Hall@medicaid.alabama.gov Pharmacy Advisory Committee
Danny Cottrell, R.Ph.
Alabama Medicaid Agency Officials Alabama Pharmacy Association
Carol Herrmann-Steckel, M.P.H.
Commissioner John Carpenter, R.Ph.
Alabama Medicaid Agency Alabama Pharmacy Association
501 Dexter Avenue
P.O. Box 5624 Louise Jones
Montgomery, AL 36103-5624 Alabama Pharmacy Association
T: 334/242-5600
F: 334/242-5097 Dan McConaghy, R.Ph.
E-mail: Almedicaid@medicaid.state.al.us Alabama Pharmacy Association
Internet address: www.medicaid.state.al.us
Vickie Little, R.Ph.
Alabama Pharmacy Association
Alison Wingate
Alabama Retail Association
Alabama-4
Steve Frawley, R.Ph. Alabama State Board of Pharmacy

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

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

Louise F. Jones
Executive Director
1211 Carmichael Way
T: 334/271-4222
F: 334/271-5423
E-mail: LJones@aparx.org
Internet address: www.aparx.org
Alabama-5
Alabama-6
ALASKA

Disabled Disabled
Prescribed Drugs ! ! ! ! ! ! ! !
Inpatient Hospital Care ! ! ! ! ! ! ! !
Outpatient Hospital Care ! ! ! ! ! ! ! !
Laboratory & X-ray Service ! ! ! ! ! ! ! !
Nursing Facility Services ! ! ! ! ! ! ! !
Physician Services ! ! ! ! ! ! ! !
Dental Services ! ! ! ! ! ! ! !
B. DRUG PAYMENTS AND RECIPIENTS

2005 2006
TOTAL $127,792,222 76,557 $90,991,988 747,747

Aged $17,960,921 5,267 $6,788,329 4,899
Blind/Disabled $65,660,858 10,895 $45,911,511 10,942
Child $2,796,568 8,937 $2,842,016 8,678
Adult $11,091,774 9,947 $11,425,664 10,077
MEDICALLY NEEDY, TOTAL $14,966,546 35,337 $13,712,497 34,027

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

Aged $4,323,747 787 $1,784,914 768
Blind/Disabled $6,018,580 963 $3,187,029 935
Child $2,119,077 1,908 $2,413,110 1,841
Adult $923,840 989 $950,629 957
BCCA Women $0 0 $0 0
TOTAL OTHER EXPENDITURES/RECIPTENTS* $1,930,311 1,527 $1,976,285 1,650
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
Source: Alaska Medicaid Management Information System, FY 2005 and 2006.
Alaska-1
C. ADMINISTRATION Formulary/Prior Authorization

Department of Health and Social Services, Division of Formulary: Open formulary with preferred drug list
Health Care Services. (PDL). PDL managed by exclusion of products based
on contracting issues and preferred products.
D. PROVISIONS RELATING TO DRUGS
Prior Authorization: State currently has a formal prior
Benefit Design authorization procedure. Request for fair hearing
required for appealing coverage of an excluded
Drug Benefit Product Coverage: Products covered: product and PA decision. Medical necessity form
cosmetics (covered with restrictions- non hair growth required.
products); prescribed insulin. Covered under DME:
disposable needles and syringe combinations used for Prescribing or Dispensing Limitations
insulin; blood glucose test strips; urine ketone test
strips. Products covered under home infusion therapy: Monthly Quantity Limit: Prescriptions are limited to
total parenteral nutrition; and interdialytic parenteral 30-day supplies (except family planning drugs).
nutrition. Prior authorization required for: Clozaril; Dispensing of generic multi-source product is required.
Lupron Depot; some DME; Synagis; Panretin; PPIs; Maximum number of units for about 50 therapeutic
Botox; Byetta; Clozapine; Revatio; Carisoprodol; and classes and 40 narcotic analgesics.
Actig Naltrexone. Products not covered: fertility
drugs; anoretics; drugs to grow hair; and experimental Drug Utilization Review
drugs.
PRODUR system implemented in June 1995. State
Over-the Counter Product Coverage: Products currently has a 6-member DUR Board that meets six
covered: Smoking deterrent products. Products times per year.
covered with restrictions: feminine products
(spermicides and vaginal miconazole and Pharmacy Payment and Patient Cost Sharing
clotrimazole); topical products (Bacitracin ointment
only). Products not covered: allergy, asthma, and sinus Dispensing Fee: $3.45 - $11.46 based on pharmacy
products; analgesics; cough and cold preparations; and volume.
digestive products.
1) $23,192 added to the number resulting from
Therapeutic Category Coverage: Categories covered: multiplying total prescriptions filled by that
anabolic steroids; analgesics, antipyretics, and pharmacy in the previous calendar year by 5.070;
NSAIDs; antibiotics; anticoagulants; anticonvulsants;
anti-depressants; antidiabetic agents; antihistamines; 2) to 1), add the result of multiplying total Medicaid
antilipemic agents; anti-psychotics; anxiolytics, prescriptions filled in the previous calendar year
sedatives, and hypnotics; cardiac drugs; chemotherapy by 12.44;
agents; contraceptives; ENT anti-inflammatory agents; 3) from 2), subtract the result of multiplying the total
estrogens; hypotensive agents; misc. GI drugs; floor space volume of the pharmacy in sq. ft. by
sympathominetics (adrenergic); and thyroid agents. 2.103;
Prior authorization required for: growth hormones; and
prescribed smoking deterrents. Categories not covered: 4) divide 3) by total prescriptions filled by that
anoretics; prescribed cold medications; amphetamines pharmacy
(except for narcolepsy and hyperactivity); cough
5) add $0.73 to 4).
suppressants; DESI drugs; vitamins (except prenatal);
and vitamins with fluoride.
Extra fee for compounding:
Long-term care pharmacies receive highest dispensing
reimbursable through both the Prescription Drug
fee once per month per NDC.
Program and physician payment when used in
physicians’ offices.
Ingredient Reimbursement Basis: EAC = AWP-5%, or
FUL + dispensing fee.
Vaccines: Vaccines reimbursable at cost as part of
EPSDT services and the Vaccines for Children
Maximum Allowable Cost: State imposes Federal
Program.
Upper Limits on generic drugs. Override requires
“Brand Medically Necessary” and the reason of
Unit Dose: Unit dose packaging reimbursable.
necessity.
Alaska-2
Incentive Fee: None. DUR Contact

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

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

Fairbanks, AK
Amber Briggs, Pharm.D.
Alaska-3
Soldotna, AK St. Michaels, AK
Alexander von Hafften, M.D. John Bringhurst

Anchorage, AK Petersburg, AK
Vincent Greear, R.Ph. Kathy Kraft (Coordinator)

Homer, AK
Jerry Fuller (Commissioner’s designee non-voting)
Pharmacy and Therapeutics Committee
Marvin Bergeson, M.D.
Mark Borher, R.Ph.
Heidi Brainerd, R.Ph. Alaska State Medical Association
Richard E. Brodsky, M.D. (Chair) Jim Jordan, Executive Director
Robert H. Carlson, M.D. 4107 Laurel Street
Kelly C. Conright, M.D. Anchorage, AK 99508
Jeffrey Demain, M.D. T: 907/562-0304
Tracy Gale, R.Ph. F: 907/561-2063
Andrej Maciejewski, M.D. E-mail: aksma@alaska.net
Amber Briggs, Pharm.D. Internet address: www.aksma.org
Vincent Greear, R.Ph.
R. Duane Hopson, M.D. Alaska Osteopathic Medical Association
Thomas Hunt, M.D. Holly Macriss
Dan Kiley, D.D.S., M.P.H. AOA Northwest Regional Manager
Diane Liljegren, M.D. 1900 Point West Way, Suite 188
Dan Kiley, D.D.S., M.P.H. Sacramento, CA 95815-4705
Gregory R. Polston, M.D. T: 800/891-0333
Sherrie D. Richey, M.D. F: 916/564-5105
Janice L. Stables, M.S.N, A.N.P. E-mail: hmcriss@osteopathic.org
Trish D. White, R.Ph.
Alaska Pharmacists Association
Medical Care Advisory Committee Nancy Davis, Executive Director
4107 Laurel Street, Suite 101
David Alexander, M.D. (Chair)
Anchorage, AK 99508-5334
Anchorage, AK
T: 907/563-8880
F: 907/563-7880
Gary Givens, R.Ph.
E-mail: akphrmcy@alaska.net
Anchorage, AK
Internet address: www.alaskapharmacy.org
Todd Wortham, D.D.S.
Alaska State Board of Pharmacy
Kenai, AK
Sher Zinn, Licensing Examiner
P.O. Box 110806
Deborah Kiley, A.N.P.
Juneau, AK 99811-0806
Anchorage, AK
T: 907/465-2589
F: 907/465-2974
Karen Sidell (Vice Chair)
E-mail: sher_zinn@commerce.state.ak.us
Bethel, AK
Internet address: www.dced.state.ak.us/occ/ppha.htm
Lavada “Sam” Bush
Alaska State Hospital and Nursing Home Association
Fairbanks, AK
Rod L. Betit, President/CEO
426 Main Street
Marie Darlin
Juneau, AK 99801
Juneau, AK
T: 907/586-1790
F: 907/463-3573
Tracy Smith
E-mail: rodbetit@msn.com
Fairbanks, AK
Internet address: www.ashnha.com
Ursula Lockwood
Alaska-4
ARIZONA
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
(AHCCCS - PRONOUNCED "ACCESS")
skyrocketed and the high costs of the programs
AHCCCS FEATURES forced the counties to turn to the Legislature for help.
In response, the Arizona Health Care Cost
The Arizona Health Care Cost-Containment System Containment System (AHCCCS), developed in
(AHCCCS), Arizona’s Medicaid program, is a Title Senate Bill 1001, was passed by the Legislature and
XIX (Medicaid) 1115 Research and Demonstration signed by the Governor in November 1981. On
Waiver project, jointly funded by the federal October 1, 1982, AHCCCS became the first
government and the State of Arizona. AHCCCS is an statewide managed care system in the nation. It
innovative program designed to deliver quality, contained six major mechanisms for restraining
defraying the cost of indigent health care. health care costs at the same time ensuring that
Implemented in October 1982, it serves as a model appropriate levels of quality health care services are
for providing medical services to the indigent in a provided to eligible persons in a dignified fashion.
managed care system rather than through fee-for- The goal of these 6 items was to contribute to the
service arrangements. Typically, Medicaid programs establishment of health care financing that is less
have incorporated the traditional hallmarks of the expensive than conventional fee-for-service systems.
U.S. health care system: namely, independent The six mechanisms were:
providers and fee-for-service reimbursement. In
contrast, organized health plans and capitation mark ! Primary Care Physicians Acting as
the AHCCCS model. This capitated model, although Gatekeepers
new to Medicaid in 1982, was patterned on the way ! Prepaid Capitated Financing
many consumers paid for private healthcare ! Competitive Bidding Process
insurance. ! Cost Sharing
! Limitations on Freedom-of-Choice
AHCCCS is a partnership between the State and ! Capitation of the State by the Federal
private and public managed care health plans, Government.
opening up the private physician network to
Medicaid recipients and allowing AHCCCS members Primary Care Physicians as Gatekeepers
to choose a primary care provider who acts as a
gatekeeper and case manager. In traditional Medicaid AHCCCS legislation provided that all members must
programs, the States assume responsibility for be under the care and supervision of a primary care
contracting with individual pharmacies and physician who assumed the role of gatekeeper. A
reimbursing them. In the AHCCCS model however, statewide network of primary care physicians was
the State contracts, instead, with pre-paid health established to perform the gatekeeping function for
plans, HMOs and HMO-like entities. These plans the system and manage all aspects of a member’s
are paid on a capitation basis and are responsible for medical care.
providing all of the services covered by the program.
Thus, with the exception of behavioral health drugs Prepaid Capitated Financing
which are carved out of managed care, the delivery
of pharmacy services is the responsibility of each It was the intent of the AHCCCS legislation that
prepaid plan. health plans and their providers offer all covered
services to groups of members within a geographical
area for a fixed price, for a definite period. The law
GENERAL INFORMATION allowed for the establishment of a statewide bidding
process to accomplish this. Services are provided on
Prior to 1982, Arizona was the only State in the a county-by-county basis, by prepaid health plans.
nation that was not participating in the Medicaid Providers may bid on a prepaid capitated basis for
program. State leaders avoided the national program covered services to be provided within a particular
primarily because of concerns about high costs and county. The law allows for expansion and
big bureaucracies. Instead of accepting Federal contraction of bids to achieve the best possible
funds for healthcare, Arizona retained its system of system. In the event there are insufficient bids for a
indigent health care provided by individual counties given area, the legislation permits capped fee-for-
as they saw fit and could afford. However, by 1980, service arrangements. It is intended, however, that
health care costs for poor Arizona residents had
Arizona-1
capped fee-for-service will be authorized as a last completely blanketed with prepaid capitated
resort only. arrangements. Members are linked to selected or
assigned plans for definite durations of time.
In essence, AHCCCS prepaid health plans (PHPs), Freedom-of-choice is permitted to the extent
health maintenance organizations (HMOs), and other practicable for members to select the particular group
types of organized health delivery systems charge a with which to enroll, as well as the primary care
fixed fee per individual enrolled (i.e., a capitation physician within the selected group. Capped fee-for-
rate) and assume responsibility for providing a broad service health service arrangements are used as a last
array of health care services to members. The plan or resort, and only in areas not covered by prepaid
contractor is then “at risk” to deliver the necessary capitated plans.
services within the capitated amount. AHCCCS
receives Federal, State, and county funds to operate, CAPITATION BY THE FEDERAL
plus some monies from Arizona’s tobacco tax. GOVERNMENT
Competitive Bidding Process The State of Arizona will itself be capitated by the
Federal government and therefore will be at financial
The statewide competitive aspect of the bid process risk for containing health care costs. Capitation rates
for selecting providers and offering prepaid capitated are established according to sound actuarial
services is the most unique feature of the AHCCCS principles, and represent no more than 95 percent of
model. A competition of this magnitude had never the estimated cost of services delivered in Arizona
been attempted in any other State. The AHCCCS under conventional fee-for-service arrangements.
administration believes competitive bidding for Capitation provides a key incentive for the State to
health care service contracts, as opposed to monitor health care costs on a careful and continuous
conventional negotiation processes, provides basis.
accessible cost-effective delivery of health care
without sacrificing quality performance. IMPLEMENTATION OF AHCCCS
The AHCCCS administration issues an invitation to AHCCCS is based on plans that have been tested, in
qualified health plans once every five years. part, on smaller scales in different areas of the
Qualified health plans may bid to offer the full range country. By combining a number of key mechanisms
of AHCCCS services in one or more counties. on a statewide basis, AHCCCS represents a novel
health care model. The purpose of this section is to
Cost Sharing present a discussion of how the key concepts
embodied in the AHCCCS legislation will be
The fourth major device for containing costs in the implemented and rendered operational.
AHCCCS model is a provision for cost sharing by
users. A statewide copayment schedule was Provider Participation
developed for this purpose, and the medically needy
participate in coinsurance cost sharing. It is expected Providers may participate in AHCCCS in 2 different
that the imposition of nominal copayments will ways. First, they may contract with prepaid capitated
ensure optimal effectiveness in the area of service plans as either full or partial benefit providers.
utilization. The copayment schedule accomplishes
three objectives: curtailment of over-utilization; The second mode of participation is on a capped fee-
enhancement of patient dignity; and service for-service basis. Here, providers agree to accept
utilization by members for truly needed health care. capped fee payments as payments in full for services
There is no copayment for drugs and medication, provided on a FFS basis.
prenatal care including all obstetrical visits, members
in long care facilities and for visits scheduled by the Functions of the AHCCCS Administration
primary care physician or practitioner, and not at the
request of the member. The Arizona Health Care Containment System
Administration (AHCCCSA) contracts health plans
Limitations On Freedom-of-Choice and other program contractors to serve AHCCCS
members through a network of providers, paying
The fifth major item for containing costs is a them a monthly capitation amount prospectively for
restriction on provider/physician selection by each enrolled member. The plan or contracor is then
AHCCCS members. Unlike conventional delivery “at risk” to deliver the necessary services within that
models, Arizona does not rely on fee-for-service
arrangements. The goal is to have the State
Arizona-2
amount. AHCCCS receives Federal, State, and ! Provider, Member Call Center
county funds to operate. ! Grievances and Complaints
! Fee-for-Service for IHS
Contracting Health Plans
AHCCCS became effective December 1, 1981, and
Under the Contracting Health Plan arrangement, services commenced October 1, 1982. Services
plans are defined in terms of explicit groups of include: inpatient, outpatient, laboratory, long-term
providers organized as entities that are more formal. care, x-ray, prescription drugs, medical supplies,
These consortia, or formal entities, are capable of prosthetic devices, emergency dental care including
providing the full range of AHCCCS benefits within extractions and dentures, treatment of eye conditions
a defined service area for all AHCCCS members who and EPSDT.
elect to join the plans, up to a predetermined
capacity. This is the dominant mode of operation From the beginning, AHCCCS has operated under an
within AHCCCS -- with two or more competing 1115 Research and Demonstration waiver granted by
plans wherever possible. the U.S. Department of Health and Human Services.
Though AHCCCS was a three-year experiment that
The Contracting Health Plans are delivery systems, was to end in October 1985, the Federal government
not simply insurance plans, but they need not be continues to extend funding for the program. In
Health Maintenance Organizations by any legal or 1988, AHCCCS received a five-year extension from
conventional definition of the term. The AHCCCS the Federal government and in 1993, it received an
legislation provides for the creation of provider additional one-year extension. In 1994, AHCCCS
consortia for the purpose of participation in the received a three-year extension and in 1998, it
program. The Contracting Health Plan may be a received a one-year extension. Since then, AHCCCS
loosely organized system, but it must be capable of has received additional extensions. Currently,
providing the full range of AHCCCS benefits to a AHCCCS is operating under a five year waiver
defined population at a capitation rate. extension that will expire on September 30, 2011.
Some 25 years after it first began, AHCCCS has
The Organizational Role of AHCCCS grown in numbers from the first wave of 180,000
Administration enrollees to over 1 million beneficiaries, representing
18 percent of Arizona’s population. The program
The AHCCCS Administration has been charged with covers all mandatory Medicaid eligibility groups, 12
the general implementation and monitoring of the optional groups and 4 expansion groups. AHCCCS
AHCCCS program. has evolved into a mature, well-respected health care
system and has become a model as managed care is
The AHCCCS Administration develops the Rules increasingly by being implemented in other States’
and Regulations; manages the health plan bidding Medicaid programs.
processes; awards the contracts; provides technical
assistance to providers for the purpose of forming (Additional information about AHCCCS can be
consortia to contract with AHCCCS; and monitors found on the agency’s website at
the overall operation of the program. The State also www.ahcccs.state.az.us)
provides regulatory oversight, including operational
and financial oversight of the plans and contract MEDICAL PLANS AND
monitoring to ensure quality of care. ADMINISTRATORS
The Operational Role of the AHCCCS AHCCCS Contracted Health Plans

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

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

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

P.O. Box 9020 Yavapai County Department of Medical Assistance
Window Rock, AZ 86515-9020 6717 East Second Street, Suite D
928/871-5811 Prescott Valley, AZ 86314
T: 800/850-1020
Long-Term Care Contractor List F: 928/771-3542
Bridgeway Health Solutions
1501 W. Fountainhead Corporate Park, Suite 201
Tempe, AZ 85282
866/475-3129
Arizona-4
STATE CONTACTS Executive Officers of State Medical and

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

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

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

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

Arizona Department of Economic Security
Sundin Applegate, MD.., Medical Director
Arizona Department of Health Services
Arizona-5
Arizona-6
ARKANSAS

Disabled Disabled

2004 2005
TOTAL $393,948,896 422,424 $437,398,315 439,712
RECEIVING CASH ASSISTANCE, TOTAL $210,757,332 120,252 $229,296,123 119,986

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

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

Aged $4,253,583 3,247 $5,631,949 3,810
Blind/Disabled $1,524,348 971 $1,799,938 1,026
Child $54,878,958 171,130 $62,059,015 181,286
Adult $1,484,865 9,209 $1,562,246 9,877
Source: Arkansas Medicaid Statistical Information System, FY 2004 and FY 2005.
Arkansas-1
C. ADMINISTRATION Vaccines: Vaccines reimbursable as part of EPSDT

services, the Children’s Health Insurance Program,
Department of Human Services, Division of Medical and the Vaccines for Children Program.
Services, Pharmacy Program.
Unit Dose: Unit dose packaging not reimbursable.
Formulary/Prior Authorization
Benefit Design
Formulary: State has a preferred drug list (PDL).
Drug Benefit Product Coverage: Products covered Covers outpatient drugs whose manufacturers have
with restrictions: prescribed insulin; disposable signed a rebate agreement with CMS. General
needles and syringe combinations used for insulin. exclusions include:
Products not covered: blood glucose test strips; urine
ketone test strips; total parenteral nutrition, 1. Agents used for hair growth.
interdialytic parenteral nutrition; cosmetics; fertility
drugs; experimental drugs; and vitamins (other than 2. Vitamin products except prescription prenatal
prenatal vitamins for pregnant women). Prior vitamins.
authorization required for: nitroglycerin patches; 3. Drugs determined by the FDA to be ineffective
agents for impotence; Synagis; Respigam; Xenical- (DESI drugs).
hyperlipidemia; Remicade; Regranex; Kineret;
Enbrel; Xolair; Humira, and Xopenex. Some self – 4. Sedatives and hypnotics in the benzodiazepine
administered injectables may also require prior category (partial coverage).
authorization. 5. Compounded prescriptions (mixtures of two or
more ingredients). States are not allowed to
Over-the-Counter Product Coverage: Limited have state codes such as 99999-9999-99. All
coverage for: allergy, asthma and sinus products; drugs reimbursed by the State must be traced by
analgesics; cough and cold preparations (under 21 NDC code and appear on the utilization report.
years and long-term care limited needs); digestive
products; feminine products; and topical products. Drug utilization managed by preferred products,
Products covered with restriction: smoking deterrent physician profiling, restrictions on use, and prior
products. authorization (requires a Federal MedWatch form to
document why a generic can not be dispensed rather
Therapeutic Category Coverage: Therapeutic than a brand-name product).
categories covered: anabolic steroids; antibiotics; Prior Authorization: State currently has a prior
anticoagulants; anticonvulsants; anti-psychotics; authorization procedure. Beneficiaries have a right to
contraceptives; and thyroid agents. Prior appeal prior authorization decisions. Physician must
authorization required for: analgesics, antipyretics, submit letter and accredited literature explaining
NSAIDs; anti-depressants; antidiabetic agents; medical necessity leading to the request for the
antihistamines; antilipemic agents; anxiolytics, medication. For off-label use, the appeal must
sedatives, and hypnotics; cardiac drugs; ENT anti- document the medical necessity of all failed
inflammatory agents; estrogens; growth hormones; treatments leading to the request for the medication.
hypotensive agents; misc. GI drugs; and
sympathominetics (adrenergic). Partial coverage for: Prescribing or Dispensing Limitations
chemotherapy agents; prescribed cold medications;
and prescribed smoking deterrents (PA required). Prescription Refill Limit: 5 refills within 6 months
Therapeutic categories not covered: anoretics; are allowed. New Rx required every 6 months.
prescription drugs for cosmetic use and vitamin
products (other than prenatal). Monthly Quantity Limit: 31-day supply.
Coverage of Injectables: Injectable medicines are Monthly Prescription Limit: Three prescriptions per
reimbursable through the Prescription Drug Program month per recipient, except unlimited for certified
when used in home health care and extended care LTC recipients and recipients under 21 years old.
facilities, and through physician payment when used Others can receive extension of three more per month
in physicians offices (if reimbursed through the for maintenance medications.
physician’s office). Some products may require prior
authorization.
Arkansas-2
Drug Utilization Review E. USE OF MANAGED CARE
PRODUR system implemented in March 1997. State An estimated 338,000 Medicaid recipients were
currently has a DUR Board with a quarterly review. enrolled with Primary Care Physicians at the end of
2006. Pharmaceutical benefits are provided through
Pharmacy Payment and Patient Cost Sharing the State.
Dispensing Fee: $5.51 effective 3/1/02. Non-MAC

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

services.
Arkansas-3
Prescription Price Updating Department of Human Services Officials

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

None
Arkansas-4
Arkansas Osteopathic Medical Association

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

David Wroten
Executive Vice President
P.O. Box 55088
T: 501/224-8967
F: 501/224-6489
E-mail: dwroten@arkmed.org
Internet address: www.arkmed.org
Arkansas-5
Arkansas-6
CALIFORNIA

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

2003 2004
TOTAL $4,019,645,375 2,868,468 $4,611,537,385 3,173,811
RECEIVING ASSISTANCE, TOTAL $2,934,313,712 1,411,255 $3,352,065,513 1,498,982

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

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

Aged $78,787,478 46,534 $125,309,195 62,473
Disabled $122,373,649 32,105 $188,865,056 44,545
Children $7,306,335 55,378 $7,915,918 61,419
Adults $3,286,279 36,543 $3,614,378 37,955
BCCA Women $5,146,639 2,948 $7,696,754 4,081
TOTAL OTHER EXPENDITURES/RECIPIENTS* $342,196,986 1,017,375 $353,179,444 1,213,373
*Total Other Expenditures/ Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
Note: California estimates drug expenditures to be approximately $5.4 billion in 2005 and $2.6 billion in 2006. The number of
Medicaid drug recipients is estimated to be 3.6 million in 2005 and 3.3 million in 2006.
Source: CMS, MSIS Report, FY 2003 and CMS FY 2004.
California-1
C. ADMINISTRATION Patients can get prior authorization for unlisted drugs

or for listed drugs that are restricted to specific
Under the Health and Human Services Agency with use(s), if medically justified. Manufacturers
direct administration by the Department of Health frequently petition Medi-Cal to add drugs to the List.
Care Services. Based on Medi-Cal’s five criteria (safety, efficacy,
misuse potential, essential need, and cost), a drug
D. PROVISIONS RELATING TO DRUGS may be added to the List by contractual agreement
with the manufacturer to provide the State a
Benefit Design negotiated rebate. The Medi-Cal website at:
http://www.dhs.ca.gov/mcs/mcpd/MBB/contracting/h
Drug Benefit Product Coverage: The Medi-Cal tml/faqpage.htm has details of how the drug
pharmacy benefit covers practically all FDA- contracting process works.
approved drugs, including both legend and over-the-
counter products. There are very few drugs or Examples of general limitations and exclusions
classes of drugs that are non-benefits. Non-benefits (other uses require prior authorization):
include common household remedies; combination
1. CNS stimulants, e.g., amphetamines and
non-legend analgesics and time-released cough/cold
methylphenidate, are restricted to attention
medications, except when specifically listed;
deficit disorder in individuals between 4 and 16
multivitamin preparations, except certain pre-natal
years of age.
and pediatric products; cosmetics; fertility drugs;
experimental drugs, and interdialytic parenteral 2. Diazepam is restricted to use in cerebral palsy,
nutrition. Most other products are potential benefits. athetoid states, and spinal cord degeneration.
3. Most non-steroidal anti-inflammatory agents are
In general, products that are listed on the Medi-Cal
restricted to use for arthritis.
List of Contract Drugs (List) do not require prior
authorization. Those not on the List do require prior 4. Some antibiotics have diagnostic and/or age
authorization. restrictions.
5. Acyclovir capsules are restricted to herpes
Physician-administered drugs: The Medi-Cal List
genitalis, immunocompromised, and herpes
applies to drugs dispensed from pharmacies to
zoster (shingles) patients.
patients. Drugs administered directly in a
physician's, dentist's, or podiatrist's office are not 6. Codeine Combinations: payment to a pharmacy
bound by it. for aspirin or acetaminophen with codeine 30 mg
is limited to a maximum dispensing quantity of
Coverage of Injectables: Injectable medicines are 45 tablets or capsules and a maximum of 3
reimbursable through the Prescription Drug Program claims for the same beneficiary in any 75-day
when used in extended care facilities, through period.
physician payment when used in physician offices,
7. Enteral nutritional supplements or replacements
and through both the prescription drug program and
are covered, subject to prior authorization, if
physician payment when used in home health care.
used as a therapeutic regimen to prevent serious
disability or death in patients with medically
Vaccines: Vaccines are reimbursable by schedule as
diagnosed conditions that preclude the full use of
part of the Vaccines for Children Program. Vaccines
regular foodstuffs.
for adults are covered through the prescription drug
program or as administered in a physician's office. 8. Cancer, AIDS, and DESI Drugs: Any
antineoplastic drug approved by FDA for the
Unit Dose: Unit dose packaging is generally treatment of cancer and any drug approved by
reimbursed at the bulk container rate, like all other FDA for the treatment of AIDS or AIDS-related
products. condition is covered through the Medi-Cal List
of Contract Drugs; most DESI drugs rated less-
Formulary/Prior Authorization than-effective by FDA are not covered.
Formulary: The List contains over 600 drugs, in Prior Authorization: Nearly all drugs not included on
differing strengths and dosage forms, listed the Medi-Cal list of Contract Drugs require prior
generically. The PDL is managed through preferred authorization. State currently has a formal prior
products, exclusion of products based on contracting authorization procedure to appeal prior authorization
issues, restrictions on use, and prior authorization. decisions.
California-2
The patient’s physician or pharmacist may request Hospital Discharge Medications: Quantities
prior authorization from the field office Medi-Cal furnished as discharge medications are limited to no
consultant for approval of unlisted drugs or for listed more than a 10-day supply. Charges are incorporated
drugs that are restricted to specific use(s). This is in the hospital’s claims for inpatient services.
done by completing a Treatment Authorization
Request (TAR) form. Providers may appeal prior Drug Utilization Review
authorization decisions within 60 days of notification
Prospective DUR system implemented in August
to the local field office and then to field services
1995. State currently has a DUR Board with a
headquarters if necessary. Beneficiaries also have the
quarterly review.
ability to request a hearing to review the denial and
must do so within 90 days of notification.
TARs may be approved for: covered items or Dispensing Fee: $7.25 ($8.00 LTC), effective 9/1/04.
services not included on the Medi-Cal List of
Contract Drugs (including special circumstance such Ingredient Reimbursement Basis: EAC = AWP-17%
as the need to override multiple source drug price
ceilings or minimum quantity/ frequency of billing Prescription Charge Formula: Reimbursement is
limitations); and for patients exceeding the 6 Rx per based on the lowest of:
month limit. Statewide mail and fax requests are
accepted in the Stockton and Los Angeles Medi-Cal 1. Estimated Acquisition Cost (EAC) plus current
Field Offices. Requests must include adequate professional fees
information and justification. Authorization may 2. Federal Upper Limit (FUL) plus current
only be given for the lowest cost item or service that professional fees
meets the patient’s medical needs. 3. State Maximum Allowable Ingredient Cost
(MAIC) plus current professional fees
Beneficiary or Prescriber Prior Authorization: On a 4. Pharmacy’s usual price to general public.
case by case basis, the Dept. of Health Care Services
restricts, through the requirements of prior State law requires that reimbursement for blood
authorization, the availability of designated factors be by NDC and not exceed 120 percent of the
prescription drugs to certain beneficiaries or average selling price during the preceding quarter or
prescribers found by the Department to abuse those the provider’s usual and customary charge.
benefits.
Maximum Allowable Cost: State imposes a
Prescribing or Dispensing Limitations combination of Federal and State-specific limits on
generic drugs. Maximum Allowable Ingredient Costs
Prescription Refill Limit: A prescription refill can be (MAICs) are established for about 50 multi-source
dispensed as authorized by prescriber. An exception items. Override requires “Medically Necessary” or
is allowed for refill of a reasonable quantity when unavailability of drug products at or below MAC.
prescriber is unavailable (pursuant to California law). List is periodically revised and price limits changed
Fee is to be pro-rated so that total fee (for partial to reflect current market conditions.
quantity and balance of the prescription after
prescriber is contacted) does not exceed the fee for Incentive Fee: None.
the same prescription when refilled as a routine
service. Many drugs are limited to 3 claims in a 75 Patient Cost Sharing: $1.00 copayment for branded
day period. and generic products.
Monthly Quantity Limit: This is flexible, but should Cognitive Services: Does not pay for cognitive
be consistent with the medical needs of the patient. services, but this is under consideration.
Limited to 100 days’ supply on most drugs. Many
maintenance drugs are subject to minimum quantity
or maximum frequency of billing controls.
Monthly Prescription Limit: Limited to 6 per month

without prior authorization. The limit does not apply
to family planning drugs, patients in nursing
facilities, or to AIDS or cancer drugs.
California-3
E. USE OF MANAGED CARE Contra Costa Health Plan

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

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

1240 South Loop Road 1550 W. Fremont Street, Suite 200
Alameda, CA 94502 Stockton, CA 95203-2643
510/747-4500 800/932-7526
Altamed Senior BuenaCare Health Plan of San Mateo

5425 East Pomona Boulevard 701 Gateway Blvd., Suite 400
Los Angeles, CA 90022 South San Francisco, CA 94080
323/728-0411 650/616-0050
Blue Cross of California Inland Empire Health Plan

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

1120 West La Veta Ave. 393 E. Walnut Street
Orange, CA 92868 Pasadena, CA 91188
714/246-8400 800/390-3510
Care 1st Health Plan Kern Health Systems

800 Howe Avenue, Suite 420 Kern Family Health Care
Sacramento, CA 95825 1600 Norris Road
800/605-2556 Bakersfield, CA 93308
661/391-4036
Center for Elders Independence
1955 San Pablo Avenue LA Care Health Plan
Oakland, CA 94612 555 W. Fifth Street, 20th Floor
510/433-1150 Los Angeles, CA 90013
213/694-1250
Central Coast Alliance for Health
375 Encinal Street, Suite A Molina Healthcare of California
Santa Cruz, CA 95060 One Golden Shore Drive
800/700-3874 Long Beach, CA 90802
562/432-3666, ext. 1128
Community Health Group
740 Bay Blvd. On Lok Senior Health Services-Alameda
Chula Vista, CA 91910 159 Washington Boulevard
619/498-6457 Fremont, CA 94539
415/292-8888
California-4
On Lok Senior Health Services-SF New Brand Name Products Contact

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

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

EDS Federal Corp.
P.O. Box 13029, MS 4604
J. Kevin Gorospe, Pharm.D. Sacramento, CA 95813-4029
Chief, Pharmacy Policy Unit 916/636-1000
California Department of Health Care Services
Medi-Cal Policy Division
Pharmacy Contracting and Policy Section
1501 Capitol Ave., P.O. Box 997417, MS 4604
Sacramento, CA 95899-7417
T: 916/552-9500
F: 916/552-9563
E-mail: kgorospe@dhs.ca.gov
Internet Address: www.dhs.ca.gov/pharmacy
California-5
Stan Rosenstein
Medicaid Drug Rebate Contact
Deputy Director
Craig Miller Medical Care Services
Chief, Drug Rebate and Vision Section California Department of Health Care Services
California Department of Health Care Services 1501 Capitol Ave.
Medi-Cal Policy Division P.O. Box 942732
Pharmacy Contracting and Policy Section Sacramento, CA 95814
1501 Capitol Ave. T: 916/ 440-7800
P.O. Box 997417, MS 4604 F: 916/ 440-7805
Sacramento, CA 95813-4029 E-mail: srosenst.dhs.ca.gov
T: 916/552-9500
F: 916/552-9563 Medi-Cal Contract Drug Advisory Committee
E-mail: cmiller2@dhs.ca.gov
Paul Drogichen, Pharm.D.
Samuel McAlpine, M.D.
Bruce K. Uyeda, Pharm.D.
EDS Federal Corp. Ross Miller, M.D., M.P.H.
P.O. Box 13029, MS 4604 Wendy Ring, M.D., M.P.H.
Sacramento, CA 95813-4029 Clifford Wang, M.D.
916/636-1000 Adrian M. Wong, Pharm.D.
Medicaid Managed Care Contact Executive Officers of State Medical and

Pharmaceutical Associations/Boards
Ronald Sanui, Pharm D.
Pharmaceutical Consultant II California Medical Association
California Department of Health Care Services Joe Dunn
Medi-Cal Managed Care Division Executive Vice-President and CEO
1501 Capitol Ave. 1201 J Street, Suite 200
P.O. Box 997417, MS 4404 Sacramento, CA 95814
Sacramento, CA 95899-7417 T: 916/444-5532
916-449-5138 F: 415/882-3349
E-mail: rsanui@dhs.ca.gov E-mail: soehler@cmanet.org
Internet address: www.cmanet.org
Disease Management Program/Initiatives
Contact Osteopathic Physicians & Surgeons of California
Kathleen S. Creason, M.B.A.
J. Kevin Gorspe, Pharm.D.
Executive Director
916/552-9500
1900 Point West Way, Suite 188
Mail Order Drug Benefit T: 916/561-0724
State currently has a mail order pharmacy capability F: 916/561-0728
in the Medi-Cal program. All fee-for-service E-mail: opsc@opsc.org
beneficiaries are entitled to participate. Internet address: www.opsc.org
Department of Health Services California Pharmacists’ Association

Lynn Rolston, CEO
Sandra Shewry, Director 4030 Lennane Drive
Department of Health Care Services Sacramento, CA 95834
1501 Capitol Ave. T: 916/779-1400
Sacramento, CA 95899 F: 916/779-1401
T: 916/440-7400 E-mail: lrolston@cpha.com
F: 916/440-7404 Internet address: www.cpha.com
E-mail address: sshewry@dhs.ca.gov
California-6
California State Board of Pharmacy

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

C. Duane Dauner
President
1215 K Street, Suite 800
Sacramento, CA 95814
T: 916/443-7401
F: 916/552-7596
E-mail: info@calhealth.org
Internet address: www.calhealth.org
California-7
California-8
COLORADO

Disabled Disabled

2003 2004
TOTAL $251,367,181 197,128 $294,954,808 239,881

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

Aged $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

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

Source: CMS, MSIS Report, FY 2003 and FY 2004.
Colorado-1
C. ADMINISTRATION in physician offices. Prior authorization is required

for self-administration at home.
Colorado Department of Health Care Policy and
Financing administers the drug program. Eligibility Vaccines: Vaccines reimbursable as part of the
is determined by 63 County Departments of Social EPSDT Program.
Services and the Department.
Benefit Design
Formulary: Open formulary with generic mandate.
Drug Benefit Product Coverage: Products covered: Managed through restrictions on use and prior
prescribed insulin; total parenteral nutrition; and authorization.
interdialytic parenteral nutrition. Products not
covered: cosmetics; DESI drugs; fertility drugs; Prior Authorization: State currently has a formal
prescribed vitamins (except prenatal); experimental prior authorization procedure. There is an appeal
drugs; products for weight gain/loss; and hair growth process and re-review when appealing coverage of an
paroducts. Disposable needles and syringe excluded product and prior authorization decisions.
combinations used for insulin; blood glucose test
strips; and urine ketone test strips are considered Prescribing or Dispensing Limitations
DME and do not fall under the State’s drug benefit.
Monthly Quantity Limit: New prescriptions for
Over-the-Counter Product Coverage: Products chronic or acute conditions are prescribed at the
covered with restrictions: allergy, asthma, and sinus discretion of the physician. Normal quantity limit is
products (PA and must be medically necessary); a 30-day supply. Maintenanace medications can
analgesics (aspirin only without PA); cough and cold receive up to a 100 day supply.
preparations (for chronic respiratory conditions);
digestive products (PA and must be medically Other Limits: Additional quantity limits may be
necessary); and smoking deterrent products (prior applied to certain drugs. Oxycontin: 2 tablet (any
authorization, once in a lifetime benefit, 90-day strength) per day limit without prior authorization.
supply in conjunction with smoking cessation
program). Products not covered: H2 antagonists; Drug Utilization Review
feminine products; and topical products.
PRODUR system implemented in December 1998.
Therapeutic Category Coverage: Therapeutic DUR Board meets quarterly.
categories covered: analgesics, antipyretics, and
NSAIDs (partial coverage, PA required); antibiotics;
Lock-In Review Procedures: The Department
anticoagulants; anticonvulsants; antidepressants;
receives computer processed printouts designed to
antidiabetic agents; antihistamines; antilipemic
discover over-utilization of drugs prescribed by
agents; anxiolytics, sedatives and hypnotics; cardiac
physicians, dispensed by vendors, and received by
drugs; chemotherapy agents; contraceptives; ENT
eligible recipients.
anti-inflammatory agents; estrogens; hypotensive
agents; sympathominetics (adrenergic); and thyroid
agents. Prior authorization required for: anabolic
steroids; anti-psychotics (partial coverage);
Dispensing fee: $4.00 as of July 1, 2001.
prescribed cough and cold medications; growth
Institutional pharmacies receive a dispensing fee
hormones; misc. GI drugs (partial coverage); PPIs;
equal to $1.89. Dispensing physicians shall not
Leukotriences; Epoetin; COX-2 inhibitors;
receive a dispensing fee unless their offices or sites
Bactroban; brand name drugs; acne products, Revia;
of practice are located more than 25 miles from the
Xenical; and prescribed smoking deterrents.
nearest participating pharmacy. In the latter case,
Products not covered: anoretics; erectile dysfunction
physicians receive a fee equal to $1.89.
drugs.
Ingredient Reimbursement Basis: EAC = AWP-
13.5%, State MAC, or direct pricing plus 18%.
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities, and through physician payment when used
Colorado-2
Prescription Charge Formula: Benefit drugs shall be prescription stating that he/she is willing to pay the
reimbursed at the lesser of the Medicaid allowable difference in ingredient cost to the pharmacy. The
reimbursement charge, or the provider’s usual and pharmacy will be paid MAC plus a dispensing fee or
customary charge or whatever is accepted from any reimbursement charges, whichever is lower.
third party, discounts, rebates, etc.
High volume Estimated Acquisition Cost (EAC):
The Medicaid allowable reimbursement charge is the Reimbursement for single source drugs or certain
sum of the ingredient cost of the drug dispensed and multiple source drugs which are most frequently
the provider’s dispensing fee. prescribed will be based upon average wholesale
prices (AWP) minus 13.5%, or direct manufacturers’
Ingredient cost for retail pharmacies (estimated prices for package sizes containing quantities greater
acquisition cost) is the price of the drug actually than 100 dosage units or less if not available in
dispensed as defined below or the MAC or the high 100’s.
volume EAC, whichever is less.
Basis for inclusion in the high volume estimated
The ingredient cost for institutional and government acquisition cost list includes but is not limited to:
pharmacies is defined as the actual cost of acquisition
for the drug dispensed or the MAC, or the high (1) Single source manufacturers;
volume EAC, whichever is less. (2) High volume Medicaid recipient utilization;
Maximum Allowable Cost: State imposes Federal (3) Interchangeability problems with multiple source
Upper Limits as well as State-specific limits on drugs;
generic drugs. Override requires “Brand Medically
Necessary.” (4) Package sizes in excess of 100.
Drug Pricing: The Department will maintain a drug-

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

purchase price and the average wholesale price which
appears in the Red Book, its supplements, or Medi- Medicaid Drug Program Administrator
Span exceeds 18%, then the Department may adopt a
lower price after a survey is conducted to determine Catherine Traugott, R.Ph., J.D.
the validity of the published prices. The price from Pharmacy Supervisor
the distributor or manufacturer will be adjusted the Department of Health Care Policy and Financing
same as in 3 above. 1570 Grant Street
Denver, CO 80203
Special Note: The Maximum Allowable Cost shall be T: 303/866-2468
determined by the Division of Medical Assistance, F: 303/866-3552
based upon professional determination of a quality E-mail: catherine.traugott@state.co.us
product available at the least expense possible. Internet Address:
Exceptions to the above are: www.chcph.state.us/hcpf/pharmacy/pharmindex.asp
- Shelf package size oral liquid medications, in pint DUR Contact
size only, or smaller package size when not packaged
in pint size. Kimberly Eggert
Medicaid Pharmacist
- Shelf package size oral tablet and capsule Department of Health Care Policy and Financing
medications in quantities of 100 only or smaller 1570 Grant Street
when not available in package size of 100. Denver, CO 80203
- Prescriptions for less than minimum amounts will T: 303/866-3176
be denied reimbursement of the professional fee F: 303/866-3552
unless the physician notified the Department in E-mail: kimberly.eggert@state.co.us
writing of the medical need for amounts less than a
30-day supply. Medical consultation determines the DUR Board
decision. James R. Kant, R.Ph.
Incentive Fee: None. James R. Regan, M.D., F.A.C.P.
Jeffrey Almony, M.D.
Patient Cost Sharing: Brand: $3.00; Generic: $1.00 Robert D. McCartney, M.D., F.A.C.P.
Mary Newell, R.Ph.
Cognitive Services: Does not pay for cognitive Robert Lee Page, II, Pharm.D., F.A.S.C.P., B.C.P.S.
services. Terrie A. Sajbel, Pharm.D.
Edra B. Weiss, M.D., F.A.A.P.
Kristen Andrews
E. USE OF MANAGED CARE
New Brand Names Products Contact
Approximately 24,000 Medicaid recipients were
Catherine Traugott, R.Ph., J.D.
enrolled in MCOS in FY 2007. Recipients receive
303/866-2468
pharmaceutical benefits through the Managed Care
Organization. Beneficiaries enrolled in behavioral
health organizations receive drugs through the FFS
program or other Medicaid HMOs. Catherine Traugott, R.Ph., J.D.
303/866-2468
Managed Care Organizations
Medicaid Drug Rebate Contacts
Rocky Mountain HMO
2775 Crossroads Boulevard Vince Sherry
P.O. 10600 Drug Rebate Manager
Grand Junction, CO 81502-5600 Department of Health Care Policy and Financing
T: 800/843-0719 1570 Grant Street
F: 970/244-7880 Denver, CO 80203
T: 303/866-5408
Denver Health F: 303/866-3552
777 Bannock Street E-mail: vince.sherry@state.co.us
Denver, CO 80204
303/436-6000
Colorado-4
Claims Submission Contact Health Care Policy & Financing Department

Officials
Susan Pfau, Account Manager
ACS State Healthcare Joan Henneberry
600 17th Street Executive Director
Suite 600 North Department of Health Care Policy and Financing
Denver, CO 80202 1570 Grant Street
T: 800/237-0757 Denver, CO 80203-1818
F: 303/534-0439 T: 303/866-2993
F: 303/866-4411
Medicaid Managed Care Contact E-mail: joan.henneberry@state.co.us
Internet address: www.chcpf.state.co.us
Jerry Smallwood
Managed Care Manager
Barbara Prehmus, Director
Department of Health Care Policy and Financing
Office of Medical Assistance
1570 Grant Street
Department of Healthcare Policy and Financing
Denver, CO 80203
1570 Grant Street
T: 303/866-2416
Denver, CO 80203
F: 303/866-2573
T: 303/866-5929
E-mail: jerry.smallwood@state.co.us
F: 303/866-3476
E-mail: barbara.prehmus@state.co.us
Disease Management/Patient Education
Programs
Medical Services Board
Disease/Medical State: Asthma
Jeffrey Cain, M.D.
Program Name: Asthma Management Program
Julie Reiskin
Program Manager: Christy Hunter
Richard Markley (Vice President)
Program Sponsor: National Jewish Medical and
Joan M. Johnson (President)
Research Center
Wendell Phillips
Kathleen Chitty
Disease/Medical State: Diabetes
Maguerite Salazar
Program Name: Diabetes Disease Management
Byron Geer
Program
Dr. Paul Melinkovich
Program Manager: Christy Hunter
Sally Schaefer
Program Sponsor: McKesson Health Solutions, Inc.
Ginny Riley
Contact
Christy Hunter
Colorado Medical Society
Alfred Gilchrist
1570 Grant Street
Executive Director
Denver, CO 80203T: 303/866-2993
7351 Lowry Boulevard, Suite 110
F: 303/866-2524
Denver, CO 80230
E-mail: christy.hunter@state.co.us
T: 720/859-1001
F: 303/771-8659
Mail Order Pharmacy Program
E-mail: alfred_gilchrist@cms.org
None Internet address: www.cms.org
Colorado-5
Colorado Pharmacists Society

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

Marie Kowalsky
Executive Director
650 South Cherry Street, Suite 510
Denver, CO 80246
T: 303/322-1752
F: 303/322-1956
E-mail: coloradodo@aol.com
Internet address: www.coloradodo.org
Colorado State Board of Pharmacy

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

Steven J. Summer
President and CEO
7335 East Orchard Road, Suite 100
Greenwood Village, CO 80111-2512
T: 720/489-1630
F: 720/489-9400
E-mail: steven.summer@cha.com
Internet address: www.cha.com
Colorado-6
CONNECTICUT

Disabled Disabled
Laboratory & X-ray ! ! ! ! ! ! ! !
Service

2003 2004
TOTAL $402,380,645 119,698 $445,816,745 120,373

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

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

Aged $1,122,306 797 $1,435,796 924
Blind/Disabled $3,674,106 1,381 $3,987,144 1,436
Child $1,328,035 3,249 $1,597,801 3,954
Adult $85,618 999 $131,741 1,168
BCCA Women $196,805 115 $418,869 158
Connecticut-1
C. ADMINISTRATION Unit Dose: Unit dose packaging not reimbursable.

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

covered: allergy, asthma, and sinus products; Prescription Refill Limit: 5 refills per prescription
digestive products (H2 antagonists); and topical except for oral contraceptives, which have a 12-
products. Products covered with restrictions: cough month limit.
and cold preparations (children < 19 years); digestive
products (non H2 antagonists) – liquid generics only Monthly Quantity Limit: Maximum 240 tablets or
(legend drugs not covered). Products not covered: capsules/30-day supply. Oral contraceptives: 3
smoking deterrent products; analgesics; feminine months supply may be dispensed at one time.
products; iron; calcium; and some trace elements. For
nursing home patients, the department will not pay for Physicians are encouraged to prescribe drugs
OTC drugs used in nursing facilities (such drugs are generically, when possible.
covered in the per diem rate). Some drugs require
diagnosis for reimbursement such as CNS stimulants Drug Utilization Review
for ADD and narcolepsy. Pro-DUR system implemented September 1996.
Therapeutic Category Coverage: Therapeutic Retro-DUR since September 1991; the State
categories covered: anabolic steroids; analgesics, currently has a 9 member DUR Board with a
antipyretics, NSAIDs; antibiotics; anticoagulants; quarterly review.
anticonvulsants; antidepressants; antidiabetic agents;
antihistamine drugs; antilipemic agents; anti- Pharmacy Payment and Patient Cost Sharing
psychotics; anxiolytics, sedatives, and hypnotics;
cardiac drugs; chemotherapy agents; prescribed cold Dispensing Fee: $3.15, effective 7/1/04.
medications; contraceptives; ENT anti-inflammatory Ingredient Reimbursement Basis: EAC = AWP-14%.
agents; estrogens; hypotensive agents; misc. GI Special rules for Factor VIII (AAC + 8%).
drugs; sympathominetics (adrenergic); thyroid
agents; and growth hormones. Therapeutic Prescription Charge Formula: Federal MAC or EAC
categories not covered: anorectics and prescribed plus dispensing fee; or usual and customary if lower.
smoking deterrents. Prior authorization required for; Special rules for blood factor VIII.
Brand Medically Necessary prescriptions; early
refills; prescriptions costing more than $500, and Maximum Allowable Cost: State imposes a
drugs not on the preferred drug list (PDL). A combination of Federal and State-specific Upper
complete listing of the drugs on the PDL can be Limits on generic drugs. Effective 1/1/2003, the
found at www.ctmedicalprogram.com. Department implemented a state MAC to include
additional multi-source generic products that are not
Coverage of Injectables: Injectable medicines on the FUL list. The State MAC reimbursement is
reimbursable through physician payment when used in AWP-40%.
home health care, extended care facilities, and in
physicians offices. Patient Cost Sharing: None.
Vaccines: Vaccines reimbursable as part of the Cognitive Services: Does not pay for cognitive
Children Health Insurance Program. services.
Connecticut-2
E. USE OF MANAGED CARE Department of Social Services Officials

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

Community Health Services
Michael Moore, R.Ph.

Hebrew Home Hospital
Connecticut-3
Prescription Price Updating Richard Carbray, Jr., R.Ph.

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

EDS Southbury, CT
195 Scott Swamp Road
Farmington, CT 06032 Lawrence Sobel, R.Ph.
860/255-3934 West Hartford, CT
E-mail: pat.bartolatta@eds.com
Robert Zavoski, M.D.
West Simsbury, CT
Ellen Arce Executive Officers of State Medical and
Pharmacy Manager Pharmaceutical Societies
EDS 195 Scott Swamp Road
Connecticut State Medical Society
Farmington, CT 06032
Matthew C. Katz, Executive Director
860/255-3822
160 St. Ronan Street
E-mail: ellen.arce@eds.com
New Haven, CT 06511-2390
T: 800/635-7740
F: 203/865-0587
Rose Ciarcia E-mail: mkatz@csms.org
Director, Managed Care Internet address: www.csms.org
Department of Social Services
25 Sigourney Street Connecticut Pharmacists Association
Hartford, CT 06106 Margherita R. Guiliano, R.Ph. Executive V.P.
T: 860/424-5139 35 Cold Spring Road, Suite 121
F: 860/951-9544 Rocky Hill, CT 06067-3161
E-mail: rose.ciarcia@ct.gov T: 860/563-4619
F: 860/257-8241
Mail Order Pharmacy Program E-mail: mguiliano@ctpharmacists.org
Internet address: www.ctpharmacists.org
None
Connecticut Osteopathic Medical Society
Disease Management Contact Bridget Price, Executive Director
David Parrella Chicago Office – Main Headquarters
Director, Medical Care Administration 142 East Ontario Street
860/424-5116 Chicago, IL 60611800-0487
T: 800/621-1773, Ext. 8101
Pharmaceutical and Therapeutics Committee T: 312/202-8000
F: 312/202-8200
Holly Bessoni-Lutz, R.N. E-mail: Bprice@osteopathic.org
Farmington, CT Email: Connecticut@osteopathic.org
Internet address: www.osteopathicct.org/
Stella Cretella
West Haven, CT
Connecticut-4
Connecticut Commission of Pharmacy

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

Jennifer Jackson
President and CEO
110 Barnes Road
Wallingford, CT 06492-0090
T: 203/265-7611
F: 203/284-9318
E-mail: jackson@chime.org
Internet address: www.chime.org
Connecticut-5
Connecticut-6
DELAWARE1

Disabled Disabled

2003 2004
TOTAL $110,942,313 99,634 $120,225,182 104,380

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

Aged $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

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


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

prior authorization procedure. Standard procedures
Division of Medicaid and Medial Assistance, for clients to request a fair hearing to appeal prior
Department of Health and Social Services, through authorization decisions.
three county offices of the State agency.
Prescribing or Dispensing Limitations
D. PROVISIONS RELATING TO DRUGS Monthly Limit on Scripts: 15 medications per 30

days.
Benefit Design Prescription Refills: Prescription blank has space for
physician to authorize renewals.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Monthly Quantity Limit: Greater of 34-day supply or
combinations used for insulin; blood glucose test 100 dosing units. May vary depending on
strips; urine ketone test strips; total parenteral therapeutic category.
nutrition; and interdialytic parenteral nutrition.
Products not covered: cosmetics; fertility drugs; Monthly Dollar Limits: None.
experimental drugs; and quality of life medications.
Over-the-Counter Product Coverage: Products
covered: allergy, asthma and sinus products; PRODUR system implemented in August 1994. State
analgesics; cough and cold preparations; digestive has a DUR Board that meets bimonthly.
products; and topical products. Products covered
with restrictions: smoking deterrent products (prior Pharmacy Payment and Patient Cost Sharing
authorization and quantity limits); feminine products. Dispensing Fee: $3.65.
Therapeutic Category Coverage: Therapeutic Ingredient Reimbursement Basis: EAC = AWP-
categories covered: anabolic steroids; anticoagulants; 14.0%. (AWP-16% for LTC)
anticonvulsants; antidepressants; antidiabetic agents;
antihistamine drugs; chemotherapy agents; Prescription Charge Formula: Payment is based on
contraceptives; ENT anti-inflammatory agents; AWP-14.0% or maximum allowable cost (MAC)
estrogens; hypotensive agents; misc. GI drugs; plus a dispensing fee, or the usual and customary cost
sympathominetics (adrenergic); and thyroid agents. to the general public, whichever is lower.
Partial coverage and prior authorization required for:
analgesics, antipyretics, and NSAIDs; anoretics; Maximum Allowable Cost: State imposes Federal
antibiotics; antilpemic agents; anti-psychotics; Upper Limits as well as State-specific limits on
anxiolytics, sedatives, and hypnotics; cardiac drugs; generic drugs. Override requires completion of an
prescribed cold medications; growth hormones; FDA MedWatch form. Over 1,000 drugs on State
prescribed smoking deterrents; Regranex; Zyvox; MAC list.
Soma Accutane Cipro; Cholinesterase inhibitors;
Modafanil; and Epoetin. Incentive Fee: None.
Coverage of Injectables: Injectable medicines Patient Cost Sharing: $0.50-$3.00 (based on the cost
reimbursable through the Prescription Drug Program of the prescription).
when used in extended care facilities, and through
both the prescription drug program and physician
payment when used in physicians’ offices.
services.
Vaccines: Vaccines reimbursable under the CHIP
Program and Vaccines for Children program. E. USE OF MANAGED CARE
Unit Dose: Unit dose packaging not reimbursable. Approximately 99,000 Medicaid recipients were
enrolled in MCOs in FY 2006. Recipients receive
Formulary/Prior Authorization pharmaceutical benefits through the State.
Formulary: Open formulary with preferred drug list.
PDL managed through preferred products and prior
authorization. Diamond State Partners
Delaware-2
P.O. Box 907 Medicaid Drug Rebate Contacts

Manor Branch
Cynthia R. Denemark, R.Ph.
New Castle, DE 19720
302/453-8453
800/390-6093
F. STATE CONTACTS Cynthia R. Denemark, R.Ph.
302/453-8453
Cynthia R. Denemark, R.Ph. Medicaid Managed Care Contact
Director of Pharmacy Services Mary Marinari
DSS/EDS Health Policy Analyst
248 Chapman Road, Suite 100 Managed Care/QA
Newark, DE 19702 Division of Social Services
T: 302/453-8453 Herman Holloway Campus
F: 302/454-0224 Lewis Building
E-mail: cynthia.denemark@eds.com 1901 North DuPont Highway
Internet address: www.dmap.state.de.us New Castle, DE 19720
T: 302/255-9548
Prior Authorization Contact F: 302/255-4481
Cynthia R. Denemark, R.Ph. E-mail: mary.marinari@state.de.us
302/453-8453
DUR Contact None
302/453-8453 Health and Social Services Department
Officials
DUR Board Vincent P. Meconi
Calvin Freedman, R.Ph. (Chair) Secretary
Scott Harrison, D.O. Dept. of Health & Social Services
Phillip Anderson, R.Ph. 1901 North DuPont Highway-Main Bldg.
Susan Fullerton, A.P.N. New Castle, DE 19720
Mark Borer, M.D. T: 302/255-9040
Nadia Helenga, Pharm.D. F: 302/255-4429
Joseph Peoples, R.Ph. E-mail: vmeconi@state.de.us
Frank Falco, M.D. (Vice Chair) Internet address: www.state.de.us/dhhs
Howard Simon, R.Ph.
Albert Rizzo, M.D. Harry Hill
Michael Marcus, M.D. Director
Division of Medicaid and Medical Assistance
New Brand Name Products Contact Dept. of Health & Social Services
1901 North DuPont Highway-Lewis Bldg.
Joli Martini New Castle, DE 19720
Pharmacist Consultant-Clinical Reviews T: 302/255-9500
EDS F: 302/255-4454
248 Chapman Road, Suite 100 E-mail: harry.hill@state.de.us
Newark, DE 19702
T: 302/453-8453 Pharmaceutical and Therapeautics
F: 302/454-0224 Committee
E-mail: joli.martini@eds.com
Cedric T. Barnes, D.O.
Louis Bartoshesky, M.D.
Renee Beaman, R.N.
Prescription Price Updating Calvin Freedman, R.P.h.
Cynthia R. Denemark, R.Ph. Danielle Nordone, D.O.
302/453-8453 Pat Klishevich, R.Ph.
James Lafferty
Delaware-3
Brian Levine, M.D. E-mail: judy.letterman@state.de.us

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

Patricia Carroll-Grant, R.Ph., CDE
Executive Director
P.O. Box 454
Smyrna, DE 19977-0454
T: 302/659-3088
F: 302/659-3089
E-mail: depharmacy@verizon.net
Internet address: www.depharmacy.net
Delaware Osteopathic Medical Society

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

Judy Letterman
Staff Contact
Division of Professional Regulation
Cannon Building
861 Silver Lake Boulevard, Suite 203
Dover, DE 19904
T: 302/744-4504
F: 302/739-2711
Delaware-4
DISTRICT OF COLUMBIA

Disable Disabled
d

2003 2004
TOTAL $82,817,543 34,424 $102,118,065 35,939

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

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

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

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

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

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

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

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

Medical Society of the District of Columbia
K. Edward Shanbacker
Executive Director
2175 K Street, NW, Suite 200
T: 202/466-1800
F: 202/452-1542
E-mail: shanbacker@msdc.org
Internet address: www.msdc.org
Washington D.C. Pharmacy Association

Herbert Kwash, R.Ph., President
908 Caddington Avenue
Silver Spring, MD 20901-1109
T: 301/593-3292
F: 301/593-7125
E-mail: midpharm@aol.com
FLORIDA

Disabled Disabled

2004 2005
TOTAL $2,447,168,182 1,211,983 $1,418,223,186 1,216,491
RECEIVING CASH ASSISTANCE TOTAL $1,328,470,812 520,894 $880,002,105 542,759

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

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

Aged $191,895,894 68,370 $64,078,091 59,598
Blind/Disabled $214,231,198 47,179 $80,132,403 43,495
Child $97,474,208 240,919 $91,933,069 234,317
Adult $14,715,636 87,463 $13,799,093 91,642
TOTAL OTHER EXPENDITURE/RECIPIENTS $336,970,884 198,246 $170,122,763 199,162
*Total other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
Source: CMS, Florida Medicaid Statistical Information System, FY 2004 and FY 2005.
Florida-1
Agency for Health Care Administration. Claims Formulary: Preferred Drug List (PDL) with
processing and payment by contract with fiscal agent. mandatory limits and exclusions. All covered drugs
are available through the preferred drug process.
D. PROVISIONS RELATING TO DRUGS PDL managed by excluding products based on
contracting issues, restrictions on use, prior
Benefit Design authorization, therapeutic substitution, preferred
products, physician profiling and supplemental
Drug Benefit Product Coverage: Products covered: rebates. Specific limits and exclusions include:
prescribed insulin; total parenteral nutrition; and 1. Vitamins and phosphate binders only for dialysis
interdialytic parenteral nutrition. Products covered patients.
with restrictions: non-PDL products require prior 2. Prostheses; appliances; devices; and personal
authorization. Products not covered: cosmetics; care items.
fertility drugs; experimental drugs; disposable 3. Non-legend drugs (except for prescribed insulin,
needles and syringe combinations used for insulin; pancreatic enzymes, buffered and enteric coated
blood glucose test strips; and urine ketone test strips. aspirin when prescribed as an anti-inflammatory
agent only, and single entity hematinics).
Over-the-Counter Product Coverage: Products 4. Anorexants unless the drug is prescribed for an
covered with restrictions: allergy, asthma, and sinus indication other than obesity (i.e., narcolepsy,
products; analgesics (selected aspirin and Tylenol hyperkinesis).
products); cough and cold preparations (select 5. Drugs with questionable efficacy as rated by
products); digestive products (non-H2 antagonists); FDA (DESI).
feminine products; and smoking deterrent products. 6. Investigational and experimental items.
Products not covered: digestive products (H2 7. Oral vitamins with exception of fluorinated
antagonists); topical products. pediatric vitamins prescribed for pediatric
patients, vitamins for dialysis patients, prenatal
Therapeutic Category Coverage: Therapeutic vitamins.
categories covered: anabolic steroids; analgesics, 8. Nursing home floor stock drugs.
antipyretics, and NSAIDs; antibiotics;
anticoagulants; anticonvulsants; anti-depressants; Prior Authorization: State currently has a formal
antidiabetic agents; antihistamines; antilipemic prior authorization procedure. Direct appeal to
agents; antipsychotics; anxiolytics, sedatives, and AHCA and/or formal request for administrative
hypnotics; cardiac drugs; chemotherapy agents; hearing required to appeal prior authorization
contraceptives; ENT anti-inflammatory agents; decisions.
estrogens; hypotensive agents; misc. GI drugs;
prescribed smoking deterrents; sympathominetics Prescribing or Dispensing Limitation
(adrenergic); and thyroid agents. Partial coverage for:
prescribed cold medications. Prior authorization Prescription Refill Limit:
required for: growth hormones; mental health drugs;
drugs not included on the Medicaid preferred drug 1. Variable quantity limits per prescription
list; and brand name prescriptions beyond the four according to the drug.
brand cap unless exempted. Therapeutic categories 2. Drugs not included in the Preferred Drug list
not covered: anoretics; anti-retrovirals for HIV. (PDL) require PA.
3. Maintenance medication should be dispensed
Coverage of Injectables: Injectable medicines and billed for at least a one-month supply.
reimbursable through the Prescription Drug Program 4. Refills must be authorized by the prescriber
when used in home health care and extended care and can be made for up to one year, except that
facilities, and through both the Prescription Drug controlled substances can be refilled only in
Program and physician payment when used in accordance with Federal and State regulations.
physicians’ offices. 5. Nutritional supplements are covered with prior
authorization when the patient is otherwise at
Vaccines: Vaccines reimbursable as part of the risk of hospitalization.
Vaccines for Children Program. 6. Other third parties, including Medicare, must be
billed first.
Florida-2
Drug Utilization Review Buena Vista Medicaid

Vista Health Plan, Inc.
PRODUR system implemented in July 1993. State (FKA Beacon and Discovery)
currently has a DUR board with a quarterly review. 300 South Park Road
Retrospective Drug Utilization Review has been in Hollywood, FL 33021
place since 1982. The State Medicaid agency and the 866/847-8235
Florida Pharmacy Association, which performs the
reviews, share the administration of the program. Citrus Health Care, Inc.
5420 Bay Center Drive, Suite 250
Heritage Information Systems contracts to provide Tampa, FL 33609
DUR and prescriber pattern profiling and clinical T: 877/624-8787
review assistance. F: 813/490-8907
F: 813/490-8909
EverCare
Dispensing Fee: $4.23, effective 3/11/86. 601 Brooker Creek Blvd.
Oldsmar, FL 33609
Ingredient Reimbursement Basis: AWP-15.40 % or 813/818-3300
WAC+5.75%. (effective 7/1/04)
Healthease of Florida, Inc.
Prescription Charge Formula: Lower of: 8735 Henderson Road, Ren 2
Tampa, FL 33634
1. FUL (Federal Upper Limits or State MAC) plus T: 800/278-0656
dispensing fee. F: 813/290-6332
2. EAC plus dispensing fee.
3. Usual and customary charge. Humana Family
4. In-house unit dose diff. + 0.015/dose. c/o Humana Medical Plan, Inc.
3501 SW 160th Street
Maximum Allowable Cost: State imposes Federal Miramar, FL 33027
Upper Limits as well as State-specific limits on T: 800/488-6262
generic drugs. MAC override by physicians requires F: 305/626-5086
“Dispense as written” plus a completed Multi-Source
Brand Drug form and prior authorization. Jackson Memorial Health Plan
1801 NW 9th Ave., Suite 700
Incentive Fee: No incentive fee. Miami, FL 33136
T: 800/721-2993
Patient Cost Sharing: No copayment F: 305/545-5212
Cognitive Services: Does not pay for cognitive Personal Health Plan
services. 324 Datura Street, Suite 401
West Palm Beach, FL 33401
E. USE OF MANAGED CARE T: 866/930-0035
F: 561/833-9786
Approximately 740,000 Medicaid recipients received
Preferred Medical Plan, Inc.
pharmaceutical benefits through managed care plans
4950 SW 8th Street
(inclusion of such benefits is mandated under State
Coral Gables, FL 33134
law) in FY 2006.
T: 305/447-8373
F: 305/648-4094
Amerigroup Florida, Inc. StayWell Health Plan of Florida, Inc.
(FKA Physicians Health Care Plans, Inc.) 8735 Henderson Road, Ren 2
4200 W. Cypress Street, Suite 900 Tampa, FL 33634
Tampa, Fl 33607-4173 T: 813/935-5227
T: 813/830-6900 T: 866/334-7927
T: 800/600-4441 F: 813/290-6332
F: 813/314-2045
Florida-3
Total Health Choice Medicaid DUR Board

8701 SW 137th Avenue, Suite 200
Adam Golden, M.D., M.B.A.
Miami, FL 33183
Miami Beach, FL
T: 305/408-5739
F: 305/408-5880
Anna Hayden, D.O.
Fort Lauderdale, FL
United Healthcare of Florida, Inc.
13621 N.W. 12th Street
Yolangel Hernandez Suarez, M.D., FAOG
Sunrise, FL 33323
Miami, FL
T: 800/910-3145
Leanne Lai, Ph.D.
Universal HealthCare, Inc.
Ft. Lauderdale, FL
150 Second Avenue North, Suite 400
St. Petersburg, FL 33701
Larry Mattingly, D.O.
T: 727/456-6519
Fleming Island, FL
F: 727-823-3840
Lawrence Mobley, M.D.
Vista South Florida
Pensacola, FL
(FKA Foundation Health Plan)
300 South Park Road
Lesia Oliver, R.Ph.
Hollywood, FL 33021
Quincy, FL
T: 800/441-5501
F: 954/986-6082
Kevin Olson, Pharm.D.
Tampa, FL
F. State Contacts
Richard Roberts, Pharm.D.
State Drug Program Administrator Jacksonville, FL
Jerry F. Wells, Bureau Chief
Gina White, Pharm.D., M.B.A.
Medicaid Pharmacy Services
Miami, FL
Agency for Health Care Administration
2728 Mahan Drive, MS 38
Prescribing Pattern Review Panel
Tallahassee, FL 32308
T: 850/487-4441 Joshua Leuchus, D.O., R.Ph.
F: 850/922-0685 Plantation, FL
E-mail: wellsj@ahca.myflorida.com
Internet address: ahca.myflorida.com Anil Mandal
St. Augustine, FL
Stephen Melvin, Pharm.D.
Talisa Hardy, Pharm.D.
Tampa, FL
Pharmacy Program Manager
Dennis Penzell, D.O.
Tampa, FL
T: 850/487-4441
Timothy Sternberg, D.M.D., M.D.
F: 850/922-0685
Jacksonville, FL
E-mail: hardyt@ahca.myflorida.com
Pharmaceutical and Therapeutics Committee
DUR Contact
Carl Brueggemeyer, M.D.
Linda G. Barnes, R.Ph.
Ponte Verda Beach, FL
Lisa Cosgrove, M.D. (Chair)
Cocoa Beach, FL
T: 850/487-4441
Martin Lazoritz, M.D.
F: 850/922-0685
Gainesville, FL
E-mail: barnesl@ahca.myflorida.com
Florida-4
John Lelekis, R.Ph., M.B.A. (Vice Chair) Medicaid Managed Care Contact
Belleair, FL
Melanie Brown-Woofter
AHCA Administrator
Shawn Myers, R.Ph., M.B.A.
Largo, FL
Ronald Renaurt, D.O.
T: 850/487-2355
Ponte Verda Beach, FL
F: 850/410-1676
E-mail: brownme@ahca.myflorida.com
Frank Schwerin, Jr., M.D.
Naples, FL
William Torres, Pharm.D. State has a mail order pharmacy benefit under its
Valrico, FL diabetes demonstration waiver.
Ann C. Wells, Pharm.D. Disease Management/Patient Education

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

Coconut Grove, FL Program Manager: Rachel Lacroix
Program Sponsor: AIDS Healthcare Foundation
Disease/ Medical State: Asthma, Hypertension,
Jerry F. Wells Renal Disease, Congestive Heart Failure, Diabetes,
850/487-4441 Sickle Cell, COPD
Program Manager: Rachel Lacroix
Prescription Price Updating Program Sponsor: Pfizer Health Solutions
First DataBank
Disease Management Program/Initiative
1111 Bayhill Drive, Suite 350
Contact
San Bruno, CA 94066
T: 650/588-5454 Rachel Lacroix
F: 650/827-5454 Program Manager
Medicaid Drug Rebate Contacts 2727 Mahan Drive, MS 20
Tallahassee,FL 32308
Carla G. Sims
T: 850/487-2355
Rebate Coordinator
F: 850/410-1676
E-mail: lacroixr@ahca.myflorida.com
T: 850/487-4441
Officials
F: 850/922-0685
E-mail: simsc@ahca.myflorida.com Dr. Andrew Agwunobi
Secretary
Claims Submission Contact Agency for Health Care Administration
Kevin Whittington
Clinical Program Coordinator
T: 850/922-3809
ACS State Healthcare
F: 850/488-0043
904 Roswell Road
E-mail: agwunoba@myflorida.com
Roswell, GA
850/201-1111
Florida-5
Thomas W. Arnold Florida State Board of Pharmacy

Deputy Secretary for Medicaid Dana Droz, R.Ph., J.D.
Agency for Health Care Administration Executive Director
2727 Mahan Drive, MS 8 4052 Bald Cypress Way, Bin C04
Tallahassee, FL 32308 Tallahassee, FL 32399-3254
T: 850/413-9660 T: 850/245-4292 ext. 3600
F: 850/488-2520 F: 850/413-6982
E-mail: thomas.arnold@myflorida.com E-mail: mqa_pharmacy@doh.state.fl.us
Internet address: www.doh.state.fl.us/mqa/pharmacy
Sybil Richard
Assistant Deputy Secretary for Medicaid Operations Florida Hospital Association
Agency for Health Care Administration Wayne N. Nesmith
2727 Mahan Drive, MS8 President
Tallahassee, FL 32308 306 East College Avenue
T: 850/488-3560 Tallahassee, FL 32301-1522
F: 850/488-2520 T: 850/222-9800
E-mail: richards@ahca.myflorida.com F: 850/561-6230
E-mail: wayne@fha.org
Executive Officers of State Medical and Internet address: www.fha.org
Florida Medical Association, Inc.
Sandra B. Mortham
Executive Vice President and CEO
123 Adams Street
T: 850/224-6496
F: 850/222-8030
E-mail: smortham@medone.org
Internet address: www.fmaonline.org
Florida Pharmacy Association

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

Stephen R. Winn
Executive Director
The Hull Building
2007 Apalachee Parkway
T: 850/878-7364
F: 850/942-7538
E-mail: admin@foma.org
Internet address: www.foma.org
Florida-6
GEORGIA

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

2003 2004
TOTAL $1,003,853,892 1,222,323 $1,156,607,078 1,276,736

Aged $55,817,821 28,717 $60,475,792 27,786
Blind/Disabled $420,162,885 157,887 $486,365,254 162,005
Child $42,928,572 145,981 $49,539,825 152,706
Adults $48,568,376 89,699 $58,585,380 96,438

Aged $7,370,560 3,818 $2,868,859 2,025
Blind/Disabled $14,481,449 5,593 $12,758,152 4,621
Child $4,721 14 $9,311 30
Adults $271 1 $0 0

Aged $2,055,863 2,072 $9,551,738 4,364
Blind/Disabled $3,454,352 2,552 $14,731,690 5,435
Child $103,752,939 349,926 $124,795,334 375,480
Adults $14,283,462 73,530 $16,812,242 77,491
BCCA Women $2,582,111 1,713 $4,034,156 2,274
Georgia-1
C. ADMINISTRATION inflammatory agents; growth hormones; hypotensive

agents; misc. GI drugs; immunoglobulins; COX-II’s;
Department of Community Health, Division of Quinolones; Cephalosporins; Atypical
Medical Assistance. Antipsychotics; ADHD; Ophthalmic Prostaglandin
Agents; Beta Adrenergic Neb/Inhaled
D. PROVISIONS RELATING TO DRUGS Corticosteroids; Bone Ossification; Nasal Steroids;
Topical Immunodulators; Urinary Tract
Benefit Design Antispasmodics; Immunodulators; ophthalmic
mastcell stabilizers; COPD agents; and fibric acid
Drug Benefit Product Coverage: Products covered: derivatives. Therapeutic categories not covered:
Most Federal Legend products with CMS rebates anoretics; barbiturates (except Seconal,
except as otherwise noted. Selected OTC products Phenobarbital, and Mebaral); prescribed smoking
are also covered with prescriptions. Products covered deterrents; fertility drugs; Alprazolam-XR; Klonopin
with restrictions: human insulins (Novo Nordisk, Wafer; Niravam; and Doral.
Lantus, and Levemir insulins and disposable needles
and syringe combinations used for insulin Coverage of Injectables: Injectable medicines
administration are preferred – certain quantity and reimbursable through the Prescription Drug Program
age restrictions may apply); blood glucose test strips when used in home health care and extended care
(Roche products only); and urine ketone test strips. facilities, and through physician payment when used
Products requiring prior authorization: total and in physicians offices.
interdialytic parenteral nutrition (not covered for
adults). See PDL for a comprehensive list of covered Vaccines: Vaccines reimbursable as part of the
products (www.dch.state.ga.us-providers-pharmacy- EPSDT service, the CHIP program, and the Vaccines
PDL). Products not covered: cosmetics; fertility for Children Program.
drugs; experimental drugs; prescription vitamins and
minerals (except for prenatal and fluorides not in Unit Dose: Unit dose packaging reimbursable.
combination with other vitamins); barbituates (except
Seconal, Secobarbital, and Mebaral); DESI drugs; Formulary/Prior Authorization
hair growth products; products for weight gain/loss;
and smoking cessation products. Formulary: Open formulary with preferred drug list.
PDL managed through restrictions on use (quantity
Over-the-Counter Product Coverage: Products level limits; mandatory use of generics), PA,
covered (with a prescription): diphenhydramine; preferred products and physician profiling.
meclizine; H2 antagonists; and OTC iron and
multivitamins. Products covered with restrictions: Prior Authorization: State currently has a formal
allergy, asthma, and sinus products (generic OTC prior authorization procedure with right of appeal.
low sedating antihistamines – up to 6 Rx per year for Clients may write to the Pharmacy Benefit Manager
adults, unlimited for children); cough and cold (PBM) to appeal coverage and prior authorization
products (<21 years); analgesics (ibuprofen decisions.
suspension for < 21 yrs. + enteric coated aspirin); and
topical products (Klout and permethrin lotcon 1%) Prescribing or Dispensing Limitations:
Products not covered: digestive products (not Prescription Refill Limit: None.
including H2 antagonists); feminine products; and
smoking deterrent products. Monthly Quantity Limit: 34-day supply maximum.
Therapeutic Category Coverage: Therapeutic Monthly Dollar Limit: $2,999.99 requires an
categories covered: Most therapeutic categories are override; >$9,999.99 requires paper claim and a copy
covered, including but not limited to the following of the prescription.
and their exceptions: anticoagulants; anticonvulsants;
chemotherapy agents; prescribed cold medications Drug Utilization Review
(partial coverage); contraceptives; estrogens; On-line PRODUR system implemented in October
sympathominetics (adrenergic); and thyroid agents. 2000. State has a 20 member DUR Board that meets
Prior authorization required for: anabolic steroids; quarterly.
analgesics, antipyretics, NSAIDS (partial coverage);
antibiotics; antidepressants; antidiabetic agents;
antihistamines; hyperlipidemic agents;
antipsychotics; anxiolytics, sedatives, and hypnotics Dispensing Fee: $4.63 (for profit), $4.33 (non-profit)
(partial coverage); cardiac drugs; ENT anti- – eff. 7/1/2005
Georgia-2
Ingredient Reimbursement Basis: EAC = AWP - Prior Authorization Contact

11%, MFN price or GMAC.
Emily Baker
Director Clinical Programs
Prescription Charge Formula: Lower of average
Georgia Medicaid Clinical Information
wholesale price (AWP) minus 11% plus dispensing
c/o NorthStar HealthCare Consultants
fee, MAC plus fee, or usual and customary.
1120 Powers Place
Alpharetta, GA 30004
Maximum Allowable Cost: State imposes a
T: 404/308-2285
combination of Federal Upper Limits as well as
F: 877/295-0836
State- specific Limits on generic drugs. Override
E-mail: GAMedicaid@nhc-llc.com
requires Brand Medically Necessary and
GeorgiaWatch form. Approximately 1,440 drugs on
DUR Contacts
the State-specific MAC list.
Policy
Incentive Fee: None Pat Zeigler-Jeter, M.P.A., R.Ph.
DUR Coordinator-Rebate Pharmacist
Patient Cost Sharing: $0.50 per prescription for Department of Community Health
generics or preferred drugs. $0.50-$3.00 for non- Division of Medical Assistance
preferred and brand drugs, dependent on the cost of 2 Peachtree Street, 37th Floor
the drug. Atlanta, GA 30303-3159
T: 404/656-4044
Cognitive Services: Does not pay for cognitive F: 404/657-5461
services. E-mail: pjeter@dch.ga.gov
Disputes
E. USE OF MANAGED CARE Emily Baker
404/308-2285
Approximately 1 million Georgia Medicaid
beneficiaries are enrolled in care management Medicaid DUR Board
organizations through the Georgia Families Program.
Enrolled beneficiaries receive pharmaceutical William F. Bina, M.D.
benefits through their managed care plan. Bruce Welsh Bode, M.D.
Joseph R. Bona, M.D.
Amerigroup Community Care Kimberly S. Carroll, M.D.
888/874-0633 Stacy Michael Dickens, R.Ph., CDM
Gregory Allen Foster, M.D.
WellCare Doris Markowitz Greenberg, M.D.
866/231-1821 Marilavinia Jones, M.D.
James Russell Lee, Jr., R.Ph., CGP
Peach State Health Plan Robyn Loris, Pharm.D.
866/874-0633 J. Russell May, Pharm.D.
Vanessa D. Mickles, Pharm.D.
Mathew Perri, III, R.Ph., Ph.D. (Chair)
F. STATE CONTACTS Raymond Rossenberg, M.D.
Richard S. Singer, D.D.S.
State Drug Program Administrator Cynthia Allen Wainscott
Gary M. Williams, M.D.
Jerry L. Dubberly, Pharm.D., M.B.A.
Director, Pharmacy Services New Brand Name Products Contact
Department of Community Health
Division of Medical Assistance Emily Baker
2 Peachtree Street, NW, 37th Floor 404/308-2285
Atlanta, GA 30303
T: 404/656-4044
F: 404/656-8366
E-mail: jdubberly@dch.ga.gov
Internet address: www.dch.georgia.gov
Georgia-3
Prescription Price Updating Program Name: GA Enhanced Care Program

Program Mamager: APS and United Healthcare
Amy Guenette
Program Sponsor: Georgia Medicaid – Dept. of
VP, Clinical Products
Community Health
SXC
2441 Warrenville Road, Suite 610
Lisle, IL 60532-3647
Contact
T: 630/577-3120
F: 630/577-3101 Argartha L. Russell
E-mail: amy.guenette@sxc.com Director
2 Peachtree Street, NW, 37th Floor
Policy Atlanta, GA 30303
Pat Zeigler-Jeter, M.P.A., R.Ph. T: 404/657-9093
404-656-4044 F: 404/656-8366
E-mail: arussell @dch.ga.gov
Disputes
Gwen Dunwell
Mail Order Pharmacy Benefits
Account Manager
First Health Services Corporation None
900 Circle 75 Parkway, Suite 1660
Atlanta, GA 30339
T: 678-742-6560
F: 770/937-0561
E-mail: dunwelgw@fhsc.com

SXC
2441 Warrenville Road
Suite 610
Lisle, IL 60532-3647
T: 630/577-3100
F: 630/577-3101

Kathy Driggers, Chief
Division Managed Care and Quality
2 Peachtree Street, NW, 36th Floor
Atlanta, GA 30303
T: 404/657-7793
F: 404/656-5537
E-mail: kdriggers@dch.state.ga.us

Programs
Diseases/Medical States:
AIDS/HIV
Asthma/Allergy
Cardiovascular Disease
Depression
Diabetes
Oncology
COPD
Georgia-4
HAWAII

Disabled Disabled

2003 2004
TOTAL $96,404,644 41,748 $110,739,727 41,918

Aged $15,572,783 7,418 $17,162,201 7,328
Blind/Disabled $40,895,766 12,835 $46,535,817 12,932
Child $43,288 676 $58,173 514
Adult $91,096 769 $78,535 594

Aged $4,141,762 2,141 $4,860,757 2,218
Blind/Disabled $1,519,698 484 $1,904,894 482
Child $0 0 $0 0
Adult $175 2 $0 0

Aged $15,308,180 8,328 $18,053,153 8,778
Blind/Disabled $17,739,890 5,306 $20,878,273 5,601
Child $192,337 487 $143,303 454
Adult $0 0 $0 0
BCCA Women $31,577 24 $47,477 29
TOTAL OTHER EXPENDITURES/RECIPIENTS* $868,092 3,278 $1,017,144 2,988
*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
Hawaii-1

Formulary: Open formulary with specific exclusions
Hawaii Department of Human Services through its and limitations. Managed through preferred products
Med-Quest Division and four county branch offices. and prior authorization. Preferred drug list
implemented in 2004.
Prior Authorization: State currently has a formal
Benefit Design prior authorization procedure. A fair hearing may be
requested for appeal of prior authorization decisions.
prescribed insulin. Products covered as DME: Prescribing or Dispensing Limitations
disposable needles and syringe combinations used for Monthly Quantity Limit: Physicians are encouraged
insulin; blood glucose test strips; and urine ketone to prescribe a 30-day supply or 100 units. State has
test strips. Products requiring prior authorization: implemented maximum doses for certain drugs,
total parenteral nutrition (for home infusion); including Epogen, Liptor, Zofran, and Zomig.
interdialytic parenteral nutrition (for home infusion);
Clozaril; brand products on FUL price list; Drug Utilization Review
Betaseron; Oxycontin; and non-preferred PDL drugs.
Products not covered: cosmetics; fertility drugs; PRODUR system implemented in September 1997.
experimental drugs; hair growth products; vitamins State currently has a DUR board with a quarterly
(except prenatal and fluoride preparations); non- review.
rebated drugs; and DESI drugs.
Over-the-Counter Product Coverage: Products Dispensing Fee: $4.67, effective May 9, 1990.
covered: allergy, asthma, and sinus products;
analgesics; and digestive products (non-H2 Ingredient Reimbursement Basis: EAC = AWP-
antagonists). Products covered with restrictions; 10.5%.
cough and cold preparations (select products, others
require prior authorization); digestive products (H2 Prescription Charge Formula: Payment for
antagonists-cimatidine and ranitidine, others require prescription and OTC drugs listed in the formulary is
prior authorization); topical products (for non- limited to the State or Federally established MAC
cosmetic purposes only); and smoking deterrent price, or Estimated Acquisition Cost (EAC) or AWP-
products (Xyban and Chantix only, others require 10.5% when equal to average selling price plus
prior authorization). dispensing fee, or billed amount, whichever is
lowest.
Therapeutic Category Coverage: Products covered:
analgesics, antipyretics, and NSAIDs; antibiotics; Maximum Allowable Cost: State imposes Federal
anticoagulants; anticonvulsants; anti-depressants; Upper Limits and State-specific limits on generically
antidiabetic agents; antilipemic agents; anxiolytics; available drugs. Override requires PA for brand
sedatives; and hypnotics; cardiac drugs; products with FUL or SMAC. “Brand Medically
chemotherapy agents; contraceptives; estrogens; Necessary” or “Do Not Substitute” must be written
hypotensive agents; misc. GI drugs; on the prescription.
sympathominetics (adrenergic); and thyroid agents
Prior authorization required for: anabolic steroids; Incentive Fee: None.
anorectics; non-sedating antihistamine drugs;
prescribed cold medications; proton pump inhibitors; Patient Cost Sharing: No copayment.
growth hormones; and prescribed smoking
deterrents.
Cognitive Services: Emergency Contraception (eff.
2005).
when used in home health care, extended care
facilities and physicians’ offices.
Vaccines: Vaccines reimbursable as part of EPSDT

service and CHIP.
Unit Dose: Unit dose packaging reimbursable
Hawaii-2
E. USE OF MANAGED CARE DUR Contact

Approximately 155,000 Medicaid recipients were Kathleen Kang-Kaulupali, Pharmacy Consultant
enrolled in MCOs in FY 2006. Recipients receive Department of Human Services
most of their pharmaceutical benefits through Med-Quest Division
managed care plans. State has specific guidelines for 601 Kamokila Blvd., Room 506-B
the pharmacy benefit for Medicaid recipients enrolled Kapolei, HI 96707
in managed care plans. Behaviorial health drugs are T: 808/692-8065
part of the managed care plan for behavioral health if F: 808/692-8131
seriously mentally ill. Drugs prescribed by dentists
are “carved out” of managed care and provided Medicaid DUR Board
through the State. Myron Shirasu, M.D. (Internal Medicine)
Honolulu, HI
AlohaCare, Inc. Gregory E.M. Yuen, M.D. (Psychiatry)
John McComas, CEO Honolulu, HI
1357 Kapiolani Blvd., Suite 1250
Honolulu, HI 96814 Linda Tom, M.D. (Geriatric Medicine) (Vice Chair)
808/973-6395 Honolulu, HI
James Lumeng, M.D. (Medicine/Pathology)
Hawaii Medical Service Association (HMSA) Honolulu, HI
Andreas Carvalho, Administration
818 Keeaumoku Street Brian Matsuura (Medical Services Rep.)
Honolulu, HI 96814 Kapolei, HI
808/948-6486
Joy Higa, R.Ph. (Long Term Care) (Chair)
Kaiser Foundation Health Plan, Inc. Kapolei, HI
Virginia Vierra
1441 Kapiolani Blvd, Suite 1600 Jerry Smead, R.Ph. (Ambulatory Care)
808/944-0261
Kerry Kitsu, R.Ph. (Community, chain)
Summerlin Life & Health Kapolei, HI
Regina Young
1440 Kapiolani Blvd., Suite 1020 Adel Etinas (Community, Independent)
808/951-4645
F. STATE CONTACTS Lynn S. Donovan, R.Ph.

808/692-8116
Medicaid Drug Program Administrator
Lynn S. Donovan, R.Ph.
Pharmacy Consultant ACS State Healthcare
Department of Human Services 365 Northridge Road, Suite 400
Med-Quest Division Atlanta, GA 30350
601 Kamokila Boulevard, Suite 506B Attn: Hawaii Medicaid
Kapolei, HI 96707 T: 800/358-2381
T: 808/692-8116 F: 770/730-5198
F: 808/692-8131
Internet address: www.med-quest.us

808/692-8116
Hawaii-3
Medicaid Drug Rebate Contacts Executive Officers of State Medical and

Joseph Braun
Drug Rebate Supervisor Hawaii Medical Association
ACS State Healthcare Paula Arcena
365 Northridge Road, Suite 400 Executive Director
Atlanta, GA 30350 1360 S. Beretania Street, Suite 200
800/358-4122 Honolulu, HI 96814-1520
T: 808/536-7702
Claims Submission Contact F: 808/528-2376
E-mail: paula_arcena@hma-assn.org
Ulka Pandya, Account Manager
Internet address: www.hmaonline.net
365 Northridge Road, Suite 400
Hawaii Pharmacist Association
Atlanta, GA 30350
Catherine Takauye
Attn: Hawaii Medicaid
Executive Director
T: 808/952-5564
P.O. Box 1510
F: 888/725-7559
Aiea, HI 96807-1198
E-mail: ulka.pandya@acs-inc.com
T: 808/330-7738
F: 808/488-8601
E-mail: ctconsulting@hawaii.rr.com
Contact
Internet address: www.hipharm.org/
808/692-8116 Hawaii Association of Osteopathic Physicians and
Surgeons
Mail Order Pharmacy Benefit Ronald H. Kienitz, D.O., President
545 Ohohia Street
None Honolulu, HI 96819
T: 808/831-3000
Pharmacy and Therapeautic Advisory F: 808/834-5763
Committee E-mail: hmacriss@osteopathic.org
Myron Shirasu, M.D. (Chair)
James Lumeng, M.D. Hawaii State Board of Pharmacy
Emerick Orimoto, Pharm.D. Lee Ann Teshima
Stephen Wallach, M.D. Executive Officer
Rio Banner, M.D. DCCA-PVL
Sonny Borja-Barton, Pharm.D. Attn: PHAR
Stuart Rusnak, M.D. P.O. Box 3469
Steven Hong, M.D. Honolulu, HI 96801
T: 808/586-2694
Department of Human Services Officials F: 808/586-2689
E-mail: pharmacy@dcca.hawaii.gov
Lillian B. Koller, Director Internet address:
Department of Human Services www.hawaii.gov/dcca/areas/pvl/boards/pharmacy
1390 Miller Street, Room 209
Honolulu, HI 96813 Healthcare Association of Hawaii
T: 808/586-4997 Richard E. Meiers
F: 808/586-4890 President and CEO
E-mail: lillian.b.koller@hawaii.gov 932 Ward Avenue, Suite 430
Honolulu, HI 96814-2126
Wesley Mun T: 808/521-8961
Acting Administrator, Med-Quest Division F: 808/599-2879
Department of Human Services E-mail: rmeiers@hah.org
601 Kamokila Boulevard, Room 518 Internet address: www.hah.org
Honolulu, HI 96707
T: 808/692-8083
F: 808/692-8173
E-mail: wmun@medicaid.dhs.state.hi.us
Hawaii-4
IDAHO

Disabled Disabled

2003 2004
TOTAL $137,360,436 133,592 $159,792,134 139,491

Aged $5,035,074 1,892 $6,052,122 1,970
Blind/Disabled $74,893,300 21,341 $87,916,262 22,572
Child $3,215,984 11,061 $3,300,246 11,399
Adult $6,388,657 7,277 $8,043,978 7,851

Aged $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

Aged $652,036 374 $658,341 320
Blind/Disabled $527,075 219 $657,082 266
Child $14,133,061 61,070 $15,473,592 62,803
Adult $1,032,224 6,901 $1,216,304 7,280
Idaho-1
C. ADMINISTRATION used in home health care, extended care facilities,

and physicians offices.
Division of Medicaid, Idaho Department of Health &
Welfare Vaccines: Vaccines reimbursable as part of the
By the State Department of Health and Welfare Vaccines for Children Program.
through seven regional offices, each serves five or
more of the State’s 44 counties. Unit Dose: Unit dose packaging reimbursable when
used in unit dose systems.
D. PROVISIONS RELATING TO DRUGS Formulary Authorization
Benefit Design Formulary: None. State maintains a preferred drug
list. Pharmacy program is managed through an
Drug Benefit Product Coverage: Products covered: enhanced prior authorization program (Smart PA),
prescribed insulin. Products covered through DME: restrictions on use, preferred products, and generic
disposable needles and syringe combinations used for substitution for multi-source products.
insulin; blood glucose test strips; urine keton test
strips; total parenteral nutrition; and interdialytic Prior Authorization: State currently has a formal
parenteral nutrition. Products not covered: cosmetics; prior authorization procedure and a prior
fertility drugs; experimental drugs. authorization committee. Patient only may appeal a
prior authorization decision. Written “notice of
OTC Coverage: Products covered with restrictions: appeal” required for fair hearing within 30 days of
allergy, asthma, and sinus products (loratadine OTC receiving the denial.
is covered as the preferred non-sedating
antihistamine); non-H2 antagonists (Prilosec OTC); Prescribing or Dispensing Limitations
topical products (permethrin); oral iron salts; insulin
and insulin syringes. Products not covered: Monthly Quantity Limit: Prescription drugs are
analgesics, cough and cold preparations; digestive limited to a 34-day supply. Limits on the number of
products; feminine products; and smoking deterrent refills per script and early refills. The following drugs
products. are limited to a 100-day supply: cardiac glycosides,
thyroids, prenatal vitamins, nitroglycerin, fluoride,
Therapeutic Category Coverage: Therapeutic fluoride and vitamin combinations, non-legend oral
categories covered: anti-psychotics; chemotherapy iron salts and 3 cycles of birth control.
agents; prescribed cold medications; contraceptives;
ENT anti-inflammatory agents; estrogetns; and Drug Utilization Review
thyroid agents. Prior authorization required for: Contracted DUR through Idaho State University.
analgesics; antipyretics, and NSAIDs; antibiotics; PRODUR system implemented January 1998. State
anticoagulants; anticonvulsants; antidepressants; currently has a DUR board with a quarterly review.
antidiabetic agents; antihistamines; antilipemic
agents; anxiolytics, sedatives, and hypnotics; cardiac Pharmacy Payment and Patient Cost Sharing
drugs; growth hormones; hypotensive agents; misc.
GI drugs; sympathominetics (adrenergic); Dispensing Fee: $4.94 ($5.54 for unit dose),
Alzheimer’s agents; PPIs; Cox IIs; Triptans; long effective March 1999.
acting opiods; urinary incontinence products; select
prenatal vitamins; stimulants; antiemetics; retinoids; Ingredient Reimbursement Basis: Discounted AWP =
topical antiacne products; Provigil; Aldara; Synagis; AWP-12% as determined by First DataBank Data
Regranex; Androgel; Prolastin; Klonopin Wafers; File Service or manufacturer direct price for selected
Marinol; Nascobal; Xenical; Penlac; Prozac Weekly; manufacturers.
Remeron Sol. Tabs; Restasis; Strattera; Taladine;
Thalomid; Triostat; Triptans; Zetia; Xanax XR; Prescription Charge Formula: Lower of FUL,
Xolair; Vytorin; and brand names of FUL and SMAC or Discounted AWP plus a dispensing fee or
SMAC drugs. Therapeutic categories not covered: provider’s usual and customary price to the general
anabolic steroids; anorectics; prescribed smoking public.
deterrents; Alzheimer’s agents; and bladder relaxant
preparations.

reimbursable through the Physician Payment when
Idaho-2
Maximum Allowable Cost: State imposes Federal DUR Contact

Upper Limits as well as State-specific limits on
Tami Eide, Pharm.D., BCPS, FASHP
generic drugs. Override requires “Medically
208/364-1821
Necessary” and submission of appropriate
documentation through the prior authorization
Medicaid DUR Board
process.
Board Members:
Incentive Fee: None. Wayne Baures, R.Ph.
Suzette Cooper, R.Ph.
Patient Cost Sharing: No copayment. Joseph Steiner, Pharm. D.
Nancy Mann, M.D.
Cognitive Services: Does not pay for cognitive Gregory Kadlec, M.D.
services. Myrna Olsan-Fisher, F.N.P.
DUR Program Coordinator:

E. USE OF MANAGED CARE Tami Eide, Pharm.D.
Does not use MCOs to deliver services to Medicaid Staff:
recipients. Vaughn Culbertson, Pharm.D., Project Dir.
F. STATE CONTACTS New Brand Name Products Contact

Mary Wheatley, R.Ph.
Medicaid Drug Program Administrator Pharmacy Services Specialist
Tami Eide, Pharm.D., BCPS, FASHP Department of Health and Welfare
Pharmacy Unit Supervisor Division of Medicaid
Department of Health and Welfare 3232 Elder Street
Division of Medicaid Boise, ID 83705
3232 Elder Street T: 208/364-1832
Boise, ID 83705 F: 208/364-1864
T: 208/364-1821 E-mail: wheatlem@dhw.idaho.gov
F: 208/364-1864
E-mail: eidet@dhw.idaho.gov Prescription Price Updating
Internet address: www.medicaidpharmacy.idaho.gov David Mendoza
Pharmacy Tech
Prior Authorization Contact Department of Health and Welfare
Robert Faller, Medical Program Specialist Division of Medicaid
Department of Health and Welfare 3232 Elder Street
Division of Medicaid Boise, ID 83705
3232 Elder Street T: 208/364-1838
Boise, ID 83705 F: 208/364-1864
T: 208/364-1850 E-mail: mendozad@dhw.idaho.gov
F: 208/364-1864
E-mail: fallerr@dhw.idaho.gov Medicaid Drug Rebate Contact
Larry Tisdale
Pharmacy and Therapeutics Committee Program Supervisor
Bob Comstock, R.Ph. 3rd Party Recovery Unit
Catherine Gundlach, Pharm.D. Department of Health and Welfare
Stan Eisele, M.D. 3232 Elder Street
William Woodhouse, M.D. Boise, ID 83705
Phil Peterson, M.D. 208/287-1141
Michelle Miles, PA-C E-mail: tisdale@dhw.idaho.gov
Rick Sutton, R.Ph.
Thomas Rau, M.D.
Richard Markuson, R.Ph.
Donald Norris, M.D.
Tami Eide, Pharm.D.
Idaho-3
Claims Submission Contact Patti Campbell

Idaho Medicaid
Electronic Data Systems (EDS)
P.O. Box 23 Denise Chukovich
Boise, ID 83707 Idaho State Pharmacy Association
T: 208/395-2000
Greg Dickerson
F: 208/395-2030
Mental Health Provider’s Association
Medicaid Managed Care Contact Emmett Hall
Shoshone Paiute Tribes of Duck Valley
State currently has no managed care program.
Kristyn Herbert
Disease Management / Patient Education Individual
Programs
Deedra Hunt
Diseases/Medical States: Aged Community
Asthma
Toni Lawson
Cardiovascular Disease
Idaho Hospital Association
Depression
Diabetes Mark Leeper
Program Name: Pay for Perfomance Disease Disabled Community
Management
Senator Patti Lodge
Program Manager: Donald Norris, M.D., Medicaid
Idaho State Senate
Medical Director
Program Sponsor: Paul Leary, Medicaid Deputy Cathy McDougall
Administrator AARP
Representative John Rusche, M.D.
Idaho House of Representatives
State currently has no mail order pharmacy program.
Jane Smith
Division of Health
Health and Welfare Department Officials Elke Stava
Hospice Association
Richard Armstrong, Director
Department of Health & Welfare John Traylor
450 West State Street Adu County
Boise, ID 83720-0036
Robert VandeMerwe (Chair)
T: 208/334-5500
Idaho Health Care Association
F: 208/334-6558
E-mail: armstrongr@dhw.idaho.gov Mike Wilson
Living Independently Forever, Inc.
Leslie Clement, Administrator
Department of Health and Welfare Executive Officers of State Medical and
Division of Medicaid Pharmaceutical Societies
Americana Building
Idaho Medical Association
3232 Elder Street
Robert Seehusen, CEO
Boise, ID 83705
P.O. Box 2668
T: 208/334-5747
305 West Jefferson
F: 208/364-1846
Boise, ID 83701
E-mail: clementl@dhw.idaho.gov
T: 208/344-7888
F: 208/344-7903
Title XIX Medical Care Advisory Committee
E-mail: mail@idmed.org
Judith Bailey Internet address: www.idmed.org
Idaho Medical Association
Jim Baugh
CO-AD - Comprehensive Advocacy
Representative Sharon Block
Idaho House of Representatives
Idaho-4
Idaho State Pharmacy Association

Kris Jonas
Director
P.O. Box 140117
Boise, ID 83714-0117
T: 208/424-1107
F: 208/376-3131
E-mail: kris_jonas@msn.com
Internet address: www.idahopharmacy.org
Idaho State Board of Pharmacy

Richard K. Markuson, R.Ph.
Executive Director
3380 Americana Terrace, Suite 320
P.O. Box 83720
Boise, ID 83706
T: 208/334-2356
F: 208/334-3536
E-mail: rmarkuson@bop.id.gov
Internet address: www.accessidaho.org/bop
Idaho Hospital Association

Steven A. Millard
President
615 North Seventh Street
P.O. Box 1278
Boise, ID 83701
T: 208/338-5100
F: 208/338-7800
E-mail: info@teamiha.org
Internet address: www.teamiha.org
Idaho-5
Idaho-6
ILLINOIS

Disabled Disabled

2003 2004
TOTAL $1,258,646,834 1,227,361 $1,684,843,071 1,488,375

Aged $46,309,145 19,407 $55,428,768 19,411
Blind/Disabled $342,245,282 124,232 $404,913,462 126,079
Child $8,131,514 38,447 $9,869,511 41,089
Adult $4,673,507 9,797 $6,755,549 11,389

Aged $126,715,293 47,332 $143,933,137 49,255
Blind/Disabled $166,748,726 50,429 $196,605,037 54,014
Child $449,543 536 $1,120,045 802
Adult $90,739,645 175,752 $128,497,585 211,554

Aged $36,726,797 20,042 $57,880,071 29,167
Blind/Disabled $168,563,439 54,435 $224,188,166 62,692
Child $132,990,993 536,505 $155,791,883 559,125
Adult $5,558,007 36,281 $3,550,192 18,855
BCCA Women $566,881 337 $1,016,465 391
OTHER EXPENDITURES/RECIPIENTS* $128,228,062 113,829 $295,293,200 304,552
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other
recipients, and unknown.
Illinois-1

Illinois Department of Healthcare and Family Formulary: Open formulary with preferred drug list
Services (HFS). (PDL). State PDL is managed through restrictions on
use, prior authorization, and preferred products.
D. PROVISIONS RELATING TO DRUGS Prior Authorization: State currently has a formal
prior authorization procedure and a Committee on
Benefit Design Drugs and Therapeutics. Manufacturers can appeal a
Drug Benefit Product Coverage: Products covered: decision to place products on non-preferred status to
disposable needles and syringe combinations used for the Drug and Therapeutics Committee. Recipients
insulin; total parenteral nutrition; interdialytic can appeal prior authorization decisions through the
parenteral nutrition; and urine ketone test strips. Department’s Bureau of Administrative Hearings.
Products covered with restrictions: (PDL applies):
prescribed insulin; blood glucose test strips; and self- Prescribing or Dispensing Limitations
administered injectables. Products not covered: Prescription Refill Limit: State has a variety of limits
cosmetics; DESI-ineffectives; fertility drugs; to control utilization, including daily dose, refill-too-
experimental drugs; drugs for anorexia or weight soon, quanitity limits, etc.
gain/losss; erectile dysfunction products; hair growth
products; most vitamins; and most OTC products. Monthly Quantity Limit: 3 brand name scripts per
month.
OTC Coverage: Products covered: digestive products
(non-H2 antagonists); smoking deterrent products. Quantity Limit per Script: varies by drug.
Products covered with restrictions: allergy, asthma,
and sinus products (children <21); analgesics Drug Utilization Review
(children <21); cough and cold preparations (PA on
some products); digestive products (H2 antagonists) PRODUR system implemented in January 1993.
(PDL applies); and topical products (PDL applies).
Products not covered: feminine products. Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $3.40 for branded drugs; $4.60 for
Therapeutic Category Coverage: Categories covered generics.
(various products within covered categories require
prior approval): anabolic steroids; analgesics, Ingredient Reimbursement Basis: EAC: AWP-12%
antipyretics, and NSAIDs; antibiotics; (brand); AWP-25% (generics).
anticoagulants; anticonvulsants; anti-depressants;
antidiabetic agents; antilipemic agents; anti-
Prescription Charge Formula: Lowest of 1) usual
psychotics; anxiolytics, sedatives and hypnotics;
and customary, 2) Department's MAC plus fee, 3)
cardiac drugs; chemotherapy agents; prescribed cold
EAC plus fee.
medications; contraceptives; ENT anti-inflammatory
agents; estrogens; growth hormones; hypotensive
agents; misc. GI drugs; prescribed smoking
deterrents; sympathominetics (adrenergic); and
generic drugs. Override requires prior authorization
thyroid agents. Prior authorization required for:
(i.e., letter from physician justifying medical need for
antihistamines and Cox IIs.
the brand drugs).
reimbursable through physician payment when used
in home health care and extended care facilities and
Patient Cost Sharing: $3.00 for branded drugs. No
through both physician payment and the prescription
copay for generics.
drug program when used in physician offices. PDL
rules apply.
services.
Vaccines: Vaccines are reimbursable as part of the
Vaccines for Children Program.
Illinois-2
E. USE OF MANAGED CARE Medicaid Drug Rebate Contact

Jeff Naber
Approximately 155,000 Medicaid recipients are Bureau of Budget and Cash Management
voluntarily enrolled in MCOs in 2007. Recipients Illinois Department of Healthcare and Family
receive pharmaceutical benefits through the State. Services
2200 Churchill Road, Bldg A-1
Managed Care Organizations Springfield, IL 62702
Harmony Health Plan of Illinois T: 217/524-7161
200 West Adams Street F: 217/785-4174
Chicago, IL 60606 E-mail: jeff.naber@illinois.gov
T: 312/630-2025
F: 312/368-1784 Claims Submission Contact
Illinois Department of Healthcare and Family
Family Health Network Services
910 West Van Buren 201 S. Grand Avenue East
6th Floor Springfield, IL 62763
Chicago, IL 60607 T: 217/782-2570
T: 312/491-1956 F: 217/782-5672
F: 312-491-1175
F. STATE CONTACTS Laura Ray
State Drug Program Administrator Services
Lisa D. Voils, Manager 201 S. Grand Avenue East
Drug Coverage Policy Springfield, IL 62763
Illinois Department of Healthcare and Family T: 217/524-7478
Services F: 217/524-7535
201 S. Grand Avenue East E-mail: laura.ray@illinois.gov
Springfield, IL 62763
T: 217/782-2570 Disease Management / Patient Education
F: 217/782-5672 Contact
E-mail: lisa.voils@illinois.gov Steve Saunders, M.D.
Internet address: www.hfs.illinois.gov Medical Director
Prior Authorization Contact Services
Lisa D. Voils 201 S. Grand Avenue East
217/782-2570 Springfield, IL 62763
T: 217/782-2570
DUR Contact F: 217/782-5672
E-mail: steve.saunders@illinois.gov
Lisa D. Voils
217/782-2570 Disease Management / Patient Education
Programs
State has a disease management program, Your
Lisa D. Voils Healthcare Plus, that manages individuals with
217/782-2570 chronic/complex health issues, children and adults
with asthma, and high frequency emergency room
Prescription Price Updating users.
Lisa D. Voils
217/782-2570 Mail Order Pharmacy Benefit
State has a mail order pharmacy benefit. Any
Medicaid beneficiary can choose to receive pharmacy
services from a Medicaid enrolled mail order
pharmacy.
Illinois-3
Illinois Medicaid Agency Officials Myrtis Sullivan, M.D.

Springfield, IL
Barry Maram, Director
Neil Winston, M.D.
Services
Chicago, IL
201 South Grand Avenue, East, Third Floor
T: 217/782-1200
F: 217/524-7120
E-mail: directorhfs@illinois.gov Illinois State Medical Society
Rodney C. Osborn, M.D., President
Theresa Eagleson Wyatt, Administrator 20 N. Michigan Avenue, Suite 700
Medical Programs Chicago, IL 60602
Illinois Department of Healthcare and Family T: 312/782-1654
Services F: 312/782-2023
201 South Grand Avenue, East, Third Floor E-mail: info@isms.org
Springfield, IL 62763 Internet address: www.isms.org
T: 217/782-2570
F: 217/524-5672 Illinois Pharmacists Association
J. Michael Patton, Executive Director
Title XIX Medical Care Advisory Committee 204 West Cook Street
Springfield, IL 62704-2526
Robert Anselmo, R.Ph.
T: 217/522-7300
Wauconda, IL
F: 217/522-7349
E-mail: mpatton@ipha.org
Diane Coleman
Internet address: www.ipha.org
Forest Park, IL
Illinois Osteopathic Medical Society
Nancy Crossman
Elizabeth Forkins Harano
Springfield, IL
Executive Director
142 East Ontario Avenue, Suite 1023
Robyn Gabel (Vice-Chair)
Chicago, IL 60611-2854
Chicago, IL
T: 312/202-8174
F: 312/202-8224
Susan Hayes Gardon
E-mail: ioms@ioms.org
Chicago, IL
Internet address: www.ioms.org
Michael Jones
Illinois State Board of Pharmacy
Springfield, IL
Alisha Purchase, Board Liaison
Illinois Department of Professional Regulation
Debra Kinsey
Pharmacy Section
Springfield, IL
320 West Washington Street
Kim Mitroka
T: 217/782-0458
Christopher, IL
F: 217/782-7645
E-mail: PRFGROUP10@idfpr.com
Richard Perry, D.D.S.
Internet address: www.idfpr.com
OakPark, IL
Illinois Hospital Association
Eli Pick (Chair)
Kenneth C. Robbins, President
Des Plaines, IL
Center for Health Affairs
1151 East Warrenville Road
Pedro A. Poma, M.D.
P.O. Box 3015
Chicago, IL
Naperville, IL 60566
T: 630/276-5400
John S. Shlofrock
F: 630/505-9457
Northfield, IL
E-mail: krobbins@ihha.org
Internet address: www.ihatoday.org
Illinois-4
INDIANA
A. EXPENDITURES FOR DRUGS

2003 2004
TOTAL $137,360,436 133,592 $738,171,688 469,260

Aged $5,035,074 1,892 $56,210,083 17,242
Blind/Disabled $74,893,300 21,341 $280,753,566 67,735
Child $3,215,984 11,061 $16,012,868 53,791
Adult $6,388,657 7,277 $26,254,028 50,749

Aged $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

Aged $652,036 374 $285,919 419
Blind/Disabled $527,075 219 $1,092,680 907
Child $14,133,061 61,070 $52,266,862 124,917
Adult $1,032,224 6,901 $1,293,425 9,421
BCCA Women $0 0 $342,668 221
TOTAL OTHER EXPENDITURES/RECIPENTS* $31,483,025 23,457 $303,659,589 143,858
Note: Indiana estimates 2006 drug expenditures to be approximately $525 million and the number of Medicaid drug recipients to
be 325,700.
B. ADMINISTRATION
Indiana Family and Social Services Administration, Office of Medicaid Policy and Planning
*NOTE WELL—All requests for information by, or on behalf of, drug manufacturers must be made ONLY
to: PDL@FSSA.state.in.us
Phone requests will not be accepted.
Indiana-1
C. PROVISIONS RELATING TO DRUGS Legend Drug Reimbursement Methodology:

Lower/Lowest of:
Benefit Design
1. Federal MAC, if applicable, plus a dispensing
Drug Benefit Product Coverage: Products covered: fee.
All FDA-approved legend drugs from rebating 2. State MAC, if applicable, plus a dispensing fee.
labelers, excluding those products specifically non- 3. EAC plus a dispensing fee.
covered by State law (e.g., cosmetics; fertility 4. Pharmacy’s usual and customary charge to the
enhancement drugs; products to promote weight loss; general public.
DESI drugs; and experimental drugs). For more
detailed coverage information see Maximum Allowable Cost: State imposes Federal
www.indianamedicaid.com or Upper Limits as well as State-specific limits on
www.indianapbm.com. generic drugs. Overide requires “Brand Medically
Necessary” plus prior authorization (as of September
Over-the-Counter Product Coverage: Indiana has a 2001).
Medicaid OTC drug formulary. Listed drugs are
reimbursed based on State MAC. For more detailed Incentive Fee: None.
information, see www.indianapbm.com.
Patient Cost Sharing: $3.00. Exemptions include
Therapeutic Category Coverage: All coverage in institutionalized beneficiaries, pregnant women,
accordance with OBRA ’90 & ’93. children <18 years old, and family planning-related
services.
Coverage of Injectables: Covered.
Cognitive Services: None.
Vaccines: Covered under the Vaccines for Children
Program.
D. USE OF MANAGED CARE
Formulary/Prior Authorization enrolled in Hoosier Healthwise MCOs in FY 2006.
Recipients receive pharmaceutical benefits through
Formulary: Preferred Drug List (see
managed care plans.
www.indianapbm.com-pharmacyservices)
Prior Authorization: State has a prior authorization
program with formal appeal process. Prior Managed Health Services
authorization determined solely on the basis of 1099 N. Meridian Street, Suite 400
medical necessity. For additional information see Indianapolis, IN 46204
www.indianapbm.com 877/647-4848
Prescribing or Dispensing Limitations MDwise

1099 N. Meridian Street, Suite 320
Monthly Quantity Limit: None.
Indianapolis, IN 46204
800/356-1204
PRODUR system implemented in March 1996. State Indiana Hoosier Healthwise (Anthem)
currently has a DUR Board with a monthly review. 800/889-9949
For additional information on managed care, please

refer to:
Pharmacy Payment and Patient Cost Sharing http://www.indianamedicaid.com/ihcp/HoosierHealth
Dispensing Fee: $4.90, effective 05/30/02. wise
Ingredient Reimbursement Basis:
EAC = Brand: AWP-16%

Generic: AWP-20%
Indiana-2
E. STATE CONTACTS Medicaid Drug Rebate Contact

Demetrius Murphy
State Drug Program* Senior Accounting Rebate Specialist
Marc Shirley, R.Ph. ACS State Healthcare
Pharmacy Operations Manager 365 Northridge Road, Suite 400
Family and Social Services Administration Atlanta, GA 30350
Office of Medicaid Policy and Planning T: 770/901-5002 x.3291
Room West 382 F: 866/759-4100
Indiana State Government Center South E-mail: demetrius.murphy@acs-inc.com
402 W. Washington Street
Indianapolis, IN 46204-2739 Claims Submission Contact
T: 317/232-4343 EDS
F: 317/232-7382 950 N. Meridaian Street
E-mail: marc.shirley@fssa.state.in.gov Suite 1150
Internet address: www.indianamedicaid.com Indianapolis, IN 46204
800/577-3240
*NOTE WELL—All requests for information by,
or on behalf of, drug manufacturers must Prior Authorization Contact
be made ONLY to: PDL@FSSA.state.in.us
Phone requests will not be accepted. 365 Northridge Road, Suite 400
DUR Contact Atlanta, GA 30350
866/879-0106
DUR Board Secretary
Office of Medicaid Policy & Planning
Room W382, Indiana Sate Government Center South
402 West Washington Street Managed Care Director
Indianapolis, IN 46204 Office of Medicaid Policy and Planning
T: 317/232-4307 402 W. Washington Street
F: 317/232-7382 Room W382, MS07
Indianaplis, IN 46204-2739
Medicaid DUR Board T: 317/233-4697
F: 317/232-7382
Physicians
Patricia Treadwell, M.D.
John J. Wernert, M.D.
Contact
Philip N. Eskew, Jr., M.D. (Vice Chair)
Director of Chronic Diseases
Pharmacists Office of Medicaid Policy and Planning
Brian W. Musial, R.Ph. Indiana State Government Center South
Thomas A. Smith, P.D., M.S., F.A.S.C.P. 402 W. Washington Street
G. Thomas Wilson, R.Ph., J.D. Room W382, MS07
Health Care Economist
Marko A. Mychaskiw, R.Ph., Ph.D. (Chair) Mail Order Pharmacy Program
None
Pharmacologist
Terry Lindstrom, Ph.D.
Representative from HMO

Vicki Perry
Prescription Pricing Updating

First DataBank
1111 Bay Hill Drive
San Bruno, CA 94066
650/588-5454
Indiana-3
Administration Officials Indiana Pharmacists Alliance

Lawrence J. Sage
Mitch Roob, Secretary
Family & Social Services Administration
729 N. Pennsylvania
Room 461, MS 25
P.O. Box 7083
T: 317/634-4968
F: 317/632-1219
E-mail: inpharm@indianapharmacists.org
T: 317/233-4454
Internet address: www.indianapharmacists.org
F: 317/233-4693
E-mail: mitch.roob@fssa.in.gov
Indiana Osteopathic Association
Michael H. Claphan
Jeffrey M. Wells, M.D., M.H.A.
Executive Director
Director of Medicaid
3520 Guion Road, Suite 202
Office of Medicaid Policy and Planning
Indianapolis, IN 46222-1672
402 West Washington Street, Room W382
T: 317/926-3009
F: 317/926-3984
T: 317/234-2407
E-mail: info@inosteo.org
F: 317/232-7382
Internet address: www.inosteo.org
E-mail: jeffrey.wells@fssa.state.in.gov
Indiana State Board of Pharmacy
Other Advisory Committees
Marty Allain
For information on the following Medicaid program Director
advisory commttees please see 402 W. Washington Street, Room W072
http://www.in.gov/fssa/admin/about/advisory/ompp.h Indianapolis, IN 46204-2739
tml: T: 317/234-2067
Medicaid Advisory Committee F: 317/233-4236
E-mail: pla4@pla.IN.gov
Hoosier Healthwise Clinical Advisory
Internet address: www.in.gov/hpb/boards/isbp
Committee
Prescription Drug Advisory Committee Indiana Hospital and Health Association
Kenneth G. Stella
Indiana Therapeutics Committee President
One American Square
C. Andrew Class, M.D. Suite 1900
Harry Clifton Knight, Jr., M.D. Indianapolis, IN 46282
Michael C. Sha, M.D. (Chair) T: 317/633-4870
James T. Poulos, M.D. F: 317/633-4875
Anne J. Stump, M.D., F.A.A.P. E-mail: kstella@inhha.org
Bill Malloy, M.S., Pharm.D., B.C.P.S. Internet address: www.inha.org
Bruce G. Hancock, M.S., R.Ph.

Indiana State Medical Association
James G. McIntire, J.D.
322 Canal Walk
T: 317/261-2060
F: 317/261-2076
E-mail: jmcintire@ismanet.org
Internet address: www.ismanet.org
Indiana-4
IOWA

Disabled Disabled

2003 2004
TOTAL $325,270,012 258,417 $366,931,835 273,391

Aged $16,875,749 6,062 $15,511,622 5,485
Blind/Disabled $103,389,600 32,840 $110,480,706 33,062
Child $12,173,997 43,671 13925756 44635
Adult $18,418,316 32,426 20469412 33904

Aged $3,776,810 1,794 $3,478,093 1,523
Blind/Disabled $6,006,180 1,553 $6,125,646 1,355
Child $161,104 382 $212,734 451
Adult $1,922,123 2,044 $2,099,148 2,281

Aged $362,790 514 $427,803 540
Blind/Disabled $603,963 474 $619,890 506
Child $13,671,673 53,806 $15,809,069 58,110
Adult $2,037,272 9,269 $2,314,218 10,016
Iowa-1
C. ADMINISTRATION Coverage of Injectables: Injectable medicines

State Department of Human Services, Division of when used in home health care and extended care
Medical Services. facilities, and through both the Prescription Drug
Program and physciaian and physician payment
D. PROVISIONS RELATING TO DRUGS when used in physicians’ offices.

Benefit Design
prescribed insulin. Products covered requiring prior
authorization: PPIs; dipyridamole; epoetin; Formulary/Prior Authorization
filgrastim; vitamins and minerals; ergotamine
Formulary: No formulary. Preferred drug list
derivatives; narcotic agonist-antagonist nasal sprays;
managed through exclusion of products based on
isotretinoin; oral antifungals; non-parenteral
contracting issues, prior authorization, and preferred
vasopressin derivatives; and Serotonin 5-HT1
products.
receptor agonists. Products not covered: fertility
drugs; experimental drugs; cosmetics; disposable
needles and syringe combinations for insulin; blood
prior authorization procedure. State appeals and a
glucose test strips; urine ketone test strips; total
fair hearing procedure required for appeal of prior
parenteral nutrition; interdialytic parenteral nutrition;
authorization decisions and coverage of an excluded
and DESI drugs. For additional information on drug
product.
product coverage, see www.iowamedicaidpdl.com.
Prescribing and Dispensing Limitations:
Prescribing or Dispensing Limitations: Maximum 30
covered: allergy, asthma, and sinus products;
day supply except 90 days for oral contraceptives.
analgesics; cough and cold preparations; topical
Certain categories of drugs have quantity limits.
products; feminine products; and smoking deterrent
products. Products covered with restrictions:
digestive products (non-H2 antagonists). Products
not covered: digestive products (H2 antagonists). PRODUR system implemented in July 1997. State
currently has a DUR Board that meets 8 times per
The Iowa Department of Human Services adopted an year.
administrative rule that permits coverage for certain
non-prescription drugs. A list of covered OTC Pharmacy Payment and Patient Cost Sharing
products, may be found at
www.iowamedicaidpdl.com. Dispensing Fee: $4.52, effective 7/1/06.
Therapeutic Category Coverage: Therapeutic Ingredient Reimbursement Basis: EAC = AWP-12%.
categories covered: anabolic steroids; antibiotics;
anticonvulsants; antidepressants; antilipemic agents; Prescription Charge Formula: Payment will be
anti-psychotics; cardiac drugs; chemotherapy agents; based on the pharmacist's usual, customary and
prescribed cold medications; contraceptives; ENT reasonable charge, but payment may not exceed EAC
anti-inflammatory agents; estrogens; hypotensive plus a dispensing fee.
agents. Prior authorization required for: analgesics, Maximum Allowable Cost: State imposes Federal
antipyretics, NSAIDs; anticoagulants; antidiabetic Upper Limits as well as State-specific limits on
agents; amphetamines; antihistamines; anxiolytics, generic drugs. Override requires “Brand Medically
sedatives, and hypnotics; growth hormones; and Necessary” and completion of a PA form.
misc. GI drugs. Partial coverage for: anoretics (PA
required) prescribed smoking deterrents. Therapeutic Incentive Fee: None.
categories not covered: drugs for strictly cosmetic
purposes and hair growth; fertility drugs; and drugs
without signed Medicaid rebate agreements.
Additional information on product coverage and

preferred drug lists may be found at:
www.iowamedicalpdl.com.
Iowa-2
DUR Contact
Patient Cost Sharing: $1.00 for preferred drugs and
generics, $1-$3 for non-preferred brand drugs, Shelly Larson
depending on the cost of the medication. Director
Iowa Medicaid Enterprise
Cognitive Services: State pays for pharmaceutical 100 Army Post Road
case management. Des Moines, IA 50315
T: 515/725-1295
F: 515/725-1355
E. USE OF MANAGED CARE E-mail: slarson@dhs.state.ia.us
Approximately 285,000 Medicaid beneficiaries were
enrolled in managed care organizations in 2006. This Medicaid DUR Commission
includes both medical managed care organizations Richard Rinehart, M.D.
and the behavioral care carve-out program. Iowa Connie Connolly, R.Ph.
Medicaid recipients enrolled in managed care receive Ronald Miller, M.D., M.B.A.
pharmaceutical benefits through the State fee-for- Bruce Alexander, R.Ph., Pharm.D., B.C.C.P.
service payment program. Laura Ann Griffith, D.O.
Dan Murphy, R.Ph.
Managed Care Organizations Susan Parker, Pharm.D.
Coventry Health Care of Iowa Craig Logemann, R.Ph., Pharm.D., B.C.P.S.
Cheryl Barkau Sara Schutte-Schenck, D.O., F.A.A.P.
Account Manager
4600 Westown Parkway, Suite 301 New Brand Name Products Contact
West Des Moines, IA 50266 Chad Bissell, Pharm.D.
515/225-1234 515/725-1271
Magellan Heath Services
Joan Discher, COO Prescription Price Updating
2600 Westown Parkway, Suite 200 Sandy Pranger, R.Ph.
West Des Moines, IA 50266 POS Account Manager
515/273-0306 Iowa Medicaid Enterprise
100 Army Post Road
F. STATE CONTACTS Des Moines, IA 50315
T: 515/725-1272
State Drug Program Administrator F: 515/725-1357
E-mail: sprange@dhs.state.ia.us
Susan L. Parker, Pharm.D.
Pharmacy Consultant Medicaid Drug Rebate Contacts
Iowa Department of Human Services
1305 E. Walnut Street Sandy Pranger, R.Ph.
Des Moines, IA 50131 515/725-1272
T: 515/725-1226
F: 515/725-1360 Claims Submission Contact
E-mail: sparker2@dhs.state.ia.us Sandy Pranger, R.Ph.
Internet address: www.ime.state.ia.us 515/725-1272
Prior Authorization Contact Medicaid Managed Care Contact

Chad Bissell, Pharm.D. Dennis Janssen, Chief
Clinical Pharmacy Manager Iowa Medicaid Enterprise
Iowa Medicaid Enterprise 100 Army Post Road
100 Army Post Road Des Moines, IA 50315
Des Moines, IA 50315 T: 515/725-1136
T: 515/725-1271 F: 515/725-1360
F: 515/725-1358 E-mail: djansse@dhs.state.ia.us
E-mail: inof@iowamedicaidpdl.com
Iowa-3
DiseaseManagement / Patient Education Title XIX Medical Assistance Advisory

Programs Council
Diseases/Medical States: College of Medicine
Asthma (Breathe Easier) Stacey T. Cyphert, Ph.D.
CHF
Depression House of Representatives
Diabetes Rep. Eric Palmer
Complex Care Rep. Deborah Berry
Program Name: IME Care Management
Program Manager: Linda Westrope Iowa Nurses Association
Program Sponsor: Iowa Medicaid Enterprise Linda Goeldner
Disease Management Program / Initiative Iowa Medical Society

Contact Karla Fultz McHenry
Linda Westrope
Opticians Assn. of Iowa
Ron Bolar
100 Army Post Road
Des Moines, IA 50315
Iowa Senate
T: 515/4725-1340
Senator James Seymour
F: 515/725-1355
Senator Amanda Ragan
E-mail: Lwestro@dhs.state.ia.us
Iowa Dept. of Public Health
Dr. Robert Russell
State currently has a mail order pharmacy program. Tom Newton (Chair)
Participating pharmacies must be enrolled as an Iowa
Medicaid provider. Iowa Dept. of Elder Affairs
John McCalley
Iowa Speech &Hearing Association
Bruce Alexander, R.Ph., Pharm.D., B.C.P.P. Barbara Nebel
Bradley J. Archer, M.D.
Michael A. Flaum, M.D. Iowa Hospital Association
Carole A. Frier, D.O. Shannon Strickler
Hayley L. Harvey, D.D.S., M.S.
Mathew Osterhaus, R.Ph. Iowa Health Care Association
Susan Purcell, R.Ph., C.G.P. Dr. Cindy Baddeloo
Priscilla Ruhe, M.D.
Mary F. Winegardner, PA-C, M.P.A.S. Iowa Assn. for Home Care
Mark Wheeler
Iowa Human Services Department Officials
Kevin W. Concannon, Director Iowa Chiropractic Society
Department of Human Services Jay Iverson
Hoover State Office Bldg., 5th Floor
Des Moines, IA 50319-0014 Iowa Pharmacy Association
T: 515/281-5452 John Forbes, R.Ph.
F: 515/281-7791
E-mail: kconcan@dhs.state.ia.us Iowa Assn. of Homes and Services for the Aging
Dana Petrowsky
Eugene Gessow, Medicaid Director
Department of Human Services Iowa Association of Community Providers
Division of Medical Services Shelly Chandler
Hoover State Office Building, 5th Floor
Des Moines, IA 50319-6242 Iowa Dental Association
T: 515/725-1121 Larry Carl
F: 515/725-1010
E-mail: egessow@dhs.state.ia.us
Iowa-4
Iowa Council of Health Care Centers Coalition for Family and Children’s Services in Iowa
George W. Appleby Kim D. Schmett
Iowa Osteopathic Medical Association AARP

Leah McWilliams Vacant
Iowa Optometric Association Free Clinics of Iowa

Gary Ellis Vacant
Iowa Podiatric Medical Association Iowa Adult Day Services Association

Dr. Richard Spencer Jo Benson-Vorwald
Iowa Psychological Society Iowa Association of Area Agencies Aging

Dan Courtney Donna Harvey
Iowa Association of Hearing Health Professionals Iowa Caregivers Association

Bev Thomas Vacant
Alliance for the Mentally Ill of Iowa Iowa HCBS for Seniors
Margaret Stout David Purdy
Iowa Psychiatric Society Iowa Nurse Practitioner Society

James J. Pullen, M.D. Vacant
Iowa Governor’s Developmental Disabilities Council Iowa/Nebraska Primary Care Association

Richard Shannon Ron Kemp
Iowa Academy of Family Physicians Public Representatives

Dr. Dave Carlyle John Grush
Jodi Tomlonovic
Iowa Physical Therapy Association Julie Frischmeyer
Lorelie Heisinger Kathy Clayton
Kenneth Dietzenbach
Iowa Physician Assistant Society Juanita Brown
Don St. John Karen Tedrow
Caroline Vernon
Iowa Association of Nurse Practitioners William Trout
Janine Petitgout Jim Mulac
Patricia Ann Guyette
Iowa Association of Rural Health Clinics Rita Lyman
Ed Friedmann Lisa Dobson
Elizabeth Walker
Iowa Occupational Therapy Association Cynthia Jewell
Vacant Angela Gomez
Marjorie Stubberrud
The ARC of Iowa Jean Bell
Vacant Charles Clayton
Katey Oakley-Hemming
Iowa Chapter-Nat’l. Association of Social Workers
Jay J. Cayner, A.C.S.W., L.I.S.W.
Iowa Chapter-Am. Academy of Pediatrics

Rizwan Z. Shah, M.D.
Iowa State Association of Counties

Jill Davisson
Iowa-5

Iowa Medical Society
Michael Abrams
1001 Grand Avenue West
T: 515/223-1401
F: 515/223-0590
E-mail: mambrams@iowamedical.org
Internet address: www.iowamedical.org
Iowa Pharmacy Association

Thomas R. Temple, R.Ph., M.S.
8515 Douglas Avenue
Des Moines, IA 50322-2927
T: 515/270-0713
F: 515/270-2979
E-mail: ipa@iarx.org
Internet address: www.iarx.org
Iowa Osteopathic Medical Association

Leah McWilliams
Executive Director
950 12th Street
T: 515/283-0002
F: 515/283-0355
E-mail: leah@ioma.org
Internet address: www.ioma.org
Iowa State Board of Pharmacy Examiners

Lloyd K. Jessen
Executive Secretary/Director
400 SW 8th Street, Suite E
T: 515/281-5944
F: 515/281-4609
E-mail: lloyd.jessen@ibpe.state.ia.us
Internet address: www.state.ia.us/ibpe
Iowa Hospital Association

J. Kirk Norris
President
100 East Grand Avenue, Suite 100
T: 515/288-1955
F: 515/283-9366
E-mail: norrisk@ihaonline.org
Internet address: www.ihaonline.org
Iowa-6
KANSAS1

Disabled Disabled

2003 2004
TOTAL $235,117,999 165,599 $280,750,753 183,107

Aged $16,005,647 6,470 $17,295,558 6,465
Blind/Disabled $81,334,253 29,382 $93,384,590 30,911
Child $3,896,596 17,649 $5,450,405 19,740
Adult $5,921,955 14,581 $7,642,819 16,725

Aged $2,283,434 1,229 $2,241,761 1,233
Blind/Disabled $10,012,044 2,924 $13,154,476 3,399
Child $7,397 15 $497,392 205
Adult $5,216 32 $53,884 146

Aged $669,176 532 $201,237 366
Blind/Disabled $1,219,472 742 $996,733 784
Child $9,647,890 42,624 $11,862,551 47,378
Adult $817,823 6,593 $1,163,350 7,596
BCCA Women $86,437 65 $107,112 76
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and unknown.
1 The State of Kansas did not participate in the 2007 NPC Survey. Using data from CMS, the State’s website and other source materials, we have
to the extent possible, updated the profile and the tables in other sections of the Compilation. Users should contact the Kansas Medicaid program
to assess the accuracy and currency of the information included.
Kansas-1
Kansas Health Policy Authority. Formulary: State currently maintains an open

formulary along with a Preferred Drug List (PDL)
D. PROVISIONS RELATING TO DRUGS (see www.da.ks.gov/hpf). The formulary/ PDL is
managed through restrictions on use, preferred
Benefit Design products, and clinical equivalency determined by the
PDL Committee. Prior authorization required for
Drug Benefit Product Coverage: Products covered: non-PDL products.
prescribed insulin. Products covered under DME:
disposable needles and syringe combinations used for Prior Authorization: State currently has a formal
insulin (prior authorization required); blood glucose prior authorization procedure. The individual
test strips; urine ketone test strips; total parenteral appealing may request an administrative hearing to
nutrition (prior authorization required); and appeal a prior authorization decision by sending a
interdialytic parenteral nutrition (prior authorization request in writing to:
required). Products not covered: cosmetics; fertility
drugs; erectile dysfunction drugs; experimental drugs; Administrative Hearing Office
hair growth products; products for weight gain/loss; 1020 S. Kansas
DESI drugs; and drugs not rebated by the Topeka, KS 66612
manufacturer.
covered: allergy, asthma, and sinus products; Monthly Prescription Limit: 5 single source
analgesics; digestive products; and topical products. scripts/month.
Products covered with restrictions; cough and cold
preparations (for children only); feminine products Prescription Refill Limit: As authorized by the
(some covered); and smoking deterrent products prescriber and allowed by statute up to a one-year
(zyban and patches covered for limited time period). period from the date of issuance of the prescription
Products not covered: OTC nutritional supplements. for non-controlled drugs. No early refills (<80% Rx
utilized).
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; antibiotics; Monthly Quantity Limit: 31-day supply.
anticoagulants; anticonvulsants; antidepressants;
antidiabetic agents; antihistamine drugs; anti- Other: Narcotics, Ketorolac, Toradol Relenza and
psychotics; antilipemic agents; anxiolytics, sedatives, triptans have specific limits.
and hypnotics; cardiac drugs; chemotherapy agents;
contraceptives; ENT anti-inflammatory agents; Drug Utilization Review
sympathominetics (adrenergic); growth hormones PRODUR system implemented in November 1996.
(PA required); and thyroid agents. Partial coverage State currently has a DUR Board that meets every
for: analgesics, antipyretics, and NSAIDs (PA two months.
required on some); anoretics; prescribed cold
medications (children only); and prescribed smoking Pharmacy Payment and Patient Cost
deterrents. Prior authorization required for: triptans; Sharing
nasal steroids; PPIs, statins; Cox-II inhibitors; wound
Dispensing Fee: $3.40, effective 7/1/02.
products; brand name drugs with bioequivalent
generics; and all non-preferred drugs. Ingredient Reimbursement Basis: EAC Brand, =
AWP-13%. Generics, AWP-27%. IV fluids, AWP-
Coverage of Injectables: Injectable medicines 50%. Blood fraction products, AWP-30%.
when used in home health care and extended care Prescription Charge Formula: Pharmacies are
facilities, and through physician payment program reimbursed the lesser of usual and customary, MAC,
when used in physician offices. FUL, or acquisition cost (EAC) plus a dispensing
fee.
Vaccines: Vaccines reimbursed as part of the
Vaccines for Children Program. Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific maximum
Unit Dose: Unit dose packaging not reimbursable. allowable cost (MAC) limits on generic drugs.
Kansas-2
Override requires prior authorization and MedWatch DUR Contact

form.
Anne Ferguson, R.Ph.
DUR Director
Kansas Health Policy Authority
900 SW Jackson, Suite 900
Patient Cost Sharing: A recipient copay charge of
Topeka, KS 66612
$3.00 (effective 7/02) applies to each new and refill
T: 785/296-7788
prescription not specifically exempted under Federal
F: 785/296-4813
regulations.
DUR Board
services. Michael Burke, M.D., Ph.D. (Chair)
Kevin Kentfield, Pharm.D.
Dennis W. Grauer, Ph.D.
E. USE OF MANAGED CARE Tom Wilcox, R.Ph.
Kevin Waite, Pharm.D.
Approximately 160,000 Medicaid Recipients were Brenda Schewe, M.D.
enrolled in MCOs in FY 2006. Recipients receive Roger D. Unruh, D.O.
most pharmaceutical benefits through managed care Judy McDaniel Dowd, P.A-C.
plans. However, hemophilia drugs and certain other
specific compounds are carved out of managed care. Prescription Price Updating
Managed Care Organizations Dr. Margaret Smith
785/296-4753
Children’s Mercy Family Health Partners
215 W. Pershing, Suite 600 Medicaid Preferred Drug List Advisory
Kansas City, MO 64108 Committee
T: 800/347-9363
F: 816/855-1890 Michael Burke, M.D., Ph.D.
Kristen H. Fink, Pharm.D.
UniCare Health Plan of Kansas, Inc. Robert Haneke, Pharm.D.
825 S. Kansas Avenue Glenn Harte, Pharm.D.
Topeka, KS 66612 Brenda Schewe, M.D.
T: 877/604-0462 Donna Sweet, M.D.
F: 785/233-0332 Dennis Tietze, M.D.
Kenneth Mishler, Pharm.D.
Matthew Schlotterback, M.D.
F. STATE CONTACTS
Policy: Anne S. Ferguson, R.Ph.
Dr. Margaret Smith Drug Rebate Program Manager
Pharmacy Program Manager 785/296-7788
900 SW Jackson, Suite 900 Technical: Cindy LaClair
Topeka, KS 66612 Rebate Analyst
T: 785/296-4753 EDS
F: 785/296-4813 3600 SW Topeka Boulevard, Suite 204
Internet address: www.khpa.ks.gov Topeka, KS 66611
T: 785/274-5987
New Brand Name Products Contact F: 785/267-7687
E-mail: cindy.laclair@ksxix.hcg.eds.com
Dr. Margaret Smith
785/296-4753 Claims Submission Contact
Prior Authorization Contact EDS

3600 SW Topeka Boulevard, Suite 204
Dr. Margaret Smith Topeka, KS 66611
785/296-4753 T: 785/274-4200
F: 785/267-7687
Kansas-3

Debra Bachmann, R.N. IV
Manager, HealthWave Title XIX Kansas Medical Society
Kansas Health Policy Authority Jerry Slaughter, Executive Director
900 SW Jackson, Suite 900 623 SW 10th Avenue
Topeka, KS 66612 Topeka, KS 66612
T: 785/296-3981 T: 785/235-2383
F: 785/296-4813 F: 785/235-5114
E-mail: djzb@srskansas.org E-mail: jslaughter@kmsonline.org
Internet address: www.kmsonline.org
Kansas Pharmacists Association
None
Mike Larkin, Executive Director
1020 SW Fairlawn Road
Kansas Health Policy Authority Officials Topeka, KS 66604-2275
Marcia Nielsen, Ph.D., M.P.H. T: 785/228-2327
Executive Director F: 785/228-9147
Kansas Health Policy Authority E-mail: info@kansaspharmacy.org
Landon State Office Building Internet address: www.kansaspharmacy.org
Topeka, KS 66612 Kansas Association of Osteopathic Medicine
T: 785/296-3484 Charles Wheelen, Executive Director
F: 785/296-4813 1260 SW Topeka Boulevard
Internet address: www.khpa.ks.gov Topeka, KS 66612
T: 785/234-5563
Andrew Allison, Ph.D. F: 785/234-5564
Medicaid Director and Deputy Director E-mail: kansasdo@aol.com
Kansas Health Policy Authority Internet address: www.ostheopathic-kansas.org
900 SW Jackson, Suite 900-N
Topeka, KS 66612 Kansas State Board of Pharmacy
T: 785/368-8162 Debra L. Billingsley, Executive Secretary/Director
F: 785/296-4813 Landon State Office Building
E-mail: andrew.allison@khpa.ks.gov 900 SW Jackson, Room 560
Topeka, KS 66612-1231
Kansas Health Policy Authority Board T: 785/296-4056
Appointed Members F: 785/296-8420
Connie Hubbel (Chair) E-mail: pharmacy@ pharmacy.state.ks.us
Joe Tilghman (Vice Chair) Internet address: www.accesskansas.org/pharmacy
Garen Cox
Dr. Ray Davis Kansas Hospital Association
E.J. Holland, Jr. Tom Bell, President
Rob Kaplan 215 Southeast Eighth Avenue
Arneatha Martin P.O. Box 2308
Dr. Vernon Mills Topeka, KS 66603-2308
Susan Page T: 785/233-7436
F: 785/233-6955
Ex-Offico Members E-mail: tbell@kha-net.org
Robert L. Bremby, Secr., Dept. Health & Internet address: www.kha-net.org
Environment
Don Jordan, Secr., Dept. Soc. & Rehab Services
Duane Goosen, Secr., Dept. of Admin.
Kathy Greenlee, Secr., Dept. of Aging
Sandy Praeger, Commis., Insurance Dept.
Howard Rodenberg, Dept. Health & Environment
Kansas-4
KENTUCKY1

Disabled Disabled

2003 2004
TOTAL $693,988,604 512,351 $812,180,180 537,941

Aged $35,882,620 14,823 $39,150,809 14,101
Blind / Disabled $394,291,384 143,625 $468,111,867 147,629
Child $20,659,837 61,746 $28,788,197 70,891
Adult $26,740,703 38,074 $33,073,233 42,686

Aged $5,450,146 2,072 $5,737,119 1,920
Blind / Disabled $5,688,534 2,104 $5,385,053 2,183
Child $3,007,622 7,453 $2,801,023 6,323
Adult $7,364,132 7,897 $8,231,076 7,831

Aged $882,373 702 $844,966 738
Blind / Disabled $1,902,056 1,233 $2,042,753 1,318
Child $49,747,130 140,644 $59,853,338 145,649
Adult $3,954,292 18,654 $4,823,809 20,876
BCCA Woman $320,796 169 $427,611 273
TOTAL OTHER EXPENDITURES/RECIPIENTS* $138,096,979 $73,155 $152,909,326 $75,523

1
The State of Kentucky did not participate in the 2007 NPC Survey. Using information from CMS, the State’s website and other
source materials, we have, to the extent possible, updated the Profile and the tables in the other sections of the Compilation. Users
should contact the Kentucky Medicaid program to assess the accuracy and currency of the information included.
Kentucky-1
C. ADMINISTRATION Program and physician payment when used in

physician offices. Reimbursement is limited to
Department for Medicaid Services, within the antineoplastic drugs with “J” codes in physician
Cabinet for Health and Family Services. offices, several antibiotics, Depo-Provera for birth
control.
Vaccines: Vaccines reimbursable in the cost of the
Benefit Design physician visit as part of EPSDT service, Children’s
Health Insurance Program, Vaccines for Children
Drug Benefit Product Coverage: Products covered: Program and through the Pharmacy Program.
Most legend drugs including prescribed insulin and
syringe combinations used for insulin. Products Unit Dose: Unit dose packaging reimbursable.
covered with restrictions (i.e., require prior Formulary/Prior Authorization
authorization): total parenteral nutrition; and
interdialytic parenteral nutrition. Products not Formulary: Closed Formulary. The Kentucky
covered: cosmetics; fertility drugs; experimental Medicaid Program maintains a closed formulary and
drugs; disposable needles used for insulin; blood covers all rebated products. The State manages the
glucose test strips; urine ketone test strips; hair formulary through a variety of techniques including
growth products; drugs for weight loss or weight the exclusion of products based on contracting issues,
gain; vitamins (except prenatal and fluoride restrictions on use, prior authorization, algorithms,
preparations); and DESI drugs. and preferred products. Prior authorization required
for many brand name products with generic
Over-the-Counter Product Coverage: Products equivalents.
covered with restrictions (i.e., prior authorization and
prescription required): allergy, asthma, and sinus Prior Authorization: State currently has a prior
products; analgesics; digestive products (H2 and non- authorization procedure. A formal appeals process is
H2 antagonists); feminine products; topical products; available if a request is denied.
and other OTCs with signed rebate agreements.
Products not covered: smoking deterrent products; Prescribing or Dispensing Limitations
most supplies; and non-rebatable items except
covered vitamins and vaccines. Monthly Limit on Scripts: 4 scripts per month with
exceptions (children <19, nursing home residents,
Therapeutic Category Coverage: Therapeutic insulin) and override criteria. Override possible for
categories covered: antibiotics; anticoagulants; specific medical conditions and with prior
anticonvulsants; antidepressants; antidiabetic agents; authorization.
chemotherapy agents; contraceptives; ENT anti-
inflammatory agents; estrogens; and thyroid agents. Monthly Dollar Limit: None.
Prior authorization required for: anabolic steroids; Quantity Limit per Script: 32 day supply except
analgesics, antipyretics, NSAIDs; anoretics; maintenance drugs (93 days or 100 units as per the
antihistamine drugs; antilipemic agents; anti- prescriber’s directions).
psychotics; anxiolytics, sedatives, and hypnotics;
cardiac drugs; prescribed cold medications; growth Prescription Refill Limit: Up to 5 refills within a 366
hormones; hypotensive agents; misc. GI drugs; day period from date of original prescription.
topical steroids; erectile dysfunction products;
Leukotriene inhibitors; Synagis; Respigam; Zetia; Drug Utilization Review
CNS stimulants for ADHD and other disorders;
Avodart; Proscar; anti-fungals for nails; Serotonin PRODUR system implemented in 1987. State
5HT1 Receptor Agonosts; GCSF products; currently has a DUR Board with a quarterly review.
Recombinant Human Erythropoietin agents; and
Xolair. Therapeutic categories not covered: Pharmacy Payment and Patient Cost Sharing
prescribed smoking deterrents; agents for cosmetic Dispensing Fee: B: $4.50, G: $5.00.
purposes or hair growth and agents to promote
fertility. Ingredient Reimbursement Basis: EAC =
B: AWP-14%, G: AWP-15%.
when used in home health care and extended care
facilities, and through both the Prescription Drug
Kentucky-2
Prescription Charge Formula: Reimbursement Prior Authorization Contact

consists of the lowest of: (1) the usual and customary
Nici Gaines
charge; (2) the FUL, if any, plus a dispensing fee; or
502/564-7940
(3) the EAC plus a dispensing fee, or (4), SMAC if
any, plus a dispensing fee.
Pharmacy and Therapeutics Advisory
Committee (as of September 2007 posting on
State’s website)
generic drugs. Override requires “Brand Necessary,” Allen J. Brenzell, M.D., M.B.A.
“Brand Medically Necessary,” or Prior Truman Perry, M.D.
Authorization. Dale E. Toney, M.D. (Chair)
Christopher A. Cunha, M.D.
Incentive Fee: None. Praticia Grodecki, M.D.
Connie Gayle White, M.D. (Vice Chair)
Patient Cost Sharing: Tiered copayments based on Naren N. James, M.D.
ability to pay and prescription costs. Pregnant Jeffrey Danhauer, R.Ph.
women, children <19, and institutionalized Kyle Childers, M.D.
beneficiaries are exempt. Porter L. Ramsey, IV, M.D.
Stephen Hill, R.Ph.
$1.00 – Generic
Garry A. Hamm. R.Ph.
$2.00 – Preferred brand
Thomas Badgett, M.D. (non-voting)
$3.00 – Non-preferred brand
Harold Harrison, M.D. (non-voting)
Annual out-of-pocket cost of $225.
Cognitive Services: Does not pay for cognitive DUR Contact
services.
Nici Gaines
502/564-7940
Drug Management Review Advisory Board
Approximately 142,000 Medicaid recipients were (as of September 2007 posting on State’s
enrolled in MCOs in FY 2006. Recipients receive website)
pharmaceutical benefits through both the State and Richard Arnold, M.D. (Chair)
managed care plans. Medications prescribed by a Phillip Bressoud, M.D.
board certified psychiatrist are carved out of Phillip Baier, O.D.
managed care. Patricia Freeman, R.Ph., Ph.D.
James S. Davis, M.D.
Managed Care Organization Karen Barnes, M.D.
Passport Health Plan Janice Sullivan, M.D.
305 West Broadway Madonna H. Ringswald, D.O.
Third Floor John Spencer, Pharm.D.
Louisville, KY 40202 Sandra Thornbury
502/585-7900 Jacob Hutti, Pharm.D.
Misha Glendening, A.R.N.P.
Pam Koob, Ph.D. A.R.N.P.
F. STATE CONTACTS Scott Moody, Pharm.D. (non-voting)
Medicaid Drug Program Administrator Drugs Technical Advisory Committee (as of

Nici Gaines September 2007 posting on State’s website)
Pharmacy Director Clarence Sullivan, Pharm.D.
Department for Medicaid Services Steven Adams, R.Ph.
CHR Building, 6 W-A Ralph Bouvette, R.Ph., Ph.D., J.D.
275 East Main Street Rick Sutton, R.Ph.
Frankfort, KY 40621 Joe Carr, R.Ph.
T: 502/564-7940
F: 502/564-1351
E-mail: nici.gaines@ky.gov
Internet address: www.chs.ky.us/dms
Kentucky-3

Nici Gaines
Kentucky Medical Association
502/564-7940
William T. Applegate
4965 U.S. Highway 42, Suite 2000
Nici Gaines Louisville, KY 40222-6301
502/564-7940 T: 502/426-6200
F: 502/426-6877
Medicaid Drug Rebate Contact E-mail: member@kyma.org
Internet address: www.kyma.org
Nici Gaines
502/564-7940 Kentucky Pharmacists Association
Brad Hall
Claims Submission Contact Executive Director
Nici Gaines 1228 U.S. Highway 127 South
502/564-7940 Frankfort, KY 40601
T: 502/227-2303
Medicaid Managed Care Contact F: 502/227-2854
E-mail: info@kphanet.org
Lorraine Dumas Internet address: www.kphanet.org
Department of Medicaid Services
CHR Building, 6 C-C Kentucky State Board of Pharmacy
275 E. Main St Michael A. Burleson
Frankfort, KY 40621 Executive Director
T: 502/564-3207 Spindletop Administration Building, Suite 302
F: 502/564-0223 2624 Research Park Drive
E-mail: Lorraine.Dumas@ky.gov Lexington, KY 40511
T: 859/246-2820
Mail Order Pharmacy Program F: 859/246-2823
Sate currently has a mail order pharmacy program. E-mail: mike.burleson@ky.gov
Mail order pharmacy program is open to all Medicaid Internet address: http://pharmacy.ky.gov
recipients. Must use a pharmacy that participates in
the Kentucky Medicaid Program. Kentucky Society of Health-System Pharmacists
Dwaine K. Green
Department for Medicaid Services Officials Executive Vice President
One Quality Street
Mark D. Birdwhistell, Secretary Lexington, KY 40507-1428
Cabinet for Health and Family Services T: 859/433-3641
CHR Building, 5 C-A F: 859/257-7297
275 East Main Street E-mail: dgree1@uky.edu
Frankfort, KY 40621 Internet address: www.kshp.org
T: 502/564-7042
F: 502/564-7091 Kentucky Osteopathic Medical Association
E-mail: mark.birdwhistell@ky.gov J. Tom Underwood, Executive Director
Internet address: www.chfs.ky.gov 1501 Twilight Trail
Frankfort, KY 40601
Glenn Jennings, Acting Commissioner T: 502/223-5322
Department for Medicaid Services F: 502/223-4937
Cabinet for Health and Family Services E-mail: info@koma.org
Sixth Floor, Mail Stop 6 W-A Internet address: www.koma.org
275 East Main Street
Frankfort, KY 40621
T: 502/564-7940
F: 502/564-0509
E-mail: anna.dunn@ky.gov
Kentucky-4
Kentucky Hospital Association

Michael T. Rust
President
2501 Nelson Miller Parkway
Louisville, KY 40223
T: 502/426-6220
F: 502/426-6226
E-mail: mrust@kyha.com
Internet address: www.kyha.com
Kentucky Association of Health Care Facilities

Ruby Jo Cummins Lubarsky
9403 Mill Brook Road
Louisville, KY 40223
T: 502/425-5000
F: 502/425-3431
E-mail: rcummins@kahcf.org
Internet address: www.kahcf.org
Kentucky-5
Kentucky-6
LOUISIANA

Disabled Disabled

2003 2004
TOTAL $783,761,071 758,388 $900,611,528 804,196

Aged $108,101,238 38,976 $117,381,252 37,992
Blind/Disabled $307,220,117 120,726 $354,731,039 122,191
Child $18,699,813 59,659 $24,151,257 68,175
Adult $26,138,382 45,526 $32,973,663 49,354

Aged $4,188,723 1,254 $4,579,992 1,267
Blind/Disabled $2,339,144 1,377 $1,907,468 1,087
Child $90,876 310 $134,297 454
Adult $2,943,059 4,286 $3,201,645 4,797

Aged $1,333,418 1,090 $1,321,095 955
Blind/Disabled $2,210,314 1,647 $2,331,768 1,510
Child $114,819,243 325,018 $140,712,923 355,914
Adult $7,169,380 34,198 $8,312,387 36,059
BCCA Women $1,046,784 240 $2,052,599 522
Louisiana-1
C. ADMINISTRATION Prior Authorization: State currently has a formal

prior authorization procedure. Provider request in
Department of Health and Hospitals, Pharmacy writing required to appeal a prior authorization
Benefits Management Unit. decision.

Prescription Refill Limit: Permitted as indicated by
Benefit Design physician within 6 months and not to exceed 5 refills.
Drug Benefit Product Coverage: Products covered: Monthly Quantity Limits: New prescription must be
prescribed insulin; disposable needles and syringe issued for drugs given on a continuing basis, after 5
combinations used for insulin; blood glucose test refills or after 6 months. Maximum quantity for
strips; and urine ketone test strips. Products covered prescriptions shall be either 30-day supply or 100
as DME: total parenteral nutrition and interdialytic unit doses, whichever is greater. Monthly limit of 8
parenteral nutrition. Products not covered: prescriptions per recipient.
cosmetics; DESI drugs; fertility drugs; experimental
drugs; and cough and cold preparations. Other: Viagra and other drugs to treat impotence are
limited to a quantity of 6 pills per month.
covered with restrictions: allergy, asthma, and sinus Drug Utilization Review
products. Products not covered (with limited
exceptions): analgesics; cough and cold preparations; PRODUR system implemented in April 1996. State
digestive products; feminine products; topical has a DUR Board that meets quarterly.
products; and smoking deterrent products.
categories/products covered: all except cosmetics; Dispensing Fee: $4.59 on average, to $5.77
cough and cold preparations; DESI drugs; and maximum, effective 7/1/94.
experimental drugs. Prior authorization required for:
analgesics, antipyretics, and NSAIDs; antibiotics; Ingredient Reimbursement Basis: EAC = AWP-
anticoagulants; anti-depressants; antidiabetic agents; 13.5% for Independent Pharmacies. AWP-15% for
antihistamines; antilipemic agents; anxiolytics, chain pharmacies. (Chain pharmacies are defined as
sedatives, and hypnotics; cardiac drugs; ENT anti- ownership of more than fifteen (15) Medicaid
inflammatory agents; estrogens; growth hormones; enrolled pharmacies under common ownership.)
hypotensive agents; misc. GI drugs; and
sympathominetics (adrenergic). Partial coverage for: Prescription Charge Formula: Medicaid
anoretics; prescribed cold medications. reimbursement for pharmacy services will be based
on the lower of:
reimbursable under the Prescription Drug Program 1. AWP minus 13.5% for independent pharmacies
and through physician payment when used in and AWP minus 15% for chain pharmacies plus
physician offices. a dispensing fee for single source products or
multiple source products with no maximum
Vaccines: Vaccines reimbursable at cost as part of allowable cost limitations or when physician
EPSDT service and the Vaccines for Children authorizes “Brand Medically Necessary” for a
Program. brand name product which has a State MAC or
FUL.
Unit Dose: Unit dose packaging not reimbursable. 2. Louisiana Maximum Allowable Costs (LMAC)
or the Federal Upper Limit plus the dispensing
Formulary/Prior Authorization fee.
3. AWP for multi-source drugs when lower than
Formulary: Open formulary with preferred drug list FUL or LMAC.
(PDL). General management techniques include
4. The provider’s usual and customary charge to
restrictions on use, prior authorization, and preferred
other payors.
products.
Louisiana-2

Mary J. Terrebonne, Pharm.D.
generic drugs. Approximately 800 drugs are listed on
225/342-9768
the State-specific MAC list. Override requires
“Brand Necessary” or “Brand Medically Necessary.”
DUR Board
Incentive Fee: None. Edwin Adams, Pharm.D.
Monroe, LA
Patient Cost Sharing: $ 0.50 - $3.00 copayment
depending of the cost of the prescription, effective Ken Ardoin, Senior Manager
7/13/95. Westlake, TX
Cognitive Services: Does not pay for cognitive LeAnn Causey, Pharm.D.
services Natchitoches, LA
Jule Assercq, M.D.

E. USE OF MANAGED CARE Baton Rouge, LA
Does not use MCOs to deliver services to Medicaid Jeffrey S. Nopoli, Pharm.D.
recipients. Baton Rouge, LA
F. STATE CONTACTS Richard A. Soileu, Pharm.D.

New Iberia, LA
David Thomas, M.D.
Mary J. Terrebonne, Pharm.D. Baton Rouge, LA
Pharmacy Director
Department of Health & Hospitals Charmaine Venters, M.D.
Pharmacy Benefits Management Unit Baton Rouge, LA
Bienville Building
628 N. Fourth Street, 7th Floor
P.O. Box 91030 New Brand Name Products Contact
Baton Rouge, LA 70821 Mary J. Terrebonne, Pharm.D.
T: 225/342-9768 225/342-9768
F: 225/342-1980
E-mail: mterrebo@dhh.la.gov Prescription Price Updating
Internet address: www.lamedicaid.com or
www.dhh.la.gov Maggie Vick
Unisys
Department of Health and Hospital 8591 United Plaza Boulevard, Suite 300
Administration Officials Baton Rouge, LA 70809
T:225/216-6251
Frederick P. Cerise, M.D., M.P.H., Secretary F: 225/216-6334
Department of Health and Hospitals E-mail: margaret.vick@unisys.com
P.O. Box 629, Bin #2
Baton Rouge, LA 70821-0629 Medicaid Drug Rebate Contacts
T: 225/342-9500
F: 225/342-5568 Policy: Mary J. Terrebonne, 225/342-9768
E-mail: fcerise@dhh.la.gov Disputes: Amanda Caire, 225/342-0427
Jerry Phillips, Medicaid Director

Bureau of Health Services Financing
Department of Health and Hospitals
P.O. Box 91030
Baton Rouge, LA 70821-9030
T: 225/342-3891
F: 225/342-9508
E-mail: jphillips2@dhh.la.gov
Louisiana-3
Claims Submission Contact Medicaid Pharmaceutical and Therapeutics

Committee
Carol Simpson
Project Manager Mr. Joseph Adams, R.Ph.
Unisys Mandeville, LA
8591 United Plaza Blvd., Suite 300
Baton Rouge, LA 70809 Donnie Battie, M.D.
T: 225/216-6312 Baton Rouge, LA
F: 225/924-6179
E-mail: carol.simpson@unisys.com Frederick P. Cerise, M.D., M.P.H.
Baton Rouge, LA
Richard Doskey, M.D.
State has a voluntary mail order pharmacy program
River Ridge, LA
open to all Medicaid recipients.
Conchetta W. Fulton, Ph.D.
New Orleans, LA
Mary J. Terrebonne, P.D.
225/342-9768 Mary L. Gauthier-Lewis, M.D.
Prairieville, LA
Medical Care Advisory Committee
Larry Hebert, M.D.
Sandra C. Adams (Chairperson) Baton Rouge, LA
Rep. John Alario
Brenda Armstrong Ernest W. Kinchen, M.D.
Ralph D. Balentine Lafayette, LA
Dr. Donnie Battie
Danny Bond Michael L. Kudla, M.D.
Francine Boyles Lake Charles, LA
Dr. Floyd A. Buras
Marcia Daigle James R. Lang
Partricia DeMichele Many, LA
Annette Droddy
Daly Dupre, Jr. W. Chapman Lee, M.D.
Rep. Sydnie Durand Baton Rouge, LA
Wanda Ellis
Warren Hebert Catherine A. McDonald, M.D.
Sen. Francis Heitmeier Lafayette, LA
Paul Hildreth
Amelia Lafont Marty R. McKay, R.Ph.
Rhonda Litt Woodworth, LA
Kay Marcel
Dr. Robert L. Marier Donald R. Parker, M.D.
Sen. William “Joe” McPherson Lake Charles, LA
June Peach
Dr. Keith M. Perrin Paul E. Perkowski, M.D.
Tawana Pounders Baton Rouge, LA
Sean Prados
Willa Rawls John B. Pope, M.D.
Greg Scott Shreveport, LA
Richard “Andy” Soileau
Mary Tonore Kenyatta D. Shamlin, M.D.
Dr. Leonard Weather, Jr. Baton Rouge, LA
Linda Welch
Ms. Ann Williamson Carolyn Tackett
Hammond, LA
Louisiana-4
Ann Henderson Tilton, M.D. Louisiana State Board of Pharmacy

Metarie, LA Malcolm J. Broussard
Executive Director
Roxane Townsend, M.D. 5615 Corporate Boulevard, Suite 8E
Baton Rouge, LA Baton Rouge, LA 70808-2537
T: 225/925-6496
Leonard J. Weather, Jr., M.D. F: 225/925-6499
Shreveport, LA E-mail: mbroussard@labp.com
Internet address: www.labp.com
Lolie C. Yu, M.D.
New Orleans, LA Louisiana Pharmacists Association
Robert “Rock” LeBas
Medical Pharmacy Benefits Management President
Advisory Committee 450 Laurel Street, Suite 1400
Baton Rouge, LA 70801
Ken Ardoin
T: 225/346-6883
Michelle Wolf-Selfo
F: 225/344-1132
Scott Napoli
E-mail: familydrugstore@aol.com
Lamar Pritchard
Internet address: www.louisianapharmacists.com
Allan Brinkhaus
Clovis Burch
Louisiana Society of Health-System Pharmacists
Horace Bynum
Tommy Mannino
Wayne T. Harris
President
Tim Jacks
8550 United Plaza Boulevard, Suite 1001
Ruth “Cookie” Jean
Ricky Guidry
T: 225/922-4520
Carl Aron
F: 225/922-4611
Andy Soileau
E-mail: tommann40@aol.com
Marty McKay
Internet address: www.lshp.org
Jerry Wallace
Kirt Soileau
Louisiana Hospital Association
Kyle Ardoin
John A. Matessino
Sandy Blake
President and CEO
Peggy Van
9521 Brookline Avenue
Jessica Monroe
Baton Rouge, LA 70898-0720
David Osborn
T: 225/928-0026
LeAnn Causey
F: 225/923-1004
E-mail: jmatessino@lhaonline.org
Internet address: www.laha.org
Louisiana State Medical Society
Dave L. Tarver
6767 Perkins Road, Suite 100
T: 225/763-8500
F: 225/763-6122
E-mail: executive@lsms.org
Internet address: www.lsms.org
Louisiana Osteopathic Medical Association

Joel Glen Eldridge, D.O.
President
215 Friedrichs Avenue
Metairie, LA 70005-4516
800/621-1773, ext. 8188
E-mail: lomadocs@bellsouth.net
Internet address: www.loma-net.org
Louisiana-5
Louisiana-6
MAINE

Disabled Disabled

2003 2004
TOTAL $278,812,700 245,562 $304,330,901 223,450

Aged $21,153,681 8,250 $20,217,951 7,345
Blind/Disabled $86,417,385 26,886 $92,191,476 27,517
Child $247,840 640 $6,641 9
Adults $9,275,349 11,492 $12,232,707 14,477

Aged $8,217,440 2,869 $6,656,755 2,410
Blind/Disabled $2,917,815 739 $1,939,846 524
Child $137,612 355 $139,003 262
Adults $203,363 316 $160,893 295

Aged $19,221,778 12,418 $22,670,181 9,632
Blind/Disabled $31,829,526 11,168 $35,711,661 10,562
Child $19,666,507 61,729 $23,036,240 64,106
Adult $474,798 1,560 $496,743 1,710
BCCA Women $152,519 98 $166,218 126
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and unknown.
Source: CMS, MSIS Report FY 2003 and FY 2004.
Maine-1

State Department of Health and Human Services, Formulary: Open formulary with preferred drug list
Office of MaineCare Services. (PDL). PDL managed through exclusion of
products based on contracting issues; restrictions on
use; prior authorization; therapeutic substitution;
D. PROVISIONS RELATING TO DRUGS preferred products, and physician profiling. (The
Maine Care Preferred Drug List can be seen at
Benefit Design www.ghsinc.com.)
prescribed insulin; disposable needles and syringe Prior Authorization: State currently has a formal
combinations used for insulin (not covered for prior authorization procedure. Prior authorization
nursing home patients); blood glucose test strips may be obtained in the case of necessary
(with HbA1e values); urine ketone test strips; total exceptions. Fair hearing appeal of denials through
parenteral nutrition; and interdialytic parenteral the Office of Administrative Hearings.
nutrition. Products not covered: cosmetics; fertility
drugs; experimental drugs; vitamins and vitamin Prescribing or Dispensing Limitations
preparations (except pregnancy); and injectables Monthly Prescription Limit: 4 brand name scripts
when oral medication is available for equally per month.
effective treatment.
Monthly Quantity Limit: In-general, 34-day for
Over-the-Counter Product Coverage: Products brand name drugs and 90 days for generic drugs.
covered with restrictions: allergy, asthma, and sinus May vary by drug.
products; analgesics; cough and cold preparations;
digestive products; feminine products; topical Prescription Refill Limit: maximum of 11 refills
products; smoking deterrent products (by Rx only). per prescription.

categories covered (PA required): anabolic steroids;
analgesics, antipyretics, and NSAIDs; anoretics; PRODUR system implemented in 1995. State
antibiotics; anticoagulants; anticonvulsants; anti- currently has a DUR Board that meets 9 times per
depressants; antidiabetic agents; antihistamine year.
drugs; antilipemic agents; anti-psychotics;
anxiolytics, sedatives, and hypnotics; cardiac drugs; Pharmacy Payment and Patient Cost
chemotherapy agents; prescribed cold medications; Sharing
contraceptives; ENT anti-inflammatory agents; Dispensing Fee: $3.35.
estrogens; growth hormones; hypotensive agents;
misc. GI drugs; prescribed smoking deterrents; Ingredient Reimbursement Basis: EAC = AWP-
sympathominetics (adrenergic); thyroid agents; 15% (Retail); -17% (Specialty); -20% (Mail Order).
injectable arthritis medications; acute migraine
medications; Synvisc; antifungals; EPO; Synagis, Prescription Charge Formula: Lowest of usual and
and erectile dysfunction products. customary, FUL, AWP-15%, or Maine MAC.
Maine MAC includes 300 products.
reimbursable through the Prescription Drug Maximum Allowable Cost: State imposes Federal
Program when used in home health care and Upper Limits as well as State-specific limits on
extended care facilities, and through physician generic drugs. Override requires prior
payment when used in physician offices. Specialty authorization.
pharmacy rates apply to most self-administered
injectable drugs. Incentive Fee: None.
Vaccines: Vaccines reimbursable based at cost as Patient Cost Sharing: $3.00 per script up to a
part of the EPSDT service (admin. fees), the maximum of $30.00 per month.
Vaccines for Children Program and the Prescription
Drug “Safety Net” Program. Cognitive Services: State does not pay for cognitive
services.
Maine-2
E. USE OF MANAGED CARE Laurie Roscoe, R.Ph.

Brenda McCormick.
State does not use managed care organizations to Jessica R. Osterheld, M.D.
provide service services to Maine Medicaid Jude Walsh
beneficiaries. Approximately 165,000 Medicaid
recipients were enrolled in primary care case
management in 2005. Medicaid recipients enrolled
in primary care case management receive Bruce McClenahan
pharmaceutical benefits through the State. 207/287-4018

F. STATE CONTACTS
Marcia Pykare
State Drug Program Administrator Goold Health Systems
5 Community Drive
Bruce McClenahan P.O. Box 708
Pharmacy Unit Manager Augusta, ME 04332-0708
Department of Health and Human Services T: 207/622-7153
Office of MaineCare Services F: 207/623-5125
11 SHS, 442 Civic Center Drive E-mail: mpykare@ghsinc.com
Augusta, ME 04330
T: 207/287-4018 Medicaid Drug Rebate Contact
F: 207/287-6533
E-mail: bruce.mcclenahan@maine.gov Rossi Rowe, Director
Internet address: www.mainecarepdl.org Third Party Liability
Department of Health and Human Services
Prior Authorization Contact Office of MaineCare Services
11 SHS, 442 Civic Center Drive
Brenda McCormick, Director Augusta, ME 04333
Heatlh Care Management Division T: 207/287-1838
Department of Health and Human Services F: 207/287-1788
442 Civic Center Drive E-mail: rossi.rowe@maine.gov
Augusta, ME 04333
T: 207/287-8419 Claims Submission Contact
F: 207/287-6533
E-mail: Brenda.McCormick@maine.gov Marcia Pykare
207/622-7153
DUR Contact
Kim Rackleff
Goold Health Systems Bruce McClenahan
5 Community Drive 866/796-2463
P.O. Box 708
Augusta, ME 04332-0708 Mail Order Pharmacy Program
T: 207/622-7153 State has a mail order Medical Assistance
F: 207/623-5125 pharmacy program. All MaineCare (Medicaid),
E-mail: krackleff@ghsinc.com Maine Rx, and Drugs for the elderly (SPAP)
enrollees may participate.
MaineCare DUR Board
Timothy Clifford, M.D. Disease Management Program/Initiative
William Alto, M.D. Contact
Michael Ouellette, R.Ph. Brenda McCormick
James Demosthenes, R.Ph. 207/287-8419
Julie Pease, M.D.
Courtney Oland, R.Ph.
Syd Sewall, M.D., M.P.H.
Laureen Biczak, D.O.
Lisa Wendler, Pharm.D.
Bruce McClenahn
Andrew Cook, M.D.
Maine-3
Human Services Department Officials Maine Board of Pharmacy

Geraldine L. “Jeri” Betts
Brenda M. Harvey, Director
Board Administrator
Division of Health Care Management
Office of Licensing and Registration
35 State House Station
State House Station 11
Augusta, ME 04333
221 State Street
T: 207/624-8620
Augusta, ME 04333-0011
F: 207/624-8637
T: 207/287-3707
E-mail: kelly.l.mclaughlin@maine.gov
F: 207/287-3005
Internet address: www.maine.gov/pfr/professional
E-mail: brenda.harvey@maine.gov
licensing/professions/pharmacy
Internet address: www.maine.gov/dhs
Maine Hospital Association
Tony Marple, Director
Steve Michaud
President
Office of MaineCare Services
33 Fuller Road
State House Station 11
Augusta, ME 04330
442 Civic Center Drive
T: 207/622-4794
F: 207/622-3073
T: 207/287-2674
E-mail: smichaud@themha.org
F: 207/287-2675
Internet address: www.themha.org
E-mail: tony.marple@maine.gov
Internet address: www.maine.gov/bms
Maine Health Care Association
Richard A. Erb
Executive Officers of State Medical and President and CEO
Pharmaceutical Societies 317 State Street
Maine Medical Association Augusta, ME 04330
Gordon Smith, Esq. T: 207/623-1146
Executive Vice President F: 207/623-4080
Frank O. Stred Building E-mail: rerb@mehca.org
30 Association Drive Internet address: www.mehca.org
P. O. Box 190
Manchester, ME 04351
T: 207/622-3374
F: 207/622-3332
E-mail: gsmith@mainemed.com
Internet address: www.mainemed.com
Maine Pharmacy Association

Laurier Lamie, R.Ph.
127 Pleasant Hill Road
P.O. Box 1450
Scarborough, ME 040704
T: 207/396-5340
F: 207/396-5341
E-mail: president@mparx.com
Internet address: www.mparx.com
Maine Osteopathic Association

Jack Ginty
Executive Director
693 Western Avenue, #1
Manchester, ME 04351
T: 207/623-1101
F: 207/623-4228
E-mail: jginty@mainedo.org
Internet address: www.mainedo.org
Maine-4
MARYLAND

Disabled Disabled

2003 2004
TOTAL $380,007,833 204,994 $429,074,160 213,731

Aged $41,207,179 16,388 $46,123,782 16,892
Blind / Disabled $152,246,273 54,413 $167,680,185 55,307
Child $3,845,292 9,082 $4,551,848 8,327
Adult $4,918,650 10,441 $4,876,922 10,513
Unknown
$89,444,721 39,119 $99,153,010 40,369
Aged $26,695,684 12,819 $31,231,054 14,100
Blind / Disabled $4,454,401 3,440 $5,122,859 3,248
Child $2,829,241 5,015 $2,700,519 5,108
Adult
$18,841,661 42,835 $21,522,917 37,308
POVERTY RELATED, TOTAL $631,778 427 $795,284 532
Aged $384,513 252 $367,959 225
Blind / Disabled $16,801,320 34,230 $19,859,856 31,854
Child $1,024,050 7,926 $499,818 4,697
Adult $0 0 $0 0
BCCA Women
$69,504,057 32,716 $85,165,496 45,015
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
Maryland-1

State Department of Health and Mental Hygiene, reimbursable through the Prescription Drug
Division of Health Care Financing, Office of Program when used in home health care and
Operations, Eligibility and Pharmacy. extended care facilities, and through both the
Prescription Drug Program and physician payment
D. PROVISIONS RELATING TO DRUGS when used in physician offices.
Benefit Design Vaccines: Vaccines reimbursable as part of the

legend drugs; prescribed insulin; and disposable Unit Dose: Unit dose packaging not reimbursable.
needles and syringe combinations used for insulin;
total parenteral nutrition: Products covered under Formulary/Prior Authorization
DME: blood glucose test strips; urine ketone test
strips. Products covered with restrictions: Formulary: Open formulary with a preferred drug
interdialytic parenteral nutrition (according to list (PDL) managed through preferred products and
Medicare criteria). Products not covered: prior authorization and restrictions on use. Prior
cosmetics; fertility drugs; experimental drugs; authorization required for all non-PDL products.
DESI drugs; prescriptions and injections for central
nervous system stimulants; food supplements or Prior Authorization: State currently has a prior
infant formulas; products for which Federal authorization procedure. A general appeals
financial participation is not allowed, i.e., "less than procedure is available when a physician can
effective" drugs and products whose manufacturers provide additional information to justify the
have not signed rebate agreements; and certain medical necessity of a particular product.
other items as specified in the State's Medicaid
Plan. Preauthorization is needed for any prescription with
a usual and customary charge exceeding $400.
Over-the-Counter Product Coverage: Products Prior authorization is also needed for early refills,
covered: contraceptives; oral ferrous sulfate. nutritional supplements, brand medically necessary
Products covered with restrictions: allergy, asthma, and excessive quantities.
and sinus products (specific preferred products);
analgesics (enteric coated aspirin only); H2 Prescribing or Dispensing Limitations
antagonists (specific preferred products). Products
not covered: cough and cold preparations; non-H2 Prescription Refill Limit: Maximum of eleven
antagonists; feminine products (except refills. The original prescription and its refills may
contraceptives); topical products; and smoking not exceed a 360-day supply. Certain medications
deterrent products. may have quanitity limits.
Therapeutic Category Coverage: Therapeutic Monthly Quantity Limit: In general, the amount of
categories covered*: anabolic steroids; analgesics, medication to be dispensed on a prescription at one
antipyretics, NSAIDs; antibiotics; anticoagulants; time is limited to a less than 34-day supply except
anticonvulsants; antidepressants; antidiabetic for specific maintenance drugs for chronic
agents; antihistamine drugs; antilipemic agents; conditions, where up to a 100-day supply may be
anti-psychotics; anxiolytics, sedatives, and dispensed at one time. Certain medications may
hypnotics; cardiac drugs; chemotherapy agents; have quantity limits.
prescribed legend cold medications; contraceptives;
ENT anti-inflammatory agents; estrogens;
hypotensive agents; misc. GI drugs; prescribed
PRODUR system implemented January 1993. State
legend smoking deterrents; sympathominetics
currently has a DUR Board with a quarterly review.
(adrenergic); and thyroid agents. Prior authorization
required for: growth hormones; synagis; and
nutritional supplements for tube-fed recipients and
for children in the Rare and Expensive Case
Management (REM) Program (if preauthorized).
Therapeutic categories not covered: anorectics.
*Prior authorization required for all drugs not on

the preferred drug list.
Maryland-2
Helix Family Choice, Inc.

Pharmacy Payment and Patient Cost
8094 Sandpiper Circle
Sharing
Baltimore, MD 21236
Dispensing Fee: $2.69 - $4.69 as of July 2004. 410/933-2200
$2.69 - non-PDL Brand.
$3.69 - PDL Generic Jai Medical Systems, Inc.
$3.69-Nursing Home non-PDL 5010 York Road
Brand Baltimore, MD 21212
$4.69 - Nursing Home PDL or 410/433-2200
Generic
Maryland Physicians Care MCO
Ingredient Reimbursement Basis: Estimated
509 Progress Drive
Acquisition Cost (EAC) equals/lowest of:
Lithicum, MD 21090
1. Wholesale Acquisition Cost (WAC) plus 8%. 410/401-9400
2. Direct cost plus 8%.
Diamond Plan
3. Distributor's price plus 8%. Coventry Health Care of Delaware, Inc.
4. Average Wholesale Price (AWP) minus 12%. Ambassador Center D
7125 Ambassador Road
Prescription Charge Formula: Reimbursement will Suite 100
be the lower of: (1) the calculated ingredient cost Baltimore, MD 21244
plus a dispensing fee; (2) the usual and customary 866/212-5305
fee. Blood factors require documentation of direct
price for payment. Priority Partners MCO
Baymeadow Industrial Park
Maximum Allowable Cost: State imposes Federal 6704 Curtis Court
Upper Limits as well as State-specific limits on Glen Burnie, MD 21060
generic drugs. Approximately 1,000 drugs are 410/424-4500
listed on the State-specific MAC list. Override
requires a MedWatch form documenting the reason AMERIGROUP Community Care
for the request. 857 Elkridge Landing Road, #300
Incentive Fee: None Linthicum, MD 21090
410/859-5800
Patient Cost Sharing: Copayment = $3.00 for
Brands not on the PDL; $1.00 for generics and F. STATE CONTACTS
drugs on the PDL. Does not apply to managed
care, family planning, nursing home residents,
recipients under 21 years old.
Jeffrey C. Gruel
Cognitive Services: Does not pay for cognitive Director
services. Maryland Pharmacy Program
DHMH, Office of Operations, Eligibility, and
Pharmacy
E. USE OF MANAGED CARE 201 West Preston Street, Room 408
Baltimore, MD 21201
Approximately 501,000 Medicaid recipients were T: 410/767-1455
enrolled in MCOs in FY 2006. Recipients receive F: 410/333-5398
pharmaceutical benefits through the State and E-mail: gruelj@dhmh.state.md.us
through comprehensive managed care plans. Internet address:
(Mental health drugs and Fuzeon are “carved out” www.dhmh.state.md.us/mma/mpap
of managed care.)

United Healthcare
Lyndwood Executive Center
6095 Marshalee Drive
Elkridge, MD 21075
800/487-7391
Maryland-3

Policy:
Frank T. Tetkoski, P.D., Chief
Dorine B. Rascoe
Division of Pharmacy Services
Accountant
Pharmacy
Pharmacy
201 West Preston Street, Room 409
201 West Preston Street, Room 409
Baltimore, MD 21201
Baltimore, MD 21201
T: 410/767-1460
T: 410/767-6992
F: 410/333-5398
F: 410/333-5398
E-mail: tetkoskif@dhmh.state.md.us
E-mail: rascoed@dhmh.state.md.us
Prior Authorization Contact Disputes:
Tuong A. Nguyen, P.D. Antoine Nelson
Pharmacist Consultant Rebate Analyst
Maryland Pharmacy Program ACS
DHMH, Office of Operations, Eligibility and 1120 N. Charles Street
Pharmacy Baltimore, MD 21201
201 W. Preston St., Room 409 T: 410/230-5452
Baltimore, MD 21201 F: 410/244-1268
T: 410/767-5701 E-mail: antoine.nelson.nashccon@acs-inc.com
F: 410/333-5398
E-mail: nguyent@dhmh.state.md.us Claims Submission Contact
James Demery
DUR Contact Manager, Pharmacy Services
Philip H. Cogan, Chief DHMH, Office of Operations, Eligibility, and
Clinical Pharmacy Services Division Pharmacy
DHMH, Office of Operations, Eligibility, and Division of Claims Processing
Pharmacy 201 W. Preston St.
201 W. Preston Street, Room 408 Baltimore, MD 21201
Baltimore, MD 21201 T: 410/767-6028
T: 410/767-5878 F: 410/333-5398
F: 410/333-5398 E-mail: demeryj@dhmh.state.md.us
E-mail: coganp@dhmh.state.md.us
(Note: State contracts with ACS for Pharmacy POS
DUR Board System)
Ruth Ebiasah, Pharm.D.
John Boronow, M.D.
Stephen Wienner, R.Ph. (Chair) Philip H. Cogan, Chief
Steven J. Kravet, M.D. 410/767-5878
Lori Fantry, M.D., M.P.H. (Vice Chair)
Vincent Ferrari, R.Ph. Mail Order Pharmacy Benefit
Michael S. Kaplan, M.D.
None
Elliot S. Gottlieb, R.Ph.
Bernard J. Lechman, R.Ph.
Neil Leikah, R.Ph. Maryland Medicaid Advisory Committee
Kevin Lindamood
Prescription Price Updating Kathleen Loughran
Lori Doyle
Frank T. Tetkoski, P.D.
Donna Imhoff
410/767-1460
Miguel McInnis
Floyd Hartley
Grace Williams
Ann Rasenberger
Virginia Keane, M.D.
Adam Brickner
C. David Ward
Maryland-4
Michele Douglas Phil Cogan, Chief

Harold S.Goodman, D.M.D. Clinical Pharmacy Services Division
Peter Perini Maryland Pharmacy Program
Charles I. Shubin, M.D. 201 W. Preston Street, Room 408
Kate Tumulty, R.N. Baltimore, MD 21201
Winifred Booker, D.D.S.
Delores G. Kelley Tuong Nguyen, P.D.
Eric M. Bromwell Pharmacist Consultant
Robert A. Costa Maryland Pharmacy Program
Shirley Nathan-Pulliam 201 W. Preston Street, Room 409
Christine Bailey Baltimore, MD 21201
Stephen Wienner
Tyan Williams Executive Officers of State Medical and
Charles Moore, M.D. Pharmaceutical Societies
Kevin M. McGuire (ex-officio))
Ulder Tillman, M.D. (ex-officio) Maryland State Medical Society
Rex Cowdry, M.D. (ex-officio) Martin P. Wasserman, M.D., J.D.
Executive Director
1211 Cathedral Street
Health and Mental Hygiene Department
Baltimore, MD 21201
Officials
T: 410/539-0872
John M. Colmers, Secretary F: 410/547-0915
Department of Health and Mental Hygiene E-mail: mwasserman@medchi.org
201 W. Preston Street Internet address: www.medchi.org
Baltimore, MD 21201
T: 410/225-6505 Maryland Association of Osteopathic Physicians
F: 410/161-6489 Ross Van Antwerp, D.O.
E-mail: ktobias@dhmh.state.md.us President
3603 Southside Drive
John G. Folkemer Phoenix, MD 21131
Deputy Secretary for Health Care Financing T: 410/683-8100
Department of Health and Mental Hygiene F: 410/683-8200
201 W. Preston Street E-mail: rossva@comcast.net
Baltimore, MD 21201 Internet address: www.maops.com
T: 410/767-5806
F: 410/333-7505 Maryland Pharmacists Association
E-mail: jfolkemer@dhmh.md.state.us Howard Schiff
Executive Director
Medical Assistance Staff Committee 650 West Lombard Street
Members Baltimore, MD 21201
T: 410/727-0746
Jeffrey Gruel, Director
F: 410/727-2253
Maryland Pharmacy Program
E-mail: hschiff@marylandpharmacist.org
201 W. Preston Street, Room 408
Internet address: www.marylandpharmacist.org
Baltimore, MD 21201
Maryland Society of Health-System Pharmacists
Athos Alexandrou, Deputy Director
Jennifer K. Thomas, President
8480-M Baltimore National Pike, Ste. 252
Ellicott City, MD 21042
Baltimore, MD 21201
T: 410/465-9975
F: 410/465-7073
Frank Tetkoski, P.D.
E-mail: jthomas@stagnes.org
Services and Preauthorization
Internet address: www.mshp.org
Baltimore, MD 21201
Maryland-5
Maryland State Board of Pharmacy

LaVerne G. Naesea
Executive Director
4201 Patterson Avenue
Baltimore, MD 21215-2299
T: 410/764-4755
F: 410/358-6207
E-mail: mdbop@dhmh.state.md.us
Internet address:
www.dhmh.state.md.us/pharmacyboard
Association of Maryland Hospitals and Health

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

Adele Wilzack, President
7135 Mistrel Way, Suite 104
Columbia, MD 21046
T: 410/290-5132
F: 410/290-6930
E-mail: awilzack@hfam.org
Internet address: www.hfam.org
Maryland-6
MASSACHUSETTS

Disabled Disabled

2003 2004
TOTAL $938,275,647 640,437 $967,418,472 583,820

Aged $48,960,556 25,887 $48,713,481 24,991
Blind/Disabled $376,925,117 134,500 $394,900,348 131,919
Child $6,187,997 28,725 $5,766,948 22,931
Adult $10,895,144 21,883 $9,776,681 18,826

Aged $18,248,984 10,251 $19,093,980 9,806
Blind/Disabled $18,118,167 7,212 $18,859,507 6,389
Child $0 0 $0 0
Adult $0 0 $0 0

Aged $71,965,071 29,759 $72,370,148 28,437
Blind/Disabled $174,283,623 54,685 $184,730,423 54,177
Child $40,345,346 141,485 $40,953,480 122,785
Adult $28,389 199 $0 0
unknown.
Massachusetts-1

reimbursable through the Prescription Drug
Executive Offices of Health and Human Services, Program when used in home health care and
Office of Medicaid. extended care facilities and through both the
Prescription Drug Program and physician payment
when used in physician offices.
Vaccines: Vaccines if not provided by the
Benefit Design Department of Public Health.
Drug Benefit Product Coverage: Products covered: Unit Dose: Unit dose packaging not reimbursable.
prescribed insulin. Products covered (except in
LTC facilities): disposable needles and syringe Formulary/Prior Authorization
strips; urine ketone test strips. Products covered Formulary: Open formulary with PDL managed
with restrictions: total parenteral nutrition (prior through restrictions on use, prior authorization,
authorization required). Products not covered: preferred products, and physician profiling.
cosmetics; fertility drugs; experimental drugs; Prior Authorization: State currently has a prior
interdialytic parenteral nutrition; DESI drugs; authorization procedure. A recipient may file a
legend vitamins not on Drug List, non-legend drugs request for a fair hearing to appeal a prior
not on Drug List; propoxyphene-containing authorization decision.
products; drugs for the treatment of sexual
dysfunction; and products rated by the FDA as less- Prescribing or Dispensing Limitations
than-effective.
Prescription Refill Limit: Prescription may be
Over-the-Counter Product Coverage: Products refilled, as authorized, with a limit of up to 5 refills
covered with restrictions (limited OTC list-generics from the filling of the original prescription
only- not covered in LTC facilities): allergy, Monthly Quantity Limit: Schedule II and III drugs
asthma and sinus products; analgesics; cough and are generally limited to a 30-day supply. Limits on
cold preparations; digestive products; feminine units per month on some medications.
products; topical products; and smoking deterrent
products. Monthly Dollar Limits: None.

categories covered: anabolic steroids; antibiotics; PRODUR system implemented in October 1995.
anticoagulants; chemotherapy agents; State currently has a DUR Board with a quarterly
contraceptives; estrogens, and thyroid agents. Prior review.
authorization required for: growth hormones;
Erythropoeitin; selected biotech drugs; non-generic Pharmacy Payment and Patient Cost
multiplesource drugs; and drug products not Sharing
appearing on the MassHealth drug lists. Partial
coverage for: prescribed cold medications. Partial Dispensing Fee: $3.00 (basic) plus $1.00-$2.00
coverage with prior authorization required for: additional for compounded Rx’s ($10.00 for
analgesic, antipyretics, and NSAIDs; participants in the US Public Health Service’s drug
anticonvulsants; anti-depressants; antidiabetic pricing program), effective 1/1/2004.
agents; antihistamines; antilipemic agents; anti-
psychotics; anxiolytics, sedatives, and hypnotics; Ingredient Reimbursement Basis: EAC = WAC +
cardiac drugs; ENT anti-inflammatory agents; 5%.
hypotensive agents; misc. GI drugs; prescribed
somking deterrents; and sympathominetics Prescription Charge Formula: Payment shall be for
(adrenergic). Therapeutic categories not covered: the lowest of:
anoretics; weight loss or gain medications;
1. EAC plus dispensing fee;
medications to treat sexual dysfunction;
2. The usual and customary charge defined as
experimental or investigational drugs; and less than
the lowest price charged or accepted by a
effective drugs.
provider for any payor;
3. FULP plus a dispensing fee; or
4. MULP plus a dispensing fee.
Massachusetts-2
Maximum Allowable Cost: State imposes Federal F. STATE CONTACTS

generic drugs. Override requires “Dispense as State Drug Program Administrator
Written,” and “Brand Medically Necessary” plus
prior authorization. Paul L. Jeffrey
Director of Pharmacy
Patient Cost Sharing: Copayment = $3.00 (Brands) Office of Medicaid
and $1.00 (Generics and OTC products), effective 600 Washington Street, Suite 5000
2/1/2004. Exceptions include: Boston, MA 02111
T: 617/210-5319
# Institutionalized patients F: 617/210-5865
E-mail: paul.jeffrey@state.ma.us
# Children under age 19 Internet Address:
# Pregnant and postpartum women www.mass.gov/masshealth/pharmacy
# Hospice care
# Family planning items Prior Authorization Contact
Incentive Fee: None. Paul L. Jeffrey
617/210-5319
services.
DUR Contact
Paul L. Jeffrey
E. USE OF MANAGED CARE 617/210-5319
enrolled in MCOs in FY 2006 with another 289,000 DUR Contact
enrolled in pre-paid health plans (PHPs) and
Information not available
268,000 in PCCM.. Recipients in managed care
plans receive pharmaceutical benefits through
managed care plans. Enrollees in the PCCM
program receive pharmaceutical benefits from the Christopher T. Burke
State. Program Analyst
Office of Medicaid
600 Washington Street, Suite 5000
Managed Care Organization
Boston, MA 02111
Primary Care Clinician Plan T: 617/210-5592
800/841-2900 F: 617/210-5865
E-mail: christopher.burke@state.ma.us
Boston Medical Center HealthNet Plan
617/748-6000 Prescription Price Updating
First Data Bank
Fallon Community Health Plan
508/799-2100
San Bruno, CA 94066
T: 650/588-5454
Neighborhood Health Plan
F: 650/827-4578
617/772-5500
Network Health Medicaid Drug Rebate Contact

888/688-7348 Emily Toohey
260 Franklin Street, 10th Floor
Boston, MA 02110
T: 617/423-9841
F: 617/423-9846
E-mail: emily.toohey@acs-inc.com
Massachusetts-3
Massachusetts Pharmacists Association

John F. Heffernan
ACS State Healthcare Executive Vice President
365 North Ridge Road, Suite 400 500 West Cummings Park, Suite 3475
Atlanta, GA 30350 Woburn, MA 01801
T: 800/358-2381 T: 781/933-1107
F: 770/730-5198 F: 781/933-1109
E-mail: jheffernan@masspharmacists.org
Medicaid Managed Care Contact Internet address: www.masspharmacists.org
Sharon Hanson, Director
Massachusetts Osteopathic Society, Inc.
MCO Program Jonathan Webb, M.P.H.
EOHHS, Office of Acute and Ambulatory Care Interim Executive Director
One Ashburton Place, 10th Floor P.O. Box 487
Boston, MA 02108 Winchester, MA 01890
T: 617/573-1793
800/621-1773, ext. 8164
F: 617/573-1843 E-mail: jwebb@osteopathic.org
E-mail: sharon.hanson@state.ma.us Internet address: www.massosteopathic.org
Mail Order Pharmacy Benefit Massachusetts Board of Registration in Pharmacy
None James D. Coffey
Interim Director
Executive Offices of Health and Human 239 Causeway Street, 2nd Floor
Services Boston, MA 02114
T: 800/414-0168
JudyAnn Bigby, M.D., Secretary F: 617/973-0983
Executive Office of Health and Human Services E-mail: james.d.coffey@state.ma.us
One Ashburton Place, Room 1109 Internet address: www.state.ma.us/reg/boards/ph
Boston, MA 02108
T: 617/573-1600 Massachusetts Society of Health-Systems
F: 617/727-5134 Pharmacists
E-mail: judyann.bigby@state.ma.us Christian Hartman, Pharm.D.
Internet address: www.mass.gov/eohhs President
925 Concord Street, PMD 196
Tom Dehner, Director Framingham, MA 01701
Office of Medicaid T: 508/499-3235
One Ashburton Place, Room 1109 F: 508/519-8426
Boston, MA 02108 E-mail: admin@mashp.org
T: 617/573-1700 Internet address: www.mashp.org
F: 617/210-5697
E-mail: Thomas.Dehner@state.ma.us Massachusetts Hospital Association
Internet address: www.mass.gov/masshealth Robert E. Gibbons
President
Executive Officers of State Medical and Five New England Executive Park
Pharmaceutical Societies Burlington, MA 01803
Massachusetts Medical Society T: 781/272-8000
Corrine Broderick F: 781/272-0466
Executive Vice President E-mail: info@mhalink.org
860 Winter Street Internet address: www.mhalink.org
Waltham Woods Corporate Center
Waltham, MA 02451-1411 Massachusetts Extended Care Federation
T: 781/893-4610 Abraham E. Morse
F: 781/893-9136 President
E-mail: cbroderick@mms.org 2310 Washington Street
Internet address: www.massmed.org Newton Lower Falls, MA 02462
T: 617/558-0202
F: 617/558-3546
E-mail: amorse@mecf.org
Internet address: www.mecf.org
Massachusetts-4
MICHIGAN
Disabled Disabled

2003 2004
TOTAL $753,841,353 610,641 $777,599,687 624,745

Aged $39,617,598 17,936 $37,774,868 17,441
Blind/Disabled $287,126,309 132,399 $302,261,574 135,280
Child $4,318,047 23,215 $5,009,374 22,261
Adult $9,534,302 29,436 $10,865,054 31,211

Aged $10,836,168 5,840 $10,687,225 5,992
Blind/Disabled $19,905,645 6,274 $22,694,961 6,633
Child $2,294,856 7,567 $2,471,201 8,454
Adult $8,500,027 22,112 $10,653,282 27,572

Aged $2,479,740 1,804 $2,195,084 1,639
Blind/Disabled $7,654,264 3,152 $6,569,602 2,611
Child $20,085,467 95,054 $23,506,404 96,763
Adult $4,530,057 21,366 $5,590,539 25,268
unknown.
Michigan-1
C. ADMINISTRATION The complete Michigan Pharmaceutical Product

list and preferred drug list can be viewed at
Michigan Department of Community Health, www.michigan.fhsc.com.
Medical Services Administration.
D. PROVISIONS RELATING TO DRUGS Program when used in home health care and
extended care facilities, and through physician
Benefit Design payment when used in physician offices. Some
self-administered injectables require prior
Drug Benefit Product Coverage: Products covered: authorization.
prescribed insulin; disposable needles used for
insulin; and interdialytic parenteral nutrition. Vaccines: Vaccines reimbursable at cost plus a
Products covered under DME: syringe combinations fee/or vaccine replacement as part of the EPSDT
used for insulin; blood glucose test strips; and urine Service, the Children Health Insurance Program
ketone test strips. Prior authorization required for: and the Vaccines for Children Program.
total parenteral nutrition; some self-administered
injectables; brand name products equivalent to Unit Dose: Unit dose packaging reimbursable.
MACs; Accutane & Retin-A; Dexedrine and
Adderall; Persantine; Lactulose (Cephulac); Formulary/Prior Authorization
Methylphenidate (selected ages); selected
benzodiazepines; Epogen administered in the home Formulary: Open formulary and a preferred drug
setting; dietary formulas; and drugs not listed on the list (PDL). (See www.michigan.fhsc.com for
formulary. Products not covered: cosmetics; listing of drugs on the PDL.) Formulary managed
fertility drugs; experimental drugs; vitamins for through restrictions on use, prior authorization
general health and well-being; products to treat requirements, preferred products, and MAC
impotence; and other categories specified by CMS pricing.
as excluded. For additional information on the
scope of Michigan Medicaid drug coverage, see Prior Authorization: State currently has a formal
www.michigan.fhsc.com. prior authorization procedure. Beneficiaries
receive written notice of denial and have a right to
Over-the-Counter Product Coverage: Products appeal prior authorization decisions on the basis of
covered: smoking deterrent products (tablets, medical necessity. Informal review of additional
patches, and gum quantity limits per beneficiary per information from prescriber can be conducted at
year). Products covered with restrictions any time. Beneficiaries also have fair hearing
(prescription required and selected products only in rights to appeal denial of coverage for an excluded
each category): allergy, asthma and sinus products product. (See the Pharmacy Chapter of the
(antihistamines); analgesics (payment limits, Medicaid Provider Manual at
considered part of nursing home per diem www.michigan.gov/mdch for additional
reimbursement); non-H2 antagonists (payment information.)
limits, considered part of nursing home per diem
reimbursement); H2 antagonist (payment limits); Prescribing or Dispensing Limitations
feminine products (payment limits); topical Prescription Refill Limit: None
products;. Products not covered: cough and cold
preparations. Monthly Quantity Limit: Prescribed quantities
should be limited to an amount necessary to keep
Therapeutic Category Coverage: Therapeutic the recipient supplied during the therapy regimen.
categories covered: analgesics, antipyretics, 34-day supply is the normal maximum (100-day
NSAIDs; antibiotics; anticoagulants; for maintenance drugs). Quantity limits for
anticonvulsants; antidepressants; antidiabetic selected pharmaceuticals (e.g., sedative hypnotics).
agents; antihistamine drugs; antilipemic agents; In certain cases and conditions, more than a
anti-psychotics; anxiolytics, sedatives, and month’s supply will be appropriate. However, in
hypnotics; cardiac drugs; chemotherapy agents; no instance may more than 100-days supply be
contraceptives; ENT anti-inflammatory agents; dispensed per prescription. (See the Pharmacy
estrogens; growth hormones hypotensive agents; Chapter of the Medicaid Provider Manual at
misc. GI drugs; prescribed smoking deterrents; www.michigan.gov/mdch for additional
sympathominetics (adrenergic); and thyroid agents. information.)
Therapeutic categories not covered: anabolic
steroids; prescribed cold medications; and anoretics.
Michigan-2
Drug Utilization Review # Health Maintenance Organization (HMO), or a

capitated Clinic Plan.
PRODUR system implemented in July 2000. State
currently has a DUR Board with a quarterly review. Cognitive Services: Does not pay for cognitive
services.
Sharing
Dispensing Fee: $2.50, ($2.75 for long-term care)
effective Nov. 1, 2004. Additional dispensing fee Approximately 975,000 Medicaid recipients were
for compounding. enrolled in MCOs in FY 2006. Recipients receive
pharmaceutical benefits through traditionally
Ingredient Reimbursement Basis: 1-4 stores = capitated managed care plans. Psychotropics,
AWP-13.5%, 5 or more stores = AWP-15.1%. antidepressants, anti-mania, central nervous system
Special rules for potassium supplements, oral stimulants, HIV antiretrovirals and other select
contraceptives, and anti-hemophilia factors. classes of drugs are administered by managed care
organizations but paid for by the State.
Prescription Charge Formula: Reimbursement for
legend drugs is limited to the lower of: Managed Care Organizations
1. AWP-13.5% for 1 to 4 stores & AWP-15.1% Community Choice Michigan
for 5 or more stores or LTC, plus dispensing 2369 Woodlake Drive
fee minus patient copay, or Okemos, MI 48864
2. The MAC rate, plus dispensing fee, or T: 517/349-9922
T: 800/390-7102
3. The provider’s usual and customary charge to Internet address: www.ccmhmo.org
the general public.
Great Lakes Health Plan, Inc.
Maximum Allowable Cost: State imposes Federal 17117 W. Nine Mile, Suite 1600
Upper Limits as well as State-specific limits on Southfield, MI 48075
generic drugs. Override requires “Brand Medically T: 248/559-5656
Necessary” plus prior authorization. T: 800/903-5253
Internet address: www.glhp.com
Health Plan of Michigan, Inc.
Patient Cost Sharing: Effective Jan. 1, 2005, 17515 W. Nine Mile, Suite 650
ambulatory recipients age 21 and older are required Southfield, MI 48075
to pay a $3.00 copayment for brand name drugs and T: 248/557-3700
a $1.00 copayment for generic drugs. Effective T: 888/437-0606
March 1, 2005, Adult Benefit Waiver (ABW) Internet address: www.hpmich.com
beneficiaries are required to pay a $1.00 copayment
for each prescription drug dispensed. If the HealthPlus Partners, Inc.
recipient is unable to pay a required copayment on 2050 S. Linden Road
the date of service, the pharmacy cannot refuse to P.O. Box 1700
render the service. However, the pharmacy may bill Flint, MI 48501-1700
the recipient for the copayment amount, and he/she T: 810/230-2222
is responsible for paying it. If the recipient fails to T: 800/322-9161
pay a copayment, the pharmacy could, in the future, Internet address: www.healthplus.org
refuse to serve the recipient as a Medicaid recipient.
M-Caid
Drugs not requiring a co-payment include 2301 Commonwealth Blvd.
pregnancy-related and family planning products. Ann Arbor, MI 48105-1573
800/527-5549
Recipients are not required to make a copayment if: Internet address: www.mcare.org
# They are under age 21, or McLaren Health Plan
# They reside in a long-term care facility (nursing G 3245 Beacher Road, Suite 200
home, hospital long-term care facility, or Flint, MI 48532
medical care facility), or 888/327-0671
Internet address: www.mclarenhealthplan.org
Michigan-3
Midwest Health Plan F. STATE CONTACTS

5050 Schaefer Road
Dearborn, MI 48126 State Drug Program Administrator
T: 313/581-3700
T: 888/654-2200 Trish O’Keefe, Pharmacy Director
Internet address: www.midwesthealthplan.com MDCH/Medical Services Administration
400 South Pine Street
Molina Healthcare of Michigan P.O. Box 30479
100 W. Big Beaver Road, Suite 600 Lansing, MI 48909-7979
Troy, MI 48084 T: 517/335-5181
T: 248/925-1700 F: 517/241-8135
T: 888/898-7969 E-mail: okeefet@michigan.gov
Internet address: www.molinahealthcare.com Internet address: www.michigan.gov/mdch
OmniCare Health Plan, Inc. New Brand Names Products Contact

1333 Gratiot, Suite 400 Trish O’Keefe
Detroit, MI 48207 517/335-5181
T: 313/465-1564
T: 866/728-8507 Prior Authorization Contact
Internet address: www.omnicarehealthplan.com
First Health Service Corporation
PHP- MM Family Care 4300 Cox Road
P.O. Box 30377 Glen Allen, VA 23060
Lansing, MI 48909-7877 T: 800/884-2822
T: 517/364-8400 F: 804/527-6849
T: 800/661-8299
Internet address: www.phpmm.org DUR Contact
MDCH- Medical Services Administration
Priority Health, Government Programs, Inc. Office of Medical Affairs
1231 E. Beltline, NE 400 S. Pine St.
Grand Rapids, MI 49525-4501 P.O. Box 30479
T: 616/942-0954 Lansing, MI 48909-7979
T: 888/975-8102 T: 517/335-5181
Internet address: www.priority-health.com F: 517/241-8135
ProCare Medicaid DUR Board
3956 Mt. Elliot
Detroit, MI 48207 Stephen Bernstein, M.D., M.P.H.
T: 313/925-4607 Gerard Breitzer, D.O.
T: 866/776-0891 Duane Kirking, Pharm.D., Ph.D.
Dawn Parsons, R.Ph., M.B.A.
Total Health Care Karen Jonas, R.Ph., F.A.S.C.P.
3011 W. Grand Blvd., Suite 1600 Sahar Swidan, Pharm.D.
Detroit, MI 48202 Jonathan Henry, M.D.
T: 313/871-2000
T: 800/826-2862 Prescription Price Updating
Internet address: www.totalhealthcareonline.com
4300 Cox Road
Upper Peninsula Health Plan
T: 8007884-2822
Marquette, MI 49855
F: 804/527-6849
T: 906/225-7500
T: 800/835-2556
Internet address: www.uphp.com
4300 Cox Road
T: 8007884-2822
F: 804/527-6849
Michigan-4
Claims Submission Contact Larry Wagenknecht

Walt Stillner
First Health Services Corp
Dean Sienko
4300 Cox Road
Vernice Davis-Anthony
Mark Tucker
T: 800/884-2822
Diane Haas
F: 804/527-6849
Don Mussman
Claude Young
Medicaid Managed Care Contact Harvey Zuckerberg
Trish O’Keefe Anita Liberman-Lampear
517/335-5181 Sara Slocum
Warren White
Disease Management Program/Initiative Andrew Farmer
Contact Jackie McLean
Daniel Briskie
(Not applicable) Paul Shaheen
Daniel Wilhelm
Mail Order Pharmacy Program Kim Sibilsky
None Michigan Pharmacy and Therapeutics
Committee
Michigan Dept. of Community Health
(MDCH) Jonathan Arend, Pharm.D.
Ronald H. Bradley, D.O., Ph.D.
Janet Olszewski, Director Paul Dake, M.D.
MDCH James E. Dillon, M.D.
Capitol View Building Neil B. Dorfman, R.Ph.
201 Townsend Street Justus J. Feichtner, M.D.
Lansing, MI 48913 Erin E. Inman, Pharm.D.
T: 517/335-0267 Khan J. Nedd, M.D.
F: 517-373-4288 Giovannino A. Perri, M.D.
E-mail: norris@michigan.gov Rockelle Rogers, M.D.
Internet address: www.michigan.gov/mdch Dean Van Loo, Pharm.D.
Paul Reinhart, Senior Deputy Director Executive Officers of State Medical and
MDCH Pharmaceutical Societies
Medical Services Administration
400 South Pine Street Michigan State Medical Society
Lansing, MI 48909 Kevin A. Kelly, Executive Director
T: 517/241-7882 120 West Saginaw Street
F: 517/335-5007 East Lansing, MI 48823
E-mail: reinhartpl@michigan.gov T: 517/337-1351
F: 517/337-2490
Medical Care Advisory Committee E-mail: kkelly@msms.org
Internet address: www.msms.org
Jan Hudson (Chair)
Priscilla Cheever Michigan Pharmacists Association
Alison Hirschel Larry D. Wagenknecht, CEO
Patricia Anderson 815 N. Washington Avenue
Ed Kemp Lansing, MI 48906-5198
Brandon Barton T: 517/484-1466
Jackie Doig F: 517/484-4893
Jocelyn Vanda E-mail: larry@michiganpharmacists.org
Dave Herbel Internet address: www.michigan pharmacists.org
Diana Hines
William Mayer
David LaLumia
Roger Anderson
Gregory Piaskowski
Peter Schonfeld
Michigan-5
Michigan Osteopathic Association

Dennis Paradis, Executive Director
2445 Woodlake Circle
Okemos, MI 48864
T: 800/657-1556
F: 517/347-1566
E-mail: moa@mi-osteopathic.org
Internet address: www.mi-osteopathic.org
Michigan State Board of Pharmacy

Melanie Brim, Director
Bureau of Health Services
Licensing Division
611 W. Ottawa, First Floor
P.O. Box 30670
Lansing, MI 48909-8170
T: 517/335-0918
F: 517/373-2179
E-mail: mbbrim@michigan.gov
Internet address: www.michigan.gov/mdch/
Michigan Health and Hospital Association

Spencer C. Johnson, President
6215 West St. Joseph Highway
Lansing, MI 48917
T: 517/323-3443
F: 517/323-0946
E-mail: sjohnson@lans.mha.org
Internet address: www.mha.org
Health Care Association of Michigan

Daniel Gustafson
President and CEO
P.O. Box 80050
Lansing, MI 48908
T: 517/627-1561
F: 517/627-3016
E-mail: melissasamuael@hcam.org
Internet address: www.hcam.org
Michigan-6
MINNESOTA

Disabled Disabled

2003 2004
TOTAL $336,444,933 201,366 $363,035,295 213,727

Aged $6,932,527 3,953 $5,864,523 4,023
Blind / Disabled $166,664,528 52,926 $178,587,527 54,731
Child $8,880,555 32,733 $10,981,388 39,159
Adult $10,840,563 30,709 $11,582,503 36,022

Aged $11,148,028 7,420 $10,223,130 7,008
Blind / Disabled $16,316,515 4,687 $19,821,510 5,181
Child $31,471 174 $23,158 109
Adult $514,363 1,399 $457,630 1,243

Aged $6,621,030 4,075 $6,342,557 4,601
Blind / Disabled $23,117,430 8,588 $25,701,494 10,030
Child $947,882 6,412 $1,130,300 6,779
Adult $166,199 1,264 $166,122 1,286
BCCA Women $65,132 119 $132,126 164
unknown.
Minnesota-1
C. ADMINISTRATION Vaccines: Vaccines reimbursable when billed as

part of the Children’s Health Insurance Program
Minnesota Department of Human Services, Health and the Vaccines for Children Program.
Care Management Division, Medical Assistance
Program. Unit Dose: Unit dose packaging reimbursable.
D. PROVISIONS RELATING TO DRUGS Formulary/ Prior Authorization

Formulary: Closed formulary with preferred drug
Benefit Design list. General exclusions include prior authorization
for non-preferred drugs, new drugs, branded drugs
Drug Benefit Product Coverage: Products covered: that have a generic equivalent, and other drugs on
prescribed insulin; total parenteral nutrition; and the list of drugs requiring PA.
interdialytic parenteral nutrition. Products covered
under DME: disposable needles and syring Prior Authorization: State currently has a prior
combinations used for insulin; blood glucose test authorization procedure and a Drug Formulary
strips; and urine ketone test strips. Products Committee. Recipient has the right to appeal prior
covered with limitations: amphetamines; authorization decisions and coverage of an
atomoxetine; rapidly disintegrating tablet excluded product by appeals referee followed by an
formulations. Prior authorization required for: non- appeal in court.
preferred drugs; new drugs; brand name drugs that
have a generic equivalent; botulinum toxin; Prescribing or Dispensing Limitations
interferon; growth hromone; and certain other
drugs. Products not covered: cosmetics; drugs used Monthly Quantity Limit: Minimum 34-days for
for hair growth; fertility drugs; appetite supressants; maintenance drugs. Contraceptives may be filled to
and experimental drugs. (For a complete list of provide a 3-month supply. Quantity limits on some
products requiring prior authorization, view the drug products including triptans, antiemetics,
MHCP Enrolled Providers Pharmacy website at pregabalin, and sedatives.
http://www.dhs.state.mn.us/provider/pharm/.)
Over-the-Counter Product Coverage: Products PRODUR system implemented in February 1996.
covered with limitations: loratadine products; State currently has a DUR Board with a quarterly
analgesics; topical antifungals; laxatives; cough and review.
cold preparations; smoking deterrent products;
vitamins; ocular lubricants; pediculocides; and Pharmacy Payment and Patient Cost
activated charcoal and ipecac. Sharing
Therapeutic Category Coverage: Most therapeutic Dispensing Fee: $3.65, effective 7/1/99.
categories are covered by at least one drug in the Pharmacies that dispense drugs that they package
category. Therapeutic categories not covered: into unit packaging receive an additional $0.30 per
anabolic steroids; anoretics; drugs used for erectile prescription.
dysfunction; DESI drugs; drugs which are made by
manufactureres that do not have a rebate agreement Ingredient Reimbursement Basis: EAC = AWP-
with CMS; drugs which are limited or excluded by 12% (MAC, speciality pharmacies = AWP-15.5%).
the State as allowed by Federal law (OBRA 90);
drugs dispensed after their expiration date; drugs Prescription Charge Formula: Reimbursement is
(both legend and OTC) that are prescribed by based on the lesser of submitted AWP minus 12%
practitioners not licensed to prescribe or not within (or AWP-15.5%) plus a dispensing fee, MAC plus
their scope of practice to prescribe; herbal or a dispensing fee, or usual and customary. Special
homeopathic products; nutritional supplements rules for IV admixtures, drugs for multiple
except as specifically allowed in the DHS provider sclerosis, disease modifying anti-rheumatic drugs,
manual and updates; and drugs which require prior Hepatitis C products, anemia drugs, Neutropenia,
authorization and for which prior authorization Thrombocyopenia, Enzyme Replacement, Immune
criteria have not been met. Globulin, HIV antivirals, growth hormone, oral
chemotherapy and oral pulmonary hypertension
Coverage of Injectables: Injectable medicines preparations, Actimmune, Aldurazyme, Apokyn,
reimbursable through the prescription drug program Baraclude, Forteo, Fuzeon, Hyalgan, Leuprolide
when used in home health care and through acetate, Octreotide, Remodulin, Risperdal consta,
physician payment when used in physician offices. Rituxan, Sensipar, Synvisc, Temodar, Thryogen,
Minnesota-2
Tobi, Ventavis, Xeloda, Xolair, Zavesca, and Metropolitan Health Plan

Zoladex. 822 South 3rd Street, Suite 140
Minneapolis, MN 55415
Maximum Allowable Cost: State imposes a T: 800/647-0550
combination of Federal Upper Limits and State- F: 612/904-4493
specific MAC on generic drugs. Override requires
“dispense as written or “brand medically PrimeWest Health System
necessary.” Prescriber must also obtain prior 305 8th Avenue West
authorization. Alexandria, MN
T: 888/588-4420
Incentive Fee: None. F: 320/762-8750
Patient Cost Sharing: Brand: $3.00 South County Health Alliance

Generic: $1.00 110 W. Fremont Street
Owatonna, MN 55060
Cognitive Services: State pays for patient-specific 800/995-4543
medication therapy management to enrolled MTM
Pharmacist. UCare Minnesota
500 Stinson Boulevard NE
P.O. Box 52
E. USE OF MANAGED CARE Minneapolis, MN 55440-0052
T: 612/676-6500
Approximately 400,000 Medicaid recipients were F: 612/676-6555
enrolled in MCOs in FY 2006 and FY 2007.
Recipients receive pharmaceutical benefits through
both the State and managed care plans. F. STATE CONTACTS
Managed Care Organizations State Drug Program Administrator

Itasca Medical Care Kristen C. Young
Itasca Resource Center Pharmacy Program Manager
1209 SE 2nd Ave. Minnesota Department of Human Services
Grand Rapids, MN 55744-3983 540 Cedar Street
T: 800/843-9536 St. Paul, MN 55155
F: 218/327-5545 T: 651/431-2504
F: 651/431-7426
Blue Plus E-mail: kristen.c.young@state.mn.us
P.O. Box 64560 Internet address:
St. Paul, MN 55164-0179 www.dhs.state.mn.us/provider/pharm
T: 651/662-5200
F: 651/662-2745 Prior Authorization Contact
Mary Claire Wohletz, Pharm.D.
First Plan Blue Clinical Pharmacist
525 South Lake Avenue, Suite 222 Minnesota Department of Human Services
Duluth, MN 55802 540 Cedar Street
T: 800/635-4159 St. Paul, MN 55155
F: 218/724-9176 T: 651/431-2510
F: 651/431-7426
HealthPartners E-mail: mary.c.wohletz@state.mn.us
8100 34th Avenue South
P.O. Box 1309 DUR Contact
Minneapolis, MN 55414-1309 Mary Beth Reinke, Pharm.D., M.S.A.
T: 952/967-6633 DUR Coordinator
Minnesota Department of Human Services
Medica 540 Cedar Street
401 Carlson Parkway St. Paul, MN 55155
P.O. Box 9310 T: 651/431-2505
Minneapolis, MN 55440-9310 F: 651/431-7426
T: 800/373-8355 E-mail: mary.beth.reinke@state.mn.us
F: 952/992-3198
Minnesota-3
Medicaid DUR Board Medicaid Drug Rebate Contacts

Physicians Jarvis Jackson, R.Ph.
Pierre Rioux, M.D. Drug Rebate Coordinator
Austin, MN Minnesota Department of Human Services
540 Cedar Street
Tim Ronnenberg, M.D. St. Paul, MN 55155
St. Paul, MN T: 651/431-2543
F: 651/431-7426
Health Care Professional E-mail: jarvis.jackson@state.mn.us
Peter T. Mitchell, R.N., C.N.P.
Minneapolis, MN Disease Management Program/Initiative
Contact
Pharmacists
Ruth Buchmayer, R.Ph. None
St. Paul, MN
Laura Odell, Pharm.D. None
Rochester, MN
Department of Human Services Officials
Margaret T. Schmidt, Pharm.D., M.B.A.
Shakopee, MN Cal R. Ludeman
Commissioner
Jill Strykowski, R.Ph., M.S. Department of Human Services
Fridely, MN 444 Lafayette Road North
St. Paul, MN 55155-3815
Consumers Representative T: 651/431-2907
Vacant F: 651/431-7443
E-mail: commissioner.dhs@state.mn.us
DHS Staff
Mary Beth Reinke, Pharm.D., M.S.A. Christine Bronson
DUR Coordinator Medicaid Director
Department of Human Services
New Brand Names Product Contact 444 Lafayette Road
St. Paul, MN 55155-3852
Mary Claire Woheltz, Pharm.D. T: 651/431-2914
651/431-2510 F: 651/431-7443
E-mail: christine.bronson@state.mn.us
Prescription Drug Updating
First DataBank Drug Formulary Committee
1111 Bayhill Drive, Suite 350 Margaret Artz, R.Ph., Ph.D.
San Bruno, CA 94066 Eden Prairie, MN
T: 800/633-3453
F: 650/588/4003 Mary Graves, M.S., B.S.N.
Roseville, MN
Claims Submission Contact Al Heaton, Pharm.D., R.Ph.
Larry Woods Eagan, MN
Health Care Operations William P. Korchik, M.D.
Minnesota Department of Human Services Minneapolis, MN
540 Cedar Street
St. Paul, MN 55155 Lynne M. Schneider, R.Ph.
651/431-3082 Plymouth, MN
John Simon, M.D.
Minneapolis, MN
Paul Turcotte, D.O.
Minneapolis, MN
Nikki White, R.Ph.
Minneaplis, MN
Minnesota-4
DHS Staff Minnesota Society of Health System-Pharmacists

Mary C. Woheltz, Pharm D. Scott Marin
Clinical Pharmacist Executive Director
13911 Ridgedale Drive, Suite 260
Executive Officers of State Medical and Minnetonka, MN 55305
Pharmaceutical Societies T: 952/541-9499
F: 952/541-9684
Minnesota Medical Association
E-mail: smartin@mnshp.org
Robert K. Meiches, M.D.
Internet address: www.mnshp.org
Chief Executive Officer
1300 Godward Street, NE, Suite 2500
Care Providers of Minnesota
Minneapolis, MN 55413-1878
Rick E. Carter
T: 612/378-1875
President & CEO
F: 612/378-3875
7851 Metro Parkway
E-mail: rmeiches@mnmed.org
Suite 200
Internet address: www.mnmed.org
Bloomington, MN 55425
T: 612/854-2844
Minnesota Pharmacists Association
F: 612/854-6214
Julie K. Johnson, R.Ph.
E-mail: rcarter@careproviders.org
Executive Vice-President
Internet address: www.careproviders.org
1935 W. County Road, B2 #450
Roseville, MN 55113
T: 651/697-1771
F: 651/697-1776
E-mail: julie@mpha.org
Internet address: www.mpha.org
Minnesota Osteopathic Medical Society

Colleen Jensen
Executive Director
P.O. Box 314
Lakeland , MN 55043-0314
T: 612/623-3268
F: 612/677-3200
E-mail: info@mndo.org
Internet address: www.mndo.org
State Board of Pharmacy

Cody C. Wiberg, Pharm.D., R.Ph.
Executive Director
2829 University Avenue SE, #530
Minneapolis, MN 55414-3251
T: 612/201-2825
F: 612/201-2837
E-mail: cody.wiberg@state.mn.us
Internet address: www.phcybrd.state.mn.us
Minnesota Hospital and Healthcare Partnership

Bruce Rueben
President
2550 University Avenue West, Suite 350S
St. Paul, MN 55114-1900
T: 651/641-1121
F: 651/659-1477
E-mail: brueben@mnhospitals.org
Internet address: www.mnhospitals.org
Minnesota-5
Minnesota-6
MISSISSIPPI

Disabled Disabled
Skilled Nursing Home Services ! ! ! !

2003 2004
TOTAL $568,265,605 547,268 $666,491,588 581,702

Aged $33,956,990 18,673 $61,309,256 27,196
Blind/Disabled $205,788,046 105,600 $210,024,497 97,193
Child $21,387,336 79,735 $25,271,441 81,990
Adult $22,539,921 48,947 $27,968,135 53,390

Aged $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

Aged $68,372,665 34,444 $79,174,766 33,684
Blind/Disabled $91,090,396 34,067 $98,517,399 31,300
Child $54,284,789 182,409 $57,309,906 179,508
Adult $4,083,389 22,345 $3,832,854 18,037
BCCA Women $0 0 $184,558 120
**Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
Mississippi-1
C. ADMINISTRATION Must be administered by credentialed pharmacist

and counts against monthly Rx limits.
Division of Medicaid, Office of the Governor.
D. PROVISIONS RELATING TO DRUGS Formulary: Open formulary with preferred drug list
(PDL). General exclusions include:
Benefit Design 1. Drugs used for anorexia or weight gain.
Drug Benefit Product Coverage: Products covered: 2. Drugs when used for the symptomatic relief of
prescribed insulin; total parenteral nutrition. Prior cough and colds (except legend and OTC
authorization required for: brand name multisource quaifenesin products, or promethaine with
products; enteral feeding/nutritional products; codeine).
immunosuppressant agents; Xenical, Synagis; and 3. Prescription vitamins and mineral products
non-preferred drugs. Products not covered: drugs (except prenatal vitamins and fluoride
for cosmetic use; fertility drugs; experimental preparations and some ESRD vitamins, which
drugs; disposable needles and syringe combinations are covered).
used for insulin; blood glucose test strips; urine
4. Covered outpatient drugs for which the
ketone test strips; and interdialytic parenteral
manufacturer requires (as a condition of sale)
nutrition.
that associated tests or monitoring services be
purchased exclusively from the manufacturer
or its designee.
covered with restrictions (i.e., must be on limited
formulary, requires a prescription, and counts 5. Barbiturates (coverage limited to
against monthly service limits): allergy, asthma, mephobarbital and phenobarbital).
and sinus products; analgesics; cough and cold 6. Benzodiazepines (generic formulations only).
preparations; digestive products; feminine products; 7. DESI drugs (those drugs that are designated
topical products; smoking deterrent products; less than effective by the FDA).
certain vitamins (prenatal and dialysis).
Additional techniques to manage the PDL include
Therapeutic Category Coverage: Therapeutic restrictions on use, prior authorization, preferred
categories covered: anabolic steroids; analgesics, products, and academic detailing. Additional
antipyretics, and NSAIDs; antibiotics; information about the PDL can be found at
anticoagulants; anticonvulsants; antidepressants; www.dom.ms.us.
antidiabetic agents; antihistamines; anti-psychotics;
Prior Authorization: State currently has a prior
anxiolytics, sedatives, and hypnotics; cardiac drugs;
authorization procedure. A written request
chemotherapy agents; contraceptives; ENT anti-
(including medical justification for beneficiaries
under age 21) must be made within 30 days of
hypotensive agents; misc. GI drugs; antilipemic
denial to appeal a prior authorization decision.
Review and determination made by clinical
agents. Partial coverage for: prescribed cold
specialists within 3 days of receipt. All parties
medications; prescribed smoking deterrents.
notified in writing within 24 hours of decision.
Products not covered: anoretics; weight loss drugs;
fertility drugs; vitamins and minerals (except
prenatal); and DESI drugs.
Prescription Refill Limit: Limited to 11 scripts per
Coverage of Injectables: Injectable medicines year.
Program when used in home health care and Monthly Quantities Limit: 31-day. Birth control
extended care facilities, and through physician pills may be supplied in 13-month quantities by MS
payment when used in physicians’ offices. Deparment of Health only.
Unit Dose: Unit dose packaging is reimbursable. Monthly Prescription Limit: Maximum of 5 scripts
per month with no more than 2 branded.
Vaccines: Vaccines reimbursable as part of the Beneficiaries in long term care facilities are exempt
Vaccine for Children Program. LTC reimbursed in from monthly prescription limits. Beneficiaries
cost reports. Only influenza a pneumonia are under the age of 21 may receive more than the
covered via POS for adult non-LTC beneficiaries. montlhy limits with Medical Necessity or Plan of
Care.
Mississippi-2
Drug Utilization Review Division of Medicaid Official

PRODUR system implemented in 1993. State has a Dr. Robert L. Robinson, Executive Director
12 member DUR Board that meets quarterly. Division of Medicaid
239 North Lamar Street
Pharmacy Payment and Patient Cost Robert E. Lee Building, Suite 801
Sharing Jackson, MS 39201-1399
T: 601/359-9562
Dispensing Fee: $3.91 sole source, $4.91
F: 601/359-6048
multisource (eff. 7/1/05).
E-mail: rlrobinson@medicaid.state.ms.us
Ingredient Reimbursement Basis: EAC = lower of Prior Authorization Contact
AWP-12% or WAC/Wholesale Net Unit (WNU) +
9%. Judith P. Clark, R.Ph.
601/359-5253
Prescription Charge Formula: Reimbursement for
legend drugs will be at the lessor of AWP-12% or DUR Contact
WAC+9% plus a dispensing fee or usual and Paige Black Clayton, Pharm.D.
customary charge. OTC drugs will be paid at lessor
Pharmacist
of AWP plus a dispensing fee, usual and customary Division of Medicaid
price, or estimated shelf price plus a dispense fee. Walter Sillers Building, 10th Floor
550 High Street
Maximum Allowable Cost: State imposes Federal Jackson, MS 39201
Upper Limits on generic drugs. Override requires T: 601/359-5253
“Medically Necessary” or “ Brand Medically F: 601/359-9555
Necessary” (e.g., brand name multi-source prior E-mail: phpbc@medicaid.state.ms.us
authorization form showing allergic Rx, ADR, or
failure to respond) for brand multi-source drugs.
Mississippi DUR Board
Incentive Fee: None. Lee Montgomery, M.D.
Magnolia, MS
Patient Cost Sharing: $3.00
Harold B. Blakely, R.Ph.
Cognitive Services: Pays for disease management Tupelo, MS
services for diabetes, hyperlipidemia, asthma, and
coagulatory disorders (effective 8/1/98). Pays $20 Roy L. Arnold, Jr., R.Ph.
for average 30-minute encounter. Collins, MS
Troy Griffin
E. USE OF MANAGED CARE Magee, MS
No Medicaid recipients receive health benefits Andrea Phillips, M.D.

through MCOs. Jackson, MS
Laura Gray, M.D. (Vice Chair)

F. STATE CONTACTS Tupelo, MS
State Drug Program Administrator Frank Marascalco (Chair)
Judith P. Clark, R.Ph. Grenada, MS
Pharmacy Director
Division of Medicaid Lee Voulters, M.D.
Walter Sillers Building, 10th Floor Gulfport, MS
550 High Street
Jackson, MS 39201 John M. Wallace, M.D.
T: 601/359-5253 Laurel, MS
F: 601/359-9555
E-mail: phipc@medicaid.state.ms.us Billy R. Brown, Pharm.D.
Internet address: www.dom.state.ms.us Jackson, MS
Mississippi-3
Wallace Strickland Mail Order Pharmacy Program

Meridian, MS
None
Randy Calvert, R.Ph.
Jackson, MS Pharmacy and Therapeutics Committee
Garry McFerrin, R.Ph.
New Brand Names Product Contact Mantachie, MS
Judith P. Clark, R.Ph.
Jennifer Gholson, M.D.
601/359-5253
Summit, MS
John Cook M.D.
Terri R. Kirby, R.Ph. Jackson, MS
Pharmacist
Divison of Medicaid Michael L. O’Dell, M.D. (Vice Chair)
Walter Sillers Building, 10th Floor Tupelo, MS
550 High Street
Jackson, MS 39201 Deborah King, F.N.P.
T: 601/359-5253 Corinth, M.S.
F: 601/359-9555
E-mail: phtrk@medicaid.state.ms.us Robert H. Lomenick, R.Ph.
Potts Camp, MS
Steve Roark
Christopher Yount Yazoo City, MS
DRAMS Business Analyst
ACS State Healthcare Pearl Wales, Pharm.D.
385-B Highland Colony Parkway Canton, MS
Ridgeland, MS 39157
T: 601/206-2904 Robert Smith, M.D.
F: 601/572-3200 Jackson, MS
E-mail: christopher.yount@acs-inc.com
Manisha Sethi, M.D.
Claims Submission Contact Ridgeland, MS
Chris Bryan
Pharmacy Services Manager Jeff Jones, R.Ph.
ACS State Healthcare Carthage, MS
385-B Highland Colony Parkway
Ridgeland, MS 39157 Larry Calvert, R.Ph. (Chair)
T: 601/206-2995 Gulfport, MS
F: 601/572-3200
E-mail: chris.bryan@acs-inc.com Executive Officers of State Medical and
Disease Management/Patient Education Mississippi State Medical Association
Contact William F. Roberts
Roxane Coulter, R.N. Executive Director
Nurse Administrator P.O. Box 2548
Care Management Division Ridgeland, MS 39158-2548
Medical Services 601/853-6733
Division of Medicaid E-mail: wroberts@msmaonline.com
Walter Sillers Building, 10th Floor Internet address: www.msmaonline.com
550 High Street
Jackson, MS 39201
T: 601/359-5243
F: 601/359-5252
E-mail: msrmc@medicaid.state.ms.us
Mississippi-4
Mississippi Pharmacists Association Mississippi Health Care Association

Bo Dalton, R.Ph. Vanessa P. Henderson
Executive Director Executive Director
341 Edgewood Terrace Drive 114 Marketridge Drive
Jackson, MS 39206-6217 Ridgeland, MS 39157
T: 601/981-0416 T: 601/956-3472
F: 601/981-0451 F: 601/977-0273
E-mail: mpha@bellsouth.net E-mail: vanessa@mshca.com
Internet address: www.mspharm.org Internet address: www.mshca.com
Mississippi State Board of Pharmacy

Leland “Mac” McDivitt
Executive Director
204 Key Drive, Suite C
Madison, MS 39110
T: 601/605-5388
F: 601/605-9546
E-mail: lmcdivitt@mbp.state.ms.us
Internet address: www.mbp.state.ms.us
Mississippi Osteopathic Medical Association

Jeffrey J. LeBoeuf
Executive Director
5260 Cedar Park Drive
Suite 1-B
P.O. Box 16890
Jackson, MS 39236
T: 601/366-3105
F: 601/366-2868
E-mail: info@moma-net.org
Internet address: www.moma-net.org
Mississippi Hospital Association

Sam W. Cameron
President/CEO
P.O. Box 1909
116 Woodgreen Place
Madison, MS 39110-1904
T: 800/289-8884
F: 601/368-3200
E-mail: scameron@mhanet.org
Internet address: www.mhanet.org
Mississippi Society of Health-System Pharmacists

Dianna McGowan, R.Ph.
Association Manager
328 Dover Lane
Madison, MS 39110
T: 601/856-9273
F: 601/856-8539
E-mail: johnnymcg@msn.com
Internet address: www.pharmd.org/mshp
Mississippi-5
Mississippi-6
MISSOURI

Disabled Disabled

2003 2004
TOTAL $953,324,877 526,991 $1,133,878,803 550,572

Aged $64,882,571 20,403 $70,739,483 19,914
Blind/Disabled $292,802,776 75,297 $333,613,144 76,528
Child $42,232,069 111,107 $48,815,217 112,821
Adult $59,086,387 87,016 $68,285,826 88,465

Aged $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

Aged $930,643 667 $842,454 544
Blind/Disabled $1,541,379 1,010 $2,082,034 864
Child $14,202,725 37,004 $16,695,535 39,136
Adult $2,115,795 12,960 $2,627,677 13,893
BCCA Women $0 0 $2,131,223 420
**Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
Missouri-1

Formulary: Open formulary with preferred drug
Division of Medical Services, Missouri Department list. PDL managed through exclusions and
of Social Services. restrictions, including preferred products, prior
authorization, therapeutic substitution, clinical
D. PROVISIONS RELATING TO DRUGS edits, and step therapy.
Benefit Design Prior Authorization: State currently has a prior

authorization procedure and a Drug Prior
Drug Benefit Product Coverage: Categories or Authorization Committee composed of 9 members
drugs that are covered: prescribed insulin; who meet quarterly. Fair hearing process to appeal
disposable needles and syringe combinations used prior authorization decisions.
for insulin; blood glucose test strips; urine ketone
test strips; total parenteral nutrition; and Prescribing or Dispensing Limitations
interdialytic parenteral nutrition. Limited coverage
(limited to OTC formulary) for: allergy, asthma, Prescription Refill Limit: None
and sinus products; analgesics; cough and cold
preparations; digestive products; and topical Monthly Quantity Limit: Physician encouraged to
products. Prior authorization required for: prescribe 31-day or 100 dose supply but may, at
amphetamines; barbiturates; Isotretinoin; Orlistat; own discretion, prescribe up to a maximum 90-day
and Retinoic Acid. Products not covered: supply.
cosmetics; fertility drugs; experimental drugs;
smoking deterrent products; feminine products; hair Dose Limit: Prescriptions for the following must be
growth products; Halazepam; Prazepam; dispensed for at least 200 units per prescriptions:
Estazolam; Quazepam; and non-legend products. Acetaminophen 5 gr. Prenatal vitamins must be
dispensed in a quantity of at least 30.
Therapeutic Catogory Coverage: Therapeutic
categories covered: analgesics, antipyretics, and Drug Utilization Review
NSAIDs; antibiotics; anticoagulants; PRODUR system implemented in 1993. State
anticonvulsants; anti-depressants; antidiabetic currently has a 13 member DUR Board with a
agents; antihistamines; antilipemic agents; anti- quarterly review.
psychotics; cardiac drugs; chemotherapy agents;
contraceptives; ENT anti-inflammatory agents; Pharmacy Payment and Patient Cost
estrogens; hypotensive agents; sympathominetics Sharing
(adrenergic); and thyroid agents. Prior authorization
required for: anxiolytics, sedatives, and hypnotics; Dispensing Fee: $4.09 (out-of-state), $8.04 (in-
prescribed cold medications; growth hormones; and state), $8.19 (long-term care pharmacies).
Misc. GI drugs. Partial coverage for: anabolic
steroids (PA required). Categories not covered: Ingredient Reimbursement Rate: EAC = AWP-
anoretics; prescribed smoking deterrents. 10.43% or WAC+10%.
(For additional information on products and/or Prescription Charge Formula:

category coverage, see the pharmacy provider
1. Method of reimbursement payment is based on
bulletin at www.medicaid.state.mo.us.)
acquisition cost plus a dispensing fee per
prescription filled. Acquisition may vary
depending whether it is based on AWP Federal
or Missouri MAC, or usual and customary
Program when used in physician offices, home
(UCR).
health care settings, and extended care facilities.
2. Any drug that is not a Federal or Missouri
Vaccines: Vaccines reimbursable as part of the MAC drug will be based on the AWP-10.43%
Vaccines for Children Program. Adult vaccines are or the WAC+10%. The majority of drugs listed
paid through the Pharmacy Program. are based on AWP. The method of pricing will
be taken from the NDC number.
Missouri-2
Maximum Allowable Cost: State imposes Federal Mercy CarePlus

Upper Limits as well as State-specific limits on 10123 Corporate Square Drive
generic drugs. Approximately 1,200 drugs are listed St. Louis, MO 63132
on the State-specific MAC list. Override requires 314/432-9300
“Brand Medically Necessary,” prior authorization
and a MedWatch form. Children’s Mercy Family Health Partners Plan
215 W. Pershing Road, 6th Floor
Incentive Fee: None. P.O. Box 411806
Kansas City, MO 64108
Patient Cost Sharing: Variable tiered copayment: 816/855-1888
Drug Ingredient Cost Copayment Missouri Care

2404 Forum Boulevard
$0.00 to $10.00 $0.50 Columbia, MO 65203
573/441-2100
$10.01 to $25.00 $1.00
$25.01 or more $2.00 F. STATE CONTACTS
($5.00 copayment for certain 1115 waiver State Drug Program Administrator
populations (see Pharmacy Bulletin).) George L. Oestreich, Pharm.D., M.P.A.
Deputy Director, Clinical Services
Copayment retained by pharmacist. Department of Social Services
Cognitive Services: Payment for cognitive services 205 Jefferson Street, 10th Floor
is provided to qualified pharmacies who enroll to P.O. Box 6500
provide asthma/COPD, diabetes, heart failure, Jefferson City, MO 65102-6500
sicklecell, GERD, and depression education. T: 573/751-6961
F: 573/522-8514
E. USE OF MANAGED CARE E-mail: George.L.Oestreich@dss.mo.gov
Internet address: www.dss.mo.gov/dms
enrolled in managed care organizations in 2006. Social Services Department Officials
All receive pharmacy services through both the Deborah Scott, Director
State and managed care. Protease inhibitors are Department of Social Services
carved out of managed care. Broadway State Office Building
221 West High Street
Managed Care Organizations P.O. Box 1527
Healthcare USA Jefferson City, MO 65102-1527
10 South Broadway, Suite 1200 T: 573/751-4815
St. Louis, MO 63102 F: 573/751-3203
314/241-5300 E-mail: dscott@mail.state.mo.us
Blue Cross and Blue Shield of Kansas City Steve Renne, Interim Director
Blue-Advantage Plus of Kansas City, Inc. Department of Social Services
P.O. Box 419169 Division of Medical Services
2301 Main St., 3rd Floor 615 Howerton Court, P.O. Box 6500
Kansas City, MO 64108 Jefferson City, MO 65102-6500
816/395-2119 T: 573/751-3425
F: 573/751-6564
Harmony Health Plan of Missouri
23 Public Square, Suite 400
Belleville, IL 62222
866/822-1340
Missouri-3
New Brand Name Products Contact DUR Contact

Rhonda A. Driver Tisha A. Honse
Clinical Pharmacist DUR Coordinator
Department of Social Services Department of Social Services
Division of Medical Services Division of Medical Services
205 Jefferson Street, 10th Floor 205 Jefferson Street, 10TH Floor
P.O. Box 6500 P.O. Box 6500
Jefferson City, MO 65102- 6500 Jefferson City, MO 65102-6500
T: 573/751-6961 T: 573/751-6961
F: 573/522-8514 F: 573/522-8514
E-mail: Rhonda.Driver@dss.mo.gov E-mail: Tisha.A.Honse@dss.mo.gov
Prior Authorization Contact DUR Board

Rhonda A. Driver John W. Newcomer, M.D. (Chair)
573/751-6961 Stacy Mangum, Pharm.D.
David C. Campbell, M.D., M.Ed.
Pharmacy Advisory Group Joy S. Gronstedt, D.O.
Joseph M. Yasso, D.O.
Matt Carlise, R.Ph. Randy Beckner, Pharm.D.
St. Peters, MO
Karla Dwyer, R.Ph.
Susan Abdel-Rahman, Pharm.D.
Gene Forrester, R.Ph. Peggy Wanner-Barjenbrunch, M.D.
Columbia, MO
Sandra Bollinger, Pharm.D.
Stephen Calloway, R.Ph.
Curtis Hartin, R.Ph. Robert Dale Potter, R.N.
St. Louis, MO
Sharad Parikh, M.D.
Ed Powers, R.Ph.
Drug Prior Authorization Committee
Macon, MO
Patrick J. Bryant, Pharm.D.
Steve Hartwig, R.Ph. Kansas City, MO
Marshall, MO
Joseph Parks, M.D.
Jim Harlan, R.Ph. Jefferson City, MO
Poplar Bluff, MO
Gene Forrester, R.Ph.
Shirley Schneider/Dennis Hunt (Alternate) Columbia, MO
Deerfield, IL
Henry Petry, D.O.
Christie Beisner, R.Ph. Edina, MO
Nevada, MO
Jay R. Bryant-Wimp, R.Ph.
John Fester, R.Ph. Columbia, MO
Steelville, MO
Lorraine C. Brown, D.O.
Janice Steiger, R.Ph. Lebanon , MO
Florissant, MO
Conrad S. Balcer, D.O.
John Luebker, R.Ph. Jefferson City, MO
Bentonville, AR
Lindsey Collins, Pharm.D. (Alternate)
Kansas City, MO
Missouri-4
Prescription Price Updating Executive Officers of State Medical and

First DataBank
1111 Bayhill Drive Missouri State Medical Association
San Bruno, CA 94066 C. C. Swarens
T: 650/588-5454 Executive Secretary
F: 650/872-4510 113 Madison Street, P.O. Box 1028
Jefferson City, MO 65102
Medicaid Drug Rebate Contact T: 573/636-5151
F: 573/636-8552
Jacqueline K. Hickman
E-mail: cswarens@msma.org
Medicaid Unit Supervisor
Internet address:
www.momed.net/momed/index.htm
Division of Medicaid Services
205 Jefferson Street, 10TH Floor
Missouri Pharmacy Association
P.O. Box 6500
Ron Fitzwater
Jefferson City, MO 65102-6500
T: 573/526-5664
211 East Capitol Avenue
F: 573/522-4650
E-mail: jacquelin.k.hickman@dss.mo.gov
T: 573/636-7522
F: 573-636-7485
Claims Submission Contact E-mail: ron@morx.com
Diane Twehous Internet address: www.morx.com
Account Manager
Infocrossing Health Care Services, Inc. Missouri Assoc. of Osteopathic
905 Weathered Rock Road Physicians/Surgeons, Inc.
Jefferson City, MO 65109 Bonnie M. Bowles
573/635-2434 Executive Director
1423 Randy Lane
Medicaid Managed Care Contact Jefferson City, MO 65101
T: 573/634-3415
Steve Renne F: 573/634-5635
573/751-3425 E-mail: contact@maops.org
Internet address: www.maops.com
None Missouri State Board of Pharmacy
Debra Ringgenberg
Disease Management/ Patient Education Executive Director
Programs 3605 Missouri Boulevard
P.O. Box 625
Disease Medical States: Asthma Jefferson City, MO 65102-0625
Cardiovascular Disease T: 573/751-0091
Depression F: 573/526-3464
Diabetes E-mail: pharmacy@pr.mo.gov
Hypertension Internet address: www. pr.mo.gov/pharmacists.asp
COPD
Hyperlipidemia Missouri Hospital Association
GERD Marc D. Smith, Ph.D.
Program Manager: Jennifer Cornelius President and CEO
Program Sponsor: State of Missouri 4712 Country Club Drive
P.O. Box 60
Disease Management Initiatives Contact Jefferson City, MO 65102-0060
George Oestreich, Pharm.D., M.P.A. T: 573/893-3700
573/781-6961 F: 573/893-2809
E-mail: msmith@mail.mhanet.com
Internet address: www.mhanet.com
Missouri-5
Missouri-6
MONTANA

Disabled Disabled

2003 2004
TOTAL $86,637,045 74,400 $96,711,936 70,441

Aged $3,351,536 1,546 $3,603,368 1,585
Blind / Disabled $30,983,393 10,766 $35,695,689 10,805
Child $2,327,687 10,520 $2,571,067 9,787
Adult $4,424,066 7,241 $4,652,217 7,045

Aged $14,384,986 5,371 $15,300,115 5,293
Blind / Disabled $10,295,043 2,427 $11,662,065 2,466
Child $22,076 30 $6,752 20
Adult $12 1 $0 0

Aged $12 1 $1,100 2
Blind / Disabled $0 0 $411 1
Child $2,789,551 13,719 $3,406,556 14,305
Adult $428,314 2,386 $516,870 2,575
BCCA Women $89,901 73 $169,721 97
unknown.
Note: Montana estimates 2005 drug expenditures to be approximately $105 million and the number of Medicaid drug
recipients to be 71, 077.
Source: CMS MSIS Reports, FY 2003 and FY 2004 and Montana Department of Public Health and Human Services, Health
Resources Division.
Montana-1

reimbursable through the physician payment when
Department of Public Health and Human Services, used in extended care facilities and physician
Health Resources Division, Acute Services Bureau offices, and through both physician payment and
the prescription drug program when used in home
health care.
Benefit Design EPSDT service, the Children Health Insurance
Drug Benefit Product Coverage: Products covered: Program, and the Vaccines for Children Program.
legend drugs,; certain prescribed over-the-counter
products; vaccines except children 18 and under Unit Dose: Unit dose packaging reimbursable.
and clients with Medicare Part B coverage;
compounded prescriptions; contraceptive supplies Formulary/Prior Authorization
and devices. Products covered as DME: disposable Formulary: Open formulary with a preferred drug
needles and syringe combinations used for insulin, list. Formulary managed through exclusion of
blood glucose test strips. Prior authorization products based on contracting issues, restrictions on
required for: prescribed insulin; total parenteral use, prior authorization, preferred products, and
nutrition; interdialytic parenteral nutrition; non- physician profiling. Drugs classified as less-than-
steroidal anti-inflammatory drugs; all single source effective (LTE) by the FDA are not covered. Drugs
NSAIDs; Celebrex; disease-modifying anti- with no manufacturer rebate are not covered.
rheumatic drugs (Arava, Enbrel, Remicade); growth
hormones; single-source benzodiazepines; gastro- Prior Authorization: State has a formal prior
intestinal drugs (proton pump inhibitors); migraine authorization procedure. Expedited administrative
headache drugs for certain monthly quantities on review and a formal appeal procedure through the
Imitrex, Maxalt, Zomig, Migranal, Amerge; Department possible for PA decisions. Prescriber
smoking-cessation drugs; Toradoloral; letter documenting evidence for use of prescribed
Dipyridamole; Aggrenox; Trental; Ambien; medication in treatment of disease is reviewed by
Lunesta; Roserem; Sonata; Viagra; Thalomid; DUR Board for appeal of excluded product.
Zyvox; Tretinoin; Zoloft; Kineret; Stadol. Products
not covered: fertility drugs; weight loss drugs, Prescribing or Dispensing Limitations
cosmetics; experimental drugs; and urine ketone
test strips. Prescription Refill Limit: None
Monthly Quantity Limit: 34-day supply. May have

Over-the-Counter Product Coverage: Products quantity limits on certain medications selected by
covered (i.e., when prescribed): analgesics (aspirin the DUR Board.
only); allergy, asthma, and sinus products;
(loratadine, diphenhydramine); insulin; laxatives; Drug Utilization Review
head lice treatments; digestive products; GI
products; bronchosaline; and smoking deterrent PRODUR system implemented in September 1994.
products (prior authorization required). Products State DUR Board meets monthly.
not covered: cold and cough preparations; feminine
products; and topical products. Pharmacy Payment and Patient Cost
Sharing
categories covered: anabolic steroids; antibiotics; Dispensing Fee: $2.00-$4.70; effective 7/1/02.
anticoagulants; anticonvulsants; anti-psychotics; Pharmacies submit documentation showing their
chemotherapy agents; prescribed cold medications; costs. Dispensing fee is based on their cost up to a
contraceptives; estrogens; sympathominetics maximum of $4.70. Pharmacies that do not submit
(adrenergic); and thyroid agents. Prior authorization documentation receive a dispensing fee of $2.00
required for: antihistamines; analgesics, Out-of-State pharmacies receive $3.50.
antipyretics, and NSAIDs; antidepressants;
antidiabetic agents; antilipemic agents; anxiolytics, Ingredient Reimbursement Basis: EAC = AWP-
sedatives, and hypnotics; cardiac drugs; ENT anti- 15%.
inflammatroy drugs; misc. GI products; prescribed
smoking deterrents; hypotensive agents; and growth Prescription Charge Formula: The lower of EAC,
hormones. Therapeutic categories not covered: the Federal MAC (plus a dispensing fee), or the
anoretics. provider usual and customary charge.
Montana-2
Maximum Allowable Cost: State imposes Federal John Chappuis

Upper Limits on generic drugs. Override requires Medicaid Director
“Brand Necessary” or “Brand Required” on the Division of Health Policy and Services
prescription. Department of Public Health and Human Services
111 N. Sanders
Incentive Fee: None. P.O. Box 4210
Helena, MT 59604-4210
Patient Cost Sharing: Copayment of $1.00 - $5.00. T: 406/444-4084
Recipient pays 5% of Medicaid allowable cost F: 406/444-1861
between $1.00 and $5.00 based on cost of the drug. E-mail: j.chappuis@state.mt.us
$5.00 copayment cap per prescription. $25.00
copayment cap per month. Prior Authorization Contact
Wendy C. Blackwood
406/444-2738
services.
DUR Contact
E. USE OF MANAGED CARE Mark Eichler, R.Ph., FASCP
Pharmacy Programs Director
Does not use MCO’s to provide services to Mountain-Pacific Quality Health Foundation
Medicaid recipients. 3404 Cooney Drive
Helena, MT 59602
F: 406/443-7014
State Drug Program Administrator E-mail: meichler@mpqhf.org
Wendy C. Blackwood Montana DUR Board

Pharmacy Program Officer
Department of Public Health and Human Services Mark Eichler, R.Ph., FASCP
Acute Services Bureau DUR Coordinator
1400 Broadway
P.O. Box 202951 Lee Ann Bradley, Pharm.D.
Helena, MT 59620-2951 Sherrill Brown, Pharm.D.
T: 406/444-2738 Bill Burton, R.Ph.
F: 406/444-1861 Carla Cobb, Pharm.D.
E-mail: wblackwood@mt.gov Jim Crichton, M.D.
Internet address: www.mtmedicaid.org Lori Fitzgerald, Pharm.D.
V. Lee Harrison, M.D.
Stephen S. Nagy, M.D.
Public Health and Human Services Officials Richard Sargent, M.D.
Joan Miles, J.D., Director
Department of Public Health and Human Services New Brand Name Products Contact
111 N. Sanders, Room 301 Wendy C. Blackwood
P.O. Box 4210 406/444-2738
Helena, MT 59604-4210
T:406/444-5622 Prescription Price Updating
F: 406/444-1970
E-mail: j.miles@state.mt.us First DataBank
1111 Bayhill Dr.
Mary Dalton San Bruno, CA 94066
Administrator T: 650/588-5454
Health Resources Division F: 650/827-4578
Department of Public Helath and Human Services
1400 Broadway
Helena, MT 59601
T: 406/444-4540
F: 406/444-1861
E-mail: mdalton@mt.gov
Montana-3
Montana State Board of Pharmacy

Starla Blank, R.Ph.
Betty DeVaney, Drug Rebate Coordinator Executive Director
Department of Public Health & Human Services P.O. Box 200513
Medicaid Services Bureau 301 South Park, 4th Floor
P.O. Box 202951 Helena, MT 59620-0513
1400 Broadway T: 406/841-2371
Helena, MT 59620-2951 F: 406/841-2305
T: 406/444-3457 E-mail: dlibspdha@state.mt.gov
F: 406/444-1861 Internet address:
E-mail: bdevaney@mt.gov http://mt.gov/dli/license/bsd_boards/pha_board
Claims Submission Contact Montana Osteopathic Medical Association

Carmen Bell
Brett Jakovac, Executive Account Manager Executive Director
ACS State Healthcare 1600 2nd Avenue, SW, Suite 120
34 N. Last Chance Gulch, Suite 200 Minot, ND 58701
Helena, MT 59601 701/852-8789
T: 406/457-9555 E-mail: ndoma@ndoma.org
F: 406/442-2819 Internet Address: www.mtoma.org
E-mail: brett.jakovac@acs-inc.com
Association of Montana Health Care Providers
Medicaid Managed Care Contact Dick Brown
Chris Silvonen, Program Officer Sr. Vice President/Executive Director
Dept. of Public Health and Human Services P.O. Box 5119
Medicaid Services Bureau 1720 Ninth Avenue
1400 Broadway Helena, MT 59601
P.O. Box 202951 T: 406/442-1911
Helena, MT 59620-2951 F: 406/443-3894
T: 406/444-1292 E-mail: dick@mtha.org
F: 406/444-1861 Internet address: www.mtha.org
E-mail: csilvonen@mt.gov

None

Montana Medical Association
G. Brian Zins
2021 11th Avenue, Suite 1
Helena, MT 59601-4890
T: 406/443-4000
F: 406/443-4042
E-mail: brian@mmaoffice.com
Internet address: www.mmaoffice.com
Montana Pharmacy Association

Jim E. Smith
Executive Director
P.O. Box 1569
34 West 6th Avenue, Suite 2E
Helena, MT 59601-5074
T: 406/449-3843
F: 406/443-1592
E-mail: jimesmith@quest.net
Internet address: www.rxmt.org/services.htm
Montana-4
NEBRASKA

Disabled Disabled

2003 2004
TOTAL $197,698,309 196,184 $225,374,331 193,596

Aged $9,807,871 4,024 $10,398,763 3,930
Blind/Disabled $52,135,738 16,263 $60,655,652 16,855
Child $5,092,514 20,462 $6,095,152 21,039
Adult $5,945,488 10,572 $6,785,575 10,656

Aged $30,233,914 9,765 $31,838,102 9,624
Blind/Disabled $7,398,281 1,634 $8,832,125 1,690
Child $1,441,864 4,773 $330,593 1,180
Adult $5,347,583 11,368 $5,731,432 7,886

Aged $15,841,510 6,575 $17,573,233 6,694
Blind/Disabled $28,882,233 8,348 $34,112,355 8,649
Child $20,005,068 72,915 $23,090,844 69,478
Adult $885,258 5,656 $1,017,807 6,029
BCCA Women $82,463 88 $140,875 140
unknown.
Nebraska-1
C. ADMINISTRATION Vaccines: Vaccines reimbursable by Medicaid for

individuals under 21 years of age through the
State Department of Health and Human Services, Vaccines for Children Program.
Finance and Support, Medicaid Division.
Benefit Design Formulary: Open formulary managed through
Drug Benefit Product Coverage: Products covered: restrictions on use, prior authorization, therapeutic
legend drugs, compound prescriptions, prescribed substitution, and preferred products. General
insulin with prior approval (i.e., must be medically exclusions include:
necessary pre-filled syringes). Products covered
1. More than a three-month supply of birth
under the supplier program: disposable needles
control tablets;
used for insulin; blood glucose test strips; urine
ketone test strips; total parenteral nutrition; and 2. Experimental drugs or non-FDA approved
interdialytic parenteral nutrition. Products not drugs;
covered: DESI drugs, drugs for weight control; 3. Drugs or items when the prescribed use is not
cosmetics; fertility drugs; and experimental drugs. for a medically accepted indication;
Prior authorization required for: methadone; IV 4. Liquors (any alcoholic beverages);
infusions; and protein replacement supplements.
5. DESI drugs and all identical, related, or similar
drugs;
covered with restrictions (must be prescribed and 6. Personal care items (e.g., non-medical
subject to rebate): allergy, asthma, and sinus mouthwashes, deodorants, talcum powders,
products; analgesics; topical products; bath powders, soaps, dentrifices, eye washes,
vitamin/mineral supplements; eye/ear products; and contact solutions);
cough and cold preparations; and digestive 7. Medical supplies and certain drugs for nursing
products. Products not covered: feminine products; facility and intermediate care facility for the
and smoking deterrent products. mentally retarded (ICF/MR) patients;
8. Over-the-counter (OTC) drugs not listed on the
Therapeutic Category Coverage: Therapeutic Department’s Drug Name/License Number
categories covered: antibiotics; anticoagulants; Listing microfiche;
anticonvulsants; anti-depressants; antidiabetic
9. Baby foods or metabolic agents (Lofenalac,
agents; antilipemic agents; anti-psychotics;
etc.,) normally supplied by the Nebraska
Department of Health;
contraceptives; ENT anti-inflammatory agents; 10. Drugs distributed or manufactured by certain
estrogens; hypotensive agents; sympathominetics drug manufacturers or labelers that have not
(adrenergic); and thyroid agents. Prior agreed to participate in the drug rebate
authorization required for: sunscreens; program.
Erythropoetin (e.g., Epogen, Procrit); modified Drugs, items, or manufacturers that are identifiable
versions of FUL or SMAC drugs; convenience as non-covered are so designated on the NE-POP
packaged drugs (e.g., Refresh Ophthalmic 0.3 ml system, and on the Department’s Drug
and Novalin penfil insulin); drugs to prevent or Name/License Number Listing microfiche or
treat Respiratory Syncytial Virus Immune Globulin website.
(e.g., Palivizumab, RSV-IG); and drugs for sexual
dysfunction (e.g., Sildenafil, Alprostadil); Prior Authorization: State currently has a formal
analgesics, antipyretics, NSAIDs; antihistamines; prior authorization procedure. Prescriber must
growth hormones; and misc. GI drugs. Partial submit a letter of medical necessity with
coverage (PA required) for: prescribed smoking documentation to the Pharmacy Consultant. The
deterrents. Therapeutic categories not covered: Department requires that authorization be granted
anabolic steroids and anorectics. prior to payment for certain products. Prior
authorization can be verified through the NE-POP
Coverage of Injectables: Injectables reimbursable System, or by contacting the Department. (or its
through the pharmacy program when used in home designated contractor) if authorization is not
health care and extended care facilities, and through verified through the NE-POP System.
physician payment when used in physician offices.
Nebraska-2
Prescribing or Dispensing Limitations Managed Care Organizations

None Share Advantage
United Healthcare of the Midland
Drug Utilization Review 2717 North 118th Circle
Omaha, NE 68164
PRODUR system implemented in April 1995.
State currently has a DUR Board that meets 6 times Primary Care +
each year.
Blue Cross/Blue Shield of Nebraska
P.O. Box 241739
Pharmacy Payment and Patient Cost Omaha, NE 68124
Sharing
Dispensing Fee: $3.27 - $5.00. The Nebraska Magellan Behavioral Health
Department of Health and Human Services assigns P.O. Box 82047
a dispensing fee to each individual pharmacy based Lincoln, NE 68501
on location, services, volume, and other third-party
participation. The fee is calculated from
information obtained through the Department’s
F. STATE OFFICIALS
Prescription Survey.
Ingredient Reimbursement Basis: EAC = AWP - Barbara Mart
11%. Pharmacy Consultant
Prescription Charge Formula: Lower of: Finance and Support /Medicaid Division
301 Centennial Mall South, 5th Floor-NSOB
1. Product cost (EAC, SMAC, or FUL) plus a P.O. Box 95026
dispensing fee, or Lincoln, NE 68509
2. The usual and customary price to the general T: 402/471-9301
public. F: 402/471-9092
E-mail: barbara.mart@hhss.ne.gov
Listed OTCs are reimbursed at the lower of: Internet address : www.hhs.state.ne.us/med/pharm
1. Product cost (EAC, SMAC, or FUL) plus a
dispensing fee, Health and Human Services Department
Officials
2. The usual and customary shelf price to the
general public, or Scot Adams, Ph.D., Director
3. Product cost (EAC, SMAC, or FUL) plus a Finance and Support
50% mark-up. P.O. Box 95044
Maximum Allowable Cost: State imposes Federal Lincoln, NE 68509-5044
Upper Limits as well as State-specific limits on T: 402/471-2306
generic drugs. Override requires a State-specific F: 402/471-9449
form signed by the physician. E-mail: kelly.ostrander@hhss.ne.gov
Incentive Fee: None. Vivianne Chaumont, Director

Medicaid Division
Patient Cost Sharing: Copayment = $2.00.
Division of Medicaid and Long Term Care
P.O. Box 95026
Additional Pharmacy Payments: Additional
301 Centennial Mall South
payments for tablet splitting (effective 2000)
Lincoln, NE 68509-5026
T: 402/471-3121
Approximately 170,000 unduplicated Medicaid Prior Authorization Contacts

recipients were enrolled in managed care in 2006. Barbara Mart
Recipient enrolled in MCOs receive pharmaceutical 402/471-9301
services through the State.
Nebraska-3
DUR Contact Claims Submission Contact

Marcia Mueting, DUR Director George Jackson
Nebraska Pharmacists Association Account Manager
6221 South 58th Street, Suite A ACS State Healthcare
Lincoln, NE 68516 365 Northridge Road
T: 402/420-1500 Northridge Center One, Suite 400
F: 402/420-1406 Atlanta, GA 30350
E-mail: marcia@npharm.org T: 770/901-5502 x.5034
F: 888/772-2250
Nebraska DUR Board E-mail: george.jacksoniii@acs-inc.com
Pharmacist Members:
Kevin Borcher, R.Ph.
Elissa Carney, R.Ph. David Cygan
Shana Castillo, R.Ph. Managed Care Program Administrator
Patty Gollner, R.Ph. HHSS-Finance & Support-Medicaid
David Hutsell, R.Ph. 301 Centennial Mall South, 5th Floor, NSOB
John Franklin, R.Ph. P.O. Box 95026
Kim Hamik, R.Ph. Lincoln, NE 68509
Phillip Vuchetich, R.Ph. T: 402/471-9050
F: 402/471-9092
Physician Members: E-mail: david.cygan@hhss.ne.gov
Gary Conell, M.D.
Syed Mohivddin, M.D. Mail Order Pharmacy Program
Kirk Muffly, M.D.
None
Thomas B. Murray, M.D.
Medicaid Reform Council
(Former) Sen. Don Penderson (Chair)
Barbara Mart
Kathy Campbell
402/471-9301
Gayle-ann Douglas
Sen. Philip Erdman
Mary Lee Fitzsimmons
Barbara Mart Steve Martin
402/471-9301 Linda Ollis
Cory Shaw
Medicaid Drug Rebate Contacts Pat Snyder
Technical
Karen Jaques, Accountant II
Health and Human Services
Finance and Support Nebraska Medical Association
301 Centennial Mall South, 5th Floor, NSOB Sandra Johnson
P.O. Box 95026 Executive Vice President
Lincoln, NE 68509 233 S. 13th Street, Suite 1512
T: 402/471-9397 Lincoln, NE 68508-2091
F: 402/471-7783 402/474-4472
E-mail: karen.jaques@hhss.ne.gov E-mail: sandyj@nebmed.org
Internet address: www.nebmed.org
Policy
Jim Piazza Nebraska Pharmacists Association
Health and Human Services Joni Cover, J.D.
Financial and Support Executive Vice President
301 Centennial Mall South, 5th Floor, NSOB 6221 South 58th Street, Suite A
P.O. Box 95026 Lincoln, NE 68516-3679
Lincoln, NE 68509 T: 402/420-1500
T: 402/471-9105 F: 402/420-1406
F: 402/471-7783 E-mail: joni@npharm.org
E-mail: jim.piazza@hhs.ne.gov Internet address: www.npharm.org
Nebraska-4
Nebraska Assn. of Osteopathic Physicians &

Surgeons
(Inactive)
Nebraska State Board of Pharmacy

Becky Wisell
Section Administrator
Pharmacist Licensure
P.O. Box 94986
Lincoln, NE 68509
T: 402/471-2118
F: 402/471-3577
E-mail: becky.wisell@hhss.state.ne.us
Internet address:
www.hhs.state.ne.us/crllcal/pharm/pharmlic/board.
htm
Nebraska Hospital Association

Laura J. Redoutey, FACHE
President
3255 Salt Creek Circle, Suite 100
T: 402/742-8140
F: 402/742-8191
E-mail: lredoutey@nhanet.org
Internet address: www.nhanet.org
Nebraska-5
Nebraska-6
NEVADA1

Disabled Disabled
2003 2004
TOTAL $110,070,582 76,745 $128,676,465 90,740

Aged $14,834,799 6,710 $16,295,040 6,929
Blind/Disabled $59,845,368 18,996 $71,338,301 19,734
Child $1,667,220 8,731 $3,414,548 19,542
Adult $2,843,593 7,676 $4,585,501 13,034

Aged $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

Aged $165,273 187 $201,302 190
Blind/Disabled $507,039 373 $560,664 403
Child $971,617 5,651 $1,186,851 8,418
Adult $220,511 1,557 $177,594 1,849
BCC Women $0 0 $177,340 126
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and
unknown.
1 The State of Nevada did not participate in the 2007 NPC Survey. Using information from CMS, the State’s website, and
other source materials, we have, to the extent possible, updated the profile and the tables in other sections of the Compilation.
Users should contact the Nevada Medicaid Program to assess the accuracy and currency of the information included.
Nevada-1

Division of Health Care Financing and Policy of Program when used in home health care and
the Department of Health and Human Services. extended care facilities, and through physician
payment when used in physicians’ offices.
D. PROVISIONS RELATING TO DRUGS Vaccines: Vaccines reimbursable at cost plus an

administration fee as part of the EPSDT service.
Benefit Design
Drug Benefit Product Coverage: Products covered: Unit Dose: Unit dose packaging reimbursable.
Most legend drugs from companies with rebate
agreements and drugs on the Nevada Preferred Formulary/Prior Authorization
Drug List including prescribed insulin; disposable Formulary: Open formulary with preferred drug
needles and syringe combinations used for insulin; list. General exclusions include:
blood glucose test strips; and urine ketone test
strips. Products covered under DME: total parental 1. Agents used for cosmetic purposes or hair
nutrition; interdialytic parenteral nutrition. Products growth.
not covered: cosmetics; fertility drugs; 2. Yohimbine (e.g., Yocon).
experimental drugs; hair growth products; weight 3. Radiopaque agents (e.g., Telepaque, Hypaque,
loss products; and DESI drugs. Barium Sulfate).
4. Radiographic adjuncts (e.g., Perchloracap).
covered: allergy, asthma, and sinus products; 5. Pharmaceuticals designed “ineffective,” or
analgesics; cough and cold preparations; digestive “less than effective” (including identical,
products; and smoking deterrent products. Products related, or similar drugs) by the FDA.
covered with restrictions: topical products. OTC 6. Non-rebated medications.
drugs are reimbursed at EAC+$4.76 or the usual
and customary amount, whichever is less, and Prior Authorization: State currently has a prior
require prior authorization. Products not covered: authorization procedure with appeals process. Prior
feminine products. authorization procedure screening for individual
drugs. Drugs requiring PA include:
Therapeutic Category Coverage: Therapeutic 1. Amphetamine (e.g., Dexedrine)
categories covered: analgesics, antipyretics, and 2. Chorionic Gonadotropin (HCG)
NSAIDs; antibiotics; anticoagulants;
anticonvulsants; anti-depressants; antidiabetic 3. Dipyridamole (e.g., Persantine)
agents; antihistamine drugs; antilipemic agents; 4. Erythropoietin (e.g., Epogen, Procrit)
anti-psychotics; anxiolytics, sedatives, and 5. Gonadotropin releasing hormone analog (e.g.,
hypnotics; cardiac drugs; chemotherapy agents; Lupron, Zoladex)
prescribed cold medications; contraceptives; ENT 6. Growth hormone (e.g., Protropin, Nutropin)
anti-inflammatory agents; hypotensive agents;
misc. GI products; prescribed smoking deterrents; 7. Interferon (all combinations manufactured by
sympathominetics (adrenergic); and thyroid agents. recombinant DNA technology)
Prior authorization required for: CNS stimulants; 8. Intravenous antibiotic therapy
antifungals; Hemapopoiletic; PPIs; Cox2 inhibitors; 9. Methylphenidate (e.g., Ritalin)
duragisic patches; HCG; Gonadotropin, 10. Non-legend pharmaceuticals
Gonadotropin releasing hormone analog;
Erythropoetin; Interferon; IV antibiotic; 11. Nutritional supplements or replacements
Methylpenidate, Peomoline; vitamins; and 12. Pemoline (e.g., Cylert)
Remicade. Partial coverage for: growth hormones 13. Pulmozyme
(prior authorization required); estrogens; and
14. Vitamins, vitamin/mineral combinations or
anabolic steroids. Therapeutic categories not
hematinics
covered: anorectics; amphetamine combinations;
erectile dysfunction medications; radiopaque and 15. Non-preferred drugs in listed classes
radiographic products; DESI drugs; yohimbine; and
drugs not participating in the drug rebate program.
Nevada-2

Monthly Limit on Number of Scripts: None. PA Health Plan of Nevada
required if more than 2 OTC prescriptions per class P.O. Box 15645
within a 30 day period. Las Vegas, NV 89114
800/962-8074
Monthly Quantity Limit: The maximum dispensable
quantity is limited to a 34-day supply. Maintenance NevadaCare, Inc.
medications limited to a 100-day supply. 10600 W. Charleston Blvd.
P.O. Box 379020
Refill Limits: 5 refills within 6 months for Las Vegas, NV 89137
controlled drugs. Up to 11 refills for non- T: 702/304-5500
controlled drugs. F: 702/474-7592
E-mail: NevadaCare@Imxinc.com
State currently has a DUR Board with a quarterly F. STATE CONTACTS
review by a PRODUR contractor. PRODUR system
implemented in 2003. State Drug Program Administrator
Colleen Lawrence, Chief
Pharmacy Payment and Patient Cost Program Services
Sharing Division of Health Care Financing and Policy
Dispensing Fee: $4.76, effective 10/1/98. IV 1100 E. Williams Street
dispensing fee is $16.80 for first ingredient; $5.60 Carson City, NV 89701
for other ingredients. 775/684-3744
E-mail: colleenl@dhcfp.state.nv.us
15%. Mary Griffith
Division of Health Care Financing and Policy
Prescription Charge Formula: The lowest of (1) Pharmacy Program
AWP-15% plus a dispensing fee, (2) specific upper 1100 E. Williams Street
limit (SUL) plus a dispensing fee, (3) estimated Carson City, NV 89701
acquisition cost (EAC) plus a dispensing fee, or (4) 775/684-3751
the pharmacy's usual charge to the general public. E-mail: mary.griffith@dhcfp.state.nv.us
Maximum Allowable Cost: State imposes Federal Human Resources Department Officials
Upper Limits plus State-specific limits on generic Michael J. Willden, Director
drugs. Override requires “Dispense as Written.” Department of Health and Human Services
4126 Technology Way, Room 100
Incentive Fee: None. Carson City, NV 89706-2009
T: 775/684-4000
Patient Cost Sharing: None for general Medicaid F: 775/684-4010
population. $1.00 (generics) and $3.00 (brand) for E-mail: nvdhhs@dhhs.nv.gov
dual eligibles.
Charles Duarte, Administrator
Cognitive Services: Does not pay for cognitive Division of Health Care Financing and Policy
services. 1100 E. Williams Street, Suite 116
Carson City, NV 89710
T: 775/684-3676
E-mail: cduarte@dhhs.nv.gov
enrolled in MCOs in 2006; all receive pharmacy
benefits through their managed care plan.
Mary Griffith.
775/684-3751
Nevada-3

Steve Espy, R.Ph., Director of Drug Utilization
Health Information Design, Inc. Trudy Larson, M.D. (Chair)
1550 Pumphrey Avenue Paul Boyar (LTC Administrator)
Auburn, AL 36832 Patricia Craddock, D.D.S.
T: 205/402-9530 Jessie Harris
F: 205/402-9531 Keith MacDonald, Pharm.D.
Ken Richardson (Admnistrator, Health Care Clinic)
DUR Contact Linda Sheldon (Advocate for Children)
Bradford Lee, M.D. (Nevada State Health Officer)
Mary Griffith.
775/684-3751
DUR Board Steven L. Phillips, M.D. (Chair)
Steven E. Rubin, M.D. Diana L. Bond, R.Ph.
Steven W. Parker, M.D. Judy Britt, Pharm.D.
David England, R.Ph., Pharm.D. (Chair) Linda Flynn, R.Ph.
Keith W. MacDonald, Pharm.D. Carl Heard, M.D.
Marjorie Uhalde, M.D., Ph.D. Robert L. Horne, M.D.
Larry L. Pinson, Pharm.D.
New Brand Name Products Contact Susan L. Pintar, M.D.
Mary Griffith. Executive Officers of State Medical and
775/684-3751 Pharmaceutical Societies
Prescription Price Updating Nevada State Medical Association
Lawrence P. Matheis
First DataBank Executive Director
1111 Bayhill Drive, Suite 350 3660 Baker Lane, Suite 101
San Bruno, CA 94066 Reno, NV 89509
T: 650/588-5454 T: 775/825-6788
F: 650/827-4578 F: 775/825-3202
E-mail: nsma@nsmadocs.org
Medicaid Drug Rebate Contacts Internet address: www.nsmadocs.org
Mary Griffith.
775/684-3751 Nevada Pharmacy Alliance
Khanh Pham
Claims Submission Contact President
P.O. Box 35668
First Health Services Corp. Las Vegas, NV 89133
P.O. Box 30042 T: 702/683-1855
Reno, NV 89520-3042 F: 702/657-2089
877/638-3472 E-mail: snaplv@aol.com
E-mail: nevadamedicaid@fhsc.com Internet address: www.nevadapharmacistassoc.com
Medicaid Managed Care Contact Nevada Osteopathic Medical Association

Hilary Jones, R.N. Denise Selleck Davis
Medicaid Services Specialist III Executive Director
1100 E. Williams Street, Suite 204 405 Max Court, Suite K
Carson City, NV 89701 Henderson, NV 89015
775/684-3697 T: 702/434-7112
E-mail: hjones@dhcfp.state.nv.us F: 702/434-7110
E-mail: nvoma@earthlink.com
Mail Order Pharmacy Program Internet address: www.nevadaosteopathic.com
None
Nevada-4
Nevada State Board of Pharmacy

Larry Pinson
Executive Secretary
555 Double Eagle Court, Suite 1100
Reno, NV 89521
T: 775/850-1440
F: 775/850-1444
E-mail: pharmacy@pharmacy.nv.gov
Internet address: www.bop.nv.gov
Nevada Hospital Association

Bill M. Welch
President and CEO
5250 Neil Road
Suite 302
Reno, NV 89502
T: 775/827-0184
F: 775/827-0190
E-mail: mary@nvha.net
Internet address: www.nvha.net
Nevada-5
Nevada-6
NEW HAMPSHIRE

Disabled Disabled

2003 2004
TOTAL $117,004,510 85,787 $128,650,584 91,392

Aged $3,822,611 1,369 $3,997,865 1,399
Blind/Disabled $21,981,872 5,874 $23,871,115 6,081
Child $2,085,516 7,918 $2,301,032 7,899
Adult $3,109,350 4,241 $3,198,160 4,105

Aged $12,076,396 4,405 $13,495,112 4,557
Blind/Disabled $12,283,197 2,681 $13,381,925 2,827
Child $582,921 974 $549,064 1,003
Adult $2,936,071 1,638 $3,257,916 1,851

Aged $573,700 349 $668,741 372
Blind/Disabled $721,235 374 $871,954 483
Child $9,344,114 31,412 $10,571,030 33,406
Adult $513,361 2,138 $530,001 2,334
TOTAL OTHER EXPENDITURES/ RECIPIENTS* $46,974,166 22,414 $51,956,669 25,075
unknown.
New Hampshire-1
C. ADMINISTRATION Vaccines: Vaccines reimbursable as part of the

EPSDT, CHIP, and VCP service. Childhood
Office of Medicaid, Business and Policy; immunization vaccine is provided to all children
Department of Health and Human Services. through the Division of Public Health Services.
The Medicaid program does not reimburse
D. PROVISIONS RELATING TO DRUGS providers for routine vaccines, although an
administration fee is allowed.
Benefit Design
prescribed insulin; disposable needles and syringe Formulary/Prior Authorization
combinations for insulin; blood glucose test strips;
urine ketone test strips; total parenteral nutrition; Formulary: States maintain an open formulary with
interdialytic parenteral nutrition; and drugs covered a preferred drug list. General exclusions include
by rebate agreements. Products not covered: cosmetic agents for hair growth, experimental and
cosmetics; fertility drugs; DESI drugs; and fertility drugs. Management of formulary includes
experimental drugs. prior authorization, quantity limits on certain
products (e.g., anti-emetics, anti-migraine agents,
Over-the-Counter Product Coverage: Products etc.), and therapeutic substitution.
covered: The New Hampshire Medicaid program
covers over-the-counter drugs that are medically Prior Authorization: State currently has a formal
necessary including, allergy, asthma, and sinus prior authorization procedure with an associated
products; analgesics; cough and cold preparations; grievance and appeal procedure. Prior authorization
digestive products (including H2 antagonists); requests must be initiated by the prescriber.
feminine products; smoking deterrents; and topical
products. Only generic versions of certain OTCs Prescribing or Dispensing Limitations
are covered. An exception process is available. Monthly Quantity Limit: Limited to 34-day supply
Maintenance Medications: Limited to 90-day
Therapeutic Category Coverage: Therapeutic supply. Quantity limits on some classes of drugs
categories covered: anabolic steroids; (For additional information, see:
anticoagulants; anticonvulsants; chemotherapy www.dhs.nh.gov/DHHS/MedicaidProgram/PBM.ht
agents; prescribed cold medications; m).
contraceptives; estrogens; growth hormones;
thyroid agents; and prescribed smoking deterrents. Prescription Refill Limits: Up to 5 refills within 6
Therapeutic categories/products requiring prior months for controlled drugs; up to 1 year for non-
authorization: analgesics, antipyretcs; and controlled drugs.
NSAIDs*; anorectics; antibiotics; antidepressants;
antidiabetic agents; antihistamines; antilipemic Monthly Dollar Limits: None.
agents; anti-psychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; ENT anti-inflammatory Drug Utilization Review
agents; hypotensive agents; misc. GI drugs*;
sympathominetics (adrenergic); erectile dyfunction PRODUR system implemented in July 1995. State
products; PPIs; Cox IIs; CNS stimulants; anti- currently has a DUR Board with a quarterly review.
fungals for nail fungus; leukotrine modifiers;
glaucoma agents; triptans; anti-emetics; anti- Pharmacy Payment and Patient Cost
obesity drugs; Alzheimer’s agents; Oxycontin; and Sharing
rheumatoid arthritis agents.
*Brand approval override required for NSAIDs,
controlled substances, and GI drugs for which there Ingredient Reimbursement Basis: EAC = AWP-
are therapeutically equivalent (A-rated) generics 16%.
available.
Prescription Charge Formula: Lesser of usual and
customary charge or AWP-16%, Federal Upper
reimbursable through both the Prescription Drug
Limit; State MAC; or DOJ pricing, plus a
dispensing fee. Special rules for Blood Factor
home healthcare, extended care facilities, and
products on the DOJ price list.
New Hampshire-2

Lise C. Farrand, R.Ph.
generic drugs. Override requires “Brand Medically
Pharmaceautical Services Specialist
Necessary” with an explanation as to why the
Office of Medicaid Business and Policy
generic cannot be used.
129 Pleasant Street, Annex Building
Concord, NH 03301
T: 603/271-4419
F: 603/271-8701
Patient Cost Sharing: Copayment – Generics:
E-mail: lfarrand@dhhs.state.nh.us
$1.00; Brand: $2.00, effective 3/1/04. Copayments
apply to all recipients except patients in nursing
homes or ICF facilities; home and community Medicaid DUR Board
based care waived recipients holding form 949;
Steve Paris, M.D.
pregnant women; children under 18 years; and
Franklin Hubbell, D.O.
prescriptions for family planning drugs.
Lisa Mistler, M.D.
James Rigas, M.D.
Maryann Tonias, R.N., M.S.
services.
Frederick Potter, R.Ph.
Helen Pervanas, R.Ph.
E. USE OF MANAGED CARE Michael Smith, R.Ph.
Alicia Desilets, Pharm.D.
None as of June 2006.
F. STATE CONTACTS Lise C. Farrand, R.Ph.

603/271-4419
Pharmacy Administrator
Office of Medicaid Business and Policy Robert Coppola, Pharm.D.
129 Pleasant Street, Annex Building Account Manager
Concord, NH 03301 First Health Services Corporation
T: 603/271-4210 17 Chenell Drive
F: 603/271-8701 Concord, NJ 03301
Internet address: T: 603/224-2083
www.dhhs.state.nh.gov/dhhs/medicaidprogram F: 603/224-6690
E-mail: coppolro@fhsc.com
Officials Medicaid Drug Rebate Contacts
John A. Stephen John Cox

Commissioner Rebate Pharmacist
Department of Health and Human Services First Health Services Corporation
129 Pleasant Street 4300 Cox Road
Concord, NH 03301-3857 Glen Allen, VA 23060
T: 603/271-4334 T: 800/884-2822
F: 603/271-4912 F: 804/965/7647
E-mail: jstephen@dhhs.state.nh.us E-mail: coxjo@fhsc.com
Norman Cordell, Director Claims Submission Contact

129 Pleasant Street Sherrill Bryant
Concord, NH 03301-3857 Plan Administrator
T: 603/271-8166 First Health Services Corporation
F: 603/271-4727 4300 Cox Road
E-mail: ncordell@dhhs.state.nh.us Glen Allen, VA 23060
T: 800/884-2822
F: 804/965-7647
E-mail: bryantsh@fhsc.com
New Hampshire-3

Pharmaceutical Services
None
New Hampshire Medical Society
Mail Order Pharmacy Benefit Palmer P. Jones
None
7 N. State Street
Concord, NH 03301-4018
Disease Management/Patient Education T: 603/224-1909
Contact F: 603/226-2432
Doris Lotz, M.D. E-mail: palmer.jones@nhms.org
Medicaid Medical Director Internet address: www.nhms.org
Office of Health Planning & Medicaid New Hampshire Pharmacists Association
129 Pleasant Street, Annex Building Mike Smith, R.Ph.
Concord, NH 03301 Executive Director
T: 603/271-8166 26 S. Main Street, PMB 188
F: 603/271-8701 Concord, NH 03301
E-mail: dlotz@dhhs.state.nh.us T: 603/229-0292
F: 603/224-7769
Pharmacy & Therapeutics Advisory E-mail: mjsmith@worldpath.net
Committee Internet address: www.nhpharmacists.org
Belinda Castor, M.D. New Hampshire Osteopathic Association, Inc.
Mary Brunetta, M.D. Christopher FitzMorris, D.O.
Doris Lotz, M.D. President
F. Burton Dibble, M.D. 7 North State Street
Steven Paris, M.D. Concord, NH 03301
Harriet Redmond, ARNP 603/224-1909
Leon Parker, R.Ph. E-mail: Joy.Potter@nhms.org
Roger Hebert, R.Ph. Internet address: www.nhosteopath.org
Paul Santos, Pharm.D.
Robert Lenza, R.Ph. New Hampshire State Board of Pharmacy
Clint Koenig Paul G. Boisseau, R.Ph.
Lise Farrand, R.Ph. Executive Secretary
57 Regional Drive
Medical Care Advisory Committee Concord, NH 03301-8518
Denise Brewitt T: 603/271-2350
Gail T Brown, J.D., M.S.W. F: 603/271-2856
Michael Cohen E-mail: paul.boisseau@nh.gov
Ellen Curelop, R.N., B.S., C.M.C. Internet address: www.nh.gov/pharmacy
Tom Donovan
Jane Guilmette New Hampshire Hospital Association
William L. Hamilton, Jr. Michael J. Hill, C.H.E.
Dorothy Hitchmoth President
Katrina Iserman 125 Airport Road
Luetta Kaminski Concord, NH 03301-7300
Kristi Kistler T: 603/225-0900
Margaret Lins F: 603/225/4346
Paul Manganiello, M.D. E-mail: mhill@nhha.org
Jacki Mike Internet address: www.nhha.org
Cindy Robertson
Melvin Spierer, M.S.W.
Carol Stamatakis, Esq.
Maureen Stimpson
James Williamson
Michelle Winchester
New Hampshire-4
NEW JERSEY

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

2003 2004
TOTAL $757,754,210 297,997 $1,007,400,013 310,150

Aged $81,267,270 29,390 $99,760,317 30,221
Blind / Disabled $306,832,621 92,493 $454,383,540 106,172
Child $2,316,229 14,224 $2,755,892 13,753
Adult $2,973,450 9,818 $3,722,719 10,620

Aged $10,594,448 3,552 $12,346,569 3,626
Blind / Disabled $1,347,369 284 $1,770,708 325
Child $3,234 8 $6,852 4
Adult $0 0 $0 0

Aged $39,002,255 14,217 $46,095,506 14,753
Blind / Disabled $83,922,280 17,553 $103,775,160 19,195
Child $3,072,647 19,137 $3,631,130 18,738
Adult $619,861 6,756 $674,521 7,228
BCCA Women $188,227 117 $429,641 176
unknown.
Note: The State of New Jersey estimates 2005 drug expenditures to be approximately $1.1 billion and 2006 drug expenditures to
be $770 million.
New Jersey-1
C. ADMINISTRATION Monthly Quantity Limit: Original, 34-day supply.

Refills, 34 days or 100 units, whichever is more.
Division of Medical Assistance and Health
Services, Department of Human Services. Drug Utilization Review
PRODUR system implemented in October 1996.
D. PROVISIONS RELATING TO DRUGS State currently has a DUR Board with a quarterly
review.
Benefit Design
Drug Benefit Product Coverage: Products covered: Sharing
all FDA-approved drugs with Federal Medicaid
drug rebate agreements; prescribed insulin; Dispensing Fee: $3.73. Additional add-ons per Rx
disposable needles and syringe combinations used shall be given to pharmacy providers who provide
for insulin; blood glucose test strips; urine ketone the following:
test strips; total parenteral nutrition; and
1. 24-hr. Emergency Service: add $0.11
interdialytic parenteral nutrition. Products not
covered: cosmetics; fertility drugs; ED drugs; 2. Patient Consultation: add $0.08
experimental drugs; and DESI drugs. Prior
authorization required for: methadone; IV infusion; 3. Impact Area Location: add $0.15 (provider
and protein replacement supplements. shall have a combined NJ FamilyCare/
Medicaid and PAAD prescription volume
equal to or greater than 50% of total
prescription volume).
covered: Adults: PPIs; smoking deterrent products;
family planning products. Products covered with
restrictions (for children under age 21 only): Ingredient Reimbursement Basis: EAC = AWP-
allergy; asthma, and sinus products; analgesics; 12.5%.
topical products; and cough and cold preparations.
Products not covered: feminine products; digestive Prescription Charge Formula: “Maximum
products (H2 antagonists); and inhalation drugs. Allowable Cost,” or Average Wholesale Price-
12.5% (reduction from AWP is pharmacy specific)
Therapeutic Category Coverage: All covered plus a dispensing fee or the provider’s usual and
except erectile dysfunction; cosmetic; and fertility customary charge, whichever is lower.
drugs.
Coverage of Injectables: Both physician- Upper Limits on generic drugs. Override requires
administered and self-administered injectables are “Brand Medically Necessary.”
covered.
Vaccines: Vaccines covered by Vaccine for
Children Program. Patient Cost Sharing: None.
Unit Dose: Unit dose packaging reimbursable in Cognitive Services: Does not pay for cognative
long-term care facilities only, not in retail settings services.
(unless unit dose is only way item is packaged).
Formulary: Open. Approximately 660,000 Medicaid and SCHIP
eligible clients were enrolled per month to receive
Prior Authorization: State currently has a formal pharmacy benefits through managed care in 2006.
prior authorization procedure. Prior authorization is These clients receive pharmaceutical benefits both
based on medical necessity using DUR standards. through the State and through MCOs. Mental
Fair hearing for appealing prior authorization health drugs and prescriptions for the aged, blind,
decisions. and disabled (ABD) population are carved out of
managed care.
Prescription Refill Limit: 5 times within a 6-month
period.
New Jersey-2
DUR Contact
Kaye S. Morrow
AMERIGROUP New Jersey, Inc
Assistant Division Director
399 Thornall Street, 9th Floor
Edison, NJ 08837
Division of Medical Assistance and Health Services
Office of Provider Relations
Health Net of New Jersey, Inc.
P.O. Box 712
90 Matawan Road
Trenton, NJ 08619
Matawan, NJ 07747
T: 609/631-2396
F: 609/588-3889
AmeriChoice of New Jersey, Inc.
E-mail: kaye.s.morrow@dhs.state.nj.us
Two Gateway Center, 13th Floor
Newark, NJ 07102
Medicaid DUR Board
Horizon NJ Health Judith Barberio, A.P.N., C., Ph.D.
210 Silvia Street Thomas a. Cavalieri, D.O.
Trenton, NJ 08628 David V. Condoluci, D.O.
Linda Gochfeld, M.D.
University Health Plans, Inc. Linda Gooen, Pharm.D., R.Ph.
499 Thornall Street 4th Floor Alan S. Lichtbroun, M.D.
Edison, NJ 08837 Steven Matthew Marcus, M.D.
Judith Martinez Rodriguez, R.Ph.., M.B.A., FACA
Sandra Moore, Pharm.D.
F. STATE CONTACTS Eileen Moynihan, M.D.
Kristine M. Olsen, M.S., R.N., A.P.N., C.
State Drug Program Administrator Jay R. Schafer, R.Ph.
Vacant David Ethan Swee, M.D.
Pharmaceutical Services Donald K. Woodward, Pharm.D.
Division of Medical Assistance and Health Services Prior Authorization Contact
Office of Utilization Management Dalia S. Hanna, Pharm.D.
P.O. Box 712 MEP Manager
Trenton, NJ 08619 Unisys
3705 Quakerbridge Road
Department of Human Services Officials Trenton, NJ 08619-1288
Jennifer Velez, Acting Commissioner T: 609/631-6686
Department of Human Services F: 609/588-5508
Capitol Place One CN-700, 5th Floor E-mail: dalia.hanna@unisys.com
P.O. Box 700
Trenton, NJ 08625-0700 New Brand Name Products Contact
T: 609/292-3717 Open Formulary – Contact not required
F: 609/292-3824
E-mail: jennifer.velez@dhs.state.nj.us
John Guhl, Director First DataBank
Division of Medical Assistance and Health Services 1111 Bayhill Dr.
Department of Human Services San Bruno, CA 94066
P.O. Box 712 415/588-5454
Trenton, NJ 08625-0712
T: 609/588-2600 Medicaid Drug Rebate Contacts
F: 609/588-3583
Technical: Daniel Upright, 609/588-8522
E-mail: john.guhl@dhs.state.nj.us
Policy: Kaye S. Morrow, 609/631-2396
New Jersey-3
New Jersey Association of Osteopathic Physicians

& Surgeons
Mark Nemerson, Administrative Analyst Robert W. Bowen
Department of Human Services Executive Director
Division of Medical Assistance and Health Services 1 Distribution Way, Suite 201
P.O. Box 712 Monmouth Junction, NJ 08852
Trenton, NJ 08619 T: 732/940-9000
T: 609/588-4304 F: 732/940-8899
F: 609/588-3889 E-mail: rbowen@njosteo.com
E-mail: mark.nemerson@dhs.state.nj.us Internet address: www.njosteo.com
Medicaid Managed Care Contact New Jersey State Board of Pharmacy

Joanne Boyer
Jill Simone, M.D., Director Executive Director
Managed Health Care P.O. Box 45013
Department of Human Services Newark, NJ 07101
Division of Medical Assistance and Health Services T: 973/504-6450
P.O. Box 712 F: 973/648-3355
Trenton, NJ 08619 E-mail: askconsumeraffairs@dca.lps.state.nj.us
T: 609/588-2703 Internet address:
F: 609/588-2774 www.state.nj.us/lps/ca/brief/pharm.htm
E-mail: jill.simone@dhs.state.nj.us
New Jersey Hospital Association
Mail Order Benefit Program Gary S. Carter, FACHE
None President & CEO
760 Alexander Road, P.O. Box 1
Elderly Expanded Drug Coverage Contact Princeton, NJ 08543-0001
609/275-4000
Wade Epps, Director E-mail: gcarter@njha.com
Department of Health and Senior Services Internet address: www.njha.com
12 Quakerbridge Plaza
Mercerville, NJ 08619
T: 609/588-7032
F: 609/631-4667
E-mail: wad.epps@doh.state.nj.us

Medical Society of New Jersey
Michael T. Kornett
Executive Director and CEO
2 Princess Road
Lawrenceville, NJ 08648-2302
T: 609/896-1766
F: 609/896-1368
E-mail: mkornett@msnj.org
Internet address: www.msnj.org
New Jersey Pharmacists Association

Joseph V. Roney, R.Ph.
760 Alexander Road, P.O. Box 1
Princeton, NJ 08543-0001
T: 609/275-4246
F: 609/275-4066
E-mail: joeroney@njaj.com
Internet address: www.njpharma.org
New Jersey-4
NEW MEXICO

Disabled Disabled

2003 2004
TOTAL $108,079,641 99,931 $129,922,833 104,871

Aged $11,742,774 7,327 $13,644,681 7,349
Blind/Disabled $44,574,741 19,905 $52,664,986 20,708
Child $903,358 11,862 $1,003,368 11,479
Adult $2,008,303 12,301 $2,207,964 11,951

Aged $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

Aged $127,806 185 $200,154 249
Blind/Disabled $1,242,161 880 $1,934,721 1,128
Child $2,212,807 22,460 $2,564,759 21,530
Adult $257,957 3,366 $302,227 3,445
BCCA Women $129,572 157 $264,645 239
unknown.
New Mexico-1
C. ADMINISTRATION classified by FDA as “ineffective;” hypnotic drugs

(barbiturates); and drugs without Medicaid rebate
Human Services Department (HSD), Medical participation agreement.
Assistance Division.
Over-the-Counter Product Coverage: OTC
products covered (prescription required) when a)
D. PROVISIONS RELATING TO DRUGS they may be the drug of choice for common medical
conditions or b) when they are an appropriate
Benefit Design economic and therapeutic alternative to prescription
Drug Benefit Product Coverage: Approximately drugs. Products not covered: personal care items
three-fourths of New Mexico Medicaid recipients (i.e., over-the-counter shampoo and soap); feminine
with full benefits are enrolled in the SALUD! products.
Medicaid managed care program via three Managed
Care Organizations (MCO): Lovelace Community Therapeutic Category Coverage: Products covered:
Health Plan, Presbyterian Healthcare Services and anabolic steroids; analgesics, antipyretics, and
Molina Healthcare. As a waiver program, the NSAIDs, antibiotics; anticoagulants;
MCOs are allowed to maintain closed formularies, anticonvulsants; antidepressants; antidiabetic
with required exception and appeals processes. agents, antihistamines; antilipemic agents; anti-
Medicare-Medicaid dual elegibles are not enrolled psychotics; anxyolitics, sedatives, and hypnotics;
in managed care. Those not in SALUD! Managed cardiac drugs; chemotherapy agents; prescribed
care (i.e., fee-for-service) receive pharmacy benefits cold medications; contraceptives; ENT anti-
through either the NMRx Preferred Drug List inflammatory agents; estrogens; growth hormones;
(PDL) program administered by Presbyterian, or the hypotensive agents; misc. GI drugs; prescribed
non-PDL pharmacy benefit administered directly by smoking deterrents; and thyroid agents. Prior
the State via its fiscal agent, ACS. The NMRx authorization required: anoretics; sympathominetics
program provides pharmacy coverage for Native (adrenergic); and drugs used to treat impotence.
Americans who have not opted into managed care,
and Medicare-Medicaid dual eligibles for Part D Coverage of Injectables: Injectable medicines
excluded drug coverage. The state directly reimbursable through physician payment when used
administers the pharmacy benefit for Medicaid in physician offices and home health care.
recipients residing in nursing homes and ICF/MR
facilities, those transitioning into managed care Vaccines: Vaccines reimbursable as part of the
during the election period, and for pharmacy claims EPSDT service, the Children’s Health Insurance
from Indian Health Service (IHS) and tribally Program, the Vaccine for Children Program, and
operated pharmacies. New Mexico has a single various Department of Health Programs.
Statewide enitity for behavioral health services,
ValueOptions of New Mexico. With the exception Unit Dose: Does not reimburse for unit dose
of HIS/tribal pharmacies and State operated packaging or for prefilling syringes. The Medical
facilities, prescriptions written by behavioral health Assistance Division does reimburse for commercial
providers are covered by the Statewide entity. New unit dose packaged drugs.
Mexico Medicaid does not cover Medicare Part D
copays for dual eligibles. Part D excluded drug Formulary/Prior Authorization
coverage is provided by the applicable plan, NMRx, Formulary: Open formulary with preferred drug list
non-PDL fee-for-service or ValueOptions of New (PDL). PDL management is contracted to
Mexico, in the same manner and to the same extent Presbyterian Health Plan, one of the New Mexico
as non-dual eligibles. Products covered: Most FDA- Medicaid program’s managed care organizations.
approved prescription drugs; prescribed insulin;
disposable needle and syringe combinations used
for insulin; blood glucose test strips; urine ketone
prior authorization procedure screening for drug
test strips; total parenteral nutrition; and
classes with right of fair hearing to appeal a prior
interdialytic parenteral nutrition. Prior authorization
authorization decision.
required for: CNS stimulants for ADD (adults
only); anorexiants; nutritional supplements;
disposable diapers. Products not covered: drugs for
treatment of tuberculosis; cosmetics; experimental None
drugs; fertility drugs; drugs and immunizations
available from any other source; medications
supplied by the New Mecico State Hospital to
clients on convalescent leave from hospital; drugs
New Mexico-2
Drug Utilization Review Presbyterian Salud

2501 Buena Vista SE
PRODUR system implemented in October 1993. P.O. Box 26666
State currently has a DUR Board that meets at Albuquerque, NM 87125
between 1-4 times per year. 800/672-8880

F. STATE CONTACTS
14%. Julie A. McKeay
Pharmacy PKrogram Administrator
Human Services Department
Prescription Charge Formula: Prescriptions
Medical Assistance Division
reimbursed at the lesser of the following:
P.O. Box 2348
1. Cost (EAC or MAC) dispensed plus a Santa Fe, NM 87504-2348
dispensing fee or, T: 505/827-6202
2. The usual and customary charge by the F: 505/827-3196
pharmacy to the general public. E-mail: julie.mckeay@state.nm.us

John Erb, Pharm.D.
generic drugs. Override requires “Medically
Pharmacist
Necessary,” “Brand Necessary,” or “Brand
Medically Necessary.” Also prescriber is not
prohibited from generic substitution and, if due to
P.O. Box 2348
drug shortage, requesting reimbursement at the
Santa Fe, NM 87504-2348
brand level.
T: 505/827-3129
F: 505/827-3196
E-mail: JohnN.Erb@state.nm.us
Patient Cost Sharing: No copayment, except $5.00
DUR Board
for SCHIP clients and working disabled clients.
Greg D’Armour, Pharm.D.
Gregory Toney, R.Ph., Pharm.D.
services.
John Pieper, R.Ph., Pharm.D.
John Lauriello, M.D.
E. USE OF MANAGED CARE Gayle Dine-Chacon, M.D.
John Seibel, M.D.
Approximately 250,000 Medicaid recipients Judy Romero, Pharm.D.
enrolled in are MCOs in FY 2006. Recipients Manual Archuleta, M.D.
receive pharmaceutical benefits through managed
care plans. Prior Authorization Contact
John Erb, Pharm.D.
Managed Care Organizations 505/827-3129
Molina Healthcare of New Mexico
P.O. Box 3887 Medicaid Drug Rebate Contact
Albuquerque, NM 87110 Sherry Montoya, Pharmacist
800/377-9594 Human Services Department
Lovelace Community Health Plan P.O. Box 2348
4101 Indian School Road NE Santa Fe, NM 87504-2348
Albuquerque, NM 87190 T: 505/827-7777
800/808-7363 F: 505/827-3196
E-mail: sherry.montoya@state.nm.us
New Mexico-3
New Brand Name Products Contact Steve Adelshelm

DOH School Health
Julie A. McKeay
505/827-6202
Polly Arango
Famiy Voices of NM
Prescription Price Updating Contact
Julie A. McKeay Mike Battle
505/827-6202 Department of Insurance
Claims Submission Mary Beresford

Governor’s Commission on Disability
365 Northridge Road Arlene Brown
Northridge Center One, Suite 400 NM Medical Society
Atlanta, GA 30350
T: 800/365-4944 William Doggett
F: 770/730-5198 Chiropractor
Medicaid Managed Care Contact Raul Burciaga
Alana Reeves, Chief Legislative Council Service
Contract Administration Bureau
Human Services Department Jeff Dye
Medical Assistance Division NM Hospital & Health Systems
P.O. Box 2348
Santa Fe, NM 87504-2348 Mary Eden
T: 505/827-3131 Presbyterian Healthcare Services
F: 505/827-3185
E-mail: alana.reeves@state.nm.us Pam Galbraith
Value Options
Joie Glenn
None NM Association for Home & Hospice Care
Human Services Department Officials Patty Golbuski

Pamela Hyde, J.D., Secretary St. Vincent Hospital
New Mexico Department of Human Services
2009 S. Pacheco, Pollon Plaza Ron Gurley
P.O. Box 2348 Nami NM
Santa Fe, NM 87504-2348
T: 505/827-7750 Rick Harter
F: 505/827-6286 NM Pharmaceutical Association
E-mail: pam.hyde@state.nm.us
Internet address: www.state.nm.us/hsd Bill Hawk
Pediatritian
Carolyn Ingram
Director Ruth Hoffman
Medicaid Assistance Division Lutheran Office of Government Ministry
New Mexico Department of Human Services
P.O. Box 2348 Sam Howarth
Santa Fe, NM 87504-2348 DOH Long Term Services Division
T: 505/827-3106
F: 505/827-3185 Nancy Koenigsberg
E-mail: carolyn.ingram@state.nm.us NM Protection & Advocacy
Medicaid Advisory Committee Members Patricio Larragoite

NM Health Policy Commission
Garrey Carruthers (Chair)
NMSU Bernadette LeRouge
NM DDPC
New Mexico-4
Marise McFadden New Mexico Osteopathic Medical Association

ALTSD Elizabeth “Betty” Barrett
Executive Director
Steve Mckman P.O. Box 53098
UNM Hospital Albuquerque, NM 87153-3098
T: 505/332-2146
David Murchio F: 505/332-4861
Parents Reaching Out E-mail: admin@nmoma.org
Internet address: www.nmoma.org
Joyce Naseyowma-Chalan
Pueblo Health Care New Mexico State Board of Pharmacy
William Harvey, R.Ph.
Anselm Roanhorse, Jr. Executive Director/Chief Drug Inspector
Navaho Division of Health 5200 Oakland, NE, Suite A
Albuquerque, NM 87113
Carolyn Roberts T: 505/222-9830
NM Nurses Association F: 505/222-9845
E-mail: william.harvey@state.nm.us
David Roddy Internet address: www.state.nm.us/pharmacy
NM Primary Care Association
New Mexico Hospitals and Health Systems
Marilyn Rohn Association
SH Consumer Affairs Jeff Dye
President and CEO
Thomas J. Schripsema 2121 Osuna Road, NE
NM Dental Association P.O. Box 92200
Linda Sechovec T: 505/343-0010
NM Health Care Association F: 505/343-0012
E-mail: jdye@nmhsc.com
Gena Valera Internet address: www.nmhhsa.org
AARPNM
Mario Vigil
Public Education Department

New Mexico Medical Society
G. R. “Randy” Marshall
Executive Director
7770 Jefferson NE, Suite 400
T: 505/828-0237
F: 505/828-0336
E-mail: rmarshal@nmms.org
Internet address: www.nmms.org
New Mexico Pharmaceutical Association

R. Dale Tinker
Executive Director
2716 San Pedro, NE, Suite C
T: 505/265-8729
F: 505/255-8476
E-mail: daletinker@cs.com
Internet address: www.nm-pharmacy.com
New Mexico-5
New Mexico-6
NEW YORK

Disabled Disabled

2005 2006
TOTAL $5,032,941,827 2,770,487 $3,790,138,009 2,733,261
RECEIVING CASH ASSISTANCE, TOTAL $2,919,829,296 836,347 $2,120,210,972 804,675

Aged $532,163,745 140,344 $212,654,848 132,745
Blind/Disabled $2,256,381,019 467,521 $1,785,046,467 463,104
Child $52,566,932 161,935 $52,714,088 153,405
Adult $78,717,600 66,547 $69,795,569 55,421
MEDICALLY NEEDY, TOTAL $1,337,392,683 1,110,744 $884,436,859 1,124,874

Aged $345,750,536 124,339 $152,558,341 121,291
Blind/Disabled $599,928,503 121,821 $320,136,705 120,194
Child $177,721,423 568,844 $196,582,997 588,167
Adult $213,992,221 295,740 $215,158,816 295,222

Aged $35,745 450 $54 1
Child $117,926,573 399,573 $116,389,684 384,561
Adult $624,169,272 378,486 $635,591,176 376,362
TOTAL OTHER EXPENDITURES/ RECIPIENTS* $33,588,258 44,887 $33,509,264 42,788
* Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
Source: New York State Medicaid Statistical Information System, 2005 and 2006.
New York-1
C. ADMINISTRATION covered: erectile dysfunction products; drugs used

for weight loss or weight gain; cosmetic agents;
State Department of Health, Office of Health hair growth products; prescription drugs used for
Insurance Programs. the symptomatic relief of coughs and colds; and
drugs used to promote fertility.
D. PROVISIONS RELATING TO DRUGS Coverage of Injectables: Injectable medicines

Benefit Design
Program when used in home health care facilities
Drug Benefit Product Coverage: Products covered: and through physician payment when used in
prescribed insulin; disposable needles and syringe physician offices. In extended care facilities
combinations for insulin; blood glucose test strips; reimbursement for non-self administered injectable
urine ketone test strips; total parenteral nutrition; medicines is included in the facility rate. No special
and interdialytic parenteral nutrition. Products not coverage policies exist for self-administered
covered: cosmetics; fertility drugs; and injectable medicines.
experimental drugs.
Vaccines: Vaccines are reimbursable under the
Over-the-Counter Product Coverage: Products EPSDT service, CHIP, and the Vaccines for
covered: allergy, asthma and sinus products; Children program.
analgesics; cough and cold preparations; digestive Unit Dose: Unit dose packaging not reimbursable.
products; feminine products; smoking deterrent
products (max. 2 courses of treatment/year); and
topical products.
Formulary: Open formulary with a preferred drug
Therapeutic Category Coverage: Therapeutic list. Utilization managed through prior
categories covered: anabolic steroids; analgesics, authorization and quantity limits. General
antipyretics, NSAIDs; anticoagulants; exclusions: New York State follows OBRA '90
anticonvulsants; antidepressants; antidiabetic guidelines in the reimbursement of prescription
agents; antihistamine drugs; antilipemic agents; drugs.
anti-psychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; chemotherapy agents; Prior Authorization: The State uses an automated
contraceptives; ENT anti-inflammatory agents; voice activation system and a staffed call center,
estrogens; hypotensive agents; prescribed smoking and has a Pharmacy and Therapeutics Committee
deterrents; sympathominetics (adrenergic); and that meets quarterly. Prior authorization is required
thyroid agents. Therapeutic categories partially for: all brand name drugs with A-rated generics, all
covered: prescribed cold medication and misc. GI non-preferred drugs that are not on the preferred
drugs. Therapeutic categories requiring prior drug list, and drugs that are subject to the Clinical
authorization: drugs not on the preferred drug list in Drug Review Program (Zyvox and Serostim).
the following classes: ace inhibitors; ace inhibitors
and calcium channel blackers; ace inhibitors and Prescribing or Dispensing Limitations
diuretics; anti-emetics (oral); anti-fungals; second
Prescription Refill Limit: Maximum of 5 refills
generation antihistamines;anti-virals; beta blockers
within 6 months. Also, annual limits on number of
and diuretics; bisposphonates (oral); calcitonins
prescriptions and prescription and nonprescription
(nasal); calcium channel blockers (DHP);
drugs without an override.
cephalosporins-3rd generation; fluoroquinolones
(oral); hepatitis C agents; HME-CoA reductase
Monthly Dollar Limits: None.
inhibitors (statins); immunodulators (topical);
inhaled anticholinergics; inhaled beta2 and renergic
agents; inhaled corticosteroids; leukotriene Drug Utilization Review
modifiers; narcotics (long acting); phosphate PRODUR system implemented in March 1995.
binders/regulators; proton pump inhibitors; sedative State currently has a DUR Board which meets
hypnotics/sleep agents; serotonin receptor agonists bimonthly.
(triptans); steroids (intranasal); thiazolidinesdiones;
triglyceride lowering agents and antibiotics (Zyvox Pharmacy Payment and Patient Cost
only); second generation antihistamines; growth Sharing
hormones (Serostim only); medical/some surgical
supplies; brand name products if A-rated generic is Dispensing Fee: $3.50 for brand name drugs, $4.50
available; orthopedic shoes; compression stockings; for generic drugs. Effective 8/1/98.
and some DME items. Therapeutic categories not
New York-2
Ingredient Reimbursement Basis: EAC as of July 1, # HealthFirst PHPS

2007 = AWP-14.0% for brand name drugs and # Health Insurance Plan of Greater New York
AWP-25.0% for generics. For specialized HIV # HealthPlus PHPS
Pharmacies that meet specific criteria, AWP-12.0% # Hudson Health Plan
for brands and generics. # Independent Health Association
# Managed Health Inc./A+ Health Plan
Prescription Charge Formula: # MetroPlus Health Plan
1. Payment for multiple source drugs must not # MVP Health Plan
exceed the aggregate of the specified upper # Neighborhood Health Providers
limit set by the Federal Centers for Medicare # NYP Community Health Plan
and Medicaid Services (CMS), plus a # NYS Catholic Health Plan
dispensing fee, for a particular drug; and # Preferred Care
2. Payment for brand name drugs and other # St. Barnabas/Partners in Health
multiple source drugs not covered by clause (1) # Suffolk Health Plan
will be the lower of: EAC plus a dispensing # United Healthcare Plan of NY, Inc.
fee; or # Univera Community Health
# VidaCare, Inc.
3. The billing pharmacy's usual and customary
# Wellcare of New York
price charged to the general public.
Maximum Allowable Cost: State imposes Federal F. STATE CONTACTS

Upper Limits on generic drugs. Must get prior
authorization for most brand name products. (see State Drug Program Administrator
www.health.state.ny.us/nysdoh/medicaid/
ptcommittee/mandatorggen.htm) Linda J. Jones, Director
Bureau of Pharmacy Policy and Operations
Incentive Fee: $1.00 for dispensing a lower cost Office of Health Insurance Programs
multi-source product. NYS Department of Health
99 Washington Avenue
Patient Cost Sharing: Copayment is $3.00 for Albany, NY 12210
brand name drugs, $1.00 for generic and $0.50 for T: 518/474-9219
OTC drugs. Exceptions include psychotropic drugs F: 518/473-5508
as well as drugs FDA approved for the treatment of E-mail: ljm07@health.state.ny.us
tuberculosis and family planning drugs. Internet address: www.nyhealth.gov
Cognitive Services: Does not pay for cognitive Pharmacy Advisory Committee
services. Kandyce Daley, R.Ph.
James DeFranco, R.Ph.
Patricia Donato, R.Ph.
Steven Giroux, R.Ph.
Thomas Golden, R.Ph.
Approximately 3.0 million Medicaid recipients John Navarra, R.Ph. (Chair)
were enrolled in MCOs in FY 2006. Recipients Mel Poliakoff, R.Ph.
receive pharmaceutical benefits through the State. Mohammed Saleh, R.Ph.
Sam Scuderi, R.Ph.
Health Maintenance Organizations John Westerman, R.Ph.
# Affinity Health Plan
# AmeriChoice of New York Formulary Contact
# Blue Choice Option Carl Cioppa, Pharm.D.
# Capitol District Physicians’ Health Plan Pharmacy Operations Manager
# CarePlus, LLC Office of Health Insurance Programs
# Center Care/Manhattan PHSP NYS Department of Health
# Community Blue 99 Washington Avenue
# Community Choice HP of Westchester Albany, NY 12210
# Community Premier Plus T: 518/486-3209
# Fidelis/NYS Catholic Health Plan F: 518/473-5508
# GHI HMO Select E-mail: ctc02@health.state.ny.us
New York-3
Prior Authorization Contact Prescription Price Updating

Linda J. Jones Carl T. Cioppa, Pharm,D.
T: 518/474-9219 518/486-3209
Pharmacy and Therapeutics Committee Medicaid Drug Rebate Contacts

Susan P. Bruce, Pharm.D. Joseph A. Maiello
Roxanne Hall Richardson, R.Ph. Pharmacy Rebate Manager
Donna Chiefari, Pharm.D. Office of Health Insurance Programs
Andrew G. Flynn, R.Ph., C.G.P. NYS Department of Health
William P. Scheer, R.Ph. 99 Washington Avenue
Marc A. Johnson, M.D. Albany, NY 12210
Scott C. Bello, M.D. T: 518/486-3209
Steven E. Barnes, D.O. F: 518/473-5508
Aaron Satloff, M.D. E-mail: jam22@health.state.ny.us
Glenn A. Martin, M.D.
Janice Gay Claims Submission Contact
Marla Suzan Eglowstein, M.D.
John Westerman, Jr., R.Ph. eMedNY
Kevin Huang-Cruz Computer Sciences Corporation (CSC)
Jeffrey Dubitsky, R.Ph. Attn: eMedNY Webmaster
David F. Lehman, M.D., Pharm.D. One CSC Way
Rensselaer, NY 12144
800/343-9000
DUR Contact
E-mail: general@emedny.org
Lydia J. Kosinski, R.Ph., Manager
Recipient Activities and Utilization Review Medicaid Managed Care Contact
Office of Inspector General
NYS Department of Health Barbara M. Frankel, Assistant Director
800 North Pearl Street Office of Managed Care Planning
Albany, NY 12204 Office of Health Insurance Programs
T: 518/474-6866 NYS Department of Health
F: 518/473-5332 Room 1927, Corning Tower
E-mail: ljk02@health.state.ny.us Empire State Plaza
Albany, NY 12237
T: 518/473-0122
DUR Committee
F: 518/474-5886
Physicians E-mail: bmf01@health.state.ny.us
Richard S. Blum, M.D.
Ronald J. Dougherty, M.D. Disease Management/Patient Education
David F. Lehmann, M.D. Programs
Jill Braverman-Panza, M.D.
Molly Finnerty, M.D. Disease/Medical State: AIDS/HIV
Program Name: Aids Intervention Management
Pharmacists Program
Sidney Falow, R.Ph. Program Manager: Guthrie Birkhead
John Gotowko, R.Ph., M.S., M.B.A. Program Sponser: AIDS Institute, NYSDOH
Marc L. Speert, R.Ph.
Frank Barone, R.Ph. Disease/Medical State: Asthma
Marilyn Fortin, R.Ph. Program Name: NYS Asthma Grant
Robert Hamilton, Pharm.D. Program Manager: Patricia Waniewski
Elaena Quatrocchi, Pharm.D., R.Ph. Program Sponser: Division of Family Health,
Teofila A. Daley, R.Ph., M.Sc. NYSDOH

Program Name: Diabetes Prevention and Control
Carl T. Cioppa, Pharm.D. Program
518/486-3209 Program Manager: Maureen Spence
Program Sponser: Bureau of Chronic Disease
Services, NYSDOH
New York-4
Disease/Medical State: Smoking Cessation Title XIX Medical Care Advisory Committee
Program Name: Smokers’ Quit Line (866/697-
Ruben P. Cowart, D.D.S., (Chairman)
8487)
John Angerosa, M.D.
Program Manager: QuitSite@Roswellpark.org
Steven E. Barnes, D.O.
Program Sponsor: Roswell Park and NYSDOH
Russel N. Cecil, M.D.
David Cerniglia, D.C.
Disease/Medical State: Cardiovascular Disease
Stoner E. Horey, M.D.
Program Name: Healthy Heart Program
Mary K. Lashomb
Program Manager: hhp@health.state.ny.us
Norman R. Loomis, M.D.
Program Sponser: NYSDOH
Augustus Mantia, M.D.
Tanton Mustapha, M.D.
Check the NYSDOH website for further
Dennis P. Norfleet, M.D.
information about disease management
Elena Padilla, Ph.D.
demonstrations.
Carl P. Sahler, M.D., Ph.D.
Robert A. Schwartz, M.D.
Gavin Setzen, M.D.
Contacts
Buddhi Shreshta, D.D.S.
Donna Haskin Kathleen Benson Smith
Program Research Specialist III Russel Sykes, Deputy Commissioner, NYS Office
Office of Health Insurance Programs of Temporary and Disability Assistance (DSS
NYS Department of Health Representative)
99 Washington Avenue
Albany, NY 12210 Executive Officers of State Medical and
T: 518/473-2160 Pharmaceutical Societies
F: 518/486-6984
Medical Society of the State of New York
E-mail: dlh04@health.state.ny.us
William R. Abrams
420 Lakeville Road
None P.O. Box 5404
Lake Success, NY 11042-5404
Department of Health Officials T: 516/488-6100
F: 516-488-6136
Richard F. Daines, M.D. E-mail: rabrams@mssny.org
Commissioner Internet address: www.mssny.org
NYS Department of Health
Corning Tower Pharmasists Society for the State of New York
The Governor Nelson A. Rockefeller Empire State Craig M. Burridge, M.S., CAE
Plaza Executive Director
Albany, NY 12237 210 Washington Avenue Extension
T: 518/474-2011 Albany, NY 12203-5335
F: 518/474-5450 T: 518/869-6595
E-mail: rfd02@health.state.ny.us F: 518/464-0618
E-mail: craigb@ppssny.org
Deborah Bachrach Internet address: www.pssny.org/index_new.htm
Deputy Commissioner/Medicaid Director
Office of Medicaid Management New York State Osteopathic Medical Society, Inc.
Office of Health Insurance Programs Freda Lozanoff, D.O.
NYS Department of Health Interim Executive Director
Corning Tower 1855 Broadway, Suite 1102A
The Governor Nelson A. Rockefeller Empire State New York, NY 10023
Plaza T: 800/841-4131
Albany, NY 12237 F: 312/261-1786
T: 518/474-3018 E-mail: info@nysoms.org
F: 518/486-6852 Internet address: www.nysoms.org
E-mail: dsb10@notes.health.state.ny.us
New York-5
New York State Board of Pharmacy

Lawrence H. Mokhiber
Executive Secretary
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue, Second Floor W
Albany, NY 12234-1000
T: 518/474-3817
F: 518/473-6995
E-mail: pharmbd@mail.nysed.gov
Internet address: www.nysed.gov/prof/pharm.htm
Healthcare Association of New York State

Daniel Sisto
President
One Empire Drive
T: 518/431-7600
F: 518/431-7915
E-mail: dsisto@hanys.org
Internet address: www.hanys.org
Greater New York Hospital Association

Kenneth E. Raske
President
555 W. 57th Street
15th Floor
New York, NY 10019
T: 212/246-7100
F: 212/262-6350
E-mail: raske@gnyha.org
Internet address: www.gnyha.org
New York-6
NORTH CAROLINA

Disabled Disabled

2003 2004
TOTAL $1,263,258,395 1,015,932 $1,555,955,045 1,071,753

Aged $174,382,845 61,692 $202,897,239 60,413
Blind/Disabled $396,791,857 134,345 $483,205,579 138,794
Child $34,113,598 118,940 $42,903,251 121,553
Adult $80,078,099 117,427 $109,429,886 131,740

Aged $53,452,383 17,280 $62,972,249 17,785
Blind/Disabled $21,081,515 6,648 $27,348,821 7,265
Child $278,677 709 $556,417 757
Adult $4,334,457 4,753 $6,131,984 5,307

Aged $171,128,310 62,497 $203,385,925 63,656
Blind/Disabled $182,952,327 58,567 $238,146,284 64,350
Child $85,906,187 299,651 $113,314,503 335,946
Adult $6,844,570 32,880 $8,706,802 35,669
TOTAL OTHER EXPENDITURES/RECIPIENTS $51,913,570 100,543 $56,956,105 88,518
unknown.
North Carolina-1
C. ADMINISTRATION Prior Authorization: Formal prior authorization

process can be found at: ww.ncmedicaidpbm.com.
Division of Medical Assistance, Department of A prescriber’s written justification is required to
Health and Human Services. appeal a prior authorization decision.

Monthly Quantity Limit: 34-day supply maximum.
Benefit Design Except birth control tablets and hormonal
replacement therapy dial packs: 3 months;
Drug Benefit Product Coverage: Products covered: maintenance non-controlled medications, tied with
prescribed insulin. Products not covered: cosmetics; the FUL and/or SMAC after a prior successful fill
fertility drugs; experimental drugs; disposable may receive a 3 month supply upon the prescriber's
needles and syringe combinations used for insulin; discretion.
blood glucose test strips; urine ketone test strips;
total parenteral nutrition; and interdialytic Monthly Prescription Limit: Eight prescriptions per
parenteral nutrition; OTC drugs not listed on the month per with additional 3 prescriptions available
selected coverage list; and those on override at the pharmacy. If over 11
products/categories mentioned below under prescriptions per month, beneficiary is “locked in”
“Therapeutic Category Coverage” section. to a single pharmacy and focused risked
management medication review is required.
Over-the-Counter Product Coverage: North
Carolina covers a select list of OTC products. (See Prescription Dollar Limits: None.
www.dhhs.state.nc.us/dma/mp/mpindex.htm for a
complete list of covered OTC products.) Drug Utilization Review
Therapeutic Category Coverage: North Carolina PRODUR system implemented in May 1996. State
provides coverage for all therapeutic categories currently has a DUR Board with a quarterly review.
except anoretics; products used for cosmetic
purposes; fertility drugs; weight loss/gain; erectile Pharmacy Payment and Patient Cost
dysfunction; diaphragms; IV fluids (Dextrose Sharing
500ml or greater) and irrigations fluids used in an Dispensing Fee: B: $4.00; G: $5.60, effective 2002.
inpatient facility; drugs on the DESI list; any drug
manufactured by a company who has not signed the Ingredient Reimbursement Basis: EAC = AWP-
Federal rebate agreement; and experimental drugs. 10%.
Prior authorization required for: analgesics,
antipyretics, and NSAIDs; estrogens; drugs used to Prescription Charge Formula: The lowest price of
treat ADHD; Procrit/Epogen; Neupogen; Aranesp; AWP minus 10%, State MAC or FUL plus a
OxyContin; Growth Hormones; Provigil; Rebetron; dispensing fee or usual and customary, whichever
Vioxx; Celebrex; Bextra; Botox; Myobloc; Zyban, is lowest. The pharmacist filling the original
Nicotrol, Nicotine Patch; Synagis; and RespiGam. prescription will not be reimbursed for refills for
(See www.ncmedicaidpbm.com for additional the same drug within a calendar month.
information.)
Coverage of Injectables: Injectable medicines Upper Limits as well as State-specific maximum
reimbursable through the Prescription Drug allowable cost (MAC) limits generic drugs. 1,068
Program when used in home health care and drugs are listed on the State-specific MAC list.
extended care facility, and through physician Override requires “Brand Medically Necessary”
payment when used in physician offices. written on the face of the prescription by the
prescriber.
Vaccines for Children Program. Incentive Fee: $1.60 to dispense a lower cost
multisource product.
Patient Cost Sharing: $3.00 copayment/Rx.
Formulary: Open formulary with restrictions on Cognitive Services: Pays a medication regimen
use, prior authorization, and preferred products. review service fee for focused risk management
reviews.
North Carolina-2
E. USE OF MANAGED CARE Medicaid Drug Utilization Review Board

Physicians:
Approximately 7,500 Medicaid recipients were Edward Treadwell, M.D.
enrolled in MCOs in FY 2006. Recipients receive Jarrett Barnhill, Jr., M.D.
pharmaceutical benefits through the State. Sandy Newton, M.D.
Ramon Velez, M.D.
Managed Care Organizations John Perry, M.D.
SouthCare/Coventry
2815 Coliseum Center Drive Pharmacists:
Suite 550 Joseph S. Moose, Pharm. D.
Charlotte, NC 28217 Al Lockamy, R.Ph.
800/350-6294 Wayne Creech, R. Ph.
Brooke Rawls, Pharm. D.
Thomas Thutt, R.Ph.
F. STATE CONTACTS Gina Upchurch, R.Ph., M.P.H.
State Drug Program Administrator New Brand Name Products Contact

Tom D’Andrea, R.Ph., M.B.A. Tom D’Andrea, R.Ph., M.B.A.
Chief of Pharmacy and Ancillary Services 919/855-4300
Division of Medical Assistance Prescription Price Updating
1985 Umstead Drive
2501 Mail Service Center Tom D’Andrea, R.Ph., M.B.A.
Raleigh, NC 27699-2501 919/855-4300
T: 919/855-4300
F: 919/715-1255 Medicaid Drug Rebate Contact
E-mail: Tom.Dandrea@ncmail.net Sharon Greeson, R.Ph.
Internet address: www.dhhs.state.nc.us/dma Pharmacy Director
EDS
Prior Authorization Contact 4905 Waters Edge Drive
Lisa Weeks, Pharm.D. Raleigh, NC 27606
Pharmacy Manager T: 919/816-4475
Division of Medical Assistance E-mail: sharon.greeson@ eds.com
1985 Umstead Drive
2501 Mail Service Center Claims Submission Contact
Raleigh, NC 27699-2501 Sharon Greeson, R.Ph.
T: 919/855-4300 919/816-4475
F: 919/715-1255
E-mail: Lisa.Weeks@ncmail.net Medicaid Managed Care Contact
DUR Contact Jeffrey Simms
Assistant Director- Managed Care
Glenda Adams, Pharm.D. Department of Health and Human Services
DUR Coordinator Division of Medical Assistance
Department of Health and Human Services 1985 Umstead Drive
Division of Medical Assistance 2501 Mail Service Center
1985 Umstead Drive Raleigh, NC 27699
2501 Mail Service Center T: 919/647-8170
Raleigh, NC 27699 F: 919/733-6608
T: 919/855-4300 E-mail: jeffrey.simms@ncmail.net
F: 919/715-1255
E-mail: Glenda.Adams@ncmail.net Mail Order Pharmacy Program
None
North Carolina-3
North Carolina Osteopathic Medical Association

Department of Human Resources Officials
Jeffrey J. LeBoeuf
Dempsey E. Benton Executive Director
Secretary 8311 Brier Creek Parkway
Department of Health and Human Services Raleigh, NC 27617
101 Blair Drive F: 910/763-4666
Raleigh, NC 27699-2001 E-mail: jeffrey@ncoma.org
T: 919/733-4534 Internet address: www.ncoma.org
F: 919/715-4645
E-mail: dempsey.benton@ncmail.net North Carolina State Board of Pharmacy
Jack W. “Jay” Campbell IV
L. Allen Dobson, Jr. Executive Director
Assistant Secretary for Health Policy and Medical P.O. Box 4560
Assistance Chapel Hill, NC 27515-4560
Division of Medical Assistance F: 919/967-5757
1985 Umstead Drive E-mail: jcampbell@ncbop.org
2501 Mail Service Center Internet address: www.ncbop.org
Raleigh, NC 27699-2501
T: 919/855-4100 North Carolina Hospital Association
F: 919/733-6608 William A. Pully
E-mail: allen.dobson@ncmail.net President
P.O. Box 4449
Mark Benton, Director Cary, NC 27519-4449
Division of Medical Assistance F: 919/677-4200
1985 Umstead Drive E-mail: wpully@ncha.org
2501 Mail Service Center Internet address: www.ncha.org
T: 919/855-4100
F: 919/733-6608
E-mail: mark.benton@ncmail.net

North Carolina Medical Society
Robert W. Seligson, M.B.A., CAE
P.O. Box 27167
T: 919/833-3836
F: 919/833-2023
E-mail: rseligson@ncmedsoc.org
Internet address: www.ncmedsoc.org
North Carolina Association of Pharmacists

Fred Eckel
Executive Director
109 Church Street
Chapel Hill, NC 27516-2502
T: 919/967-2237
F: 919/968-9430
E-mail: fred@ncpharmacists.org
Internet address: www.ncpharmacists.org
North Carolina-4
NORTH DAKOTA

Disabled Disabled

2003 2004
TOTAL $56,433,414 47,738 $59,815,955 46,768

Aged $4,539,319 1,749 $4,521,393 1,693
Blind/Disabled $15,856,619 5,230 $17,238,740 5,343
Child $1,802,985 7,723 $2,047,947 7,577
Adult $2,880,852 5,199 3204665 5158

Aged $15,589,991 5,869 $16,292,358 5,583
Blind/Disabled $8,091,292 2,349 $8,137,246 2,061
AFDC-Child $626,548 1,461 $682,442 1,048
AFDC-Adult $735,517 1,215 $622,236 808
POVERTY RELATED, TOTAL $934,696 3,589 $1,611,616 6,172

Aged $7,622 26 $89,219 127
Blind/Disabled $29,770 20 $91,936 109
AFDC-Child $777,771 3,195 $1,282,020 5,293
AFDC-Adult $119,533 348 $148,441 643
unknown.
Note: North Dakota estimates 2005 drug expenditures to be approximately $61.6 million.
North Dakota-1
C. ADMINISTRATION Additional information on benefit design may be

found at www.hidndmedicaid.com.
North Dakota Department of Human Services.
D. PROVISIONS RELATING TO DRUGS Formulary: Open formulary
Benefit Design Prior Authorization: State currently has a formal

prior authorization procedure. Beneficiary can
Drug Benefit Product Coverage: Products covered: request a fair hearing to appeal a prior authorization
prescribed insulin; disposable needles and syringe decision.
strips; and total parenteral nutrition. Products not Prescribing or Dispensing Limitations
covered: cosmetics; fertility drugs; urine ketone test
strips; interdialytic parenteral nutrition; drugs used Prescription Refill Limit: None.
for hair growth; prescription vitamins (except
prenatal vitamins); experimental drugs; drugs for Monthly Quantity Limit: 34-day supply.
weight gain/loss; erectile dysfunction products; and
DESI drugs. Prior authorization required for: Monthly Dollar Limits: None.
nutritional supplements; and orlistat.
Over-the-Counter Product Coverage: Products PRODUR system implemented in July 1996. State
covered: antacids; analgesics; iron supplements; has a DUR Board that meets quarterly.
digestive products; and anti-ulcer medications.
Products covered with restriction: allergy, asthma,
and sinus products (loratadine only); and topical
Sharing
products (artificial tears only); smoking deterrent
products (lifetime limits). Products not covered: Dispensing Fee: $5.60 for generic, $4.60 for brand
cough and cold preparations; feminine products. effective 8/1/03.
Therapeutic Category Coverage: Categories
Ingredient Reimbursement Basis: EAC = lesser of
covered: anabolic steroids; analgesics, antipyretics,
AWP-10%, WAC+12.5%, FUL, or MAC.
and NSAIDs; antibiotics; anticoagulants;
anticouvulsants; anti-depressants; antidiabetic
Prescription Charge Formula: Acquisition Cost
agents; antilipemic agents; anti-psychotics;
plus a dispensing fee per prescription or the usual
and customary retail charge, whichever is lower.
Acquisition Cost = AWP-10%, WAC+12.5%, FUL
contraceptives; ENT anti-inflammatory agents;
or MAC.
estrogens; growth hormones; hypotensive agents,
sympathominetics (adrenergic); thyroid agents; and
prescribed smoking deterents (partial coverage). Maximum Allowable Cost: State imposes Federal
Prior authorization required for: brand name Upper Limits as well as State-specific limits on
NSAIDs, anoretics (orlistat); antihistamines; and drugs. Override requires “Dispense As Written.”
PPIs.
reimbursable through the Prescription Drug Patient Cost Sharing: $3.00 (brand-name drugs)
Program when used in home health care, and
extended care facilities, and through both the Cognitive Services: Does not pay for cognitive
Prescription Drug Program and physician payment services.
when used in physician offices.

EPSDT service.
North Dakota-2
E. USE OF MANAGED CARE Medicaid Drug Rebate Contact

Brendan K. Joyce, Pharm.D., R.Ph.
Currently, no North Dakota Medicaid beneficiaries 701/328-4023
are enrolled in managed care organizations. The
contract with Altru Health Systems, the State’s only Claims Submission Contact
managed care plan, terminated on November 1,
2006. Brendan K. Joyce, Pharm.D., R.Ph.
701/328-4023
F. STATE CONTACTS Medicaid Managed Care Contact
State Drug Program Administrator Tanya Hellman, Administrator
Managed Care
Brendan K. Joyce, Pharm.D., R.Ph. ND Department of Human Services
Administrator, Pharmacy Services 600 East Boulevard Avenue, Dept. 325
Department of Human Services Bismark, ND 58505-0261
600 East Boulevard Avenue, Dept. 325 T: 701/328-3598
Bismarck, ND 58505-0250 F: 701/328-1544
T: 701/328-4023 E-mail: thellman@nd.gov
F: 701/328-1544
E-mail: sojoyb@nd.gov Disease Management Program/Initiative
Internet address: www.state.nd.us/humanservices Contact
Prior Authorization Contact Tanya Hellman
701/328-3598
701/328-4023 Mail Order Pharmacy Benefit Program
DUR Contact None
701/328-4023 Department of Human Services Officials
Carol K. Olson
DUR Board Executive Director
Carrie Sorenson, Pharm.D. ND Dept. of Human Services
Patricia Churchill, R.Ph. 600 E. Boulevard Avenue, Dept. 325
Leann Ness, Pharm.D. Bismarck, ND 58505-0250
Greg Pfister, Pharm.D. T: 701/328-2538
John Savageau, R.Ph. F: 701/328-1545
Robert Treitline, R.Ph. E-mail: dhseo@nd.gov
Todd Twogood, M.D. Internet address: www.nd.gov/humanservices
Cheryl Huber, M.D.
Norman Byers, M.D. Maggie Anderson, Director
Albert Samuelson, M.D. Division of Medical Services
Carlotta McCleary Department of Human Services
Gary Betting, M.D. 600 E. Boulevard Avenue, Dept. 325
Brendan K. Joyce, Pharm.D., R.Ph. Bismarck, ND 58505-0261
Scott Setzepfandt, R.Ph. T: 701/328-1603
F: 701/328-1544
New Brand Name Products Contact E-mail: dhsmed@state.nd.us

701/328-4023

701/328-4023
North Dakota-3

North Dakota Medical Association
Bruce Levi
Executive Director
P.O. Box 1198
Bismarck, ND 58502-1198
T: 701/223-9475
F: 701/223-9476
E-mail: blevi@ndmed.com
Internet address: www.ndmed.com
North Dakota State Osteopathic Association

Carmen Christianson Bell
Executive Director
1600 2nd Avenue, SW, Suite 20
Minot, ND 58701
701/852-8798
E-mail: ndoma@ndoma.org
Internet address: www.ndoma.org
North Dakota Pharmacists Association

Michael Schwab
1661 Capitol Way, Suite 102
T: 701/258-4968
F: 701/258-9312
E-mail: mschwal@nodakpharmacy.net
Internet address: www.nodakpharmacy.net
North Dakota State Board of Pharmacy

Howard C. Anderson, Jr., R.Ph.
Executive Director
P.O. Box 1354
T: 701/328-9535
F: 701/328-9536
E-mail: ndboph@btinet.net
Internet address: www.nodakpharmacy.com
North Dakota Healthcare Association

Arnold R. Thomas, President
P.O. Box 7340
1622 E. Interstate Avenue
Bismarck, ND 58503
T: 701/224-9732
F: 701/224-9529
E-mail: athomas@ndha.org
Internet address: www.ndha.org
North Dakota-4
OHIO

Disabled Disabled

2003 2004
TOTAL $1,569,067,697 1,054,737 $1,870,162,977 1,083,593

Aged $110,953,538 33,529 $127,118,095 34,207
Blind/Disabled $560,947,230 161,391 $674,990,705 176,893
Child $15,779,840 52,660 $18,106,772 49,403
Adult $17,935,100 27,657 $20,267,115 26,447

Aged $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

Aged $2,354,962 1,748 $2,847,483 1,972
Blind/Disabled $8,742,743 5,460 $8,893,208 4,622
Child $46,513,012 150,042 $55,177,727 147,379
Adult $4,506,362 21,667 $5,310,193 21,721
unknown.
Ohio-1
C. ADMINISTRATION Approved Drug List (ADL)/Prior

Authorization
Ohio Department of Job and Family Services, Bureau ADL: Closed ADL of preferred products with
of Health Plan Policy. approximately 28,000 NDC-specific trade and
generic drugs. Products excluded include obesity,
D. PROVISIONS RELATING TO DRUGS fertility, and experimental drugs. ADL managed by
excluding products based on contracting issues,
Benefit Design restrictions on use, prior authorization, therapeutic
Drug Benefit Product Coverage: Products covered: substitution, preferred products, and physician
most drugs including prescribed insulin. Products not profiling.
covered: cosmetics; fertility drugs; obesity drugs; Prior Authorization: State currently has a formal
experimental drugs. Prior authorization required for prior authorization procedure. Prior authorization is
some drugs including these examples: Ceredase; needed for certain individual drugs (see examples
Cerebyx; Cerezyme; Clorazepates; Depo-Provera; above) A beneficiary may appeal a prior
Enbrel; immunoglobulins; Lioresal Intrathecal; authorization decision and be granted an
Lodosyn; Nascobal; Orgaran; Oxandrin Panretin; administrative hearing. Manufactures may also
Periostat; Priftin; Prolastin; Proleukin; Provigil; request reconsideration for an excluded product.
Psoralens; Remicade; Rituxan; Stimate; Synagis; and
Targretin. Products covered under DME: disposable Prescribing or Dispensing Limitations
blood glucose test strips; urine ketone test strips; total Monthly Dollar Limits: None
parentaral nutrition (PA required); and interdialytic
parenteral nutrition (PA required). Monthly Quanity Limits: None
OTC Coverage: Selective coverage for: allergy, Quanity Limit per Prescription: 34-day supply. 102-
asthma, and sinus products; analgesics; feminine day supply for chronic maintenance medications.
products; smoking deterrent products; cough and cold
preparations; digestive products; topical products; Prescription Refill Limit: 5 refills per script.
laxatives; antacids; and vitamins and minerals.
categories covered: anticoagulants; anticonvulsants; PRODUR system implemented through POS in Feb.
anti-depressants; antidiabetic agents; antilipemic 2000. State currently has a DUR Board with quarterly
agents; anti-psychotics; cardiac drugs; chemotherapy review.
agents; contraceptives; estrogens; hypotensive
agents; prescribed smoking deterrents; Pharmacy Payment and Patient Cost Sharing
sympathominetics (adrenergic); and thyroid agents. Dispensing Fee: $3.70, effective 7/1/98. ($0.50 fee
Partial coverage for: anabolic steroids; analgesics, for flu vaccine.)
antipyretics, and NSAIDS; antibiotics;
antihistamines; anxiolytics, sedatives, and hypnotics; Ingredient Reimbursement Basis: EAC = WAC+7%
prescribed cold medications; ENT anti-inflammatory (or AWP-14.4% if WAC cannot be determined) (eff.
agents; growth hormones; and misc. GI drugs. 10/1/05).
Therapeutic categories not covered: anorectics;
innovator multi-source drugs; selected high-risk Prescription Reimbursement Formula:
drugs (e.g., Accutane); and drugs used in special Reimbursement for legend drugs and selected OTC
settings (e.g., outpatient hospital). products based on the lowest of:
Coverage of Injectables: Injectable medicines 1. Provider’s submitted charge, which should
reimbursable through both the Prescription Drug reflect usual and customary charge to the general
Program and physcian payment when used in public;
physicians' offices. 2. WAC+7% plus a dispensing fee.
Vaccines: Vaccines reimbursable as part of the 3. FUL or State-established Maximum Allowable

Vaccines for Children Program. Cost (MAC), for specifically designated
generically equivalent drugs plus a dispensing
Unit Dose: Unit dose packaging not reimbursable. fee.
Ohio-2
Non-legend drugs - reimbursement is based on WAC Gateway Health Plan of Ohio, Inc.
+ 7% plus a dispensing fee, or MAC if applicable. U.S. Steel Tower - Floor 41
Special reimbursement for Blood Factors 8 and 9 600 Grant Street
(EAC +1.5%). Pittsburgh, PA 15219
412/255-1303
Upper Limits as well as State-specific limits on Molina Healthcare of Ohio, Inc.
generic drugs. Override requires prior authorization. 8101 N. High Street, Suite 210
Columbus, OH 43235
Incentive Fee: None. 614/781-4303
Patient Cost Sharing: $2.00 for brand name drugs; Unison Health Plan of Ohio, Inc.
$3.00 for prior authorized drugs. 300 Oxford Drive
Monroeville, PA 15146
800/600-9007
services.
F. STATE CONTACTS
E. USE OF MANAGED CARE State Program Drug Administrator
Approximately 1.2 million Medicaid recipients were Robert P. Reid, R.Ph.

enrolled in managed care in 2007. All received Administrator, Pharmacy Services Unit
pharmacy services through managed care plans. Ohio Department of Job and Family Services
Bureau of Health Plan Policy
Managed Care Organizations P.O. Box 182709
Columbus, OH 43218-2709
Buckeye Community Health Plan T: 614/466-6420
U.S. Bank Building F: 614/466-2908
175 South Third Street, Suite 1200 E-mail: reidr@odjfs.state.oh.us
Columbus, OH 43215 Internet address: www.jfs.ohio.gov
866/246-4356
CareSource
One South Main Street, Suite 900 Robert P. Reid, R.Ph.
Dayton, OH 45402 614/466-6420
937/224-3300
Prior Authorization Contacts
Partnership Plan, Inc. (Anthem) Drugs: Robert P. Reid, R.Ph.
8333 Rockside Road, Suite 200 614/466-6420
Valleyview, OH 44125
866/896-6625 DME/Nutritions: Trina Hazley
614/466-6734
Paramount Advantage
P.O. Box 928 DUR Contact
Toledo, OH 43697-0928
419/887-2550 Margaret Scott, R.Ph.
Pharmacologist
WellCare of Ohio, Inc. P.O. Box 182709
6060 Rockside Woods Blvd., Suite 300 Columbus, OH 43218-2709
Independence, OH 44131 T: 614/466-6420
866/507-1407 F: 614/466-2908
AMERICGROUP Community Care

10123 Alliance Road
Suite 140
Cincinnati, OH 45242
513/733-2300
Ohio-3
DUR Board Pharmacy and Therapeutics Committee

Thomas E. Gretter, M.D. Robert P. Reid, R.Ph., Chairman
Jacob F. Palomaki, M.D. Administrator, Pharmacy Services Unit
Lenard G. Presutti, D.O. ODJFS
Robert B. Kubasak, R.Ph.
Kevin J. Mitchell, R.Ph. Suzanne Eastman, R.Ph., M.S.
John A. Petracci, R.Ph. Ohio Pharmacists Association
Donald Sullivan, Ph.D., R.Ph.
Robert Hunter, D.O.
DUR Committee Ohio Osteopathic Association
Donald L. Sullivan, Ph.D., R.Ph.
Ruth E. Purdy, D.O.
Kevin Mitchell, R.Ph.
Ohio Osteopathic Association
David C. Brookover, R.Ph.
Robert Kubasak, R.Ph.
Susan Baker, APN
Shelia M. Thomas, Pharm.D., R.Ph.
Ohio Nurses Association
John A. Petracci, R.Ph.
Mary Jo Welker, M.D.
Prescription Price Updating Ohio State Medical Association
First DataBank
1111 Bayhill Drive, Suite 350 Sandra Hrometz, R.Ph, Ph.D.
San Bruno, CA 94066 Assistant Professor of Pharmacology
T: 650/588-5454
F: 650/827-4578 Tammie J. Armeni, R.Ph.
Pharmacy Services Program
Medicaid Drug Rebate Contacts ODJFS
F. Joseph Brown Michael P. Wascovich, R.Ph., M.B.A.
ACS State Healthcare Ohio Pharmacists Association
Atlanta, GA 30350 Department of Job and Family Services
Officials
Helen E. Jones-Kelley, Director
F. Joseph Brown Ohio Department of Job and Family Services
ACS State Healthcare 30 East Broad Street, 32nd Floor
375 Northridge Road, Suite 400 Columbus, OH 43215
Atlanta, GA 30350 T: 614/466-6282
F: 614/466-2815
Jon Barley, Chief Cristal A. Thomas
Bureau of Managed Health Care Medicaid Program Director
Ohio Department of Job and Family Services Ohio Health Plans
50 W. Town Street, 4th Floor Ohio Department of Job and Family Services
P.O. Box 187209 50 W. Town Street, 4th Floor
Columbus, OH 43218-2709 P.O. Box 187209
614/466-4693 Columbus, OH 43218-2709
T: 614/466-4443
Mail Order Pharmacy Benefit F: 614/752-3986
State has mail order providers. Recipients free to

select mail order pharmacy of their choosing.
Ohio-4
Ohio State Board of Pharmacy

William T. Winsley, M.S., R.Ph.
Jerry Friedman, (Chair) Executive Director
Cindy Norwood 77 S. High Street, Room 1702
Ed Lentz Columbus, OH 43215-6126
Hubert Wirtz T: 614/466-4143
Eugene King, J.D. F: 614/752-4836
Janet Grant E-mail: exec@bop.state.oh.us
Frank Giganti Internet address: www.pharmacy.ohio.gov
Sam Chapman
Richard Tuck, M.D. Ohio Hospital Association
Jack Cera James R. Castle
Art Schlesinger President and CEO
Randall Garland 155 E. Broad Street, 15th Floor
Lolita M. McDavid, M.D., M.P.A. Columbus, OH 43215-3620
Maureen Mitchell, R.N., Ed.D. T: 614/221-7614
Christopher Moore F: 614/221-4771
Nancy Lee E-mail: jimc@ohanet.org
Kathleen Anderson Internet address: www.ohanet.org
Katherine Kuck
Donna Skoda, M.S., R.D., L.D.
Randy Runyon
Brian Tilow

Ohio State Medical Association
Brent Mulgrew
Executive Director
3401 Mill Run Drive
Hilliard, OH 43026
T: 800/766-6762
F: 614/527-6763
E-mail: brentm@osma.org
Internet address: www.osma.org
Ohio Pharmacists Association

Ernest E. Boyd
Executive Director
2155 Riverside Drive
T: 614/586-1497
F: 614/586-1545
E-mail: eboyd@ohiopharmacists.org
Internet address: www.ohiopharmacists.org
Ohio Osteopathic Association

Jon F. Wills
Executive Director
53 W. 3rd Avenue
P.O. Box 8130
Columbus, OH 43201
T: 614/299-2107
F: 614/294-0457
E-mail: execdir@ooanet.org
Internet address: www.ooanet.org
Ohio-5
Ohio-6
OKLAHOMA

Disabled Disabled

2003 2004
TOTAL $290,182,401 302,424 $396,855,999 421,476

Aged $22,620,092 16,892 $25,578,445 16,232
Blind/Disabled $62,411,793 33,730 $105,008,801 48,532
Child $5,987,955 20,694 $9,795,219 31,297
Adult $7,151,135 19,939 $14,827,226 31,165
MEDICALLY NEEDY, TOTAL $52,656 100 $0 0

Aged $788 7 $0 0
Blind/Disabled $39,188 22 $0 0
Child $6,852 43 $0 0
Adult $5,828 28 $0 0

Aged $12,870,350 8,840 $16,145,340 9,573
Blind/Disabled $16,014,945 8,040 $25,039,218 10,134
Child $32,158,562 129,135 $56,225,145 201,086
Adult $2,559,344 17,886 $4,913,746 25,667
unknown.
Oklahoma-1

Oklahoma Health Care Authority. Formulary: Open formulary with the preferred drug
list (PDL). PDL managed through restrictions on
use, prior authorization, therapeutic substitution, use
D. PROVISIONS RELATING TO DRUGS of preferred products, and step therapy.

Drug Benefit Product Coverage: Products covered: prior authorization procedure. Grievance process
prescribed insulin. Products covered (DME benefit): exists for appeal of prior authorization decisions or
disposable needles and syringe combinations for coverage of an excluded product to the agency’s
insulin; blood glucose test strips; and urine ketone Administrative Law Judge. Recipient must present
test strips. Products covered with restrictions: total compelling reason to obtain coverage.
parenteral nutrition (reimburse single most costly
ingredient, not reimbursed through pharmacy Prescription or Dispensing Limitations
program). Products not covered: cosmetics; fertility Prescription Refills: In accord with State law.
drugs; and experimental drugs.
Monthly Quantity Limits: Six prescriptions per
Over-the-Counter Product Coverage: Products month/recipient, including a maximum of three brand
covered: birth control products. Products covered name scripts. ICF-MR, Medicaid children, and
with restrictions: allergy, asthma, and sinus products nursing home recipients are allowed unlimited orders.
(Claritin OTC only for children < 21 years. PA Clients on Home and Community Based Waivers and
required for adults. Rx required for all ages.); DDSD Waivers are also allowed 7 additional generic
digestive products (non-H2 antagonists-Prilosec OTC prescriptions per month. Prior authorization required
only, Rx required); smoking deterrent products (PA for additional prescriptions beyond 13.
and Rx required). Products not covered: analgesics;
cough and cold preparations; H2 antagonists; Quantity Limit per Prescription: Greater of 34-day
feminine products; topical products. supply or 100 units or as approved by DUR Board for
individual drugs.
categories covered: antibiotics; anticoagulants; Drug Utilization Review
anticonvulsants; anti-psychotics; chemotherapy
agents; contraceptives; ENT anti-inflammatory PRODUR system implemented in 2000. State
agents; estrogens; sympathominetics (adrenergic); currently has a DUR Board with a monthly review.
and thyroid agents. Prior authorization required for:
anoretics (partial coverage); analgesics, antipyretics, Pharmacy Payment and Patient Cost Sharing
NSAIDs; antidepressants; antidiabetic agents; Dispensing Fee: $4.15, effective 10/95.
antihistamine drugs (partial coverage); antilipemic
agents; anxiolytics, sedatives, and hypnotics; cardiac Ingredient Reimbursement Basis: EAC = AWP-
drugs; growth hormones; hypotensive agents; misc. 12.0%. Multisource branded drugs subject to State
GI drugs; prescribed smoking deterrents (partial MAC limits.
coverage) stimulants for ADHD; clopidigrel;
levalbuterol; and montelukast. Therapeutic categories Prescription Charge Formula: Estimated Acquisition
not covered: anabolic steroids; and prescribed cold Cost (EAC) plus dispensing fee, or usual and
medications. OBRA ’90 drugs identified as customary charge, whichever is lower. In no event
"coverage optional." shall charges to the Welfare Department exceed
charges made to the general public for the same
Coverage of Injectables: Injectable medicines prescription or item. Special rules for hemophilia
reimbursable through both the Prescription Drug factor products and other injectable drugs on the
Program and physician payment when used in home “DOJ” list.
health care and extended care facilities, and through
physician payment when used in physician offices. Maximum Allowable Cost: State imposes Federal
Vaccines: Vaccines reimbursable as part of EPSDT generic drugs. Override requires “Brand Medically
services and the Vaccines for Children Program. Necessary” and prior authorization. Currently, 1,230
drugs on MAC list.
Oklahoma-2
Patient Cost Sharing: Copayment is $1.00 for Prescription Price Updating

prescriptions up to $29.99, $2.00 for prescriptions
First DataBank
over $30.00.
1111 Bayhill Drive
San Bruno, CA 94066
800/633-3453
services.
E. USE OF MANAGED CARE Tom P. Simonson
Drug Rebate Manager
Does not use MCOs to deliver drug services to Oklahoma Healthcare Authority
Medicaid recipients. 4545 N. Lincoln, Suite 124
Oklahoma City, OK 73105
F: 405/530-3236
State Drug Program Administrator Internet address: tom.simonson@okhca.org
Nancy J. Nesser, D.Ph., J.D. New Brand Name Products Contact

Pharmacy Director
Oklahoma Health Care Authority Rodney Ramsey
4545 N. Lincoln, Suite 124 Drug Reference Coordinator
Oklahoma City, OK 73105 Oklahoma Health Care Authority
T: 405/522-7325 4545 N. Lincoln, Suite 124
F: 405/530-3235 Oklahoma City, OK 73105
E-mail: nancy.nesser@okhca.org T: 405/522-7492
Internet address: www.okhca.org F: 405/530-7119
E-mail: rodney.ramsey @okhca.org
Ronald Graham, D.Ph.
Manager, Operations/DUR EDS
University of Oklahoma, College of Pharmacy 2401 N.W. 23rd Street, Suite 11
ORI W-4403 Oklahoma City, OK 73107
P.O. Box 26901 405/416-6794
T: 405/271-6614 Medicare Managed Care Contact
F: 405/271-2615 Becky Pasternik-Ikard
E-mail: ronald-graham@ouhsc.edu SoonerCare Director
Oklahoma Health Care Authority
DUR Contact 4545 N. Lincoln, Suite 124
Ronald Graham, D.Ph. Oklahoma City, OK 73105
405/271-6614 T: 405/522-7208
E-mail: becky.pasternik-ikard@okhca.org
Medicaid DUR Board
Evie Knisely, Pharm.D.
Dorothy Gourley, D.Ph. Oklahoma has a mail order pharmacy option.
Cliff Meece, D.Ph. (Vice Chair) Pharmacy must be a contracted provider.
Mark Feightner, Pharm.D.
Brent Bell, D.O., D.Ph. Disease Management/ Patient Education
James Rhymer, D.Ph. Programs
Dan McNeill, Ph.D., PA-C (Chair) Disease/ Medical State: Pediatric Diabetes
John Muchmore, M.D. Management
Thomas Kuhls, M.D. Program Manager: Mike Herndon, D.O.
Oklahoma-3
Disease Management Program/Initiative Ann S. Owen, Ph.D.

Contact J. Daniel Post, D.C.
William Simon, M.D.
Mike Herndon, D.O.
Jerry Unruh
Physician Medical Review
Steven Walker, D.P.M.
Terri White
4545 N. Lincoln, Suite 124
Phil Woodward, Pharm.D.
Paul E. Wright, M.D.
T: 405/522-7149
Travis Yadon, O.D.
F: 405/522-3238
E-mail: mike.herndon@okhca.org
Executive Officers of State Medical,
Pharmaceutical, and Osteopathic Societies
Oklahoma Health Care Authority Officials
Oklahoma State Medical Association
Michael Fogarty, J.D.
Brian O. Foy, Executive Director
601 NW Grand Boulevard
T: 405/843-9571
F: 405/842-1834
T: 405/522-7300
E-mail: king@osmaonline.org
F: 405/522-7187
Internet address: www.osmaonline.org
E-mail: fogartym@ohca.state.ok.us
Oklahoma Pharmacists Association
Lynn Mitchell, M.D., M.P.H.
Phil Woodward, Ph.D., Executive Director
Medicaid Director
P.O. Box 18731
T: 405/528-3338
F: 405/528-1417
T: 405/530-7365
E-mail: pwoodward@opha.com
F: 405/530-3218
Internet address: www.opha.com
E-mail: mitchell@ohca.state.ok.us
Oklahoma Osteopathic Association
Oklahoma Health Care Authority Board Lynette C. McLain
Charles Ed McFall Executive Director
Wayne Hoffman (Vice Chair) 4848 N. Lincoln Boulevard
George Miller Oklahoma City, OK 73105
Lyle Roggow (Chair) T: 405/528-4848
Bill Anoatubby F: 405/528-6102
Sandra Langenkamp E-mail: lynette@okosteo.org
Internet address: www.okosteo.org
Medical Advisory Committee
Oklahoma State Board of Pharmacy
Steven A. Crawford, M.D. (Chair) Bryan H. Potter
Dan McNeil, Ph.D. (Vice Chair) Executive Director
Bonnie Bellah 4545 N. Lincoln Boulevard, Suite 112
Steve Buck Oklahoma City, OK 73105-3488
Tanya Case T: 405/521-3815
Mike Crutcher, M.D. F: 405/521-3758
Sherry Davis, A.R.N.P. E-mail: pharmacy@oklaosf.ok.gov
Steve Goforth Internet address: www.pharmacy.state.ok.us
Stanley E. Grogg, D.O.
Howard Hendrick Oklahoma Hospital Association
Jo Hill Craig W. Jones
Ragina Holiman, M.S., C.N.S. President
Craig Jones 4000 Lincoln Boulevard
Heather Kasulis, Au.D., C.C.C.-A. Oklahoma City, OK 73105
Shari Kerr, Ph.D. T: 405/427-9537
Greg Machtolff F: 405/424-4507
James Murtaugh, D.D.S. E-mail: jones@okoha.com
Michael Ogle, D.O. Internet address: www.okoha.com
Oklahoma-4
OREGON

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

2003 2004
TOTAL $251,539,420 240,228 $230,841,512 204,821

Aged $12,361,129 8,672 $12,758,150 8,359
Blind/Disabled $83,266,869 33,745 $84,241,600 33,421
Child $2,128,275 13,071 $2,469,196 12,894
Adult $8,030,128 15,906 $8,267,175 17,809
MEDICALLY NEEDY, TOTAL $4,149,067 1,726 $0 0

Aged $475,419 334 $0 0
Blind/Disabled $3,673,648 1,392 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

Aged $2,964,345 2,796 $229,054 373
Blind/Disabled $9,862,947 4,869 $1,272,925 950
Child $3,942,593 28,772 $3,448,296 21,306
Adult $953,952 6,243 $900,872 5,947
BCCA Women $103,671 100 $230,359 166
unknown.
Oregon-1

Division of Medical Assistance Programs (DMAP), in physician offices and home health care, and
Department of Human Services. through the Prescription Drug Program when used in
D. PROVISIONS RELATING TO DRUGS Vaccines: Vaccines reimbursable by Medicaid as part

of the Vaccines for Children Program.
Benefit Design
Drug Benefit Product Coverage: Drug coverage in Unit Dose: Unit dose packaging is reimbursable, but
Oregon depends on whether the product is being no additional reimbursement for unit dose or
prescribed for a condition covered by the Oregon modified unit dose packaging.
Health Plan (OHP). Oregon prioritizes health
conditions and covers the “highest prioritized” Formulary/Prior Authorization
conditions given available resources. Additional Formulary: Open formulary with a “Plan Drug List
information about OHP, including drug coverage, can (PDL).” The PDL consists of prescription drugs in
be found at www.oregon.gov/DHS/healthplan. selected classes that DHS, in consultation with the
Products covered: prescribed insulin. Products Health Resources Commission, has determined
covered under DME: disposable needles and syringe represent effective drugs available at the best possible
combinations used for insulin; blood glucose test price. The PDL is managed through physician
strips; and urine ketone test strips. Prior education and outreach efforts by the Oregon State
authorization required for: isotretinon; acute anti- College of Pharmacy and through prior authorization.
ulcer drugs; total parenteral nutrition; interdialytic Prior authorization is required to (1) ensure that the
parenteral nutrition; retinoic acid; nasal inhalers; coal drug is being prescribed for a condition that is
tar preparations; and topical testosterone. Products covered by OHP or (2) for clinical reasons (i.e.,
not covered: cosmetics; fertility drugs; experimental medical appropriateness) as recommended by the
drugs. DUR Board and adopted by OMAP. A copy of the
current PDL is available on the OHP website at
Over-the-Counter Product Coverage: Products www.dhs.state.or.us/policy/healthplan/guides/
covered if prescribed for a condition covered by pharmacy/.
OHP: asthma and sinus products; analgesics; cough
and cold preparations; digestive products; feminine Prior Authorization: State currently has a formal
products; and topical products. Products not covered: prior authorization procedure. Client may request an
topical products (cosmetics, acne medications, and administrative hearing to appeal a prior authorization
psoriasis products); and allergy products. decision or to appeal the coverage of excluded
products.
categories covered for medical conditions covered by Prescribing or Dispensing Limitations
OHP: analgesics, antipyretics, and NSAIDs;
antibiotics; anticoagulants; anti-depressants; 34-day supply with the exception of 100-day supply
antidiabetic drugs; antilipemic agents; antipsychotics; for mail order and maintenance drugs.
cardiac drugs; chemotherapy agents; prescribed cold
medications; contraceptives; estrogens; hypotensive Drug Utilization Review
agents; prescribed smoking deterrents; PRODUR system implemented in March 1994. State
sympathominetics (andrenergic); and thyroid agents. currently has a DUR Board with a quarterly review.
Therapeutic categories requiring prior authorization
for covered diagnoses or for medically appropriate Pharmacy Payment and Patient Cost Sharing
use: anabolic steroids; anoretics; anticonvulsants;
anxiolytics, sedatives, and hypnotics; ENT anti- Dispensing Fee: effective 2/1/03.
inflammatory agents; growth hormones; misc. GI
drugs; oral and topical anitfungals; antihistamines; 1) $3.50 (retail);
topical antivirals; growth hormones; leukotriene
receptor antagonists; nasal inhalers; narcotics; 2) $3.91 (institutional/SNF: providers operating a
sedatives; stimulants; oral nutritionals; triptans; PPIs; True or Modified Dose Delivery System);
legend laxatives; anti-emetics; weight loss drugs; and
brand name products for which a generic is available. 3) $7.50 (compound prescriptions).
Ingredient Reimbursement Basis: EAC = AWP-15%

(Retail), AWP-11% (Institutional)
Oregon-2
Prescription Charge Formula: Estimated acquisition Family Care, Inc

cost (EAC) defined as the lesser of: (1) AWP-15% 2121 SW Broadway, Suite 300
(AWP-11% for institutional pharmacies), (2) Federal Portland, OR 97201
Upper Limits for multiple source drugs, (3) State 800/335-3205
MAC, or (4) the usual and customary charge plus a
dispensing fee. Intercommunity Health Network, Inc
3600 NW Samaritan Drive
Maximum Allowable Cost: State imposes Federal Corvallis, OR 97330
Upper Limits as well as State-specific maximum 800/757-5114
allowable cost (MAC) limits on generic drugs.
Override requires “Brand Medically Necessary” and Kaiser Permanente Oregon Plus
prior authorization for generic intolerance. 500 NE Multnomah Street, Suite 100
Portland, OR 97232
Incentive Fee: None. 800/813-2000
Patient Cost Sharing: $2.00 (generic); $3.00 (brand) Lane Individual Practice Association, Inc. (LIPA)
for OHP Plus population. Family planning 1800 Millrace
medications and mail order drugs exempt from Eugene, OR 97403
copay. 877/600-5472
Cognitive Services: Does not pay for cognitive Marion Polk Community Health Plan
services. 198 Commercial Street, SE, Suite 240
Salem, OR 97301
866/318-5375
Mid Rogue Independent Physician Association, Inc.
Approximately 290,000 Medicaid recipients were 820 NE 7th Street
enrolled in MCOs in FY 2006. Recipients enrolled in Grants Pass, OR 97526
MCOs receive most pharmaceutical benefits through 888/460-0185
managed care plans. However, mental health drugs
are carved out of managed care and paid for by the ODS Community Health, Inc.
fee-for-service system. 601 S.W. Second Avenue
Portland, OR 97204
Care Oregon, Inc 503/228-6554
522 SW Fifth Avenue, Suite 200
Portland, OR 97204 Oregon Health Management Services
800/224-4840 109 NE Manzanita
Grants Pass, OR 97526
Cascade Comprehensive Care, Inc. 800/471-0304
2909 Daggett Avenue, Suite 200
Klamath Falls, OR 97601 Providence Health Assurance
541/883-2947 P.O. Box 4327
Portland, OR 97208
Central Oregon Individual Health Solutions, Inc. 800/878-4445
2650 NE Courtney Drive
P.O. Box 5729 Tuality Health Alliance
Bend, OR 97708-5729 335 SE 8th Avenue
800/431-4135 P.O. Box 925
Hillsboro, OR 97123
Doctors of The Oregon Coast South (DOCS) 800/681-1901
750 Central, Suite 202
P.O. Box 1096
Coos Bay, OR 97420
541/269-7400
Douglas County IPA

1813 W. Harvard, Suite 206
Roseburg, OR 97470
800/676-7735
Oregon-3
F. STATE CONTACTS Claims Submission Contact

Bil Milne, R.Ph.
State Drug Program Administrator Account Manager
Debbie L. Bishop First Health Services Corporation
Pharmacy Program Manager P.O. Box 181
Division of Medical Assistance Programs (DMAP) Canby, OR 97013
Department of Human Resources T: 503/391-1980
500 Summer Street, NE, E-35 F: 503/391-1979
Salem, OR 97301-1077
T: 503/945-6291 Medicaid Managed Care Contact
F: 503/947-1119 DMAP
E-mail: debbie.l.bishop@state.or.us Delivery Systems Unit
Internet address: www.dhs.state.or.us/healthplan 500 Summer Street, NW, E-35
Salem, OR 97301
Prior Authorization Contact T: 503/945-5772
Debbie L. Bishop F: 503/947-5221
503/945-6291
DUR Contact Contact
Kathy L. Ketchum, R.Ph., M.P.A.: H.A. Susan E. Good
Medicaid Program Coordinator Disease Management and Prevention Coordinator
Oregon State University College of Pharmacy Division of Medical Assistance Programs
500 Summer Street, NE 500 Summer Street, NE, E-35
Salem, OR 97301 Salem, OR 97301
503/947-5220 T: 503/945-6921
E-mail: ketchumk@ohsu.edu F: 503/373-7689
E-mail: susan.e.good@state.or.us
Medicaid DUR Board
Rickland G. Asai, D.M.D. Programs
Sherry Barrett, R.Ph.
Patrick Bowman, R.Ph. Disease States/Medical Conditions: asthma,
Laura DeSimone, R.Ph. cardiovascular disease (CAD and CHF), diabetes,
George R. Gerding, R.Ph. (Vice Chair) COPD
Dean Haxby, Pharm.D. Program Name: Care Enhance
Robert Ingle, M.D., M.P.H. (Chair) Program Manager: McKesson
Gregory Johnson, M.D.
Kyle Johnson, M.D. Mail Order Pharmacy Program
John Laub, M.D. State has a mail order pharmacy program. All non-
institutionalized beneficiaries are entitled to
New Brand Name Products Contact participate.
Debbie L. Bishop
503/945-6291 Office of Medical Assistance Officials
Bruce Goldberg, M.D.
Prescription Price Updating Director
Debbie L. Bishop Department of Human Services
503/945-6291 500 Summer Street, NE, E-15
Salem, OR 97301
Medicaid Drug Rebate Contacts T: 503/945-5944
F: 503/378-2897
Debbie L. Bishop E-mail: Bruce.Goldberg@state.org.us
503/945-6291
Oregon-4
Jim Edge Osteopathic Physicians and Surgeons of Oregon

Interim Assistant Director Jeff Heatherington
Division of Medical Assistance Programs Executive Director
Department of Human Services 2121 SW Broadway, Suite 300
500 Summer Street, NE, E-49 Portland, OR 97201
Salem, OR 97301 T: 503/222-2779
T: 503/945-5772 F: 503/222-2392
F: 503/373-7689 E-mail: jeffh@opso.org
E-mail: jim.edge@state.or.us Internet address: www.opso.com
Medicaid Advisory Committee Oregon State Board of Pharmacy

Gary A. Schnabel
Carole Romm (Co-Chair)
Executive Director
Jim Russell, M.S.W. (Co-Chair)
State Office Bldg., Room 425
Robert Bach
800 NE Oregon Street
Bruce Bliatout
Portland, OR 97232
Ella Booth, Ph.D., M.B.A.
T: 971/673-0001
Donna Crawford
F:971/673-0002
Kelley Kaiser
E-mail: gary.a. schnabel@state.or.us
Yves Lefranc, M.D.
Internet address: www.pharmacy.state.or.us
Dick Stenson
Thomas Turek, M.D.
Oregon Association of Hospitals and Health Systems
Carmen Urbina
Andy Davidson
Rick Wopat, M.D.
President
4000 Kruse Way Place
Health Resources Commission Building 2, Suite 100
James H. Mackay, M.D. (Chair) Lake Oswego, OR 97035-2543
Dan L. Kennedy, R.Ph. (Vice Chair) T: 503/636-2204
Manuel S. Berman F: 503/636-8310
Dean Haxby, Pharm.D. E-mail: adavidson@oahhs.org
Diane Lovell Internet address: www.oahhs.org
Justin Leonard, J.D.
Tony Melaragno, M.D.
Katherine Merrill, M.D.
Bill Origer, M.D.
George Waldman, M.D.
Judith Wilson, P.H.R., S.P.H.R.

Pharmaceutical Associations
Oregon Medical Association
Klaus Martin
President
11740 SW 68th Parkway, Suite 100
Portland, OR 97233
T: 503/226-1555
F: 503/241-7148
E-mail: oma@theoma.org
Internet address: www.theoma.org
Oregon State Pharmacy Association

Jim Thompson
29702-B SW Town Center Loop West
Wilsonville, OR 97070-6481
T: 503/582-9055
F: 503/582-9046
E-mail: jimt@oregonpharmacy.org
Internet address: www.oregonpharmacists.com
Oregon-5
Oregon-6
PENNSYLVANIA

Disabled Disabled

2003 2004
TOTAL $769,962,791 404,586 $902,868,589 428,586

Aged $64,816,136 19,577 $74,117,846 19,795
Blind / Disabled $204,608,029 59,276 $235,107,469 61,278
Child $8,373,365 32,135 $10,732,626 35,252
Adult $13,681,594 21,647 $18,195,547 25,104

Aged $79,924,716 23,973 $67,345,248 18,054
Blind / Disabled $7,213,248 1,417 $6,531,444 1,362
Child $2,061,498 5,854 $2,676,500 6,333
Adult $1,316,963 4,239 $2,483,670 6,536

Aged $30,129,430 11,452 $32,949,461 11,277
Blind / Disabled $82,973,692 31,163 $101,916,891 34,838
Child $20,911,528 80,618 $24,354,801 81,894
Adult $1,515,344 8,855 $1,656,429 9,030
BCCA Women $2,004,579 437 $4,162,755 713
Pennsylvania-1
C. ADMINISTRATION when used in physician offices, home health care,

and extended care facilities.
Office of Medical Assistance Programs, Department Vaccines: Vaccines reimbursable as part of the
of Public Welfare. Vaccines for Children Program, the EPSDT Program,
and the Children's Health Insurance Program.
Benefit Design
prescribed insulin; disposable needles and syringe Formulary: Open formulary with preferred drug list.
combinations used for insulin; blood glucose test PDL managed through preferred products, prior
strips; and urine ketone test strips; Products not authorization, excluding products based on
covered: cosmetics; fertility drugs; and experimental contracting issues and restrictions on use (dose
drugs; total parenteral nutrition; and interdialytic optimization and quantity limits).
parenteral nutrition.
Prior Authorization: State currently has a prior
Over-the-Counter Product Coverage: Products authorization procedure screening for drug classes
covered: allergy, asthma, and sinus products and individual drugs. Products that require PA
(prescription required); digestive products (H2 include BMN brand name drugs that have A-rated
antagonists); and smoking deterrent products. generics, H2 antagonists used >90 days, and drugs
Products covered with restrictions: analgesics (not in for erectile dysfunction. Also, Oxycontin
LTC); cough and cold preparations (for recipients < prescriptions with doses in excess of 3 tablets per
21 years old); digestive products (not including H2 day, or being on more than 2 different strengths
antagonists) (not in LTC); vitamins (selected types concurrently and COX-2 drugs if the patient is taking
and populations); topical products; and hematinics another NSAID, the prescribed dose is higher than
(not long acting). Products not covered: feminine the FDA recommended dose, or the patient is under
products; and emollients. 70 years of age and is not taking an anticoagulant.
State hearing and appeals process available to appeal
Therapeutic Category Coverage: Therapeutic a prior authorization decision.
categories covered: anabolic steroids; analgesics,
antipyretics, and NSAIDs; antibiotics; anticoagulants; Prescribing or Dispensing Limitations
anticovulsants; anti-depressants; antidiabetic agents; Quantity Limit: 34-day supply or 100 units,
antihistamines; antilipemic agents; anti-psychotics; whichever is greater.
chemotherapy agents; contraceptives; ENT anti- Refill Limit: Up to 5 within 6 months.
hypotensive agents; misc. GI drugs; Monthly Prescription Limit: 6
sympathominetics (adrenergic); thyroid agents; and
prescribed smoking deterrent products. Partial Daily Limit: Doses per day based o FDA approved
coverage for: prescribed cold medications. Prior dosing guidelines and dose optimization.
authorization required for: non-preferred PDL
products; Brand Medically Necessary products; Drug Utilization Review
prescriptions with excessive quanitity limits; and PRODUR system implemented in June 1993.
products such as Byetta, Symlin, Botox, Synagis, Pharmacy and Therapeutics Committee performs
Spireva, Tysabri, Xolair, etc. that require clinical drug utilization review. Meets semi-annually.
review. Therapeutic categories not covered:
anorectics (unless for treatment of hyperkinesis or Pharmacy Payment and Patient Cost Sharing
narcolepsy); hair restoration products; drugs
prescribed for obesity or weight control; erectile Dispensing Fee: $4.00 ($5.00 for compounds),
dysfunction products; personal care items, DESI effective 10/1/95.
products, non-FDA approved products; food
supplements; vitamins (with some exceptions); and Ingredient Reimbursement Basis: EAC = AWP-14%
products from companies not participating in the or WAC+7%.
rebate program.
Prescription Charge Formula:
Coverage of Injectables: Injectable medicines 1. Payment for single source drugs and those
reimbursable through the Prescription Drug Program multisource brand name drugs certified as
Pennsylvania-2
medically necessary will be the lower of the Unison Health Plan/MedPlus+

EAC plus dispensing fee or the pharmacy's usual Unison Plaza
and customary charge. 1001 Brinton Road
Pittsburgh, PA 15221
2. State MAC for the drug plus dispensing fee or
412/858-4000
the pharmacy's usual and customary charge.
3. For compound prescriptions, an additional fee of UPMC Health Plan, Inc.
$1.00 is allowed to a pharmacy, bringing the Two Chatham Center
total dispensing fee to $5.00. 112 Washington Place, Suite 1100
Pittsburgh, PA 15219
Maximum Allowable Cost: State imposes Federal 412/454-7527
generic drugs. Approximately 1,100 drugs are listed Gateway Health Plan
on the State-specific MAC list. Override requires U.S. Steel Tower, Floor 41
"Brand Medically Necessary" and prior authorization 600 Grant Street
with evidence to show that recipient is allergic to the Pittsburgh, PA 15219
inactive ingredients in the generic product. 412/255-4640
Incentive Fee: None. F. STATE CONTACTS
Patient Cost Sharing: Brand: $3.00; Generic: $1.00 State Drug Program Administrator
Cognitive Services: Does not pay for cognitive Terri Cathers, Pharm.D.
services. (Note: tobacco cessation counseling can be Director of Pharmacy Programs
billed as a medical service with proper procedure Department of Public Welfare
code - NOT A PHARMACY BENEFIT.) 49 Beech Drive
2nd Floor, Room 228
Harrisburg, PA 17110-3591
F: 717/346-8171
Approximately 1.1 million unduplicated Medicaid E-mail:c-tcathers@state.pa.us
recipients were enrolled in managed care in 2006. Internet address:
Beneficiaries receive pharmacy services, depending www.dpw.state.pa.us/Health/MAPPharmProg/
on their category of assistance, through both
managed care and the State’s fee-for-fee service Welfare Department Officials
system.
Estelle B. Richman
Secretary
Managed Care Organizations Department of Public Welfare
AmeriHealth HMO/Mercy Health Plan Health and Welfare Building
200 Stevens Drive P.O. Box 2675
Philadelphia, PA 19113 Harrisburg, PA 17105
215/937-8200 T: 717/787-2600
F: 717/772-2062
Keystone Mercy Healthplan E-mail: ra-dpwsecretarynet@state.pa.us
200 Stevens Drive, Suite 900 Internet address: www.dpw.state.pa.us/
Philadelphia, PA 19113-1570
215/937-8200 Michael Nardone
Acting Deputy Secretary for Medical Assistance
Americhoice of PA Programs
The Wanamaker Building Department of Public Welfare
100 Penn Square East, Suite 900 Health and Welfare Building, Room 515
Philadelphia, PA 19107 P.O. Box 2675
215/832-4500 Harrisburg, PA 17105
T: 717/787-1870
Health Partners of Philadelphia F: 717/787-4639
901 Market Street, Suite 500
Philadelphia, PA 19107
215/991-4044
Pennsylvania-3
Prior Authorization Contact Medicaid Managed Care Contact

Terri Cathers, Pharm.D. Jeffrey Bechtel, Director
717/346-8156 Bureau of Managed Care Operations
Department of Public Welfare
Dur Contact 49 Beechmont Avenue, 2nd Floor
Harrisburg, PA 17110
Terri Cathers, Pharm.D. T: 717/772-6300
717/346-8156
F: 717/772-6328
Pharmacy and Therapeutics Committee Disease Management / Patient Education
Robert Mersky, M.D. Programs
Cheston Berlin, Jr., M.D.
Disease/Medical States:
Asthma
Robert Berns Cardiovascular Disease
Donadl Gerhart, R.Ph. Diabetes
Gene Bishop, M.D. Program Name: AccessPlus
James Hancovsky, M.B.A, R.Ph.
David Haverstick, M.D. Program Manager: McKesson
James Schuster, M.D.
Andrew Maiorini, Pharm.D. Disease Management Program/ Initative
Leesa Allen Contact
Mary Ellen Rehrman
Jean Whitehead
Jaan Sidorov, M.D., F.A.C.P., C.M.C.E.
Case Manager
Michael Baer, M.D.
Mary Diamond, D.O.
49 Beechmont Avenue, 2nd Floor
Glen Heise, M.D.
Harrisburg, PA 171110
David Kelley, M.D.
717/772-6777
Pamela McCarter, M.D.
Gretchen Welge, R.Ph.
Kathy Willis, R.N. Mail Order Pharmacy Program
Joseph Trautlein, M.D. None
Terri Cathers, Pharm.D., R.Ph. (Chair)
Yvonne Acrich, M.D. Medical Assistance Advisory Committee
Diane Gottleib, M.D.
Rosemary Keffer, M.D. Christine Allen
Lonnie Fuller, M.D. Genesis HealthCare Corp.
Kennett Square, PA
Kent D. W. Bream, M.D.
Terri Cathers, Pharm.D. Pennsylvania Academy of Family Physicians
717/346-8156 Philadelphia, PA
Prescription Price Updating Michael D. Chambers

County Commissioners Association of Pennsylvania
Terri Cathers, Pharm.D.
Harrisburg, PA
717/346-8156
Barbara Coffin
Pennsylvania Association of Area Agencies on Aging
Terri Cathers, Pharm.D. Reading, PA
717/346-8156
Jonna L. Stefano
Claims Submission Contact Delaware County Office of Behavioral Health
EDS Upper Darby, PA
225 Grandview Avenue
Camp Hill, PA 17011 Henry R. Fiumelli
717/731-1250 Pennsylvania Forum for Primary Health Care
(All contacts with contractor must be made through State agency.) Wormleysburg, PA
Pennsylvania-4
Robert Greenwood Rebecca May Cole - Ex-Officio Member

Hospital and Health System Association of Office of Policy
Pennsylvania Pennsylvania Department of Health
Harrisburg, PA Harrisburg, PA
Vickie Hoak (Vice-Chair) Ivonne Bucher - Ex-Officio Member

Pennsylvania Homecare Association Pennsylvania Department of Aging
Lemoyne, PA Office of Community Services and Advocacy
Harrisburg, PA
Dolores Hodgkiss
Managed Care Association of Pennsylvania Michael Nardone - Ex-Officio Member
Harrisburg, PA Pennsylvania Department of Health
Harrisburg, PA
Michelle Jones
Pittsburgh, PA Executive Officers of State Medical and
Pharmaceutical Associations
Coleen Kayden
Lancaster, PA Pennsylvania Medical Society
Mark A. Piaiso, M.D.
Mary Kohut President
Pennsylvania Mental Health Consumers Association 777 E. Park Drive
Harrisburg, PA P.O. Box 8820
Carol Lavoritano T: 717/558-7750
AmeriChoice F: 717/558-7840
Philadelphia, PA E-mail: stat@pamedsoc.org
Internet address: www.pamedsoc.org
Yvette Long
Philadelphia Welfare Rights Organization Pennsylvania Pharmacists Association
Philadelphia, PA Patricia A. Epple, CAE
Executive Director
Donald McCoy (Chair) 508 North Third Street
Pennsylvania Medical Society Harrisburg, PA 17101-1199
Harrisburg, PA T: 717/234-6151
F: 717/236-1618
Russ McDaid E-mail: pepple@papharmacists.com
PA Association of Non-Profit Homes for the Aging Internet address: www.papharmacists.com
Mechanicsburg, PA
Pennsylvania Osteopathic Medical Association
Eugene McGuire, D.D.S. Mario E.J. Lanni
PA Dental Association Executive Director
Allentown, PA 1330 Eisenhower Boulevard
Donna McMonagle T: 717/939-9318
Philadelphia Coordinated Health Care F: 717/939-7255
Philadelphia, PA E-mail: poma@poma.org
Internet address: www.poma.org
Thomas Peifer
Hospital and Health System Pennsylvania State Board of Pharmacy
Association of Pennsylvania Melanie Zimmerman, R.Ph.
Harrisburg, PA Executive Secretary
P.O. Box 2649
Mary Ellen Rehrman Harrisburg, PA 17105-2649
Spring City, PA T: 717/783-7156
F: 717/787-7769
Margery Lynn Wasko, M.D. E-mail: st-pharmacy@state.pa.us
Harrisburg, PA Internet address: www.dos.state.pa.us/pharm
Pennsylvania-5
The Hospital and Healthsystem Association of

Pennsylvania
Carolyn F. Scanlan
President and CEO
4750 Lindle Road
P.O. Box 8600
T: 717/564-9200
F: 717/561-5334
E-mail: cscanlan@haponline.org
Internet address: www.haponline.org
Pennsylvania-6
RHODE ISLAND

Disabled Disabled

2003 2004
Expended Recipients Expended Recipients
TOTAL $141,126,655 57,605 $162,380,466 58,153

Aged $9,012,796 4,308 $10,163,389 4,193
Blind/Disabled $75,319,033 25,088 $84,969,137 24,621
Child $39,916 516 $30,159 439
Adult $115,356 788 $92,695 667

Aged $7,640,485 2,975 $8,212,978 2,872
Blind/Disabled $3,637,167 820 $4,272,559 837
Child $0 0 $0 0
Adult $80 1 $24 1
POVERTY RELATED, TOTAL $688,231 1,710 $936,232 1,845

Aged $148,753 116 $246,904 137
Blind/Disabled $219,779 101 $264,699 118
Child $77,401 1,064 $96,567 1,248
Adult $28,550 219 $15,249 130
BCCA Women $213,748 210 $312,813 212
*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and
unknown.
Note: Rhode Island estimates 2005 drug expenditures to be approximately $174 million and 2006 drug expenditures to be $133
million.
Rhode Island-1

Formulary: No formulary. State has a preferred drug
Rhode Island Department Human Services. list (PDL). Prior authorization is required for specific
procedures, services, and equipment as identified by
D. PROVISIONS RELATING TO DRUGS the Rhode Island Medical Assistance Program.

prior authorization procedure. A review process is
Drug Benefit Product Coverage: Products covered: available to appeal prior authorization decisions and
prescribed insulin; disposable needles and syringe exclusion of specific products. The review process
combinations used for insulin; urine ketone test must be initiated by the provider by submitting a
strips. Products covered under DME: blood glucose prior authorization request form to ACS. Upon
test strips; total parenteral nutrition (prior review, the provider will be notified in writing of the
authorization required); and interdialytic parenteral approval or denial of the request. Administrative
nutrition (prior authorization required). Products not and/or consultative staff may determine that certain
covered: cosmetics; fertility drugs; experimental services which have been provided in the past
drugs; DESI drugs. See PDL for restrictions. without benefit of a written PA request can be
approved if the services were medically necessary,
Over-the-Counter Product Coverage: Products would have been approved if reviewed, and payment
covered: analgesics (acetaminophen); cough and cold does not represent a substantial amount.
preparations (guaifenisin, diphenhydramine,
chlorpheniramine); feminine products; topical Prescribing or Dispensing Limitations
products; (antibiotics only); antacids; and laxatives.
Products not covered: allergy, asthma, and sinus Prescription Refill Limit: Refills to a maximum of 5
products; digestive products; smoking deterrent are allowed.
products. See OTC list for covered products.
Monthly Quantity Limit: One month’s supply for
Therapeutic Category Coverage: Therapeutic non-maintenance drugs. One inhaler per fill.
categories covered: anabolic steroids; analgesics,
antipyretics, and NSAIDs; antibiotics; anticoagulants; Maintenance Medication: The attending physician
anticonvulsants; anti-depressants; antidiabetic agents; may prescribe certain maintenance drugs of 100
antihistamines; antilipemic agents; anti-psychotics; tablets, capsules or pint of liquid or a 30-day supply
anxiolytics, sedatives, and hypnotics; cardiac drugs; of these drugs - whichever is greater.
chemotherapy agents, prescribed cold medications;
contraceptives; ENT anti-inflammatory agents; Monthly Dollar Limits: None
sympathominetics (adrenergic); and thyroid agents. Drug Utilization Review
Prior authorization required for: anoretics; growth PRODUR system implemented in December 1994.
hormones; Fuzeon; PPH medications; and non-PDL State has a DUR Board that meets quarterly.
drugs. Partial coverage for: prescribed smoking
deterrents. Therapeutic categories not covered: Pharmacy Payment and Patient Cost Sharing
products for hair growth; erectile dysfunction
products. Dispensing Fee: $3.40 (ambulatory) and $2.85 (long-
term care), effective 1987.
reimbursable under the Prescription Drug Program Ingredient Reimbursement Basis: EAC = WAC.
when used in home health care, and extended care
facilities and through both the Prescription Drug Prescription Charge Formula:
program and physician payment when used in 1. In accordance with Federal regulation the upper
physician offices. limit for payment for prescribed drugs will be
based upon the amount allowed by the Medical
Vaccines: Limited coverage under the Vaccines for Assistance Program or the usual and customary
Children Program. charge to the general public, whichever is lower.
2. Payment for over-the-counter drugs (non-legend
Unit Dose: Unit dose packaging not reimbursable. drugs) will be based upon the lower of either the
allowable cost of the drug plus 5 percent, the
usual and customary charge to the general
public, or the allowable cost plus the
professional fee for service.
Rhode Island-2
Maximum Allowable Cost: State imposes Federal Pharmacy & Therapeutics Committee
Upper Limits on generic drugs. “Brand Medically
Dave Feeney, R.Ph.
Necessary" with justification required to substitute a
Rita Marcoux, R.Ph.
brand name drug where a generic is available.
L. McTyeire Johnston, M.D.
Mathew Salisbury, M.D.
Kristina Ward, Pharm.D.
Richard Wagner, M.D.
Patient Cost Sharing: No copayment.
Chaz Gross, C.A.G.S.
Gregory Allen, M.D.
Tara Higins, R.Ph.
services.
E. USE OF MANAGED CARE Paula J. Avarista, R.Ph., M.B.A.
401/462-6390
Approximated 135,000 Medicaid recipients were
enrolled in managed care in 2006. Managed care Prescription Price Updating
recipients receive pharmaceutical benefits through
managed care plans. Paula J. Avarista, R.Ph., M.B.A.
401/462-6390
# United Healthcare of New England
# Coordinated Health Partners/Blue CHIP Dawn Rousseau
# Neighborhood Health Plan of Rhode Island Rebate Analyst
EDS
171 Service Avenue
F. STATE CONTACTS Building 1, Suite 100
Warwick, RI 02886
State Drug Program Administrator T: 401/784-8825
Paula J. Avarista, R.Ph., M.B.A. F: 401/941-7712
Chief of Pharmacy E-mail: dawn.rousseau@eds.com
600 New London Avenue Claims Submission Contact
Cranston, RI 02920 EDS
T: 401/462-6390 401/784-3879
F: 401/462-6336
E-mail: pavarista@dhs.ri.gov Medicaid Managed Care Contact
Internet address: www.dhs.state.ri.us
Deborah Florio, Administrator
Prior Authorization Contact Department of Human Services
600 New London Avenue
Paula J. Avarista, R.Ph., M.B.A. Cranston, RI 02919
401/462-6390 401/462-0140
E-mail: dflorio@dhs.ri.gov
DUR Contact
Paula J. Avarista, R.Ph., M.B.A. Mail Order Pharmacy Program
401/462-6390 None
Rhode Island DUR Board Department of Human Services Officials
Raymond Maxim, M.D. Jane A. Hayward
Richard Wagner, M.D. Secretary
Steve Kogut, Ph.D., R.Ph., M.B.A. Executive Offices of Health and Human Services
Tara Higgins, R.Ph. 74 West Road – Hazards Building
John Zevzavadjian R.Ph. Cranston, RI 02920
Ellen Mauro, R.N, M.P.H. T: 401/462-5274
F: 401/462-3677
E-mail: jhayward@gw.dhs.ri.gov
Rhode Island-3
Gary Alexander Rhode Island State Board of Pharmacy

Director Catherine A. Cordy
Department of Human Services Board Administrator
Louis Pasteur Building 3 Capitol Hill, Room 205
600 New London Avenue Providence, RI 02908-5097
Cranston, RI 02920 T: 401/222-2837
T: 401/462-2121 F: 401/222-2158
F: 401/462-6504 E-mail: Catherine.Cordy@health.ri.gov
E-mail: galexand@dhs.ri.gov Internet address:
www.health.state.ri.us/hsr/professions/pharmacy.php
John C. Young, C.P.M.
Deputy Director Hospital Association of Rhode Island
Health Care Quality, Financing, and Purchasing Edward J. Quinlan, President
Department of Human Services 880 Butler Drive, Suite One
600 New London Avenue Providence, RI 02906
Cranston, RI 02920 T: 401/274-1647
T: 401/462-3575 F: 401/274-1838
F: 401/462-6338 E-mail: edwardq@hari.org
E-mail: jyoung@dhs.ri.gov Internet address: www.hari.org

Rhode Island Medical Society
Newell E. Warde, Executive Director
235 Promenade Street, Suite 500
Providence, RI 02908
T: 401/331-3207
F: 401/751-8050
E-mail: nwarde@rimed.org
Internet address: www.rimed.org
Rhode Island Society of Osteopathic Physicians and

Surgeons
Donald J. Halpin, Executive Director
P.O. Box 487
Winchester, MA 01800
T: 781/933-9001
T: 781/933-9006
E-mail: risops@comcast.net
Internet address: www.risops.org
Rhode Island Pharmacists Association

Jack Hutson
Executive Director
1643 Warwick Avenue
PMB 113
Warwick, RI 02889
T: 401/737-2600
F: 401/737-0959
E-mail: jhutson@associationsystems.com
Internet address: www.ripharmacists.org
Rhode Island-4
SOUTH CAROLINA

Disabled Disabled

2004 2005
TOTAL $651,239,970 611,557 $719,564,188 623,706

Aged $55,480,625 24,529 $54,965,146 22,506
Blind/Disabled $182,398,242 77,315 $205,257,642 79,020
Child $19,347,201 59,277 $20,706,111 59,095
Adult $34,294,854 53,884 $36,998,300 54,224

Aged $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

Aged $53,551,230 24,825 $57,915,155 25,011
Blind/Disabled $81,398,126 27,466 $95,407,260 29,932
Child $64,602,789 201,120 $69,453,968 206,504
Adult $4,171,903 20,085 $3,721,724 17,554
BCCA Women N/A N/A $262,015 205
*Total Other Expenditures/ Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
Source: South Carolina Medicaid Statistical Information System, FY 2004 and FY 2005.
South Carolina-1
C. ADMINISTRATION restrictions on use, prior authorization, preferred

products, and physician profiling.
South Carolina Department of Health & Human General Exclusions:
Services, Division of Pharmacy and DME Services.
1. Weight control products. (except for lipase
inhibitors)
D. PROVISIONS RELATING TO DRUGS 2. Investigational pharmaceuticals or products.
3. Immunizing agents. (except for influenza,
Benefit Design pneumococal, and hepatitis-B vaccines where
Drug Benefit Product Coverage: Products covered: certain criteria are met)
most rebated legend generic drugs; prescribed 4. Pharmaceuticals determined by the FDA to be
insulin; and disposable needles and syringe less than effective and identical, related, or
combinations used for insulin. Products covered as similar drugs (Referred to as “DESI” drugs).
DME: blood glucose test strips; urine ketone test 5. Injectable pharmaceuticals administered by the
strips; total parenteral nutrition; and interdialytic practitioner in the office, in a clinic, or in a
nutrition. Products not covered: pharmaceuticals for mental health center .
cosmetics purposes or hair growth; fertility drugs; 6. Products used as flushes to maintain patency of
DESI drugs; and experimental drugs. indwelling peripheral or central venipuncture
devices.
Over-the-Counter Product Coverage: Within 7. Devices and supplies (e.g., diabetic supplies,
program guidelines and limitations, the Medicaid infusion supplies, etc.)
program covers all rebated OTC medications and 8. Fertility products.
their generic equivalents. Products not covered: 9. Pharmaceuticals which are not rebated.
brand name products for which equivalent generics 10. Nutritional supplements
are available. 11. Oral hydration therapies for adults.
12. Pharmaceuticals used for cosmetic purposes or
Therapeutic Category Coverage: Therapeutic hair growth.
categories covered: anabolic steroids; analgesics, 13. Anti- hemophilia factor.
antipyretics, NSAIDs; antibiotics; anticoagulants; 14. Erectile dysfunction products prescribed to treat
anticonvulsants; antidepressants; antidiabetic agents; impotence.
antihistamine drugs; antilipemic agents; anti-
psychotics; anxiolytics, sedatives, and hypnotics; Prior Authorization: State currently has a prior
cardiac drugs; chemotherapy agents; prescribed cold authorization program. A preferred drug list (PDL)
medications; contraceptives; ENT anti-inflammatory was implemented in calendar year 2004.
agents; estrogens; growth hormones; hypotensive Consideration of additional therapeutic classes is on-
agents; misc. GI drugs; sympathominetics going. Beneficiaries can request a fair hearing and
(adrenergic); thyroid agents; and prescribed smoking exception to policy in order to appeal a prior
deterrents (some require prior authorization). For authorization decision. The prescriber must obtain
categories/products not covered or requiring prior prior authorization for Medicaid coverage of the
authorization, see “Formulary/Prior Authorization,” following products:
below. 1. Non- preferred drugs.
2. Brand name products (excluding certain
Coverage of Injectables: Injectable medicines are narrow, therapeutic index drugs) for which
reimbursable through the Medicaid Physician there therapeutically equivalent, less costly
Services Program when used in physicians’ offices. generics available.
Injectables are reimbursable through the Pharmacy 3. COX-2 inhibitors for patients < age 60.
Services Program when used at home, through home 4. Panretin®.
health care, or in long-term care facilities. 5. Proton pump inhibitors/H2RA concurrent
therapy for adults.
Vaccines: Vaccines are reimbursable based on CDC 6. Growth hormone products
price as part of the Vaccines for Children Program 7. Targretin®.
(age under 21). 8. Xenical®.
9. Xolair.
Unit Dose: Unit dose packaging is reimbursable. 10. Pharmaceuticals subject to certain maximum
quantity limits.
Formulary/Prior Authorization 11. Certain tobacco cessation products.
Formulary: Open formulary; certain drug
classifications excluded. Formulary managed through
South Carolina-2
Prescribing or Dispensing Limitations E. USE OF MANAGED CARE

Prescription Refill Limit: The prescriber authorizes Approximately 80,000 Medicaid recipients were
the number of refills. enrolled in MCOs in FY 2006. Recipients receive
pharmaceutical benefits through managed care plans.
Monthly Quantity Limit: Children (birth to age 21)
are allowed unlimited prescriptions per month. Managed Care Organizations
Beneficiaries over the age of 21 are limited to a
maximum of four prescriptions per month; however, Select Health of South Carolina, Inc.
pharmacists may override the monthly prescription P.O. Box 40849
limit for adult Medicaid beneficiaries if the Charleston, SC 29423
prescription meets certain specified override criteria.
Unison Health Plan of SC
Quantity Limit per Prescription: 34-day supply per 100 Executive Center Drive, Suite 1-A
prescription. Maximum quantity limitations have Columbia, SC 29210
been established for certain pharmaceuticals. (See
http://southcarolina.fhsc.com/Downloads/provider/ Wellpath of SC (Coventry)
QuantityLimits-SCpharmacy.pdf.) 140 Stoneridge Drive, Suite 200
Columbia, SC 29201
Monthly Dollar Limit: None.
PhyTrust of South Carolina
Drug Utilization Review 1600 N. Oak Street, Suite D
Myrtle Beach, SC 29577
PRODUR system implemented November 2000.
State currently has a DUR Panel with 10 monthly South Carolina Solutions
meetings per year. 132 Westpark Boulevard
Columbia, SC 29210
Palmetto Medical Homes Local Network
2007 Cherry Lane
Charleston, SC 29405
Ingredient Reimbursement Basis: EAC = AWP-10%.
Prescription Charge Formula: Medicaid F. STATE CONTACTS

reimbursement for pharmacy services will be based
on the lowest of: the Estimated Acquisition Cost State Drug Program Administrator
(EAC); Federal or State maximum allowable cost James M. Assey, R.Ph., Director
(MAC); or the provider's submitted usual and Division of Pharmacy and DME Services
customary charge. S.C. Department of Health & Human Services
P.O. Box 8206
Maximum Allowable Cost: State imposes Federal Columbia, SC 29202-8206
Upper Limits as well as State-specific maximum T: 803/898-2876
allowable costs (MAC) on additional drugs. F: 803/255-8353
Approximately 1,650 drugs listed on State MAC list. E-mail: asseyj@scdhhs.gov
Override requires “Brand Medically Necessary,” Internet address: http:southcarolina.fhsc.com
handwritten certification by the prescriber and prior
authorization. Prior Authorization Contact
Incentive Fee: None. James M. Assey, R.Ph., Director
803/898-2876
Patient Cost Sharing: $3.00 co-payment per
prescription for most adult beneficiaries, unless DUR Contact
otherwise excepted. James M. Assey, R.Ph., Director
803/898-2876
services.
South Carolina-3
DUR Panel Mail Order Drug Program

Gwendolyn C. Galphin, M.D. Yes. Mail order pharmacies which have obtained a
F. Joseph Hodge, R.Ph. SC special mail order permit may enroll as SC
Henry Rose, R.Ph. Medicaid providers.
Leslie M. Stuck, M.D.
New Brand Name Products Contact Programs
James M. Assey, R.Ph., Director Disease/Medical State: Diabetes Chronic Care
803/898-2876 Management
Program Manager: Joyce Eaker
Prescription Price Updating Sponsor: S.C. Department of Health & Human
Services
First DataBank
San Bruno, CA 94066
Contact
T: 650/588-5454
F: 650/872-4578 Beverly Hamilton
E-mail: editorialservices@firstdatabank.com 803/898-4502
Medicaid Drug Rebate Contacts South Carolina Department of Health and

Human Services Officials
Policy: Noelle Wriston
Accountant/Fiscal Analyst II Susan Bowling, Acting Director
S.C. Department of Health & Human Services S. C. Department of Health & Human Services
P.O. Box 8206 1801 Main Street
Columbia, SC 29202-8206 P.O. Box 8206
T: 803/898-1085 Columbia, SC 29202-8206
E-mail: wriston@scdhhs.gov T: 803/898-2500
F: 803/898-4515
Disputes: John Cox, R.Ph. E-mail: bowlings@scdhhs.gov
Rebate Pharmacist
First Health Services Corp. Melanie Giese, Chief
4300 Cox Road Bureau of Health Services
Glen Allen, VA 23060 803/898-2870
T: 804/965-6791
F: 804/965-7647 Pharmacy and Therapeutics Committee
E-mail: JohnCox@firsthealth.com
Edward M. Behling, M.D.
Gregory V. Browning, M.D.
Charmaine George, M.D.
First Health Services Corp. Joseph A. Horvath, M.D.
4300 Cox Road Kelly W. Jones, Pharm.D.
Glen Allen, VA 23060 Jerome E. Kurent, M.D.
T: 804/965-7778 Robin Kelley LaCroix, M.D.
F: 804/273-6961 James M. Lindsey, M.D.
Sara F. Lindsey, M.D.
Managed Care Contact Thomas R. Phillips, R.Ph.
Tan J. Platt, M.D.
Beverly G. Hamilton, Director
Deborah J. Tapley, R.Ph., M.B.A.
Division of Managed Care
George E. “Ed” Vess, Pharm.D.
S.C. Department of Health and Human Services
Harry H. Wright, M.D.
P.O. Box 8206
Columbia, SC 29202-8206
T: 803/898-4502
F: 803/252-8232
E-mail: HAMILTBV@scdhhs.gov
South Carolina-4
South Carolina State Board of Pharmacy

Medical Care Advisory Council
Lee Ann F. Bundrick, Administrator
John P. Barber Kingstree Building
Sue B. Berkowitz 110 Centerview Drive, Suite 306
Lynn E. Connelly, R.Ph. Columbia, SC 29210
Charles P. Darby, M.D. T: 803/896-4700
James M. DuRant, Jr., M.D. F: 803/896-4596
Lisa Goodlett E-mail: bundricl@mail.llr.state.sc.us
Great Harper, M.D. Internet address: www.llr.state.sc.us/pol/pharmacy
Pat Head
Thomas Hepfer, M.D. South Carolina Hospital Association
William Hueston, M.D. J. Thornton Kirby, President
C. Earl Hunter (Ex-Officio) 1000 Center Point Road
L. Lyndon Key, M.D. Columbia, SC 29210-5802
J. T. McLawhorn T: 803/796-3080
John Magill F: 803/796-2938
Jim Mercer, M.D. E-mail: info@scha.org
Ralph Riley, M.D. Internet address: www.scha.org
J. Michael Ross, R.Ph.
Sabra Slaughter, Ph.D.
Caughman Taylor, M.D.

South Carolina Medical Association
Gerald E. Harmon, M.D., President
132 West Park Boulevard
Columbia, SC 29210
T: 803/798-6207, Ext. 490
F: 803/772-6783
E-mail: concerns@scmanet.org
Internet address: www.scmanet.org
South Carolina Osteopathic Medical Society

Valerie Smith
Southeast Regional Manager
P.O. Box 433
Red Bay, AL 35585
800/621-1773, Ext. 8162
E-mail: southcarolina@osteopathic.org
Internet address: www.osteopathic.org/
South Carolina Pharmacy Association

Carmelo Cinqueonce, M.B.A.
1350 Browning Road
T: 800/532-4033
F: 803/354-9207
E-mail: ccinque@scrx.org
Internet address: www.scrx.org/scrx
South Carolina-5
South Carolina-6
SOUTH DAKOTA

Disabled Disabled

2003 2004
TOTAL $72,883,705 68,361 $83,907,246 71,736

Aged $3,818,994 1,722 $4,182,046 1,709
Blind/Disabled $28,086,871 9,062 $31,647,718 9,065
Child $1,902,526 7,626 $2,242,794 8,136
Adult $2,973,016 5,086 $3,559,625 5,433

Aged $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

Aged $81,274 93 $119,576 105
Blind/Disabled $170,836 111 $721,246 119
Child $6,709,127 24,148 $8,018,123 25,324
Adult $547,812 2,592 $750,567 2,680
BCCA Women $25,631 20 $58,937 32
*Total Other Expenditures/recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
South Dakota-1

Department of Social Services, Division of Medical Formulary: Open formulary.
Services.
prior authorization procedure. Prior authorization
D. PROVISIONS RELATING TO DRUGS can be appealed by contacting the State's prior
authorization vendor.
Benefit Design
Drug Benefit Product Coverage: Products covered: Prescribing or Dispensing Limitations
prescribed insulin; disposable needles and syringe Prescription Dollar Limit: None.
strips; and urine ketone test strips. Prior authorization Refill Limit: None
required for: total parenteral nutrition and
interdialytic parenteral nutrition. Products not Monthly Quantity Limit: Varies by drug or indicated
covered: cosmetics; DESI drugs; fertility drugs; dosage.
weight control products; hair growth products;
experimental drugs; drugs for impotence; and drug Monthly Prescription Limit: None
products without signed rebate agreements.
covered with restrictions: allergy, asthma, and sinus PRODUR system implemented in 1996.
products (OTC loratadine only) and digestive
products (non-H2 antagonists-OTC omeprazole Pharmacy Payment and Patient Cost Sharing
only). Products not covered: analgesics; cough and
cold preparations; digestive products; (H2 Dispensing Fee: $4.75 to $5.55 (with unit dose fee
antagonists); feminine products; topical products; and applied), effective 7/1/1991
smoking deterrents.
Therapeutic Category Coverage: Therapeutic 10.5%.
categories covered: anabolic steroids; antibiotics;
anticoagulants; anticonvulsants; antidepressants; Prescription Charge Formula: Payment is the lower
antidiabetic agents; antilipemic agents; anti- of:
psychotics; anxiolytics, sedatives, and hypnotics; 1. State MAC plus a dispensing fee, or
cardiac drugs; chemotherapy agents; contraceptives; 2. EAC plus a dispensing fee, or usual and
ENT anti-inflammatory agents; estrogens; prescribed customary charge to the general public.
smoking deterrents; sympathominetics (adrenergic);
prescribed cold medications; and thyroid agents. Maximum Allowable Cost: State imposes State-
Prior authorization required for: analgesics, specific limits on generic drugs. Approximately
antipyretics, and NSAIDs; anoretics; antihistamines; 2,000 drugs are listed on the State-specific MAC list.
growth hormones; hypotensive agents; and misc. GI Override requires prior authorization.
drugs. Therapeutic categories not covered: nutritional
supplements; clozapine. Incentive Fee: None
Coverage of Injectables: Injectable medicines Patient Cost Sharing: Copayment is B: $3.00; G: no
reimbursable through physician payment when used copay.
in physician offices, home health care, and extended
care facilities. Cognitive Services: Does not pay for cognitive
services.
Vaccines: Vaccines reimbursable with HCPC code as
part of EPSDT services, The Children’s Health
Insurance Program, and the Vaccines for Children E. USE OF MANAGED CARE
Program.
Does not use MCOs to deliver pharmacy services to
Unit Dose: Unit dose packaging reimbursable. Medicaid recipients.
South Dakota-2
F. STATE CONTACTS South Dakota Medicaid Agency Officials

Deborah K. Bowman
State Drug Program Administrator Secretary
Mark E. Petersen, R.Ph. Department of Social Services
Pharmacy Consultant 700 Governors Drive
South Dakota Medicaid Pierre, SD 57501-2291
700 Governors Drive T: 605/773-3165
Pierre, SD 57501 F: 605/773-4855
T: 605/773-3495 E-mail: dssinfo@state.sd.us
F: 605/773-5246
E-mail: mark.petersen@state.sd.us Larry Iverson
Internet address: www.dss.sd.gov/medicalservices Division Director, Medical Services
Prior Authorization Contact 700 Governors Drive
Pierre, SD 57501-2291
Mark E. Petersen, R.Ph. T: 605/773-3495
605/773-3495 F: 605/773-5246
E-mail: Medical@dss.state.sd.us
DUR Contact
Connie Hohn Pharmacy and Therapeutics Committee
Rebate Coordinator Verdayne Brandenburg, M.D.
Department of Social Services Dennis Hedge, Pharm.D.
700 Governors Drive William Ladwig, R.Ph.
Pierre, SD 57501 James Engelbrecht, M.D.
T: 605/773-5013 Dana Darger, R.Ph.
F: 605/773-4855 Galen Goeden, R.Ph.
E-mail: connie.hohn@state.sd.us Willis Sutliff, M.D.
New Brand Name Products Contact Medical Advisory Committee

Mark E. Petersen, R.Ph. Paul Engbrecht, Chairman
605/773-3495 Marion, SD
Prescription Price Updating John Jones, Vice Chairman

Pierre, SD
Mark E. Petersen, R.Ph.
605/773-3495 Jud Bergan, O.D.
Madison, SD 57042
Medicaid Drug Rebate Contact Sheryl Petersen
Connie Hohn Pierre, SD
605/773-5013 James D. M. Russell
Pierre, SD
Herb McClellan, Jr., D.D.S.
Mark E. Petersen, R.Ph. Mobridge, SD
605/773-3495
Lynn Greff
Disease Management Program/Initiative Rapid City, SD
Contact Stephen Schroeder, M.D.
Mark Petersen, R.Ph. Miller, SD
605/773-3495 Michelle Miller
Sioux Falls, SD
A.A. Lampert, M.D.
Rapid City, SD
South Dakota-3

South Dakota State Medical Association
Barb Smith
1323 South Minnesota Avenue
Sioux Falls, SD 57105
T: 605/336-1965
F: 605/336-0270
E-mail: bsmith@sdsma.org
Internet address: www.sdsma.org
South Dakota Osteopathic Association

David A. Lauer, D.O.
Secretary-Treasurer
P.O. Box 247
Sturgis, SD 57785
T: 605/347-3616
F: 605/347-4713
Internet address: www.sdpha.org
South Dakota Pharmacists Association

Sue Schaefer
Executive Director
320 East Capitol
P.O. Box 518
Pierre, SD 57501-0518
T: 605/224-2338
F: 605/224-1280
E-mail: sue@sdpha.org
Internet address: www.sdpha.org
South Dakota State Board of Pharmacy

Dennis M. Jones
Executive Secretary
4305 S. Louise Avenue, Suite 104
T: 605/362-2737
F: 605/362-2738
E-mail: dennis.jones@state.sd.us
Internet address: www.state.sd.us/dcr/pharmacy
South Dakota Association of Healthcare

Organizations
David R. Hewett
President and CEO
3708 Brooks Place, Suite 1
T: 605/361-2281
F: 605/361-5175
E-mail: hewett@sdaho.org
Internet address: www.sdaho.org
South Dakota-4
TENNESSEE – TennCare 1
On January 1, 1994, Tennessee began an innovative In addition to the TennCare managed care programs,
new health care reform program called TennCare. the Bureau of TennCare administers certain long-term
TennCare is a government-operated health insurance care services. These include care in nursing facilities
program designed for low income individuals and and intermediate care facilities for the mentally
others whose health or employment status makes it retarded, and several home and community-based
difficult for them to access private insurance. The services (HCBS) waiver programs which serve as
“core” population consists of individuals eligible for alternatives to long-term care. The Bureau also
Medicaid. In addition, TennCare extends coverage to handles Medicare cost sharing payments for eligible
uninsured and uninsurable persons who are not individuals.
eligible for Medicaid. This new program essentially
replaced the traditional Medicaid program in ELIGIBILITY FOR TENNCARE COVERAGE
Tennessee with a managed care model.
The current TennCare program is really two
The TennCare program was implemented as a five- programs: TennCare Medicaid, which is for persons
year demonstration under Section 1115 waiver Medicaid eligible, and TennCare Standard, which is
authority issued by the Health Care Financing for persons underage 19 who have had TennCare
Administration (HCFA), now the Centers for Medicaid but their eligibility through Medicaid is
Medicare and Medicaid Services (CMS). ending and/or lack access to group health insurance
Administered by the Bureau of TennCare within the through their parents' employer. TennCare Medicaid
Tennessee Department of Finance and is a continuation of the basic Medicaid program. It is
Administration, the program has received several based on Federally established criteria and
extensions of its waiver, the most recent of which, a regulations and is comprised of individuals who
three year extension, was granted in 2007. qualify for Medicaid by virtue of having low incomes
and falling into one of the standard categories (i.e.,
With an annual budget of $8 billion, TennCare children, pregnant women, families receiving public
provides health care services to approximately 1.35 assistance, people with chronic medical conditions or
million beneficiaries, approximately 23 percent of the disabilities, certain residents of nursing facilities, and
State’s population, through a network of contracted women with cervical or breast cancer). In addition to
managed care organizations. TennCare receives the Medicaid population, TennCare also serves a
about 60 percent of its annual budget from the sizable expansion population under the Section 1115
Federal government. The remaining 40 percent waiver, including previously uninsured and
consists of State funds, drug rebate revenues, and uninsurable individuals, through TennCare Standard.
premiums. TennCare Standard enrollees with family incomes at
or above the poverty level are required to pay
TennCare services are offered through managed care premiums and copays. The more than 1.1 million
organizations (MCOs) and behavioral health TennCare beneficiaries eligible for Medicaid are
organizations (BHOs) under contract to the State. enrolled in TennCare Medicaid. The other 250,000
TennCare services, as determined medically are enrolled in TennCare Standard. Both groups of
necessary by the managed care entity, cover inpatient beneficiaries receive the same services.
and outpatient hospital care, physician services, lab
and x-ray services, medical supplies, home health TENNCARE PROGRAM REFORMS
care, hospice care, and ambulance services. Each
enrollee has an MCO for primary care and TennCare MCOs originally operated under a fully
medical/surgical services, a behavioral health capitated risk arrangement with the State to provide
organization BHO for mental health and substance medical services to TennCare enrollees. However,
abuse treatment services, and a Pharmacy Benefits because of instability among some of the MCOs
Manager (PBM) for pharmacy services. Children participating in TennCare, the “at risk” concept was
under 21 years of age are also eligible for dental replaced in 2002 with an “Administrative Services
services. Enrollees are allowed to choose their MCO Only” (ASO) stabilization arrangement which lasted
from among those available in their area of residence. for several years. Under the ASO arrangement, an
MCO submitted invoices to TennCare for payment of
1 The State of Tennessee did not participate in the 2007 NPC Survey. Using information from the State’s website, CMS, and other source
materials, we have, to the extent possible, updated the Profile and the tables in other Sections of the Compilation. Users should contact the
Tennessee Medicaid program to assess the accuracy and currency of the information included.
Tennessee-1
medical services delivered and received a fixed A. ADMINISTRATION

administrative fee. The State also added its own
MCO, TennCare Select, to serve as a backup if other Tennessee Department of Finance and
plans failed or there was inadequate MCO capacity in Administration, Bureau of TennCare
any area of the State. TennCare Select is
administered by Blue Cross/Blue Shield of
Tennessee. In July 2005, the MCO network was B. PROVISIONS RELATING TO DRUGS
returned to a risk-based status.
Benefit Design
Over time, other changes have been made to the Originally, all TennCare pharmacy services were
structure and operations of TennCare. For example, provided by the MCOs. Within Federal and State
in 1996, behavioral health services were “carved out” guidelines, each MCO made its own formulary/drug
from MCO responsibilities and new behavioral health coverage decisions. However, beginning in 1998,
entities were brought into the managed care system to pharmacy services began to be carved out of the
deliver mental health and substance abuse services. managed care plans and offered directly by the State.
In 2002, dental services were carved out and offered In 2000, drugs for dual eligibles were carved out.
by a separate dental benefits manager. Also, between Finally, in 2003, all remaining drugs were carved out.
1998 and the end of 2003, all pharmaceuticals were TennCare contracts with First Health Services
carved out and remain so. Currently, a separate Corporation to manage the drug program. Pharmacy
PBM, First Health Services Corporation, manages the services are to be covered as medically necessary,
TennCare drug program. Therefore, as of 2005, each excluding DESI, less than effective and IRS drugs
Tenncare enrollee interacts with four managed care and some drugs for which TennCare does not
contractors (an MCO, a BHO, the DBM, and the mandate coverage (e.g., drugs for infertility, weight
PBM) to receive their needed health care services. reduction, cosmetic purposes, hair growth products,
Long-term care services and certain other services for products for symptomatic relief of cough and colds,
children in State custody continue to be provided experimental drugs, smoking cessation products, and
outside the managed care structure. OTCs).
In 2004, despite the success of extending health As a result of the reforms implemented in 2005,
insurance to hundreds of thousands of non-Medicaid several significant changes have occurred in the
eligible beneficiaries through TennCare, Tennessee TennCare drug benefit for enrollees age 21 and over.
faced a fiscal crisis resulting from the rapid growth of Prescription drug coverage has been eliminated for
TennCare expenditures. An independent analysis adults 21 years of age and older in the expansion
concluded that, if left unchecked, TennCare would population. With the exception of prenatal vitamins,
consume 91 percent of all new revenue growth by over-the-counter medications are no longer covered
2008, preventing the State from funding other for individuals over 21. Prescription drug coverage
departments and priorities. Because growth of for Medicaid-eligible adults who are not
TennCare threatened to bankrupt the State, the institutionalized is limited to no more than 5
Governor and the TennCare bureau developed a prescriptions per calendar month, only two of which
reform plan to address the crisis. The plan was can be brand name drug products. Pharmacy
designed to preserve full enrollment, place certain copayments have been implemented for all Medicaid-
service limits on some enrollees, and return the eligible adults age 21 and older and TennCare
benefits package to one the State could afford to fund Standard enrollees under age 21 with incomes at or
in the coming years. However, despite near above the Federal poverty level.
unanimous support in the General Assembly,
opponents blocked the initial reform plan. However, no copayments are charged for generic
New reforms to TennCare were finally approved by drugs within the monthly limit, birth control products,
CMS in 2005. The reforms were implemented in two drugs for pregnant women, drugs given in a medical
phases. Phase 1 included provisions for closing emergency, or drugs for enrollees in hospice care.
certain eligibility categories (e.g., the optional Finally, a “pharmacy short list” of certain drugs and
populations -- adult uninsured, adult medically supplies has been created for enrollees who continue
eligible, adult non-pregnant medically needy) and for to be eligible for a pharmacy benefit, listing those
disenrolling persons in these categories. Phase 2 specific products that do not count against
included provisions for limiting pharmacy benefits prescription limits and that continue to be available
for most adults and, in some cases, eliminating them even after the prescription limits have been reached.
altogether. It also included proposals for eliminating
certain benefits for adults.
Tennessee-2
A new preferred drug list (PDL) went into effect in ! tennessee.fhsc.com,

April 2007. A Pharmacy Advisory Committee meets ! www.tennessee.gov/tenncare/pharm info.htm, or
regularly to reassess the status of drugs in the ! or by calling the Family Assistance Center at
categories already included in the PDL and to 1-866-311-4287.
consider expanding the number of categories included
in the PDL.
C. USE OF MANAGED CARE
Formulary/Prior Authorization 1.2 million Medicaid recipients and the
Formulary: Preferred Drug List (PDL). The PDL is uninsured/uninsurable are enrolled in MCOs through
managed through preferred products and prior the TennCare program. All receive pharmacy
authorization. Pharmacies are encouraged to ensure benefits through the State.
that patients are using cost-effective preferred drugs.
A bonus payment of $0.10 per claim is available to Managed Care Organizations
pharmacies that achieve 90 percent or greater PDL Unison Health Plan
compliance. 890 Willow Tree Circle
Cordova, TN 38018
Prior Authorization: State currently has a formal T: 800/600-9007
prior authorization procedure. Recipient may appeal F: 901/737-1420
coverage and prior authorization decisions to
TennCare. BlueCare
801 Pine Street
Pharmacy Payment and Patient Cost Sharing Chattanooga, TN 37402-2555
T: 800/468-9736
All Children Under 21: Prescriptions as medically F: 423-752-6790
necessary. No copayments.
AmeriChoice
Medicaid Adults: 5 prescriptions (only 2 brand name 10 Cadillac Drive
drugs) per month. $3.00 copayment for each brand Suite 200
name drug. No copayments for generic drugs, birth Brentwood, TN 37027
control medications, meds received in hospice care, 800/690-1606
medical emergency meds, or meds for pregnancy
problems. AmeriChoice (East)
Executive Tower I, Suite 400
Institutionalized Medicaid Adult: Prescriptions as 408 N. Cedar Bluff Road
medically necessary. No copayments. Knoxville, TN 37923
T: 800/832-1539
Medically Needy Adult: Prescriptions as medically F: 865/690-1941
necessary. 5 script, 2 brand name drug, limit per
month. TLC Family Care
1407 Union Avenue, Suite 200
Institutionalized Medically Needy Adult: Memphis, TN 38104
Prescriptions as medically necessary. No T: 800/473-6523
copayaments. F: 901/725-2846
TennCare Standard Adult: No prescription drug UAHC (OmniCare) Health Plan, Inc.
coverage. 1769 Paragon Drive, Suite 100
Memphis, TN 38132
TennCare Standard Child at or above 100% FPL: T: 800/346-0034
Prescriptions as medically necessary. $3.00 F: 901/348-2212
copayment for each brand name drug. No
copayments for generic drugs, birth control AMERIGROUP
medications, meds received in hospice care, medical Community Care
emergency meds, or meds for pregnancy problems. Three Lakeview Place
22 Century Boulevard
Additional information on the Pharmacy Short List Suite 310
(i.e., the list of drugs that don’t count against the Nashville, TN 37214
monthly limit) and the PDL can be found at: 800/600-4441
Tennessee-3
Preferred Health Partnership (PHP) TennCare DUR Advisory Board

1420 Centerpoint Boulevard
Tracy Doering, M.D.
Knoxville, TN 37932
John Ingram III, M.D.
T: 800/705-5248
Peter Swarr, M.D.
F: 865-470-7404
Roland Gray, M.D.
Vatsal Thakkar, M.D.
TennCare Select
Philip E. Johnston, Pharm.D.
801 Pine Street
Stephanie Johnson Nichols, Pharm.D.
Chattanooga, TN 37402-2555
Richard Randolph, Pharm.D.
T: 800/276-1978
David Shepard, Pharm.D., B.C.P.P.
F: 423/752-6790
Bill Staggs, D.Ph.
Vickie Jones, A.P.N.
Windsor Health Plan of Tennessee
215 Centerview Drive, Suite 300
Brentwood, TN 37027 TennCare Pharmacy Advisory Committee
T: 615/782-7878 David Beshara, R.Ph.
F: 615/782-7812 Edward Capparelli, M.D.
Rufus Clifford, M.D.
Behavioral Health Organizations Alan Corley, Pharm.D. (Vice Chair)
Stanley Dowell, M.D.
Premier Behavioral Systems of Tennessee
Lisa D’Souza, J.D.
Jeri Fitzpatrick, M.D.
Tennessee Behavioral Health, Inc.
Lynn Knott, Pharm.D.
Wendy Long, M.D.
D. STATE CONTACTS Pat McCarthy, P.A.
Carol Minor
State Drug Program Administrator James Powers, M.D. (Chair)
Terry Shea, Pharm.D.
Jeffrey G. Stockard, D.Ph. Sheila Spates, Pharm.D.
Associate Pharmacy Director
Bureau of TennCare TennCare Medical Care Advisory Committee
310 Great Circle Road
Nashville, TN 37243 Iris Snider, M.D.
615/507-6496 Athens, TN
E-mail: jeff.stockard@state.tn.us
Internet address: www.tennessee.gov/tenncare Lloyd A. Walwyn, M.D., J.D.
Madison, TN
TennCare Pharmacy Information Line
800/816-1680 Deb Murph, R.N.
Talbott, TN
TennCare Officials
Jeannie Beauchamp, D.D.S.
Darin Gordon, Deputy Commissioner Clarksville, TN
Department of Finance and Administration
Bureau of TennCare Don Hazelwood, D.Ph.
310 Great Circle Road Milan, TN
Nashville, TN 37243
615/507-6443 Cato Johnson
E-mail: darin.gordon@state.tn.us Memphis, TN
Prior Authorization Contact Joe Brown

Jeffrey G. Stockard, D.Ph. Savannah, TN
615/507-6496
Lisa Primm
DUR Contact Nashville, TN
Jeffrey G. Stockard, D.Ph. Eddie Hamilton, M.D.

615/507-6496 Brentwood, TN
Tennessee-4
Tony Halton Mail Order Pharmacy Program

Nashville, TN
Tennessee has a mail order pharmacy option in its
Medical Assistance Program. All beneficiaries are
Tina Brill
entitled to participate.
Knoxville, TN
Sonya Nelson Disease Management Patient Education

Chattanooga, TN Contact
Jeffrey Stockard, D.Ph.
Walter Rogers 615/507-6496
Nashville, TN
Michelle Williams, M.D. Pharmaceutical Societies
Nashville, TN
Tennessee Medical Association
Michael Scarborough Donald H. Alexander, CEO
Memphis, TN P.O. Box 120909
2301 21st Avenue South
Virginia T. Lodge Nashville, TN 37212-0909
Nashville, TN T: 615/385-2100
F: 615/385-3319
J.D. Hickey, M.D. E-mail: dona@tma.medwire.org
Nashville, TN Internet address: www.medwire.org
Prescription Price Updating Tennessee Osteopathic Medical Association

Jeff Allen
First DataBank Executive Director
1111 Bayhill Drive, Suite 350 618 Church Street, Suite 220
San Bruno, CA 94066 Nashville, TN 37219
T: 650/588-5454 T: 800/808-8662
F: 650/588-6867 F: 615/254-7047
E-mail: jallen@xmi-amc.com
Medicaid Drug Rebate Contact Internet address: www.tomanet.org
Sybil Creekmore
Tennessee Pharmacists Association
Accounting Manager
Baeteena M. Black, D.Ph.
Bureau of TennCare
Executive Director
500 Church Street, Suite 650
Nashville, TN 37243
Nashville, TN 37219
615/507-6622
T: 615/256-3023
E-mail: sybil.creekmore@state.tn.us
F: 615/255-3528
E-mail: bblack@tnpharm.org
Internet address: www.tnpharm.org
First Health Service Corporator
4300 Cox Road Tennessee State Board of Pharmacy
Glen Allen, VA 23060 Sheila Mitchell, Pharm.D., President
T: 804/965-7400 Tennessee Department of Commerce and Insurance
F: 804/527-6849 Board of Pharmacy
Davy Crocket Tower
Medicaid Managed Care Contact 500 James Robertson Parkway, 2nd Floor
Nashville, TN 37243-1149
Michael Drescher T: 615/741-2718
Director of Public Affairs F: 615/741-2722
Bureau of TennCare E-mail: Martha.Agee@state.tn.us
310 Great Circle Road Internet address: www.state.tn.us/commerce/boards/
Nashville, TN 37243 pharmacy
615/507-6479
E-mail: michael.drescher@state.tn.us
Tennessee-5
Tennessee Hospital Association

Craig A. Becker
President
500 Interstate Boulevard South
Nashville, TN 37210-4634
T: 615/256-8240
F: 615/242-4803
E-mail: webmaster@tha.com
Internet address: www.tha.com
Hospital Alliance of Tennessee

Paige Kisber
President
211 Seventh Avenue North, Suite 400
Nashville, TN 37219
T: 615/254-1941
F: 615/254-1942
E-mail: paige@hospitalalliancetn.com
Internet address: www.hospitalalliance.com
Tennessee-6
TEXAS

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

2004 2005
TOTAL $2,202,193,332 2,679,025 $2,417,223,230 2,753,651
RECEIVING CASH ASSISTANCE, TOTAL $1,152,785,649 686,339 $1,264,511,870 660,919

Aged $322,771,507 156,934 $343,909,519 156,656
Blind / Disabled $738,317,836 294,691 $841,561,505 314,453
Child $52,972,206 162,411 $48,113,183 134,364
Adult $38,724,100 72,303 $30,927,663 55,446

Aged $0 0 $0 0
Child $98,614 191 $105,939 187
Adult $32,677,162 56,766 $36,522,484 60,352
POVERTY RELATED, TOTAL $433,181,729 1,531,107 $490,507,006 1,631,819

Aged $1,060,863 949 $1,014,226 893
Blind / Disabled $1,596,984 1,219 $1,733,304 1,310
Child $390,212,408 1,338,382 $443,717,709 1,427,966
Adult $39,488,880 189,885 $42,901,644 200,836
BCCA Women $822,594 672 $1,140,123 814
unknown.
Source: CMS, MSIS Report, FY 2004 and Texas Health and Human Services Commission Actuarial Report, 2005.
Texas-1

Texas Health and Human Services Commission Formulary: Open formulary; however, products
Vendor Drug Program. must be listed in the Texas Drug Code Index.
Formulary managed through restrictions on use,
prior authorization and preferred products. General
D. PROVISIONS RELATING TO DRUGS exclusions (diseases, drug categories, etc.) include:
amphetamines, appliances, durable medical
Benefit Design equipment (bedpans, etc. - either rental or
Drug Benefit Product Coverage: Products covered: purchase), elastic stockings, first aid supplies,
prescribed insulin; disposable needles (pen needles medical supplies, oxygen, supports and
only) used for insulin. Products not covered: suspensories, and trusses.
cosmetics; fertility drugs; experimental drugs;
syringe combinations used for insulin; total Prior Authorization: State currently has a prior
parenteral nutrition; interdialytic parenteral authorization procedure screening for drug classes
nutrition; blood glucose test strips; and urine ketone and individual drugs. The prescriber can request
test strips. reconsideration and the beneficiary can request a
hearing through the fair hearings process to appeal
Over-the-Counter Product Coverage: Products a prior authorization decision.
covered: topical products; allergy, asthma, and
sinus products; analgesics; cough and cold Prescribing or Dispensing Limitations
preparations; digestive products; smoking deterrent Prescription Refill Limit: Five refills, but total
products. Products not covered: feminine products. amount may not exceed 6-month supply.
Certain OTC drugs are covered on a prescription
basis except as otherwise provided in the Monthly Quantity Limit: Prescribed quantity cannot
reimbursement formula and vendor payment to exceed 6-month supply.
hospitals, nursing homes and institutions.
Monthly Prescription Limit: Limited to 3 per month
Therapeutic Category Coverage: Therapeutic except for recipients under age 21 and recipients in
categories covered: anabolic steroids; antibiotics; institutions or nursing home.
analgesics; antipyretics, NSAIDs; anticoagulants;
anticonvulsants; anti-depressants; antidiabetic Other Limit: Recipients in managed care pilots (i.e.,
drugs; antihistamines; antilipemic agents; community based waiver programs) receive
antipsychotics; anxiolytics, sedatives, and unlimited prescription coverage.
hypnotics; cardiac drugs; chemotherapy agents;
contraceptives; prescribed cold medications; ENT Drug Utilization Review
agents; misc. GI drugs; thyroid agents; prescribed PRODUR system implemented in February 1995.
smoking deterrents; and sympathominetics State currently has a DUR board with a quarterly
(adrenergic). Prior authorization required for: review.
anoretics; growth hormones; dextroamphetamines
(>21 years of age); xenical (hyperlipidemia only); Pharmacy Payment and Patient Cost
Revatio; oral antifungals; and drugs not included on Sharing
the preferred drug list. Therapeutic categories not Dispensing Fee: $5.14. The dispensing fee,
covered: anti-obesity agents; vitamins (except including all costs of filling a prescription, was
prenatal); children’s vitamins with fluoride; erectile established by cost accounting and service
dysfunction drugs; and DESI drugs. evaluation of the expenses involved in dispensing a
prescription.
reimbursable through Physician Payment when Ingredient Reimbursement Basis: EAC = AWP-
used in home health care, extended care facilities, 15% or WAC+12%, whichever is lower, AAC for
and physicians’ offices. hospitals and public health providers.
Vaccines: Vaccines reimbursable as part of the Prescription Charge Formula: Average dispensing
EPSDT service and the Vaccines for Children expense (ADE) formula for payment:
Program.
1. (EAC+5.14) divided by 0.98 = amount paid +
Unit Dose: Unit dose packaging not reimbursable. $0.15 delivery service.
2. DEAC only for Wyeth-Ayerst and Abbott.
Texas-2
Insulin and approved non-legend drugs on First Care Health Plan

prescription: pharmacists and dispensing physicians 1901 West Loop 289, Suite 9
will be reimbursed on the basis of usual charges to Lubbock, TX 79407
the general public or cost plus 50% of cost, 800/431-7798
whichever is lower; 50% of cost not to exceed
assigned variable dispensing fee. Parkland Community Health Plan (Health First)
2777 N. Stemmons Freeway, Suite 300
Maximum Allowable Cost: State imposes Federal Dallas, TX 75207
Upper Limits as well as State-specific limits on 888/672-2277
generic drugs. Override requires “Brand
Necessary” or “Brand Medically Necessary.”
F. STATE CONTACTS
Incentive Fee: $0.50 for generic products for which
there is a supplemental rebate. State Drug Program Administrator
Andy Vasquez, Director
Cognitive Services: Does not pay for cognitive Vendor Drug Program
services. Texas Health and Human Services Commission
Medicaid/CHIP Division
Patient Cost Sharing: No copayment. 11209 Metric Boulevard - H630
Austin, TX 78758
F: 512/491-1959
E-mail: Andy.Vasquez@hhsc.state.tx.us
Approximately $1.8 million Medicaid recipients
Internet address: www.hhsc.state.tx.us/HCF/VDP
were enrolled in MCOs in 2006 (all of whom are
AFDC/AFDC-related). Recipients in managed care
receive pharmaceutical benefits through the State. Health and Human Services Commission
(Pharmacy program is “carved out.”) Officials
Albert Hawkins
Managed Care Organizations Executive Commissioner
Texas Health and Human Service Commission
AMERIGROUP, Inc.
4900 N. Lamar Boulevard
1200 East Copeland Road, Suite 200
Austin, TX 78751
Arlington, TX 76011
T: 512/424-6502
800/600-4441
F: 512/424-6587
E-mail: laura.ozuna@hhsc.state.tx.us
Community First Health Plan
4801 NW Loop 410, Suite 1000
Chris Taylor
San Antonio, TX 78229
Associate Commissioner for Medicaid and CHIP
800/434-2347
Texas Health and Human Services Commission
4900 N. Lamar Boulevard, 4th Floor
El Paso First Health Plans
Austin, TX 78711
2501 North Mesa
T: 512/491-1867
El Paso, TX 79902
F: 512/491-1927
877/532-3778
E-mail: chris.taylor@hhsc.state.tx.us
Texas Children’s Health Plan
1919 Braeswood Prior Authorization Contact
Houston, TX 77230 JoAnn Foster
800/990-8247 Formulary Pharmacist
Superior Health Plan Vendor Drug Program
2100 S. IH 35, Suite 202 11209 Metric Boulevard, H630
Austin, TX 78704 Austin, TX 78758
877/391-5921 T: 512/491-1156
F: 512/491-1961
Community Health Choice E-mail: Joann.Foster@hhsc.state.tx.us
2636 South Loop, Suite 700
Houston, TX 77054
888/760-2600
Texas-3
DUR Contact Medicaid Drug Rebates Contact

Don Valdes, R.Ph., Manager Pollett Jones-Reasonover
DUR/Formulary Pharmacy Claims Rebate Administrator
Texas Health and Human Services Commission Texas Health and Human Services Commission
Vendor Drug Program Medicaid & CHIP Division
11209 Metric Boulevard, H630 11209 Metric Boulevard, H630
Austin, TX 78758 Austin, TX 78758
T: 512/491-1157 T: 512/491-1158
F: 512/491-1962 F: 512/491-1967
E-mail: Don.Valdes@hhsc.state.tx.us E-mail: Pollett.Jones-Reasonover@hhsc.state.tx.us
DUR Board Kimberly Royal

Contracts Manager (Pharmacy Contracts)
Leroy Knodel, Pharm.D.
San Antonio, TX
11209 Metric Boulevard, H630
Austin, TX 78758
James Baker, M.D.
512/491-1429
Dallas, TX
E-mail: Kim.Royal@hhsc.state.tx.us
Mark S. Gittings, D.O., R.Ph.
Austin, TX
First Health Services Corp.
Robert L. Hogue, M.D. 4300 Cox Road
Brownwood, TX Glen Allen, VA 23060
804/965-7400
Anthony Busti, Pharm.D. (Chair)
Dallas, TX Medicaid Managed Care Contact
Melissa Gerdes, M.D. Pamela Coleman, Director

Whitehouse, TX Health Plan Operations
Rolf Habersang, M.D. 11209 Metric Boulevard, Building H
Amarallio, TX Austin, TX 78758
512/491-1302
Julie Lewis, R.Ph. E-mail: Pam.Coleman@hhsc.state.tx.us
Frisco, TX
Carlos Solis, R.Ph. Program
McAllen, TX Disease/Medical States:CHF
Asthma
New Brand Name Products Contact Cardiovascular Disease
JoAnn Foster COPD
512/491-1156 Diabetes
Program Name: Texas Medicaid Enhanced Care
Prescription Price Updating Program
Program Manager: Joe Morganti
Betty Wasko
Formulary Analyst Program Sponser: Texas Health and Human
Texas Health and Human Services Commission Services Commission
Vendor Drug Program
Austin, TX 78758
512/491-1155
E-mail: Emma.Wasko@hhsc.state.tx.us
Texas-4

Contact
Texas Medical Association
Joe Morganti, Associate Director
Louis J. Goodman, Ph.D., CAE
Health Management Programs
401 W. 15th Street
Medicaid & CHIP Division
Austin, TX 78701-1680
T: 800/880-1300
Austin, TX 78758
F: 512/370-1632
T: 512/491-1425
E-mail: lou.goodman@texmed.org
F: 512/491-1969
Internet address: www.texmed.org
E-mail: joseph.morganti@hhsc.state.tx.us
Texas Pharmacy Association
Mail Order Pharmacy Program Jim Martin, R.Ph.
None Executive Director and CEO
P.O. Box 14709
Pharmaceutical and Therapeutics Austin, TX 78761-4709
Committee T: 800/505-5463
F: 512/836-0308
Richard C. Adams, M.D. E-mail: jmartin@txpharmacy.com
Plano, TX Internet address: www.txpharmacy.com
Anthony J. Busti, Pharm.D., R.Ph. Texas Osteopathic Medical Association
Plano, TX Sam Tessen
Executive Director
Harris M. Hauser, M.D. (Chair) 1415 Lavaca Street
Houston, TX Austin, TX 78701-1634
T: 512/708-8662
Melbert C. Hillert, Jr., M.D. F: 512/708-1415
Dallas, TX E-mail: sam@txosteo.org
Internet address: www.txosteo.org
David E. King, R.Ph.
Kingwood, TX Texas State Board of Pharmacy
Gay Dodson, R.Ph.
Valerie Robinson, M.D. Executive Director
Lubbock, TX William P. Hobby Building
Tower 3, Suite 600
Donna Burkett-Rogers, M.S., R.Ph. (Vice Chair) 333 Guadalupe Street, Suite 3-600
San Antonio, TX Austin, TX 78701-3942
T: 512/305-8000
J.C. Jackson, R.Ph. F: 512/305-8082
Seabrook, TX E-mail: gay.dodson@tsbp.state.tx.us
Internet address: www.tsbp.tx.us
Guadalupe Zamora, M.D.
Austin, TX Texas Hospital Association
Dan Stultz, M.D., F.A.C.P., F.A.C.H.E.
Mario Anzaldua President and CEO
Mission, TX P.O. Box 15587
Austin, TX 78761-5587
T: 512/465-1000
F: 512/465-1090
E-mail: dstultz@txosteo.org
Internet address: www.thaonline.org
Texas-5
Texas-6
UTAH

Disabled Disabled

2003 2004
TOTAL $146,490,144 160,312 $192,049,879 191,562

Aged $6,456,991 2,942 $7,213,273 3,001
Blind/Disabled $45,970,038 12,948 $51,189,079 13,370
Child $6,082,857 29,305 $7,378,738 31,905
Adult $3,017,068 11,306 $14,730,181 18,622

Aged $1,509,101 595 $2,627,862 912
Blind/Disabled $4,837,330 1,094 $7,823,552 1,703
Child $79,200 269 $96,327 337
Adult $111,596 197 $477,334 487

Aged $5,254,606 2,373 $6,283,041 2,592
Blind/Disabled $19,696,817 5,172 $23,474,507 6,108
Child $7,168,124 38,405 $8,160,252 40,661
Adult $2,749,183 13,506 $3,678,474 14,533
BCCA Women $204,883 175 $387,907 234
unknown.
Note: Utah estimates 2005 drug expenditures to be approximately $217.2 million and the number of Medicaid drug recipients to be
206,000. For 2006, it is estimated that drug expenditures totaled $188.4 million and the number of drug recipients was 204, 000.
Utah-1
C. ADMINISTRATION # Smoking deterrents

# Psyllium muciloid powder
Division of Health Care Financing, State # Quinine, 5 gr.
Department of Health. Products not covered: vitamins (except for
expectant mothers and children to age 5); vand
digestive products (H2 antagonists).
For additional information or to obtain a list of
Benefit Design covered over-the-counter products, contact the Utah
Drug Benefit Product Coverage: Products covered: Medicaid program at
prescribed insulin; disposable needles and syringe http://health.utah.gov/medicaid/pdfs/otclist.pdf
strips; urine ketone test strips. Prior authorization Therapeutic Category Coverage: Products covered:
required for: amphetamines; Ritalin/ analgesics, antipyretics, and NSAIDs; antibiotics;
methylphenidate; darvocet; darvon; enbrel; relenza; anticoagulants; anticonvulsants; anti-depressants;
human growth hormones; lactulose syrup, lufyllin, antidiabetic agents; antilipemic agents; anti-
oxandrin; panretin topiacal gel; prolastin; regranex psychotics; anxiolytics, sedatives, and hypnotics;
retin-a-gel; tamiflu; zofran; aggrenox; cerezyme; cardiac drugs; chemotherapy agents (some require
adagen; xenical; lovenox; prilosec; prevacid; PA); contraceptives; estrogens; hypotensive agents;
aciphex; protonix, normiflo; fragmin; kytril; misc. GI drugs; prescribed smoking deterrents;
anzemet; and self-administered injectables. sympathominetics (adrenergic); and thyroid agents.
Products not covered: cosmetics; fertility drugs; Prior authorization required for: anabolic steroids;
experimental drugs; hair growth products; total antihistamines; growth hormones; synergis; PPIs;
parenteral nutrition; and interdialytic parenteral Cox-2s; and anticholinergic. Partial coverage for:
nutrition. prescribed cold medications; and ENT anti-
flammatory agents. Products not covered: diet
Over-the-Counter Product Coverage: OTC medications; erectile dysfunction products; and
products that are covered require a written DESI drugs.
prescription just like legend drugs in order for the
pharmacy to fill them. Clients must present a Coverage of Injectables: Injectable medicines
Medicaid card and a prescription. Products reimbursable through the Prescription Drug
covered: Program and physician payment when used in
# Acetone tests (e.g., Acetest, Chemstrip-K, home health care and extended care facilities, and
Ketostix) through physician payment when used in physician
# Allergy, asthma and sinus products (specific offices.
products covered by special programs only)
# Analgesics (generics only) Vaccines: Vaccines reimbursable at AWP minus
# Contraceptives 15% plus a fee as part of the Vaccines for Children
# Cough and cold preparations (generics only) Program.
# Digestive products (non H2 antagonists)
# DSS, caps liquid and syrup Unit Dose: Unit dose packaging reimbursable.
# DSS concentrate drops 5%
# Feminine products Formulary/Prior Authorization
# Ferrous fumerate, All dosage forms Formulary: Open formulary. Preferred drug list
# Ferrous gluconate, All dosage forms (PDL) being implemented. PDL to be managed
# Ferrous sulfate, All dosage forms through exclusion of products based on contracting
# Glucose blood tests (e.g., Chemstrip, BG, issues, restrictions on use, prior authorization, and
Dextrostix, Visidex) physician profiling. Prior authorization required for
# Glucose urine tests (e.g., Clinitest, Clinistix, some products.
Diatrix, Tes Tape, Chemstrip G)
# Insulin Prior Authorization: State has a prior authorization
# Insulin syringes/needles/disposable procedure screening for individual drugs with fair
(100/month) hearing appeal process to DUR board.
# Kaolin w/pectin suspension (e.g., Kaopectate)
# Lactobacillus acidophilus (e.g., Bacid,
Lactinex)
# Nutrients (all nutrients require prior approval)
# Pedialyte liquid
# Prophylactics male
Utah-2

Prescription Refill Limit: Limited to five. Molina
2120 South 13th East, Suite 303
Monthly Quantity Limit: In general, the quantity of Salt Lake City, UT 84106
medication shall be limited to a supply not to 888/483-0760
exceed 31 days. Cumulative limits on specific
drugs. Review patients with more than 7 scripts per Healthy U
month. 35 W. Broadway
Salt Lake City, VT 84101
Drug Utilization Review 888/271-5870
PRODUR system implemented in 1994. State has a IHC Access
DUR Board that meets monthly. P.O. Box 116670
Salt Lake City, UT 84147
Pharmacy Payment and Patient Cost 800/442-9023
Sharing
Dispensing Fee: $3.90 for urban, $4.40 for rural;
$1.00 for OTC; $1.00 for insulin, birth control, and
F. STATE CONTACTS
special Utah MAC, effective 1998.
Ingredient Reimbursement Basis: EAC = Lesser of RaeDell E. Ashley, R.Ph.
AWP-15% or Federal/State MAC. Pharmacy Director
Utah Medicaid
Prescription Charge Formula: Lowest of: Department of Health
1. EAC/MAC plus a dispensing fee, or Division of Health Care Financing
2. Usual and customary charges to the private 288 North 1460 West
sector for legend and generic legend drugs. P.O. Box 143102
Formula for OTCs is AWP minus 15% plus Salt Lake City, UT 84114
dispensing fee. T: 801/538-6495
F: 801/538-6099
Maximum Allowable Cost: State imposes Federal E-mail: rashley@utah.gov
Upper Limits as well as State-specific limits on Internet address: www.health.utah.gov/medicaid
generic drugs. Override requires "Dispense as
Written" plus prior approval and chart New Brand Name Products Contact
documentation that generic(s) have been tried and Jennifer Zeleny
failed. Approximately 4,200 drugs on State MAC CPhT
list. Utah Medicaid
Incentive Fee: None. Division of Health Care Financing
288 North 1460 West
Patient Cost Sharing: Copayment = $3.00 (max. of P.O. Box 143102
$15.00 per patient per month) Salt Lake City, UT 84114
T: 801/538-6339
Cognitive Services: Does not pay for cognitive F: 801/538-6099
services. E-mail: jzeleny@utah.gov
DUR Contact
Tim Morley
Approximately 114,000 Medicaid recipients are Pharmacist
enrolled in managed care in 2006. Pharmacy Utah Medicaid
benefits are through the State. Division of Health Care Financing
288 North 1460 West
P.O. Box 143102
T: 801/538-6293
F: 801/538-6099
E-mail: tmorley@utah.gov
Utah-3
Prior Authorization Contact Pharmacy and Therapeutics Committee

Jennifer Zeleny Lowry Bushell, M.D.
801/538-6339 Karen Gunning, Pharm.D.
Raymond Ward, M.D.
DUR Board Jerome Wohleb, Pharm.D.
Kort DeLost, R.Ph.
Mark Balk, Pharm.D.
David Harris, M.D.
Neil Catalano, R.Ph.
Duane Parke, R.Ph.
Bradford D. Hare, M.D., Ph.D.
Thomas Miller, M.D.
Tony Dalpiaz, Pharm.D.
Koby Taylor, Pharm.D.
Don Hawley, D.D.S.
Wilhelm Lehmann, M.D.
E-mail:Department of Health Officials
Joseph Yau, M.D.
Bradley Pace, P.A.-C. David Sundwall, M.D.
Colin B. Van Orman, M.D. Executive Director
Derek Christensen, R.Ph. Department of Health
Joseph Miner, M.D. P.O. Box 141000
Dominic DeRose, R.Ph. Salt Lake City, UT 84114-1000
T: 801/538-6111
Prescription Price Updating F: 801/538-6306
E-mail: davidsundwall@utah.gov
RaeDell E. Ashley, R.Ph.
Internet address: www.health.utah.gov
801/538-6495
Michael T. Hales, Director
Medicaid Drug Rebate Contacts Department of Health
Technical: RaeDell Ashley, R.Ph., 801/538-6495 Division of Health Care Financing
Policy: RaeDell Ashley, R.Ph., 801/538-6495 P.O. Box 143101
PA: RaeDell Ashley, R.Ph., 801/538-6495 Salt Lake City, UT 84114-3101
DUR: Tim Morley, 801/538-6293 T: 801/538-6406
F: 801/538-6099
Claims Submission Contact E-mail: mthales@utah.gov
Brenda Bryant Executive Officers of State Medical and
Assistant Director Pharmaceutical Societies
Division of Health Care Financing
Department of Health Utah Medical Association
288 North 1460 West Val J. Bateman, M.B.A., M.H.A.
P.O. Box 143102 Executive Vice President
Salt Lake City, UT 84114 310 East 4500 South, Suite 500
T: 801/538-6691 Salt Lake City, UT 84107-4250
F: 801/536-0473 T: 801/747-3500
E-mail: bbryant@utah.gov F: 801/532-1550
E-mail: uma@utahmed.org
Medicaid Managed Care Contact Internet address: www.utahmed.org
Gail Rapp, Director of Managed Care Utah Osteopathic Medical Association
Division of Health Care Financing Shelly Hanks
Department of Health Secretary
P.O. Box 143102 462 South 1240 East
Salt Lake City, UT 84114 Payson, UT 84651-8533
T: 801/538-6342 T: 801/465-9545
F: 801/538-6009 F: 801/465-9546
E-mail: gailrapp@utah.gov E-mail: uoma@quest.net
Internet address: www.uoma.net
State has a mail order pharmacy program. Utah
Medicaid beneficiaries may choose to obtain
prescription drugs through mail order.
Utah-4
Utah Pharmaceutical Association

Reid L. Barker
Executive Director
1850 South Columbia Lane
Orem, UT 84097
T: 801/762-0452
F: 801/762-0454
E-mail: upha@upha.com
Internet address: www.upha.com
Utah State Board of Pharmacy

Diana L. Baker
Bureau Director
160 East 300 South
P.O. Box 146741
Salt Lake City, UT 84114-6741
T: 801/530-6628
F: 801/530-6511
E-mail: dbaker@utah.gov
Internet address:
www.dopl.utah.gov/licensing/pharmacy
Utah Hospitals and Health Systems Association

Joseph M. Krella, FACHE
President
2180 South 1300 East, Suite 440
T: 801/486-9915
F: 801/486-0882
E-mail: joe@uha-utah.org
Internet address: www.uha-utah.org
Utah-5
Utah-6
VERMONT

Disabled Disabled

2003 2004
TOTAL $129,301,879 115,381 $163,436,410 118,375

Aged $3,704,275 1,553 $3,850,805 1,431
Blind/Disabled $35,155,982 11,124 $41,371,563 11,542
Child $2,324,236 6,787 $2,486,069 6,459
Adult $2,837,757 3,621 $3,413,628 3,684

Aged $7,469,746 2,966 $8,544,077 3,038
Blind/Disabled $11,598,041 2,949 $13,495,114 3,038
Child $678,028 1,442 $670,997 1,439
Adult $2,872,689 3,977 $3,157,904 3,951

Aged $0 0 $0 0
Child $7,841,129 29,200 $8,422,860 29,022
Adult $340,287 1,566 $429,845 1,746
BCCA Women $25,371 25 $150,641 51
unknown.
Vermont-1
C. ADMINISTRATION Vaccines: The Vermont Department of Health

provides vaccines to physician offices as part of the
Agency of Human Services, Office of Vermont Vaccines for Children Program.
Health Access.
D. PROVISIONS RELATING TO DRUGS Formulary/Prior Authorization
Benefit Design Formulary: Open formulary with preferred drug list

(PDL). PDL managed through exclusion of
Drug Benefit Product Coverage: Products covered: products based on contracting issues, restrictions on
prescribed insulin; disposable needles and syringe use, prior authorization, and preferred products.
combinations used for insulin; blood glucose test General exclusions include cosmetics and
strips and urine ketone test strips. Products covered experimental, and fertility drugs.
as DME: total parenteral nutrition. Products not
covered: cosmetics; fertility drugs; experimental Prior Authorization: State has formal prior
drugs; interdialytic parenteral nutrition (covered by authorization procedure and a method for appealing
Medicare); erectile dysfunction drugs; DESI drugs; coverage of an excluded product and prior
and drug products without signed rebate authorization decisions. To appeal coverage of an
agreements. Prior authorization may be required for excluded product or a prior authorization decision,
certain self-administered injectables. a provider may contact MedMetric’s Clinical Call
Center by telephone (800/918-7549) or fax
Over-the-Counter Product Coverage: Products (866/767-2649) and request reconsideration. If the
covered with a prescription and manufacturer’s prescriber is unsatisfied with a MedMetrics
signed rebate agreement: allergy, asthma and sinus decision, the prescriber may ask for reconsideration
products; analgesics; cough and cold preparations; by a MedMetrics clinical pharmacist. If still
digestive products; single source/multisource unsatisfied with the MedMetrics decision, the
vitamins pending condition; lice shampoos; and prescriber may contact the Office of Vermont
topical products. Products covered with restrictions: Health Access Medical Director for a second
feminine products (for bladder control only) and reconsideration or request a fair hearing. Prior
smoking deterrent products (maximum of 2 scripts authorization required for drugs not listed on the
for up to 90-day supply each year). PDL.
Therapeutic Category Coverage: Therapeutic Prescribing or Dispensing Limitations

categories covered: anabolic steroids;
chemotherapy agents; contraceptives; estrogens; Prescription Refill Limit: Up to 5 may be
and thyroid agents. Prior authorization* required authorized by a physician.
for: analgesics, antipyretics, and NSAIDs;
anoretics; antibiotics; anticoagulants; Monthly Quantity Limit: Max. 34 day supply (102
anticonvulsants; anti-depressants; antidiabetic days for maintenance drugs).
agents; antihistamines; antipilipemic agents; anti-
psychotics; anxiolytics, sedatives, and hypnotics; Drug Utilization Review
cardiac drugs; ENT anti-inflammatory agents; PRODUR system implemented in November 1993.
growth hormones (must meet clinical criteria); State currently has a DUR Board that meets 10
hypotensive agents; misc. GI drugs; prescribed times per year.
smoking deterrents; sympathominetics (adrenergic);
erectile dysfunction products; and antiobesity Pharmacy Payment and Patient Cost
drugs. Partial coverage for: prescribed cold Sharing
medications (some require PA).
Dispensing Fee: $4.75 in-state; $3.65 out-of-state
*In most therapeutic categories, there are both (Effective 1/1/06, Pharmacists will receive an
preferred (not needing PA) and non-preferred additional $5.25 for compounded scripts.)
(needing PA) choices. Additional information
about the preferred drug list may be found at Ingredient Reimbursement Basis: EAC = AWP-
http://www.ovha.state.vt/Preferred_drugs.cfm. 11.9%.

in physician offices, home health care, and
Vermont-2
Prescription Charge Formula: Pharmacies bill their Joshua Slen

usual and customary charge. Medicaid pays the Medicaid Director
lower of: Agency of Human Services
1. Usual and customary charge; Office of Vermont Health Access
2. EAC plus a dispensing fee; or 312 Hurricane Lane, Suite 201
3. Maximum allowable cost plus a dispensing fee. Williston, VT 05495
T: 802/879-5900
Maximum Allowable Cost: State imposes Federal F: 802/879-5919
Upper Limits as well as State-specific limits on E-mail: joshuas@path.state.vt.us
generic drugs. Override requires “Dispense as
Written”, “Medically Necessary,” “Brand Prior Authorization Contact
Necessary,” or DAW 8 (generic not available). State does not meet with representatives from the
pharmaceutical industry.
DUR Contact
Patient Cost Sharing: State uses a system of tiered
copayments ($1.00 - $3.00): State does not meet with representatives from the
pharmaceutical industry.
$1.00 – for scripts < $30.00
$2.00 – for scripts $30.00 - $49.99 DUR Board
$3.00 – for scripts $50.00 and above. Kathleen A. Boland, Pharm.D.
Cheryl A. Gibson, M.D.
Stuart Graves, M.D.
services. Rich Harvie, R.Ph.
Virginia L. Hood, M.D.
E. USE OF MANAGED CARE Frank J. Landry, M.D.
Andrew C. Miller, R.Ph.
Does not use MCOs to deliver services to Medicaid Michael Scovner, M.D.
beneficiaries. Lynne C. Vezina, R.Ph.
Norman S. Ward, M.D.
F. STATE CONTACTS New Brand Name Products Contact
State Drug Program Administrator Diane Neal

Clinical Pharmacists
Ann E. Rugg Medmetrics Health Partners
Deputy Director 312 Hurrican Lane, Suite 200
Office of Vermont Health Access Williston, VT 05495
312 Hurricane Lane, Suite 200 T: 802/879-5605
Williston, VT 05495 F: 802/879-5919
T: 802/879-5911 E-mail: diane.neal@medmetricshp.com
F: 802/879-5919
E-mail: ann.rugg@ahs.state.vt.us Prescription Price Updating
Internet address: www.ohva.state.vt.us
Bob Rase
Agency of Human Services Officials Medmetrics Health Partners
10975 Benson Drive, Suite 100
Cynthia D. LaWare Overland Park, KS 62210
Secretary 913/451-9466
Agency of Human Services
103 South Main Street Medicaid Drug Rebate Contact
Waterbury, VT 05671-0201
T: 802/241-2220 Christine Dapkiewicz
F: 802/241-2979 EDS
E-mail: cindy.laware@state.vt.us 312 Hurricane Lane, Suite 100
Internet address: www.ahs.state.vt.us Williston, VT 05495
T: 802/879-4450
F: 802/878-3440
Vermont-3
Claims Submission Contact Executive Officers of State Medical and

Medmetrics Health Partners
100 Century Drive Vermont Medical Society
Worcester, MA 01606 Paul Harrington
Mail Order Pharmacy Benefit 134 Main Street
P.O. Box 1457
None
Montpelier, VT 05601
T: 802/223-7898
Medicaid Advisory Board F: 802/223-1201
Kim Cheney E-mail: pharrington@vtmd.org
AARP Internet address: www.vtmd.org
Dave Reynolds Vermont Pharmacists Association
Bi-State Primary Care Association James Marmar
Michael Sirotkin Executive Director
Community of Vermont Elders Box 90
Woodstock, VT 05091
Donna Sutton Fay T: 877/483-2646
Health Care Ombudsman F: 802/433-4803
Jacqueline Majoros E-mail: vtpa@sover.net
LTC Ombudsman Internet address: www.vtpharmacists.org
Peter Cobb Vermont State Association of Osteopathic
VT Assembly of Home Health Agencies Physicians & Surgeons, Inc.
Bea Grause John M. Peterson, D.O.
VT Association of Hospitals and Health Systems Executive Director
72 Barre Street
Lila Richardson Montpelier, VT 05602-3508
VT Coalition for Disability Rights T: 802/229-9418
Peter Taylor T: 802/454-9663
VT Dental Society E-mail: nocdos@comcast.net
Internet address: www.osteopathic.org/index
Mary Shriver
VT Health Care Association Vermont State Board of Pharmacy
Paul Harrington Peggy Atkins
VT Medical Society Board Administrator
26 Terrace Street, Drawer 09
Margaret Joyal Montpelier, VT 05609-1101
VT Council of Community Mental Health Services T: 802/828-2373
Kristi Kistler F: 802/828-2465
Dartmouth Hitchcock Medical Center E-mail: patkins@sec.state.vt.us
Internet address:
Julie Arel www.vtprofessionals.org/opr1/pharmacists
Parent to Parent
Garry Schaedel Vermont Association of Hospitals and Healthcare
Department of Health Systems
Marie Beatrice Grause
Edna Fairbanks-Williams President and CEO
148 Main Street
Sarah Littlefeather
Montpelier, VT 05602
Nancy Osborne T: 802/223-3461
F: 802/223-0364
Michelle Parent
E-mail: bea@vahhs.org
Linda Bassick Internet address: www.vahhs.org
Dale Hacket
Vermont-4
VIRGINIA

Disable Disabled
d
Dental Services All eligible recipients under age 21

2003 2004
TOTAL $506,529,241 325,047 $578,855,766 314,942

Aged $89,503,323 33,237 $96,819,836 31,976
Blind/Disabled $189,980,150 59,711 $215,428,434 59,440
Child $24,533 88 $28,854 38
Adult $1,319,562 2,260 $1,885,009 3,460

Aged $5,621,348 2,424 $6,564,310 2,657
Blind/Disabled $7,565,421 2,599 $10,003,018 3,114
Child $19,954 86 $28,995 55
Adult $6,981 26 $6,738 29

Aged $21,519,910 9,412 $17,784,544 8,091
Blind/Disabled $24,881,975 8,200 $30,339,281 8,868
Child $30,418,687 114,422 $33,901,779 107,947
Adult $2,427,416 16,253 $2,086,575 12,801
BCCA Women $385,203 194 $539,246 265
TOTAL OTHER EXPENDITURES/RECIPIENTS $132,854,778 76,135 $163,439,147 76,201
unknown.
Virginia-1
C. ADMINISTRATION Unit Dose: Unit dose packaging reimbursable in

nursing homes.
Department of Medical Assistance Services.
Eligibility determination by the Department of Formulary/Prior Authorization
Social Services. Formulary: Open Formulary with preferred drug
list (PDL). Managed through exclusion of products
D. PROVISIONS RELATING TO DRUGS based on contracting issues, prior authorization, and
preferred products.
Benefit Design
Drug Benefit Product Coverage: Products covered: prior authorization process with right to appeal
prescribed insulin; syringe combinations used for prior authorization decisions (see
insulin; total parenteral nutrition; and interdialytic www.dmas.virginia.gov under pharmacy initiatives
parenteral nutrition. Products covered under DME: for appropriate process). Prior authorization
disposable needles used for insulin; blood glucose procedure screening for individual drugs for weight
test strips; and urine ketone test strips. Products not loss.
covered: cosmetics; fertility drugs; erectile
dysfunction drugs; hair growth products; designated Prescribing or Dispensing Limitations
DESI drugs; experimental drugs; non-legend drugs;
drugs without signed rebate agreements; recalled Prescription Refill Limit: Physicians may authorize
drugs; and expired drugs. refills according to legal requirements.
Over-the-Counter Drug Coverage: A majority of Monthly Quantity Limit: 34-day supply.

OTC drugs reimbursable when used in nursing
homes and certain classes in outpatient populations. Drug Utilization Review
These include: allergy, asthma, and sinus products; PRODUR (online) system implemented in July
analgesics; cough and cold preparations; digestive 1994. RetroDUR Program also implemented in
products; topical products; smoking deterrent 1994. State currently has a DUR Board with
products; and feminine products. quarterly meetings.
Therapeutic Category Coverage: Therapeutic Pharmacy Payment and Patient Cost
categories covered: anabolic steroids; Sharing
anticoagulants; anticonvulsants; anti-depressants;
anti-psychotics; chemotherapy agents; prescribed Dispensing Fee: $4.00, effective 5/1/06.
cold medications; contraceptives; estrogens; growth
hormones; prescribed smoking deterrents; and Ingredient Reimbursement Basis: EAC = AWP-
thyroid agents. Prior authorization required for: 10.25% (Hemophilia drugs: AWP-25%).
anoretics. Partial coverage/PA requred for:
analgesics; antipyretics, and NSAIDs; antibiotics; Prescription Charge Formula: Based upon the
antidiabetic agents; antihistamines; antilipemic lower of VMAC or EAC plus a fee, or the usual
agents; anxiolytics, sedatives, and hypnotics; and customary charge minus a copayment of $1.00
cardiac drugs; ENT anti-inflammatory agents; for generics and $3.00 for brand-name products,
hypotensive agents; misc. GI drugs; where appropriate.
symapathominetics (adrenergic); weight loss drugs;
antivirals; CNs drugs; genitourinary drugs; Maximum Allowable Cost: State imposes Federal
osteoporosis drugs; electrolyte depleters; Serotonin Upper Limits as well as State-specific limits on
receptor agonists; topical immunodulators; and generic drugs. Override requires “Brand Necessary”
non-preferred drugs. in physician’s own handwriting. Approximately
500 drugs on State MAC list.
reimbursable through both the Prescription Drug Incentive Fee: None.
home health care, and extended care facilities, and Patient Cost Sharing: Copayment is $1.00/Rx for
through physican payment when used in physician generics and $3.00/Rx on brand-name products.
offices. Exclusions include less than 21 years old,
pregnancy related, family planning, and nursing
Vaccines: Vaccines reimbursable as part of EPSDT home patients.
services and the Vaccines for Children Program.
Virginia-2
Cognitive Services: Does not pay for cognitive Prior Authorization Contact
services at present.
Debra Moody
Clinical Manager
E. USE OF MANAGED CARE First Health Services Corporation
4300 Cox Road
Approximately 385,000 beneficiaries enrolled in Glen Allen, VA 23060
HMOs in 2006. Recipients enrolled in managed T: 804/956-7431
care organizations receive pharmaceutical benefits F: 804/273-6961
through managed care plans. E-mail: moodyde@fhsc.com
DUR Contact
AMERIGROUP Virginia
(Amerigroup Community Care) Rachel E. Cain, Pharm.D.
4425 Corporation Lane Clinical Pharmacist
Virginia Beach, VA 23462 Department of Medical Assistance Services
800/600-4441 600 East Broad Street, Suite 1300
Richmond, VA 23219
Anthem Healthkeepers Plus T: 804/225-2873
(Healthkeepers, Inc.) F: 804/786-0973
(Priority HealthCare, Inc.) E-mail: Rachel.Cain@dmas.virginia.gov
2221 Edward Holland Drive
Richmond, VA 23230 DUR Board
800/901-0020 Randy Ferrance, M.D., D.C.
Avtar Dhillon, M.D.
CareNet/Southern Health Services Jason Lyman, M.D. (Vice Chair)
9881 Maryland Drive Renita Warren, Pharm.D.
Richmond, VA 23233 Elaine Ferrary, R.N./C.F.N.P.
804/747-3700 Jane Settle, N.P.
Geneva Briggs, Pharm.D. (Chair)
Optima Family Care Sandra Dawson, R.Ph.
4417 Corporation Lane Jennifer Edwards, R.Ph.
Virginia Beach, VA 23462 Jonathan Evans, M.D., M.P.H.
800-SENTRA Bill Rock, Pharm.D.
Virginia Premier Health Plan
600 E. Broad Street, Suite 400
Richmond, VA 23219 Keith T. Hayashi
804/819-5151 Pharmacist
Department of Medical Assistance Services
600 East Broad Street, Suite 1300
F. STATE CONTACTS Richmond, VA 23219
T: 804/225-2773
State Drug Program Administrator F: 804/786-0973
H. Bryan Tomlinson, II, Director E-mail: Keith.Hayashi@dmas.virginia.gov
Department of Medical Assistance Services Prescription Price Updating
600 East Broad Street, Suite 1300 Keith T. Hayashi
Richmond, VA 23219 804/225-2773
T: 804/371-7398
F: 804/786-0973 Medicaid Drug Rebate Contact
E-mail: Bryan.Tomlinson@dmas.virginia.gov
Internet address: www.dmas.virginia.gov John Cox
Rebate Pharmacist
4300 Cox Road
T: 804/965-6791
F: 804/217-7911
E-mail: johncox@firsthealth.com
Virginia-3
Disease Management/Patient Education Cheryl Roberts

Programs Deputy Director of Operations
Diseases/Medical States: asthma, cardiovascular
diseases, diabetes, COPD
Richmond, VA 23219
Program Manager: Doug Hartman
804/786-6147
Program Sponsor: HMC, Inc.
E-mail: Cheryl.Roberts@dmas.virginia.gov
Initiatives Contact
Randy Axelrod, M.D. (Chair)
Doug Hartman
Tim Jennings, R.Ph.
Avtar Dhillon, M.D.
600 East Broad Street
James Reinhard, M.D.
Richmond, VA 23219
Gill Abernathy, M.S., R.Ph.
804/786-4112
Renita Warren, Pharm.D.
E-mail: Douglas.Hartman@dmas.virginia.gov
Mark Oley, R.Ph. (Vice Chair)
Mariann Johnson, M.D.
Claims Submission Contact Roy Beveridge, M.D.
Rachel M. Selby-Penczak, M.D.
Doug Davis
Katherine Nichols, M.D.
Claims Processing Administrator
Arther Garson, Jr., M.D.
4300 Cox Road
Virginia Medicaid Pharmacy Liaison
Committee
804/965-7400
Bill Hancock, R.Ph.
Medicaid Managed Care Contact Long Term Care Pharmacy Coalition
Mary Mitchell
Alexander Maculey, R.Ph.
Managed Care Unit Manager
Community Pharmacy
Michael Ayotte, R.Ph.
Richmond, VA 23219
Virginia Association of Chain Drug Stores
T: 804/786-3594
F: 804/786-5799
Rebecca Snead, R.Ph.
E-mail: Mary.Mitchell@dmas.virginia.gov
Virginia Pharmacists Association
Mail Order Pharmacy Program Jan Burrus
None PhRMA
Department of Medical Assistance Services Executive Officers of State Medical and

Officials Pharmaceutical Societies
Patrick W. Finnerty The Medical Society of Virginia
Director Paul Kitchen
Department of Medical Assistance Services Executive Vice President
600 East Broad Street, Suite 1300 2924 Emerywood Parkway, Suite 300
Richmond, VA 23219 Richmond, VA 23294
T: 804/786-4231 T: 804/353-2721
F: 804/225-4512 F: 804/355-6189
E-mail: Patrick.Finnerty@dmas.virginia.gov E-mail: pkitchen@msv.org
Internet address: www.msv.org
Cynthia Jones
Cheif Deputy Director
Richmond, VA 23219
804/786-8099
E-mail: Cindi.Jones@dmas.virginia.gov
Virginia-4
Virginia Pharmacists Association

Rebecca P. Snead
Executive Director
5501 Patterson Avenue, Suite 200
Richmond, VA 23226
T: 804/285-4145
F: 804/285-4227
E-mail: becky@vapharmacy.org
Internet address: www.vapharmacy.org
Virginia State Board of Pharmacy

Elizabeth Scott Russell
Executive Director
6603 W. Broad Street, 5th Floor
Richmond, VA 23230-1712
T: 804/662-9911
F: 804/662-9313
E-mail Scotti.Russell@dhp.virginia.gov
Internet address: www.dhp.state.va.us/pharmacy
Virginia Osteopathic Medical Association

Eleina Espigh, Executive Director
P.O. Box 4979
T: 804/334-4655
F: 804/334-4935
E-mail: voma@erols.com
Internet address: www.voma-net.org
Virginia Hospital and Healthcare Association

Laurens Sartoris, President
4200 Innslake Drive
T: 804/965-1216
F: 804/965-0475
E-mail: lsartoris@vhha.com
Internet address: www.vhha.com
Virginia-5
Virginia-6
WASHINGTON

Disabled Disabled

2003 2004
Expenditures Recipients** Expenditures Recipients**
TOTAL $587,309,730 198,434 $663,613,603 202,586

Aged $1,854,999 475 $6,045,302 1,935
Blind / Disabled $33,827,916 8,347 $39,079,826 8,996
Child $3,048,163 4,655 $3,113,060 4,242
Adult $8,742,617 5,933 $8,763,227 5,601

Aged $15,107,863 4,969 $16,365,734 5,089
Blind / Disabled $45,081,200 7,519 $52,440,849 7,952
Child $11,008 9 $48,269 24
Adult $5,003 6 $10,103 11

Aged $131,104,610 43,085 $140,908,625 42,503
Blind / Disabled $292,866,409 69,765 $334,058,450 72,329
Child $13,662,906 19,783 $13,517,240 18,148
Adult $14,864,777 17,548 $15,473,563 17,738
unknown.
**Recipients are average monthly recipients, not an unduplicated annual account over the entire fiscal year.
Source: Washington State Medicaid Statistical Information System, FY 2003 and FY 2004.
.
Washington-1

Health and Recovery Services Administration, Program when used in home health care and
Department of Social and Health Services. extended care facilities, and through physician
payment when used in physician offices.
D. PROVISIONS RELATING TO DRUGS Vaccines: Vaccines reimbursable at EAC as part of

EPSDT services.
Benefit Design
Drug Benefit Product Coverage: Products covered: Unit Dose: Unit dose packaging is reimbursable.
prescribed insulin; disposable needles and syringe
combinations for insulin; blood glucose test strips; Formulary/Prior Authorization
urine ketone test strips; total parenteral nutrition; and Formulary: Open formulary with preferred drug list
interdialytic parenteral nutrition. Products not (PDL). Managed through excluding products based
covered: cosmetics; fertility drugs; DESI drugs; and on contracting issues; restrictions on use, prior
experimental drugs. authorization, therapeutic substitution; preferred
products, and physician profiling.
covered with restrictions: allergy, asthma and sinus Prior Authorization: State currently has a prior
products (selected items); analgesics (ASA and authorization program and a Drug Utilization
acetaminophen); cough and cold preparations Review Team and a Drug Evaluation Matrix Team.
(selected items); digestive products (selected items); Recipients can request a fair hearing and exception
feminine products (selected items); and topical to policy to appeal an excluded product or prior
products (selected items). Products not covered: authorization decision.
smoking deterrent products. (Note: Zyban only
covered for pregnant women in smoking cessation Prescribing or Dispensing Limitations
program).
Prescription Refill Limit: Two (2) refills in 30-day
Therapeutic Category Coverage: Therapeutic period except for antibiotics and schedule drugs.
categories covered: antibiotics; anticoagulants;
anticonvulsants; anti-depressants; antidiabetic Monthly Prescription Limit: Review of client drug
agents; antihistamines; antilipemic agents; cardiac profile by a clinical pharmacist when request for 5th
drugs; chemotherapy agents; contraceptives; ENT brand name prescription in any one-month period.
agents; sympathominetics (adrenergic); and thyroid Monthly Quantity Limit: Maximum 34-day supply
agents. Therapeutic categories requiring prior (90 days on select items).
authorization: anabolic steroids; analgesics,
antipyretics, and NSAIDs; anti-psychotics; Drug Utilization Review
anxiolytics, sedatives, and hypnotics; prescribed cold PRODUR system implemented in March 1996.
medications; estrogens; growth hormones; misc. GI State currently has a P&T Committee/DUR Board
drugs; and non-preferred drugs.* Therapeutic with a quarterly review.
categories not covered: anoretics; prescribed
smoking deterrents (except Zyban for pregnant Pharmacy Payment and Patient Cost
women enrolled in a smoking cessation program); Sharing
weight loss drugs; products for hair growth; drugs
for infertility, frigidity, impotency, or sexual Dispensing Fee: $4.24 to $5.25, effective 7/1/05.
dysfunction. # $4.24 - Retail pharmacies, filling over 35,000
Rxs annually.
*Drugs considered for prior authorization are drugs # $4.56 - Retail pharmacies, filling 15,001-
with high risk/benefit ratio, high potential for 35,000 Rxs annually.
abuse/misuse, narrow therapeutic indication, and # $5.25 - Retail pharmacies, filling 15,000 or less
high cost. A complete list of drugs requiring prior Rxs annually.
authorization may be found on the Health Recovery # $5.25 - Unit dose systems (nursing home Rxs).
and Services Administration’s web site:
http://maa.dshs.wa.gov/pharmacy Ingredient Reimbursement Basis: EAC = AWP-
14%, except drugs on the MAC list with 5 or more
labelers/manufacturers are reimbursed at AWP-
50%.
Washington-2
Prescription Charge Formula: The amount shall not Molina Healthcare of Washington, Inc.
exceed the usual and customary charge to the public P.O. Box 1469
or EAC plus a dispensing fee. Any drug with more Bothell, WA 98041
than 3 labelers will be reimbursed according to the 800/669-7165
Maximum Allowable Cost.
Regence Blue Shield
Maximum Allowable Cost: State imposes Federal P.O. Box 21267
Upper Limits as well as State-specific limits on Mail Stop BR 390
generic drugs. Override requires “Brand Medically Seattle, WA 98111-3267
Necessary.” 800/669-8791

F. STATE CONTACTS
Patient Cost Sharing: No copayment.
Cognitive Services: State pays for emergency Siri A. Childs, Pharm.D.
contraceptive counseling and clozaril case PharmacyAdministrator
management. Health and Recovery Services Administration
Department of Social and Health Services
E. USE OF MANAGED CARE 626 8th Avenue, SE
P.O. Box 45506
Olympia, WA 98504-5506
T: 360/725-1564
enrolled in MCOs as of May, 2006. Recipients
F: 360/586-8827
receive pharmaceutical benefits through both the
E-mail: childsa@dshs.wa.gov
State and managed care plans. Anti-retrovirals,
Internet address: http://maa.dshs.wa.gov/pharmacy
mental health drugs, and family planning products
are carved out of managed care.
Managed Care Organizations Siri A. Childs, Pharm.D.
360/725-1564
Asuris Northwest Health Plan
P.O. Box 91130
Mail Stop BR 325 DUR Contact
Seattle, WA 98111 Nicole N. Nguyen, Pharm.D.
866/240-9560 Clinical Pharmacist
Health and Recovery Services Administration
Columbia United Providers Department of Social and Health Services
19120 SE 34th Street, Suite 201 626 8th Avenue, SE
Vancouver, WA 98683 P.O. Box 45506
800/315-7862 Olympia, WA 98504-5506
T: 360/725-1757
Community Health Plan of Washington F: 360/586-8827
720 Olive Way, Suite 300 E-mail: nguyen@dshs.wa.gov
Seattle, WA 98101
800/440-1561 DUR/Drug Evaluation Matrix Board
Group Health Cooperative Siri Childs, Pharm.D.

521 Wall Street Nicole Nguyen, Pharm.D.
Seattle, WA 98121 Jeffrey Thompson, M.D.
888/901-4636 Renee Reichelderfer
Michell Bergman
Kaiser Foundation Health Plan Charles Agte
500 NE Multnomah, Suite 100
Portland, OR 97232-2099
800/813-2000
Washington-3
Pharmacy and Therapeutics Committees Mail Order Pharmacy Program

Robert Bray, M.D. State has mail order pharmacy program for fee-for-
Carol Cordy, M.D. (Vice Chair) service clients.
Daniel Lessler, M.D. (Chair)
T. Vyn Reese, M.D. Disease Management/Patient Education
Angelo Ballasiotes, Pharm.D. Programs
Alvin Goo, Pharm.D.
Jason Iltz, Pharm.D. Disease/Medical State: Asthma
Janet Kelly, Pharm.D. Program Manager: McKesson
Patty Varley, A.R.N.P.
Ken Whitcomb, PA-C Disease/Medical State: Congestive Heart Failure
Program Manager: McKesson
Siri A. Childs, Pharm.D. Program Manager: McKesson
360/725-1564
Disease/Medical State: Renal Disease
Prescription Price Updating Program Manager: Renaissance
Johnna Ziegler
Reimbursement Analyst
Contact
Department of Social and Health Services Alice R. Lind
P.O. Box 45510 Health and Recovery Services Administration
Olympia, WA 98504-5510 Department of Social and Health Services
360/725-1841 P.O. Box 45530
E-mail: zieglje@dshs.wa.gov Olympia, WA 98504-45530
360/725-1629
Medicaid Drug Rebate Contact E-mail: lindar@dshs.wa.gov
Connie L. Riddle
Social and Health Services Department
Officials
P.O. Box 45503
Lacy, WA 98504-5503 Robin Arnold-Williams
360/725-1243 Secretary
E-mail: riddle1@dshs.wa.gov Department of Social and Health Services
P.O. Box 45010
Claims Submission Contact Olympia, WA 98504-5010
T: 360/902-7800
Joann Fulton
F: 360/902-7848
Acting Claims Processing Office Chief
E-mail: arnolr@dshs.wa.gov
Internet address: www.dshs.wa.gov
P.O. Box 45560
Doug Porter
Olympia, WA 98504
Assistant Secretary
360/725-1239
E-mail: fultojc@dshs.wa.gov
P.O. Box 45507
Medicaid Managed Care Contact Olympia, WA 98504
Peggy Wilson T: 360/725-1867
Health and Recovery Services Administration F: 360/586-9551
Department of Social and Health Services E-mail: portejd@dshs.wa.gov
P.O. Box 45530
Olympia, WA 98504
360/725-1786
E-mail: wilsopa@dshs.wa.gov
Washington-4
Department of Social and Health Services Executive Officers of State Medical and
Title XIX Advisory Committee Pharmaceutical Societies
Mary Seleky (Chair) Washington State Medical Association
Olympia, WA Thomas Curry
Executive Director
Liz Arjun 2033 Sixth Avenue, Suite 1100
Seattle, WA Seattle, WA 98121
T: 206/441-9762
Sheila Capestany F: 206/441-5863
Seattle, WA E-mail: wsma@wsma.org
Internet address: www.wsma.org
David Gallaher
Seattle, WA Washington State Pharmacy Association
Rod Shafer
David Houten, D.D.S. CEO
Kelso, WA 1501 Taylor Avenue, SW
Renton, WA 98055-3139
Christen Jankowski T: 425/228-7171
Vancouver, WA F: 425/277-3897
E-mail: rshafer@wsparx.org
Allena Barnes Internet address: www.wsparx.org
Seattle, WA
Washington Osteopathic Medical Association, Inc.
Kathy Carson Kathleen S. Itter
Seattle, WA Executive Director
P.O. Box 16486
Zena Kinne Seattle, WA 98116-0486
Olympia, WA T: 206/937-5358
F: 206/933-6529
Maria Nardella E-mail: kitter@woma.org
Olympia, WA Internet address: www.woma.org
Blanche Jones Washington State Board of Pharmacy

Tacoma, WA Steve M. Saxe
Executive Director
Barbara Malich Department of Health
Bremerton, WA 310 Israel Road
P.O. Box 47863
Eleanor Owen Olympia, WA 98504-7863
Seattle, WA T: 360/236-4825
F: 360/586-4359
Huy Nguyen E-mail: steven.sax@doh.wa.gov
Seattle, WA Internet address: wws2.wa.gov/doh/hpqa-
licensing/HPS4/Pharmacy
Claudia St. Clair
Bothell, WA Washington State Hospital Association
Leo F. Greenawalt
Kyle Yasuda, M.D. President and CEO
Seattle, WA 300 Elliott Avenue W., Suite 300
Seattle, WA 98119-4118
Gerald Yorioka, M.D. T: 206/281-7211
Mill Creek, WA F: 206/283-6122
E-mail: leog@wsha.org
Internet address: www.wsha.org
Washington-5
Washington-6
WEST VIRGINIA

Disabled Disabled
Nursing Facility Service ! ! ! ! ! ! ! !

2003 2004
TOTAL $339,840,738 285,582 $360,089,285 289,762

Aged $33,892,422 12,256 $35,692,962 12,192
Blind/Disabled $177,649,479 67,946 $188,054,513 69,610
Child $34,595 127 $53,066 169
Adult $12,750,698 19,924 $12,592,481 19,456

Aged $652,869 505 $844,794 596
Blind/Disabled $6,234,095 2,804 $7,080,695 3,272
Child $7,452 18 $7,191 13
Adult $1,596,698 1,802 $2,039,696 2,055

Aged $7,636,644 2,292 $494,097 270
Blind/Disabled $4,900,322 1,433 $1,120,650 680
Child $36,596,594 119,716 $39,725,209 122,066
Adult $5,633,329 12,616 $5,588,851 9,605
BCCA Women $330,642 298 $1,340,522 589

*Total other expenditures/recipients include foster care children, 1115 demonstration participants, other recipients and unknown.
West Virginia-1
C. ADMINISTRATION Unit Dose: Unit dose packaging reimbursable.
Bureau for Medical Services, Department of Health & Formulary/Prior Authorization

Human Resources. Formulary: Preferred Drug List (as of 1/17/03)
Restrictions include restrictions on use, preferred
D. PROVISIONS RELATING TO DRUGS products, and prior authorization through the Rational
Drug Therapy Program. General exclusions include:
Benefit Design legend agents used for cosmetics purposes or hair
growth; DESI drugs; fertility drugs; and products used
Drug Benefit Product Coverage: Products covered: for anorexia or weight gain.
prescribed insulin (PDL restrictions); disposable
needles and syringe combinations used for insulin Prior Authorization: State currently has a prior
(with limitations); blood glucose test strips; and urine authorization screening procedure for drug classes and
ketone test strips. Products covered under DME: total home health care. Written appeal to the Medical
parenteral nutrition and interdialytic parenteral Director by the prescriber required to appeal a prior
nutrition. Products not covered: cosmetics; fertility authorization decision. P&T Committee and DUR
drugs; experimental drugs; and DESI drugs. Board make prior authorization recommendations.
Over-the-Counter Product Coverage: Products Prescribing or Dispensing Limitations

covered with restrictions (i.e., limited formulary/
prescription required/age limitations, selected All covered outpatient drugs are reimbursed up to a
products only, etc.): allergy, asthma, and sinus 34-day supply and eleven refills.
products; analgesics; cough and cold preparations;
non-H2 antagonists; feminine products; topical Exceptions for antibiotics, which are covered for a 14-
products; multivitamins; and prenatal vitamins. Prior day supply and one refill.
authorization for: smoking deterrent products.
Products not covered: digestive products (H2 Limited number of scripts per month for beneficiaries
antagonists). enrolled in the Redesign Basic Plan.

categories covered: anabolic steroids; contraceptives; PRODUR system implemented in March 1995. State
and thyroid agents. Partial coverage for: prescribed currently has a DUR Board with a quarterly review.
cold medications (PA required). Therapeutic
categories requiring prior authorization: analgesics, Pharmacy Payment and Patient Cost Sharing
antipyretics, and NSAID’s; antibiotics; anticoagulants;
anticonvolsants; anti-depressants; antidiabetic agents; Dispensing Fee: $2.50 - $8.25. B: $2.50, G: $5.30,
antihistamines; antilipemic agents; antipsychotics; 340B pharmacies: $8.25. For a compounded
anxiolytics, sedatives, and hypnotics; cardiac drugs; prescription, an additional $1.00 will be added to the
chemotherapy agents; ENT anti-inflammatory agents; dispensing fee. A compound prescription is defined
estrogens; growth hormones; hypotensive agents; as any legend medication requiring a combination of
misc. GI drugs; prescribed smoking deterrents; any two or more substances to exclude normal
sympathominetics (adrenergic); most injectables; and reconstitution operations.
all stimulants except strattera (for beneficiaries > 18
yrs. of age). Therapeutic categories not covered: Ingredient Reimbursement Basis: EAC = AWP-15%
anorectics; agents for cosmetic use; weight loss for brand name drugs and AWP-30% for generics.
products; nutritional supplements; hair growth
products; and erectile dysfunction drugs. Prescription Charge Formula: Reimbursement based
on the lowest of:
Coverage of Injectables: Injectable medicines 1. The estimated acquisition cost (EAC) plus a
reimbursable under the Prescription Drug Program dispensing fee.
when used in home health care and extended care 2. The maximum allowable cost (MAC) plus a
facilities, and through physician payment in physician dispensing fee.
offices. All injectable medications dispensed through 3. The usual and customary price charged by the
outpatient pharmacies require prior authorization. pharmacy to the general public including any sale
price that may be in effect on the date of service.
Vaccines: Vaccines reimbursable as part of EPSDT
services, CHIP and the Vaccines for Children
Program and through physician payment.
West Virginia-2
Maximum Allowable Cost: State imposes a F. STATE CONTACTS

combination of Federal Upper Limits and State-
specific limits on generic drugs. Override will require State Drug Program Administrator
physician certification of “Brand Medically Peggy A. King, R.Ph.
Necessary.” 847 unique drugs listed on the PDL. Director of Pharmacy Services
Department of Health and Human Resources
Incentive Fee: None. Bureau for Medical Services
350 Capitol Street, Room 251
Patient Cost Sharing: Copayment varies - $0.50 to Charleston, WV 25301-3707
$3.00 based on ingredient costs. Exclusions include: T: 304/558-1700
F: 304/558-1542
1. Family planning services and supplies. E-mail: pking@wvdhhr.org
2. Prescriptions originating with the Early and Internet address: www.wvdhhr.org/bms/pharmacy
Periodic Screening, Diagnosis and Treatment
Program. Department of Health & Human Resources
3. Nursing home residents. Officials
4. Children under the age of 18 years.
Martha Yeager Walker, Secretary
Cognitive Services: Does not pay for cognitive Department of Health and Human Resources
services. Building 3, State Capitol Complex, Room 206
Charleston, WV 25305
T: 304-558-0684
E-mail: wvdhhrsecretary@wvdhhr.org
Approximately 138,000 unduplicated Medicaid Internet address: www.wvdhhr.org
recipients were enrolled in MCOs in 2006.
Beneficiares in managed care receive pharmacy Marsha K. Morris
services through the State. Department of Health and Human Resources
Bureau for Medical Services
Managed Care Organizations 350 Capitol Street, Room 251
Carelink Health Plans
T: 304/558-1700
500 Virginia Street East, Suite 400
F: 304/558-1509
E-mail: medcomm@wvdhr.org
T: 304/348-2900
T: 800/348-2922
F: 304/348-3948
Internet address: www.chccarelink.com Stephen Small, R.Ph., M.S.
Director, Rational Drug Therapy Program
The Health Plan of the Upper Ohio Valley West Virginia University School of Pharmacy
52160 National Road, East Robert C. Byrd Health Sciences Center
St. Clairsville, OH 43950 P.O. Box 9511
T: 740/695-3585 Morgantown, WV 26506-9511
T: 888/613-8385 T: 800/847-3859
F: 740/695-5297 F: 800/531-7787
Internet address: www.healthplan.org E-mail: ssmall@hsc.wvu.edu
Wellpoint – Unicare
5151-A Camino Ruiz
Camarillo, CO
800/782-0095
Internet address: www.unicare.com
West Virginia-3
DUR Contact
Vicki M. Cunningham, R.Ph.
Steve R. Matulis, M.D. (Chair)
DUR Coordinator
David Avery, M.D.
John D. Justice, M.D.
Teresa Dunsworth, Pharm.D.
Office of Pharmacy Services
James D. Bartsch, R.Ph.
Harriett Nottingham, R.Ph.
Charleston, WV 25301-3707
Michael Grome, PA-C
T: 304/558-1700
Barbara Koster, N.P.
F: 304/558-1542
Gretchen E. Oley, M.D.
E-mail: vickicunningham@wvdhhr.org
Robert Stanton, Pharm.D.
Rodney L. Fink, D.O.
Medicaid DUR Board
Jeffrey V. Ashley, M.D.
Scott Brown, R.Ph. Steven C. Judy, R.Ph.
Ahmed Faheem, M.D. Kevin W. Yingling, M.D., R.Ph.
Teresa Frazer, M.D., F.A.A.P. David P. Elliott, Pharm.D.
Patrick M. Regan, R.Ph.
Pharmaceutical Cost Management Council Karen Reed, R.Ph.
Mary Nemeth-Pyles, M.S.N., R.N., C.S.
Robert W. Ferguson, Jr.
Greenbrier Almond, M.D.
Cabinet Secretary
Myra Chiang, M.D.
Department of Administration
Matthew Watkins, D.O.
John R. Vanin, M.D.
Martha Yeager Walker, Secretary
Lester Labus, M.D.
Ernest Miller, D.O. (Vice Chair)
Christopher Terpening, Pharm.D., R.Ph
Felice Joseph
Kerry Stitzinger, R.Ph.
Pharmacy Director
K.C. Lovin, PA-C
Public Employees Insurance Agency
Daniel Dickman, M.D. (Chair)
Marsha Morris, Commissioner
Peggy A. King, R.Ph.
Gregory A. Burton 304/558-1700
Executive Director
Workers’ Compensation Commission Prescription Price Updating
Shana Phares Eric N. Sears, R.Ph.

Acting Pharmaceutical Advocate Pharmacy Benefits Manager
Governor’s Office Unisys Corporation
1600 Pennsylvania Avenue
Wayne C. Spiggle, M.D. Charleston, WV 25302
Primary Care Physician T: 304/348-3200
F: 304/353-6314
Stephen Neal, R.Ph. E-mail: eric.sears@unisys.com
The Health Plan
Sandra Vanin, Commissioner Gail J. Goodnight, R.Ph.
Bureau for Senior Services Rebate Coordinator
Leah Summers Bureau for Medical Services
Mylan Laboratories, Inc. 350 Capitol Street, Room 251
Kevin Outterson T: 304/558-1700
Associate Professor of Law F: 304/558-1542
West Virginia University College of Law E-mail: gailgoodnight@wvdhhr.org
J.J. Bernabei
Tri-State Medical Group
West Virginia-4

Eric N. Sears, R.Ph.
West Virginia State Medical Association
304/348-3200
Evan Jenkins, Executive Director
4307 MacCorkle Avenue SE
Medicaid Managed Care Contact P.O. Box 4106
Brandy Pierce Charleston, WV 25364
Special Programs Manager T: 304/925-0342
Bureau of Medical Services F: 304/925-0345
Department of Health and Human Resources E-mail: evan@wvsma.com
350 Capitol Street, Room 251 Internet address: www.wvsma.com
T: 304/558-1700 West Virginia Pharmacists Association
F: 304/558-4398 Keith A. Foster, R.Ph.
E-mail: brandypierce@wvdhhr.org President
2016 Kanawha Blvd., East
Mail Order Pharmacy Program Charleston, WV 25311-2212
T: 304/344-5302
None F: 304/344-5316
E-mail: kafoster@charter.net
Disease Management/Patient Education Internet address: www.wvpharmacy.org
Programs
Disease/Medical State: Diabetes West Virginia Society of Osteopathic Medicine
Program Name: Medicaid Diabetes Management Charlotte Ann Cales Pulliam
Program Executive Director
Program Manager: Peg Adams 400 Allen Drive, Suite 201
Program Sponsor: West Virginia Diabetes Control The Westmoreland Place
Network Charleston, WV 23502
T: 304/345-9836
Disease Management Initiative/Program F: 304/345-9865
Contact E-mail: charlotteann@wvsominc.org
Internet address: www.wvsominc.org
Position Vacant
West Virginia State Board of Pharmacy
Medical Services Fund Advisory Council David Potters
Violet Burdette Executive Director and General Counsel
Vacant (Alternate: Richard Stevens) 232 Capitol Street
Charles Covert Charleston, WV 25301
Jesse Samples T: 304/558-0558
Charles Smith, D.D.S. F: 304/558-0572
John Russell E-mail: dpotters@wvbop.com
Scott McClanahan Internet address: www.wvbop.com
Mark B. Ayoubi, M.D.
Larry Robertson West Virginia Hospital Association
Chris Curtis Joseph M. Letnaunchyn
Michael KilKenny President and CEO
Charles Young 100 Association Drive
Vacant (Consumer Representative) Charleston, WV 25311
T: 304/344-9744
F: 304/344-9745
E-mail: joelet@wvha.com
Internet address: www.wvha.com
West Virginia-5
West Virginia-6
WISCONSIN

Disabled Disabled

2003 2004
TOTAL $610,280,050 361,969 $707,084,087 395,711

Aged $24,752,751 11,259 $25,507,165 10,948
Blind/Disabled $221,891,423 74,774 $241,860,618 75,857
Child $3,021,662 16,623 $4,078,657 19,567
Adult $7,184,919 17,157 $9,869,581 22,186

Aged $13,889,066 5,858 $14,652,669 5,618
Blind/Disabled $22,281,110 5,240 $23,299,209 5,149
Child $495,138 4,536 $700,947 4,792
Adult $128,424 785 $157,169 834

Aged $320,834 384 $376,383 392
Blind/Disabled $19,807,950 5,420 $30,873,277 7,533
Child $3,508,408 19,036 $4,995,044 21,862
Adult $530,503 3,734 $611,363 4,023
BCCA Women $225,142 133 $317,429 210
*Total other expenditures/recipients include foster care children, 1115 demonstration participants, other recipients and unknown.
Wisconsin-1
C. ADMINISTRATION in home healthcare, extended care facilities, and

State Department of Health and Family Services,
Division of Health Care Financing. Vaccines: Vaccines provided plus reimbursement
for administrative fee as part of the EPSDT service,
CHIP, and the Vaccines for Children Program.
Benefit Design
Drug Benefit Product Coverage: Products covered: Formulary/Prior Authorization
prescribed insulin; total parenteral nutrition; and Formulary: Open formulary with preferred drug
interdialytic parenteral nutrition. Products covered list. PDL managed through restrictions on use, prior
under durable medical supplies (DMS): disposable authorization and preferred products.
blood glucose test strips; and urine ketone test Prior Authorization: State currently has formal
strips. Products covered with restrictions: fertility prior authorization procedure and a Medicaid
drugs (PA required). Products not covered: Pharmacy Prior Authorization Advisory
cosmetics; experimental drugs; progesterone for Committee. Beneficiaries can request an
PMS; topical minoxidil, legend prenatal vitamins; administrative hearing with an administrative law
impotence treatment drugs; and DESI drugs. judge to appeal prior authorization decisions or
Additional information about the Wisconsin coverage for an excluded product.
Medicaid drug benefit may be found at
hppt://dhfs.wisconsin.gov/medicaid/pharmacy/ Prescribing or Dispensing Limitations:
index.htm
Quantity of Medication: Pharmacists may not
Over-The-Counter Product Coverage: Products dispense more than 34-day supply of a legend drug.
covered: allergy, asthma, and sinus products; Certain exceptions for some maintenance drugs
analgesics; non-H2 antagonists; feminine products; (100 day supply limit).
topical products; cough and cold preparations; and Refills: 5 refills within 6 months for Schedule III,
ophthalmic lubricants. Products not covered: IV, and V drugs. Maximum of 11 refills during a
smoking deterrent products and digestive products 12-month period for non-scheduled medications.
(H2 antagonists).
Dollar Limits: None.
categories covered: anoretics; anticoagulauts; Pharmacy Payment and Patient Cost
chemotherapy agents; prescribed cold medications; Sharing
contraceptives, ENT-anti-inflammatory agents; Dispensing Fee: $4.88 to a maximum of $40.11,
estrogens; sympathominetics (adrenergic); and effective 7/1/98. Incremental increases based on
thyroid products. Partial coverage and prior pharmaceutical care services being provided.
authorization required for: analgesics; antipyretics,
and (brand name) NSAIDs; antibiotics; Ingredient Reimbursement Basis: EAC = AWP-
anticonvulsants; antidepressants; antidiabetic 13.0% (effective 7/1/04.)
agents; antihistamines; anti-psychotics; anxiolytics;
sedatives, and hypnotics; cardiac drugs; antilipemic Prescription Charge Formula: Reimbursement at
agents; human growth hormone; hypotensive the lowest of:
agents; misc. GI drugs; schedule III and IV
stimulants; enteral nutrition products; Cerezyme; AWP-13.0% plus dispensing fee; Maximum
Mupirocin; fertility enhaning drugs; anti-obesity Allowable Cost (MAC) plus dispensing fee; or
drugs; alitretinoin gel; brand name ACE inhibitors; providers usual and customary.
brand name statins; brand name PPIs, stimulants
and anti-obesity drugs; and medically necessary Maximum Allowable Cost: State imposes State-
drugs with no rebate agreement. Therapeutic specific limits on generic drugs. Override requires
categories not covered: anabolic steroids. For hand written “Brand Medically Necessary” by the
additional coverage information, please see the prescriber plus prior authorization.
PDL.
reimbursable through physician payment when used Cognitive Services: Provides an expanded
dispensing fee for cognitive services.
Wisconsin-2
Patient Cost Sharing: State uses tiered system of Managed Health Services Insurance Corp.
copayments. All generic legend drugs are subject to 1205 S. 70th Street, Suite 500
a $1.00 copay, brand legend drugs are subject to a West Allis, WI 53214
$3.00 copay, limited to $12.00 per month 888/713-6180
maximum per pharmacy. OTCs are subject to a
$0.50 copay. Disposable medical supplies are MercyCare Insurance Company
subject to a sliding scale copayment system based 3430 Palmer Drive
on allowable costs. Residents of Skilled Nursing Janesville, WI 53546
Facilities (SNF) or Intermediate Care Facilities 800/895-2421
(ICF), subsidized adoption recipients, children
under age 18 and HMO enrollees are exempt from Network Health Plan
the copayment. 1570 Midway Place
Menasha, WI 54952
888/713-6180
Approximately 400,000 Medicaid recipients were Security Health Plan of Wisconsin, Inc.
enrolled in MCOs in FY 2006. Recipients receive 1515 St. Joseph Avenue
pharmaceutical benefits through managed care Marshfield, WI 54449
plans and the State. (Some mental health plans 800/791-3044
carve out pharmaceutical benefits.)
United Healthcare of Wisconsin
Managed Care Organizations 10701 W. Research Drive
Milwaukee, WI 53226
Abri Health Plan, Inc. 800/504-9600
216 Green Bay Road, Suite 109
Thiensville, WI 53092 Unity Health Plans Insurance Corporation
888/999-2404 840 Carolina Street
Sauk City, WI 53583-1374
Children’s Community Health Plan 800/362-3310
800/482-8010
CompCare Health Plan F. STATE CONTACTS

(formerly Atrium Health Plan)
4222 Bagley Parkway Medicaid Pharmacy Policy Analyst
Madison, WI 53705
Carrie L. Gray
888/203-7771
Pharmacy Program/Policy Analyst
Wisconsin Medicaid
Dean Health Plan, Inc.
One West Wilson Street, Room 350
1277 Denning Way
Madison, WI 53702
Madison, WI 53717
T: 608/266-3901
800/279-1301
F: 608/266-1096
E-mail: grayc@dhfs.state.wi.us
Group Health Cooperative of Eau Claire
Internet address:
2503 N. Hillcrest Parkway
www.dhfs.wisconsin.gov/medicaid/pharmacy
Eau Claire, WI 54702
888/203-7770
Group Health of South Central Wisconsin Carrie L. Gray
1265 John Q. Hammons Drive 608/266-3901
Madison, WI 53717
608/828-4853
Health Tradition Health Plan

Onalaska, WI 54650
800/545-8499
Wisconsin-3
Prior Authorization Advisory Committee Disputes:

Ellen Orsburne
Rosanne Barber
Medicaid Systems Analyst
Larry Fleming, M.D.
Bureau of Systems and Operations
Kevin Izard, M.D.
Wisconsin Medicaid
Tom Frazier, Exec. Dir., CWAG
One West Wilson Street
Bradley Fedderly, M.D.
P.O. Box 309
Steve Maike, R.Ph.
Madison, WI 53702
Tom Hirsch, M.D.
608/267-7939
Alicia Walker, Pharm.D.
E-mail: orsbuer@dhfs.state.wi.us
Michael Witkowsky, M.D.
DUR Contact
EDS
Michael A. Mergener, R.Ph., Ph.D.
6406 Bridge Road
Chief Pharmacist
Madison, WI 53784-0014
APS Healthcare
T: 608/221-4746
10 East Doty Street, Suite 210
F: 608/221-4567
Madison, WI 53702
T: 608/258-3350
F: 608/258-3359 Medicaid Managed Care Contact
E-mail: mergema@dhfs.state.wi.us Marge Pifer
Managed Care Contract Administrator
DUR Board Wisconsin Medicaid
One West Wilson, Room 261
Michael Boushon, R.Ph.
P.O. Box 309
Robert M. Breslow, R.Ph.
Madison, WI 53702
Ward Brown, M.D.
608/267-7927
Daniel R. Erickson, M.D.
E-mail: pifermh@dhfs.state.wi.us
Robert Factor, M.D.
Rocky LaDien, R.Ph.
Pamela Ploetz, R.Ph. Disease Management/Patient Education
Lee C. Vermeulen, Jr., R.Ph., M.S. Programs
Mary Jo Willis, M.S., R.N., N.P. Disease/Medical State: AIDS/HIV
Program Name: ADAP
New Brand Name Prescription Contact Program Manager: Michael McFadden
Sponser: Wisconsin Medicaid
Carrie L. Gray
608/266-3901
Contact
Richard Carr, M.D.
Carrie L. Gray
Chief Medical Officer
608/266-3901
Wisconsin Medicaid
One West Wilson, Room 272
Madison, WI 53702
Audits: T: 608/266-9743
Linda Rygiewicz F: 608/267-3380
Drug Rebate Analyst E-mail: carrr@dhfs.state.wi.us
EDS
208 Olin Avenue Mail Order Pharmacy Program
Madison, WI 53703
None
T: 608/221-4746 ext. 3147
F: 608/221-0885
E-mail: rygielj@dhfs.state.wi.us
Wisconsin-4
Health and Family Services Department Cathy Kunze

Officials Consumer
Kevin Hayden, Secretary
Department of Health and Family Services
Madison, WI 53702 State Medical Society of Wisconsin
T: 608/266-9622 Susan L. Turney
F: 608/266-7882 Executive Vice President/ CEO
E-mail: Kevin.Hayden@wisconsin.gov 330 East Lakeside
P.O. Box 1109
Jason A. Helgerson Madison, WI 53715-1109
State Medicaid Director T: 866/442-3800
Department of Health and Family Services F: 608/442-3802
Division of Health Care Financing E-mail: susant@wismed.org
One West Wilson Street, Room 350 Internet address:
P.O. Box 309 www.wisconsinmedicalsociety.org
Madison, WI 53702
T: 608/266-2522 Wisconsin Association of Osteopathic Physicians &
F: 608/266-1096 Surgeons
E-mail: HelgeJA@dhfs.state.wi.us Kenneth Kurt, D.O.
Executive Director
Medicaid Advisory Committee 2405 Northwestern Avenue, Suite 200
Racine, WI 53404
John Meurer, M.D., M.B.A. (Chair)
T: 262/619-9901
Medical College of Wisconsin
F: 262/619-9902
E-mail: waops2@yahoo.com
Jon Peacock
Internet address: www.waops.org
Wisconsin Council on Children and Families
Pharmacy Society of Wisconsin
Sarah Dredrick
Christopher J. Decker, R.Ph.
Wisconsin Counties Association
701 Heartland Trail
Patricia McManus, Ph.D., R.N.
Madison, WI 53717
Black Health Coalition of Wisconsin
T: 608/827-9200, Ext. 17
F: 608/827-9292
Paul Reynolds, M.H.A.
E-mail: cdecker@pswi.org
Great Lakes Inter-Tribal Council
Internet address: www.pswi.org
Vicki Baker
Wisconsin Pharmacy Examing Board
Board on Aging and Long Term Care
Tom Ryan, Director
Bureau of Health Professions
Paul Nannis
1400 E. Washington Avenue
Aurora Health Care
P.O. Box 8935
Steve Rough, M.S., R.Ph.
T: 608/266-8098
University of Wisconsin Hospitals and Clinics
F: 608/261-7083
E-mail: thomas.ryan@drl.state.wi.us
Sheri Johnson
Internet address:
DHFS Division of Public Health
www.drl.wi.gov/boards/phm/index.htm
Mitch Hagopian
Disability Rights Wisconsin
Nancy Buckwalter
Department of Workforce Development
Janice Havrell
Consumer
Wisconsin-5
Wisconsin Health and Hospital Association

Steve Brenton, President
5510 Research Park Drive
P.O. Box 259038
T: 608/274-1820
F: 608/274-8554
E-mail: sbrenton@wha.org
Internet address: www.wha.org
Wisconsin Health Care Association

Thomas P. Moore
Executive Director
Lake Terrace Office Building
121 East Wilson Street, Suite L200
Madison, WI 53703
T: 608/257-0125
F : 608/257-0025
E-mail: tomm@whca.com
Internet address: www.whca.com
Wisconsin-6
WYOMING

Disabled Disabled

2003 2004
TOTAL $42,551,196 46,947 $51,347,525 49,784

Aged $1,629,214 744 $1,772,324 704
Blind / Disabled $10,258,910 3,749 $11,622,898 3,773
Child $1,275,427 4,663 $1,442,121 4,324
Adult $2,416,981 3,626 $2,988,212 3,932

Aged $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

Aged $42,335 28 $19,941 23
Blind / Disabled $154,396 44 $45,223 33
Child $5,088,208 20,651 $6,323,733 20,043
Adult $724,946 2,873 $756,872 2,697
BCCA Women $0 0 $191,626 85
Wyoming-1

Department of Health, Office of Pharmacy Services. in home health care, extended care facilities, and
physician offices.
D. PROVISIONS RELATING TO DRUGS Vaccines: Vaccines reimbursable at AWP plus a

$7.00 injection fee as part of the EPSDT services, the
Benefit Design Children’s Health Insurance Program and the
Drug Benefit Product Coverage: Products covered: Vaccines for Children Program.
prescribed insulin, syringe combinations and
disposable needles used for insulin; blood glucose Unit Dose: Unit dose packaging not reimbursable.
test strips; and urine ketone test strips. Products
covered under DME: total parenteral nutrition; and Formulary/Prior Authorization
interdialytic parenteral nutrition. Products not Formulary: Open formulary with preferred drug list
covered: cosmetics; fertility drugs; tobacco cessation (PDL). PDL managed through preferred products,
products; weight gain/loss products; hair growth restrictions on use, and prior authorization. General
products; DESI drugs; experimental drugs; erectile exclusions include anorexants, except amphetamines
dysfunction drugs; and drug products with no rebate and derivatives which are used for narcolepsy and
agreement. hyperkinetic states; products to stimulate hair
growth. Prior authorization implemented 10/1/02.
Over-the-Counter Product Coverage: Products Approximately 1,200 drugs listed on the PDL.
covered (must be ordered by a licensed prescribing
practitioner, furnished to a client who is not residing Prior Authorization: State currently has a formal
in a nursing facility, is listed in State’s system, and prior authorization procedure with review/appeal
filed with First DataBank): allergy, asthma, and sinus process to the Department of Health, Office of
products; analgesics; cough and cold products; Pharmacy Services Appeals Unit. DUR Board
digestive products (limited coverage for non-H2 reviews appeals on a weekly basis. If approved,
antagonists); topical agents; food thickeners; recipient receives a one-year authorization.
nutrition products; pediatric and prenatal vitamins;
and artificial tears. Products covered with Prescribing or Dispensing Limitations
restrictions: smoking deterrent products (do not
cover nicotine inhalers or sprays. Only 1 course of Monthly Quantity Limits: Quantity limits on some
therapy covered without PA). Products not covered: medications as deemed clinically appropriate.
feminine products.
Therapeutic Category Coverage: Therapeutic PRODUR system implemented in October 1995.
categories/products covered: analgesics, antipyretics, State currently has a 10 member DUR Board that
and NSAIDs (PA required for long-lasting opioids meet bimonthly.
and NSAIDs); antibiotics; anticoagulants;
antidiabetic agents; cardiac drugs; chemotherapy Pharmacy Payment and Patient Cost Sharing
agents; prescribed cold medications; contraceptives;
ENT anti-inflammatory agents; estrogens; Dispensing Fee: $5.00 (eff. 8/1/2005).
sympathominetics (adrenergic); thyroid agents;
antifungals; antiparasitic products; and Ingredient Reimbursement Basis: EAC = AWP-11%.
bronchodilators. Prior authorization required for:
anticonvulsants; anti-depressants; antihistamines; Prescription Charge Formula: Payments shall be the
antilipemic agents; anti-psychotics; hypotensive lowest of:
agents (ACE Inhibitors and calcium channel 1. The Estimated Acquisition Cost (AWP-11%) of
blockers); misc. GI drugs; and smoking deterrent the ingredient, plus a dispensing fee.
products (for more than 1 course of treatment); 2. Usual and customary charge.
Zofran; Xolair; Xopenex; doses of Oxycontin greater 3. The upper limit established by CMS for multiple
than twice per day or 2 different strengths for non- source drugs or State MAC.
cancer pain; and brand name drugs with multisource
generics. Partial coverage for: anabolic steroids; Maximum Allowable Cost: State imposes Federal
anxiolytics, sedatives, and hypnotics; and growth Upper Limits as well as State-specific limits on
hormones (PA required). Products not covered: generic drugs. Override requires “Brand Medically
anoretics. Necessary.” Currently, 870 drugs are included on
the State’s MAC list.
Wyoming-2
Incentive Fee: None. Prior Authorization Contact

Antoinette K. Brown, R.Ph.
Patient Cost Sharing: State uses a system of tiered
800/438-5785
copayments:
$3.00 – Non-preferred brand DUR Contact
$2.00 – Preferred brand
Aimee Lewis, Pharm.D.
$1.00 – Generics DUR Manager
The following recipients or products are exempt University of Wyoming School of Pharmacy
from the copayment: 1000 East University Avenue
# Pregnant women Department 3375
# Eligible recipients under age 21 Laramie, WY 82071
# Patients residing in nursing homes T: 307/766-6750
# Family planning products F: 307/778-3160
E-mail: alewis@uwyo.edu
services. DUR Board
Antoinette Brown, R.Ph. (ex-officio)
E. USE OF MANAGED CARE Becky Drnas, R.Ph. (Vice Chair)
Dean Winsch, Pharm.D.
Does not use MCOs to deliver services to Medicaid Roxanne Homar, R.Ph. (ex-officio)
recipients. Kurt Hopfensberger, M.D.
James K. Robinett, M.D.
Scott Johnston, M.D.
F. STATE CONTACTS Williams Keenan, R.Ph.
Stephen Brown, M.D.
State Drug Program Administrator Michael Carpenter, PA-C
William Harrison, M.D. (Chair)
Antoinette K. Brown, R.Ph. Donna Artery (ex-officio)
Medicaid Pharmacist Richard L. Johnson, R.Ph.
Department of Health Aimee Lewis, Pharm.D. (DUR Manager)
Office of Pharmacy Services Linda G. Martin, Pharm.D. (ex-officio)
6101 Yellowstone Road, Suite 259A Tonja Woods
Cheyenne, WY 82002
T: 800/438-5785
F: 307/777-8623
Email: abrown@state.wy.us Antoinette K. Brown, R.Ph.
Internet address: 800/438-5785
www.health.wyo.gov/healthcarefin/pharmacy
Department of Health Officials
First DataBank
Brent Sherard, M.D., M.P.H. 1111 Bayhill Drive
Director San Bruno, CA 94066
Department of Health T: 800/633-3453
401 Hathaway Building F: 650/588-4003
2300 Capitol Avenue
Cheyenne, WY 82002 Medicaid Drug Rebate Contact
T: 307/777-7656
Sheila McInerney
F: 307/777-7439
TPL Manager
E-mail: wdh@state.wy.us
P.O. Box 667
Greg Gruman, Ph.D.
Cheyenne, WY 82001
State Medicaid Agent
T: 800/251-1268
6101 Yellowstone Road, Suite 259A
F: 307/772-8405
Cheyenne, WY 82002
E-mail: sheila.mcinerney@acs-inc.com
T: 307/777-7531
F: 307/777-6964
E-mail: ggruman@state.wy.us
Wyoming-3
Claims Submission Contact Wyoming State Board of Pharmacy

James T. Carder, R.Ph.
Executive Director
Northridge Center 1, Suite 400
632 South David Street
365 Northridge Road
Casper, WY 82601
Atlanta, GA 30350
T: 307/234-0294
T: 866/322-5960
F: 307/234-7226
F: 888/335-8459
E-mail: wybop@state.wy.us
Internet address: www.pharmacyboard.state.wy.us
None Wyoming Hospital Association
Daniel J. Perdue
Disease Management/Patient Education President
Programs 2005 Warren Avenue
P.O. Box 249
Disease/Medical States: Asthma Cheyenne, WY 82003
Cardiovascular Disease T: 307/632-9344
Diabetes F: 307/632-9347
Program Manager: Michelle Harker E-mail: dan@wyohospitals.com
Program Sponser: APS Healthcare Internet address: www.wyohospitals.com
Contact
Michelle Harker
Medical Care Coordinator
Office of Health Care Financing
6101 Yellowstone Road, Suite 210
Cheyene, WY 82002
T: 307/777-7531
F: 307/777-6964

Wyoming State Medical Society
Susie Pouliot
Executive Director
1920 Evans Avenue
P.O. Box 4009
Cheyenne, WY 82003
T: 307/635-2424
F: 307/632-1973
E-mail: susie@wyomed.org
Internet address: www.wyomed.org
Wyoming Pharmacy Association

Kara Beech, B.S., C.H.C.
Executive Director
P.O. Box 228
Byron, WY 82412
T: 307/272-3361
F: 307/548-6259
E-mail: karabeech@yahoo.com
Internet address: www.wpha.net
Wyoming-4
Section 6:
State Pharmacy Assistance
Programs
6-1
6-2
State Pharmacy Assistance Programs

While policymakers continue discussing the merits and cost/benefits of the Medicare Part D program, it appears
to be having a positive impact for seniors. According to the Centers for Medicare and Medicaid Services
information released in early 2007, robust competition has meant that premiums for the basic drug benefit average
$22 per month, 40 percent less than had been projected. Seniors are estimated to be saving, on average, $1,200 a
year on drugs, and 80 percent of seniors enrolled in the program are satisfied with it. In addition to the generally
successful implementation of the Part D program, State Pharmacy Assistance Programs (SPAPs) continue
providing coverage and benefits to serve those in need. Some SPAPs are collaborating with Part D plans,
coordinating benefits to leverage better patient access to pharmacy services and more prudent spending on
pharmaceuticals by States.
As SPAP programs continue and the Medicare Part D program matures the Centers for Medicare and Medicaid
Services’ (www.cms.hhs.gov/States) and the National Conference of State Legislature’s
(www.ncsl.org/programs/health/drugaid.htm and
http://www.ncsl.org/programs/health/SPAPCoordination.htm#Summary) SPAP pages offer periodic updates and
useful information resources.
As of July 1, 2007, The Centers for Medicare and Medicaid Services has received qualified attestation forms from
25 States and the US Virgin Islands covering 44 pharmaceutical assistance programs. The following chart shows
these qualified State pharmacy assistance programs. The pages following provide profiles of the SPAPs for
which information is available.
Qualified State Pharmacy Assistance Programs
State Program Name

Alaska* SeniorCare
California Genetically Handicapped Persons Program
Colorado Colorado Ryan White Title II ADAP
Connecticut Connecticut Pharmaceutical Assistance Contract to the Elderly and Disabled
Delaware Prescription Assistance Program
Delaware
Chronic Renal Disease Program
Florida Florida Comprehensive Health Association
Illinois Cares Rx
Illinois
Circuit Breaker
Indiana Hoosier Rx
Maine Low Cost Drugs for the Elderly and Disabled Program
Maryland Senior Prescription Drug Assistance Program
Maryland
Kidney Disease Program of Maryland
Massachusetts Prescription Advantage
Missouri Missouri Rx Plan
Big Sky Rx Program
Montana Mental Health Services Plan
Bridging the Gap
Nevada Senior Rx
Nevada
Disability RX Program
Pharmaceutical Assistance for the Aged and Disabled (PAAD);
New Jersey
Senior Gold Prescription Discount Program
6-3
New York Elderly Pharmaceutical Insurance Coverage (EPIC)

NCRx Program
AIDS Drug Assistance Program
North Carolina
North Carolina ADAP
North Carolina Senior Care
Pharmaceutical Assistance Contract for the Elderly (PACE);
Pennsylvania PACE Needs Enhancement Tier (PACENET)
Pennsylvania Chronic Renal Disease Program and General Assistance
Rhode Island Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
South Carolina Gap Assistance Prescription Program for Seniors (GAPS)
Kidney Health Care Program (KHC)
Texas
Mental Health Medication Program
US Virgin Islands Senior Citizens Affairs Pharmaceutical Assistance Program
Vermont VPharm (VHAP-Pharmacy, VScript; VScript Expanded)
Virginia State Pharmaceutical Assistance Program
Virginia
DMHMRSAS Community SPAP
Washington Washington State High Risk Pool Prescription Drug Assistance (WSHIP)
SeniorCare Rx.
Chronic Renal Disease
Wisconsin Cystic Fibrosis Program
Health Insurance Risk Sharing Plan
Hemophilia Home Care
* SPAP sunsets in 2007.
6-4
ALASKA
SENIOR CARE*
Number of enrollees: 107
ELIGIBILITY CRITERIA
Demographic groups: 65+

Medicare enrollment: Not required
Income limits: 135% to 175% FPL ($20,910 to $28,053)
Asset limits: $50,000 individual / $100,000 married
Dual eligibles enrolled? No
Other eligibility notes: Enrollees are required to apply for Part D LIS if eligible. No non-
Medicare enrollees in the program currently. The SPAP will pay
$34.66/mo toward the premium of a commercial drug plan and up to
$250 toward that plan's deductible; however, no drug-only plans exist.
DRUG COVERAGE
Formulary
For non-Medicare enrollees? No
For Medicare enrollees? No
Are Part D excluded drugs covered? No
BENEFITS
For non-Medicare enrollees –

Is there a deductible? No
What are the copays? n/a
Is there a benefit cap? n/a
Enhanced benefit after catastrophic limit? n/a
For Medicare enrollees –
Premium subsidies? Yes, up to $34.66/mo.
Coverage for deductibles? Yes, 100% up to $250
Coverage for copays? No
Coverage during doughnut hole? No
Benefit cap? Yes
Enhanced benefit after catastrophic threshold? n/a
FUNDING AND REIMBURSEMENT
Actual expenditures FY06: $56,000

Actual expenditures FY07: $13,000
PROGRAM CONTACT
Dave Campana
Manager of Pharmacy Program
4501 Business Park Blvd. Ste. 24
Anchorage, AK 99503
*
Senior Care pharmacy program sunsets June 30, 2007. The Governor is seeking funds to continue a general cash assistance
component of Senior Care.
6-5
CONNECTICUT
PHARMACEUTICAL ASSISTANCE TO THE ELDERLY AND DISABLED (PACE)
Number of enrollees: 43,500
Demographic groups: 65 or older or 18 and older and disabled.

Medicare enrollment: Both Medicare and non-Medicare beneficiaries may enroll
Income limits: $23,100 single / $31,100 married (changes every January 1)
Asset limits: None
Dual eligibles enrolled? Yes, with Medicaid spenddown
Other eligibility notes: A $30 annual registration fee is required. If eligible, enrollees are
required to apply for Part D LIS and enroll in a PDP.
DRUG COVERAGE
Formulary
For non-Medicare enrollees? Yes
Are Part D excluded drugs covered? Yes, benzodiazepines, barbiturates
BENEFITS

What are the copays? $16.25
Is there a benefit cap? No
Enhanced benefit after catastrophic limit? No
Premium subsidies? Yes. Up to the cost of any PDP’s actual premium
(giving the enrollee a choice of all plans)
Coverage for deductibles? Yes, anything greater than the current $16.25
Coverage for copays? Yes, anything greater than the current $16.25
Coverage during doughnut hole? Yes, will provide coverage during the donut hole beyond
current $16.25 copayment
Benefit cap? No
Enhanced benefit after catastrophic threshold? No
Actual expenditures FY06: $64,279,927

Actual expenditures – first half FY07: $10,663,449
PROGRAM CONTACT
Evelyn Dudley Phone: 860-424-5654

Manager, Pharmacy Programs Fax: 860-951-9544
CT Dept. of Social Services, 25 Sigourney Street Email: evelyn.dudley@po.state.ct.us
Hartford, CT 06106
6-6
DELAWARE
PRESCRIPTION ASSISTANCE PROGRAM
Demographic groups: 65+ or qualify for SSDI benefits.

Income limits: 200% FPL. Couples are counted as two indiviDual. IndiviDual with
income over 200% FPL can qualify if they have prescription drug costs
exceeding 30% of their income.
Asset limits: None
Dual eligibles enrolled? No, except Medicare Savings Program (QMB, SLMB, QI) currently
enrolled.
Other eligibility notes: If eligible, enrollees are required to apply for Part D LIS. Also, if
Medicare-eligible, enrollee must enroll in a PDP. Beginning Jan. 1, 2007,
DPAP-eligible indiviDual who have Medicare, may enroll in DPAP but
must show proof of Part D coverage and LIS within 90 days.
DRUG COVERAGE
Formulary
For non-Medicare enrollees? Yes, same as Medicaid PDL
For Medicare enrollees? Yes, same as Medicaid PDL; do not cover Part D drugs.
Are Part D excluded drugs covered? Yes. OTCs, benzodiazepines, barbiturates
BENEFITS

What are the copays? $5 or 25% cost of drug, whichever is greater
Is there a benefit cap? Yes, $3,000 per year.
Premium subsidies? Yes, up to the full premium amount for any plan
selected.
Coverage for deductibles? Yes, minus standard DPAP copays of $5 or 25%
Coverage during doughnut hole? Yes, cost of drug minus standard copays of $5 or 25%
Benefit cap? Yes, $3,000 per year.
Actual expenditures FY06: $3.3 million

Budget FY07: $6.9 million
6-7
PROGRAM CONTACT
Dave Michalik Phone: 302-255-9577

Senior Administrator Fax: 302-255-4454
P.O. Box 906 Email: dave.michalik@state.de.us
New Castle, DE 19720
6-8
ILLINOIS
CARES Rx
Number of enrollees: 192,847 (excluding Medicaid) (includes about 1,000 non-Medicare enrollees
remaining in Medicaid waiver program and about 2,600 non-Medicare disabled)
Demographic groups: Group 1: Over 65, citizen or qualifying non-citizen

Group 2: Over 65 and disabled; no U.S. citizenship requirement
Income limits: Group 1: Less than $21,936 single/$29,412 couple (@ 200% FPL, plus
new income disregard for SSA COLA)
Group 2: Less than $22,793 single/$30,594 couple (@ about 215% FPL,
plus new income disregard for SSA COLA)
Asset limits: None
Dual eligibles enrolled? No. The State permits applications from Dual. The dual will only
receive benefits from the SPAP if they lose Medicaid coverage during the
year.
Other eligibility notes: Enrollees are required to apply for Part D LIS and enroll in a PDP.
DRUG COVERAGE
Formulary
For non-Medicare enrollees? Yes, Medicaid Preferred Drug List
For Medicare enrollees? Yes, two main benefit levels: Group 1 Illinois Cares Rx
Plus covers most prescription medications; Group 2
Illinois Cares Rx Basic covers drugs used in the
treatment of 10 disease states. The Medicare Part D plan
formulary is used for both groups. Law effective January
1, 2007, created coverage for members in Illinois Cares
Rx Plus or Basic who have Medicare and a diagnosis of
HIV/AIDS. Copays are $2.15 for generic drugs and
$5.35 for brand name drugs for the entire Part D plan
year for drugs on the AIDS Drug Assistance Program
(ADAP) formulary that are also on the Medicare Part D
plan formulary.
Are Part D excluded drugs covered? Yes: The State covers some OTCs, benzodiazepines,
barbiturates directly.
BENEFITS

What are the copays? $2.15 generic and $5.35 for brand name drugs
Is there a benefit cap? Yes; after the state pays $1,750, the individual begins to
pay 20% of the cost of the drug plus any applicable
copay.
Premium subsidies? Yes, up to the LIS maximum (giving the enrollees only a
choice of low cost plans); up to the full premium for
those in MA-PDs (but not for those in PDPs). Also, can
6-9
enroll in non-contracted plans and get premium
assistance either up to the LIS amount or up to $25.
Coverage for deductibles? Yes - SPAP pays Part D plan deductible
Coverage for copays? Yes. $2.15 for generic/multi-source drugs, $5.35 for
brand, and $15 for non-preferred brand/specialty drugs.
Copay amounts coincide with the LIS copays.
Coverage during doughnut hole? Yes, about 80% (less enrollee copay) from $2,400 to
$5,451.25
Benefit cap? Yes. Once member has reached the $2,400 limit,
member must pay 20% of the cost of each script plus
applicable copay. After total drug costs of $5,451.25 or
$3,850 in TrOOP, the member cost share is 5% and the
state is no longer contributing toward drug costs.
Actual expenditures FY06: $347 million

Budget FY07: not yet reconciled with the Medicare Part D plans
PROGRAM CONTACT
Sinead Madigan Phone: 217-557-1057

Chief, Bureau of Pharmacy Services Fax: 217-558-1531
201 S. Grand Avenue East Email: sinead.madigan@illinois.gov
6-10
INDIANA
HOOSIER Rx

Medicare enrollment: Must be enrolled in Medicare Part D prescription drug plan that is
working with HoosierRx; no benefits for non-Medicare beneficiaries
Income limits: $15,555 individual/$20,775 married
Asset limits: None
Other eligibility notes: HoosierRx can assist those that get partial extra help from Medicare and
those denied for Medicare's extra help due to resources. If eligible,
enrollees are required to apply for Part D LIS. Also, if Medicare-eligible,
enrollee must enroll in a PDP working with HoosierRx. HoosierRx will
pay up to $70 per month in premium assistance.
DRUG COVERAGE
Formulary
For non-Medicare enrollees? n/a
BENEFITS

Is there a deductible? n/a
Premium subsidies? Yes, up to $70 per month for Part D plans working with
HoosierRx.
Coverage for deductibles? No
Benefit cap? $70 per month in premium assistance
Budget FY06: $8 million

6-11
PROGRAM CONTACT
Renee Pryor Phone: 317-234-1629

Program Manager Fax: 317-234-3709
402 W. Washington St., W374 MS 07 Email: renee.pryor@fssa.in.gov
6-12
MAINE
DRUGS FOR THE ELDERLY PROGRAM (DEL)
Number of enrollees: 86,000 (47,867 are Dual and 38,133 are non-Dual)
Demographic groups: Residents age 62 and older or persons with disabilities age 19-61
Medicare enrollment: May be eligible for Medicaid; both Medicare and non-Medicare may
enroll
Income limits: Income at or less than 185% FPL (income limit is 25% higher if at least
40% of yearly income is spent on prescription drugs)
Asset limits: None
Dual eligibles enrolled? Yes
Other eligibility notes: Medicare eligibles must enroll in a Part D plan. Members with Medicare
Part D coverage are eligible for DEL Wrap benefits only. Coverage
through DEL is funding of last resort. Members with other prescription
drug coverage must use those benefits first.
DRUG COVERAGE
Formulary
For non-Medicare enrollees? Yes, PDL separate from Medicaid - only covers brand
drugs for 14 conditions
For Medicare enrollees? No, defer to Part D plan formulary
Are Part D excluded drugs covered? Yes
BENEFITS

What are the copays? 20% plus $2 for brand name drugs for 14 conditions; no
copay for any generic drugs
Enhanced benefit after catastrophic limit? No, but do allow higher income eligibility for persons
who pay more than 40% of income on prescription drugs

Premium subsidies? Yes, up to the LIS maximum
Coverage for deductibles? Yes. Half of the Part D plan deductible
Coverage for copays? Yes, up to $2 of generic copays; 50% of brand up to
$10/Rx.
Coverage during doughnut hole? Yes, 80% of any Medicaid covered drug
Benefit cap? No
Enhanced benefit after catastrophic threshold? No, but do allow higher income eligibility for persons
who pay more than 40% of income on prescription drugs

Budget FY06: n/a
6-13
PROGRAM CONTACT
Bruce McClenahan Phone: 207-287-4018

Mgr., Pharmacy Unit, Bureau of Medical Services Fax: 201-287-6533
11 State house Station, 442 Civic Center Drive Email: bruce.mcclenahan@maine.gov
Augusta, ME 04333
6-14
MARYLAND
SENIOR PRESCRIPTION DRUG PROGRAM
Number of enrollees: Not Available
Demographic groups:
Medicare enrollment: Only Medicare eligibles may enroll; full LIS recipients are ineligible
Income limits: 300% FPL
Asset limits: None
Other eligibility notes: New applicants are required to apply for LIS and enroll in a PDP
DRUG COVERAGE
Formulary
For Medicare enrollees? n/a
Are Part D excluded drugs covered? No, however State Medicaid program does cover non-
Part D drugs for Dual
BENEFITS


Premium subsidies? Yes, up to $25 or actual premium or actual LIS
25/50/75% copay benchmark premium
Benefit cap? No

PROGRAM CONTACT
Richard Popper Phone: 410-576-2055

Executive Director Fax: 410-625-9202
201 E. Baltimore Street, Suite 630 Email: rpopper@mhip-spdap.com
Baltimore, MD 21202
6-15
MASSACHUSETTS
PRESCRIPTION ADVANTAGE
Demographic groups:
Medicare enrollment: Does not need to be Medicare eligible to enroll, but if Medicare eligible
must be in a Part D plan or creditable coverage and apply for LIS if
eligible.
Income limits: None for non-Medicare seniors; <500% FPL for Medicare seniors;
<188% FPL for persons with disabilities under age 65.
Asset limits: None
Dual eligibles enrolled? No, but will continue enrollment of Medicare Savings Program
enrollees/partial Dual if they were already in the SPAP and want to stay.
Other eligibility notes: Persons with disabilities under age 65 must have incomes below 188%
FPL and not more than 40 work hours per month. Includes coverage
during 2-year waiting period for federal Medicare eligibility. If eligible,
enrollees are required to apply for Part D LIS. Also, if Medicare-eligible,
enrollee must enroll in a PDP.
DRUG COVERAGE
Formulary
For non-Medicare enrollees? Yes
Are Part D excluded drugs covered? Yes, benzodiazepines only
BENEFITS

Is there a deductible? Yes, $0 to $350 per quarter based on income
What are the copays? < 188% FPL: $7 / $18 / $40/mail order $14/$36/$80
>188% FPL: $12 / $30 / $50/mail order $24/$60/$100
Enhanced benefit after catastrophic limit? Yes. No copay after reaching threshold (varied by
income: $660 out-of-pocket per year for members under
135% FPL; $1,325 if 135%-188% FPL; $1845 if 188%-
225% FPL; $2205 if 225-300% FPL; $2940 if income
300-500% FPL; $4900 if >500% FPL).
Premium subsidies? Yes. Prescription Advantage bases premium subsidy
amounts on the LIS maximum (regional benchmark and
the basic plan portion of individual premiums). For
members with incomes up to 188% FPL, members
receive a subsidy of the premium up to the LIS
maximum. For members with incomes of 188-225%
FPL, members are responsible for the first $20 of the
premium and receive a subsidy for the difference up to
the LIS maximum. No premium subsidy is provided for
members with incomes of 225% or above. Members are
not restricted to low-cost plans, but are responsible for
6-16
any premium amount above the LIS maximum and
amounts attributable to enhanced Part D coverage.
Coverage for deductibles? Yes, up to SPAP copays.
Coverage for copays? Yes, up to SPAP copays.
Coverage during doughnut hole? Yes, up to SPAP copays.
Benefit cap? No
Enhanced benefit after catastrophic threshold? Yes (varied by income: $1,325 out-of-pocket per year
for members with partial LIS; $1470 if under 188%
FPL; $1845 if 188%-225% FPL; $2205 if 225-
300%FPL; $2940 if income 300-500% FPL)
Actual expenditures FY06 $91.3 million

Budget FY07 $63.6 million
PROGRAM CONTACT
Randy Garten Phone: 617-222-7412

Director of Prescription Advantage Fax: 617-727-9368
One Ashburton Place, Room 517 Email: Randy.Garten@state.ma.us
Boston, MA 02108
6-17
MISSOURI
Rx PLAN

Medicare enrollment: Must be Medicare eligible and enrolled in Part D plan.
Income limits: Up to 200% FPL
Asset limits: None
Dual eligibles enrolled? Yes
Other eligibility notes: Year round enrollment. Medicare-eligible enrollees must enroll in a PDP.
DRUG COVERAGE
Formulary
For Medicare enrollees? No. Defer to SPAP formulary, but require preferred
PDPs to add or cover all Medicaid PDL drugs.
Are Part D excluded drugs covered? No. For SPAP enrollees that are Dual, non-Part D will
be paid by Medicaid and will cover OTCs,
benzodiazepines, barbiturates and vitamins.
BENEFITS

Premium subsidies? No
Coverage for deductibles? Yes, 50% of deductible cost.
Coverage for copays? Yes, 50% of copay cost during initial benefit period, gap
and catastrophic
Coverage during doughnut hole? Yes, 50% of cost.
Benefit cap? No

Budget FY07: $19.6 million (with flexibility to increase budget with
rebate revenue collected)
PROGRAM CONTACT
Jerry Simon Phone: 573-522-3066

Senior Advisor Fax: 573-522-8043
205 Jefferson St., 14th Floor Email: jerry.simon@dss.mo.gov
6-18
MONTANA
BIG SKY Rx PROGRAM
Demographic groups: Montana resident

Medicare enrollment: Must be Medicare eligible
Income limits: 200% FPL
Asset limits: None
Other eligibility notes: If eligible, enrollees are required to apply for Part D LIS and enroll in a
PDP.
DRUG COVERAGE
Formulary
BENEFITS

Premium subsidies? Yes. Up to $33.11 per month - the LIS benchmark.
May be used toward non-LIS benchmark plans. For
partial LIS, Big Sky pays only the difference of LIS
percent up to $33.11
Benefit cap? No
PROGRAM CONTACT
Christina David Phone: 406-444-3008

Program Officer Fax: 406-444-1861
POB 202915 Email: cdavid@mt.gov
Helena, MT 59620-2915
6-19
NEVADA
SENIOR Rx
Number of enrollees: 6,282 in both programs.

Disability Rx = 526; Senior Rx = 5756
Demographic groups: >62 and disabled 18-61

Medicare enrollment: Medicare eligibility not required, but if in Medicare Part D and LIS
mandated; if full LIS, not eligible for the program/disenrolled.
Income limits: Single $24,118 / Couple $31,396 (@240% FPL) [Income limits change
every July, with the CPI.]
Asset limits: None
Dual eligibles enrolled? SPAP pays Medicaid for Part D copays, but not enrolling Dual in SPAP
Medicare-eligible, enrollee must enroll in a PDP.
DRUG COVERAGE
Formulary
For non-Medicare enrollees? Yes, PBM defines formulary (fairly broad)
For Medicare enrollees? No, follow Part D plan formulary
Are Part D excluded drugs covered? Yes, OTCs, benzodiazepines, barbiturates, vitamins
BENEFITS

What are the copays? $10/$25 for preferred brands/discount for non-preferred.
Is there a benefit cap? Yes, $5,100
Premium subsidies? Enrollees can choose any plan they want if willing to
pay amount of the premium that exceeds benchmark.
Coverage during doughnut hole? Yes, 100% of any costs not paid by the plan.
Benefit cap? Yes. $3,021
Actual expenditures FY06: $2,231,417 for drugs and PBM administration fees;
actual expenditures for FY07 YTD - $1,447,252 for
drugs and PBM administration fees. The State also pays
Part D premiums; reporting is very slow on Part D
premium payments; estimated Part D premium payments
estimated at $1M for FY07.
Budget FY06: $8,089,518 (current FY07 updates unavailable.)
6-20
PROGRAM CONTACT
Laurie Olson Phone: 775-687-7555

Program Manager Fax: 775-687-7560
4126 Technology Way, Suite 101 Email: lolson@dhhs.nv.gov
6-21
NEW JERSEY
PHARMACEUTICAL ASSISTANCE FOR THE AGED AND DISABLED (PAAD)
Demographic groups: 65 or older or disabled receiving SSDI

Income limits: Income up to $22,572 single; $27,676 married
Asset limits: None
Dual eligibles enrolled? No. PAAD does not cover full Dual, but does have some partial Dual
(i.e., in Medicare Savings Programs) among its enrollees
Medicare-eligible, enrollee must enroll in a PDP unless prohibited from
doing so due to retiree/union plan restriction or if enrollee has creditable
coverage.
DRUG COVERAGE
Formulary
For Medicare enrollees? No. Open formulary covers all drugs for which the State
has a rebate agreement.
Are Part D excluded drugs covered? Yes. benzodiazepines, barbiturates, hair loss with PA,
fertility, birth control, vitamins, weight loss with PA
BENEFITS

What are the copays? $5
Premium subsidies? Yes, up to the LIS maximum (giving the enrollees
choice of benchmark plans)
Coverage for deductibles? Yes, exclusive of the current copay of $5 per covered
prescription
Coverage for copays? Yes, exclusive of the PAAD $5 copayment
Coverage during doughnut hole? Yes, exclusive of the current PAAD $5 copayment
Benefit cap? No
FUNDING AND REIMBURSEMENT*

Budget FY07: $278,276,003
*These figures reflect full Medicare Part D implementation. State expenditures have decreased significantly
without negatively impacting beneficiaries.
6-22
PROGRAM CONTACT
Wade Epps, Dir., Office of Support Services Phone: 609-588-7032

NJ Dept. of Health and Senior Services Fax: 609-588-7139
POB 715 Email: wade.epps@doh.state.nj.us
6-23
NEW JERSEY
SENIOR GOLD PRESCRIPTION DISCOUNT PROGRAM
Demographic groups: Age 65 or older or disabled receiving SSDI benefits

Medicare enrollment:
Income limits: Income between $22,572 and $32,572 annually for single; between
$27,676 and $37,676 for married.
Asset limits: No
Other eligibility notes:
DRUG COVERAGE
Formulary
Are Part D excluded drugs covered? Yes, benzodiazepines, barbiturates, cosmetic drugs with
PA, fertility, birth control, vitamins, weight loss with PA
BENEFITS

What are the copays? $15 plus 50% of the remaining cost of the drug
Enhanced benefit after catastrophic limit? Copay flat $15 after reaching annual catastrophic cap of
$2000 single / $3,000 married
Coverage for deductibles? Yes, exclusive of Senior Gold cost share
Coverage for copays? Yes, exclusive of Senior Gold cost share
Coverage during doughnut hole? Yes, exclusive of Senior Gold cost share
Benefit cap? No

Budget FY06: $14,930,267
PROGRAM CONTACT
Wade Epps Phone: 609-588-7032

Director, Office of Support Services, NJ Dept. of Fax: 609-588-7139
Health and Senior Services Email: wade.epps@doh.state.nj.us
POB 715
6-24
NEW YORK
ELDERLY PHARMACEUTICAL INSURANCE COVERAGE
FEE PLAN AND DEDUCTIBLE PLAN

Income limits: Fee Plan = below $20,000 single/$26,000 married
Deductible Plan = $20,000 to $35,000 single / $26,000 to $50,000
married
Asset limits: None
Other eligibility notes: Effective 7/1/07, EPIC enrollees are required to join Medicare Part D,
with some exceptions. Low-income enrollees are also required to apply
for Part D LIS, with EPIC assistance
DRUG COVERAGE
Formulary
Are Part D excluded drugs covered? Yes, but prescription only including benzodiazepines,
barbiturates, cosmetic drugs, hair loss, fertility, birth
control, vitamins and weight loss
BENEFITS

Is there a deductible? Yes, in the Deductible Plan ranging from $530 to $1,715
based on income. In the Fee Plan, instead of a
deductible, enrollee pays a monthly fee of $8 - $300
based on income. There is no distinction between
Medicare and non-Medicare enrollees. Medicare
enrollees that do not enroll in Part D plans and non-
Medicare enrollees qualify for the same benefit
What are the copays? $3/$7/$15/$10 based on price of drug (after any third
party payment) in both programs.
Enhanced benefit after catastrophic limit? Yes, threshold based on income $291 - $2,000 per year
in both programs. No copays after threshold.
Premium subsidies? Yes, as of 7/1/07, for Fee Plan enrollees only, up to
benchmark premium amount. Deductible plan enrollees
receive credit towards EPIC deductible equal to
benchmark premium amount.
Coverage for deductibles? Yes, all but EPIC copay and deductible
Coverage for copays? Yes, all but EPIC copay
Coverage during doughnut hole? Yes, all but EPIC copay
Benefit cap? No
Enhanced benefit after catastrophic threshold? Yes, threshold based on 6 to 9% of income, no copays
after threshold
6-25
Actual expenditures FY05: Approximately $850 million

Budget FY06-FY07: $807 million
PROGRAM CONTACT
Julie Naglieri Phone: (518) 452-6828

Director Fax: (518) 452-6882
260 Washington Ave Ext Email: jab15@health.state.ny.us
Albany, NY 12203
6-26
NORTH CAROLINA
NCRx Program
Number of enrollees: Not Available
Demographic groups: Resident; 65+

Medicare enrollment: Only Medicare beneficiary may enroll
Income limits: Income at or below $17,868 for indiviDual; $23,958 for married couples
Asset limits: Combined savings, investments and real estate (other than home, car, and
$1500 per person to cover burial expenses) of $20,000 or less for
indiviDual and $30,000 less for married couples. If income is less than
$14,700 for an individual or $19,800 for married couples, and combined
savings, investments and real estate (not including your home, car, or a
$1500 burial allowance) are less than $10,000 for an individual and
$20,000 for a married couple, individual may be eligible for greater
federal assistance – enough to cover all drug costs except for small co-
payments. Must complete federal application process.
Other eligibility notes: Enrolled or will enroll in a Medicare Prescription Drug Plan that
participates with NCRx; No other form of drug coverage that is as good
or better than Medicare Part D; Not eligible for the full federal “Extra
Help” subsidy for Medicare Part D
DRUG COVERAGE
Formulary
Are Part D excluded drugs covered? n/a/
BENEFITS


Premium subsidies? NCRx will pay up to $18 toward monthly premiums for
Medicare Prescription Drug Plans that work with NCRx.
Currently 34 plans participate
Benefit cap? No
6-27
Budget FY07: $24 million committed for 2007 from the North Carolina
Health & Wellness Trust Fund
PROGRAM CONTACT
Michael Keough
North Carolina Department of Health and Human
Services, Office of Rural Health & Community Care
1985 Umstead Drive
Raleigh, NC 27699
(Phone): 919/733-2040
NCRx
Senior Health Insurance Information Program
11 South Boylan Avenue
Raleigh, North Carolina 27603
1-888-488-6279
6-28
PENNSYLVANIA
PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY (PACE)*
Demographic groups: 65 and older; resident for at least 90 days

Medicare enrollment: Not mandated
Income limits: Annual income up to $14,500 single and $17,700 for couples.
Moratorium in new law protects existing enrollees from being disenrolled
from PACE and PACENET due to income exceeding limits as a result of
social security cost of living increases.
Asset limits: None
Other eligibility notes: The new PACEPlus will partner with Medicare Part D plans enrolling
eligible beneficiaries. Those not enrolled in a participating Part D plan
will continue to receive benefit through PACE. PACEPlus enrolled
70,000 in the LIS. Auto-enrolled 170,000 in Part D participating plans.
DRUG COVERAGE
Formulary
For Medicare enrollees? Restricted to Part D plan pharmacy network; minimal
formulary restrictions
Part D plans waive prior authorization and step therapy
protocols for all auto-enrollees
Are Part D excluded drugs covered? Yes, benzodiazepines, barbiturates, vitamins and weight
loss.
BENEFITS

Is there a deductible? $28.45 = benchmark of all Part D premiums
What are the copays? $6 generic/ $9 brand
Premium subsidies? Yes, PACE pays Part D premium.
Coverage for deductibles? Yes, up to the current copayment
Coverage during doughnut hole? Yes, PACE coverage
Benefit cap? No
Actual expenditures FY05: ~ $296.7 million net of rebates plus $14.4 million in
admin costs for both PACE and PACENET.
Budget FY06: $138 million net of rebates excluding admin.
The State anticipates $170 million annual savings
through the PACE/PACENETPlus changes.
*
Public Act 111-2006 created PACE/PACENETPlus to partner with Part D plans. PACE and PACENET continue for non-
Medicare Plan enrollees.
6-29
PROGRAM CONTACT
Thomas Snedden, Director Phone: 717-772-0198

555 Walnut Street, 5th Floor Fax: 717-772-2730
Harrisburg, PA 17101 Email: tsnedden@state.pa.us
6-30
PENNSYLVANIA
PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY
NEEDS ENHANCEMENT TIER (PACENET) "
Demographic groups: 65 and older; resident for at least 90 days

Income limits: Annual income up to $23,500 single and $31,500 for couples.
Moratorium in new law protects existing enrollees from being disenrolled
from PACE and PACENET due to income exceeding limits as a result of
social security cost of living increases.
Asset limits: None
Other eligibility notes: The new PACENET Plus will partner with Medicare Part D plans
enrolling eligible beneficiaries. Those not enrolled in a participating Part
D plan will continue to receive benefit through PACE.
DRUG COVERAGE
Formulary
For Medicare enrollees? Restricted to Part D plan pharmacy network; minimal
formulary restrictions
Are Part D excluded drugs covered? Yes, benzodiazepines, barbiturates, vitamins and weight
loss.
BENEFITS

Is there a deductible? PACENET members not enrolled in Part D plans must
pay deductible of $28.45 equal to benchmark premium.
What are the copays? $8 generic /$15 brand
Coverage for deductibles? Yes, up to the current copayment
Coverage during doughnut hole? Yes, up to the current copayment
Benefit cap? No
Actual expenditures FY05: $144 million net of rebates excluding admin

Budget FY06: $94.3 million net of rebates excluding admin
"
Public Act 111-2006 created PACE/PACENETPlus to partner with Part D plans. PACE and PACENET continue for non-
Medicare Plan enrollees.
6-31
PROGRAM CONTACT
Thomas Snedden, Director Phone: 717-772-0198

555 Walnut Street, 5th Floor Fax: 717-772-2730
Harrisburg, PA 17101 Email: tsnedden@state.pa.us
6-32
RHODE ISLAND
PHARMACEUTICAL ASSISTANCE FOR THE ELDERLY (RIPAE)
Demographic groups: 65+ (Also 55+ with SSDI qualify for 15% discount)
Income limits: Slide scale benefit for 65+ by three income categories:
60% discount: <$18,724 single/<23,407 married
30% discount: <$23,505 single/<$29,383 married
15% discount: <$41,136 single/<$47,012 married
Asset limits: None
Medicare-eligible, enrollee must enroll in a PDP. Enrollees who are not
LIS-eligible are not required to enroll in a PDP, but the state is strongly
recommending that they apply because RIPAE is not creditable coverage.
DRUG COVERAGE
Formulary
For non-Medicare enrollees? Yes. The benefit is limited to drugs for 20 conditions
and the State has a PDL of preferred/non-preferred drugs
in these classes.
For Medicare enrollees? Yes. The benefit is limited to drugs for 20 conditions
and the State has a PDL of preferred/non-preferred drugs
in these classes.
BENEFITS

What are the copays? Yes, sliding scale by income - 40%, 70% or 85%
Enhanced benefit after catastrophic limit? Yes, threshold for the lowest income group only ($1,500
out-of-pocket) after which State pays full drug cost with
no copayment
Coverage for deductibles? Yes. For RIPAE covered drugs, State will pay up to the
current RIPAE cost-share (40%, 70% or 85% depending
on income)
Coverage during doughnut hole? Yes. For RIPAE covered drugs, State will pay up to the
current RIPAE cost-share (40%, 70% or 85% depending
on income)
Benefit cap? No
Enhanced benefit after catastrophic threshold? Yes, threshold for the lowest income group only ($1,500
out-of-pocket) after which State pays full drug cost with
no copayment
6-33

Budget FY07: $2.6 million
PROGRAM CONTACT
Kristin Pono Sousa Phone: 401-462-0510

Chief Program Development Fax: 401-462-0503
John O. Pastore Complex Email: ksousa@dea.state.ri.us
35 Howard Avenue, Building 55
Cranston, RI 02903
6-34
SOUTH CAROLINA
GAP ASSISTANCE PRESCRIPTION PROGRAM FOR SENIORS

Medicare enrollment: Yes, must be on Medicare
Income limits: >200% FPL/ $20,240
Asset limits: None
Other eligibility notes: If Medicare-eligible, enrollees must enroll in a PDP.
DRUG COVERAGE
Formulary
BENEFITS

Coverage during doughnut hole? Yes. Will cover 95% of drug costs during doughnut
hole and enrollee pays 5%.
Benefit cap? No

Budget FY06: $6 million for half the program year
PROGRAM CONTACT
Fred. W. Williams Phone: 803-898-2511

SC DHHS – Department of Pharmacy Services & Fax: 803-255-8353
DME Email: Willfred@scdhhs.gov
POB 8206
6-35
TEXAS
KIDNEY HEALTH CARE PROGRAM
Demographic groups: Residents of Texas with a diagnosis of ESRD, receiving regular renal
dialysis or having received a kidney transplant
Medicare enrollment: May have Medicare, but cannot have other insurance coverage for drugs.
Income limits: Gross income less than $60,000 a year
Asset limits: None
Medicare-eligible, enrollee must enroll in a PDP.
DRUG COVERAGE
Formulary
For non-Medicare enrollees? Yes, medications related to ESRD and comorbid
conditions
For Medicare enrollees? Yes, medications related to ESRD and comorbid
conditions
Are Part D excluded drugs covered? Yes, OTCs and vitamins
BENEFITS

What are the copays? $6 per Rx
Is there a benefit cap? Yes (4 drug limit per month)
Premium subsidies? Yes, up to a maximum allowable of $35 per month.
Coverage for deductibles? Yes, up to a 4 drug limit per month.
Coverage for copays? Yes
Coverage during doughnut hole? Yes
Benefit cap? Yes (4 drug limit per month)

Budget FY07: $11.4 million, projected
PROGRAM CONTACT
Debra Hagens Phone: 512-458-7150 ext 6879

Pharmacist Fax: 512-458-7162
1100 West 49th Street, MC 1938 Email: Debra.hagens@dshs.state.tx.us
Austin, TX 78756
6-36
VERMONT
VPHARM
Demographic groups: Residents on Medicare or SSDI

Income limits: Annual income up to 225% FPL
Asset limits: None
Medicare-eligible, enrollee must enroll in a PDP. Must pay premium for
enrollment; see below.
DRUG COVERAGE
Formulary
For non-Medicare enrollees? Yes, Medicaid Preferred Drug List
For Medicare enrollees? Yes, for Part D excluded drugs only; otherwise, defer to
PDP formulary
Are Part D excluded drugs covered? Yes, to the extent that they are currently covered (OTCs,
benzodiazepines, barbiturates, vitamins, and weight loss)
BENEFITS

Is there a deductible? No, but does pay premium of $15/mo for VHAP;
$20/mo. for VScript; and $42/mo. for VScript
Expanded.
What are the copays? None
Premium subsidies? Yes, State pays PDP premium. Requires enrollees to
pay a state premium for VPharm coverage on sliding
scale by income ($15, $20, $42 effective July, 2006)
Coverage for deductibles? Yes. 100% below 150% FPL. 150-225% FPL, 100% all
for maintenance drugs only.
Coverage for copays? Yes. 100% below 150% FPL. 150-225% FPL, 100% all
Coverage during doughnut hole? Yes. 100% below 150% FPL. 150-225% FPL, 100% all
Benefit cap? No
Actual expenditures FY06: TBD

Budget FY07: TBD
6-37
PROGRAM CONTACT
Brendan Hogan Phone: 802-879-5928

Director, Health Programs Integration Unit Fax: 802-879-5962
312 Hurricane Lane, Suite 201
Williston, VT 05495-2806
6-38
VIRGINIA
Virginia SPAP
Number of enrollees: 100
Demographic groups: Resident; 65+; enrolled in State Aids Drug Assistance Program (ADAP)
Medicare enrollment: Enrolled in Medicare Part D plan
Income limits: Annual income between 135% and 300% of the Federal Poverty Level
Asset limits: None
Other eligibility notes:
BENEFITS

Premium subsidies? Yes, state pays PDP premium. Virginia SPAP provides
quarterly payments to enrollees to cover the Medicare
Part D monthly premiums.
Budget FY07: $300,000

The SPAP is solely funded with State money received from the
General Assembly. During the 2007 session, the Assembly
reduced program funds. The Virginia Department of Health
(VDH) will continue to provide premium payments. Given the
reduction in funding, plans to cover Medicare Part D premiums
and medication costs including deductibles, copayments and full
costs during the gaps in coverage (“donut hole”) will not
proceed.
The Virginia SPAP signed a contract with vendor Patient
Services Inc. (PSI) to provide enrollment and administrative
services for enrollees. The vendor will coordinate premium
payments to enrollees and establish waiting lists for other
prescription services should the program be expanded in the
future. PSI services anticipated beginning by fall 2007.
PROGRAM CONTACT
Steven Bailey Phone: 804-864-8065

State Pharmaceutical Assistance Program steve.bailey@vdh.virginia.gov
Division of Disease Prevention, Health Care
Services
Virginia Department of Health
Post Office Box 2448
109 Governor Street
Richmond, Virginia 23219
6-39
WISCONSIN
SENIOR CARE*
Demographic groups: Resident; 65+; income limits determine program level, out-of-pocket
expenses and benefits
Income limits: Annual income up to 240% FPL, based on income limits
Asset limits: None. Assets, such as bank accounts, insurance policies, home property,
etc., are not counted
Other eligibility notes: IndiviDual with prescription drug coverage under other health plans are
eligible to enroll in SeniorCare. For those with a health insurance plan,
SeniorCare will coordinate benefit coverage with the plan. SeniorCare is
the payor of last resort. IndiviDual enrolled in Medicaid are not eligible
for SeniorCare.
DRUG COVERAGE
SeniorCare will not pay for:

! Prescription drugs administered in a physician’s office.
! Drugs that are experimental or have a cosmetic, not a medical,
purpose.
! Over-the-counter drugs such as vitamins and aspirin even if
prescribed, except for insulin.
! Prescription drugs for which prior authorization has been denied.
! Brand name drugs unless medically necessary, as determined by
physician.
! Drugs from manufacturers who have not signed a rebate agreement
with the state.
BENEFITS
Annual Out-of-Pocket
Income Limits
Expense Requirements and Benefits
Level 1 ! No deductible or spend-down.
At or below $16,336 per individual ! $5 co-pay for each covered generic prescription drug.
or $21,904 per couple annually. ! $15 co-pay for each covered brand name prescription drug.
Level 2a ! $500 deductible per person.

$16,337 to $20,420 per individual ! Pay the SeniorCare rate for drugs until the $500 deductible is met.
and $21,905 to $27,380 per couple ! After $500 deductible is met, pay a $5 co-pay for each covered
annually. generic prescription drug and a $15 co-pay for each covered brand
name prescription drug.
*
The U.S. Department of Health and Human Services rejected Wisconsin’s original request to extend
SeniorCare; program, as it currently exists. The President signed an appropriations bill May 24, 2007, funding
the program for an additional two years, through 2009.
6-40
Level 2b ! $850 deductible per person.

$20,421 to $24,504 per individual ! Pay the SeniorCare rate for most covered drugs until the $850
and $27,381 to $32,856 per couple deductible is met.
annually ! After $850 deductible is met, pay a $5 co-pay for each covered
generic prescription drug and a $15 co-pay for each covered brand
Level 3 ! Pay retail price for drugs equal to the difference between your
$24,505 or higher per individual and income and $24,505 per individual or $32,857 per couple.
$32,857 or higher per couple ! Covered drug costs for spend-down will be tracked automatically.
annually. During the spend-down, there is no discount on drug costs.
! After spend-down is met, meet an $850 deductible per person.
! Pay SeniorCare rate for most covered drugs until the $850
deductible is met.
! After the $850 deductible is met, pay a $5 co-pay for each covered
generic prescription drug and a $15 co-pay for each covered brand
Budget FY06: $120 million, proportionally from

manufacturer rebates, federal and state appropriations.
PROGRAM CONTACT
Wisconsin Department of Health & Family Services

DHFS State Office Building
1 West Wilson Street
Madison, Wisconsin 53703
SeniorCare Customer Service
Hotline: 1-800-657-2038
6-41
6-42
Appendix A:
State and Federal
Medicaid Contacts
A-1
A-2
STATE MEDICAID DRUG PROGRAM ADMINISTRATORS
ALABAMA CALIFORNIA
Kelli D. Littlejohn J. Kevin Gorospe, Pharm.D.
Director of Pharmacy Chief, Pharmacy Policy Unit
Alabama Medicaid Agency California Department of Health Care Services
501 Dexter Avenue, P.O. Box 5624 Medi-Cal Policy Division
Montgomery, AL 36103-5624 Pharmacy Contracting and Policy Section
T: 334/353-4525 1501 Capitol Avenue, P.O. Box 997413, MS 4604
F: 334/353-5623 Sacramento, CA 95899-7417
E-mail: kelli.littlejohn@medicaid.alabama.gov T: 916/552-9500
Internet address: www.medicaid.alabama.gov F: 916/552-9563
ALASKA Internet address: http://www.dhs.ca.gov/pharmacy
Dave Campana, R.Ph.

COLORADO
Division of Health Care Services Cathy Traugott, R.Ph., J.D.
4501 Business Park Blvd., Suite 24 Pharmacy Supervisor
Anchorage, AK 99503 Department of Health Care Policy and Financing
T: 907/334-2425 1570 Grant Street
F: 907/561-1684 Denver, CO 80203
E-mail: david.campana@alaska.gov T: 303/866-2468
Internet address: www.hss.state.ak.us/dhcs F: 303/866-3552
E-mail: catherine.traugott@state.co.us
Internet address:
ARIZONA
www.chcpf.state.co.us/HCPF/Pharmacy/phmindex.asp
Del Swan
Pharmacy Program Administrator
CONNECTICUT
AHCCCS
701 East Jefferson Street, MD 8000 Evelyn A. Dudley, Pharmacy Manager
Phoenix, AZ 85034 Department of Social Services, Medical Operations
T: 602/417-4726 25 Sigourney Street
F: 602/254-1769 Hartford, CT 06106-5033
E-mail: DEL.SWAN@AZAHCCCS.GOV T: 860/424-5654
Internet address: www.ahcccs.state.az.us F: 860/951-9544
E-mail: evelyn.dudley@ct.gov
Internet address: www.ct.gov/dss
ARKANSAS
Suzette Bridges, Pharm.D., Administrator
DELAWARE
Pharmacy Program
Department of Human Services Cynthia R. Denemark, R.Ph.
Division of Medical Services Director of Pharmacy Services
P.O. Box 1437, Slot 415 DSS/EDS
Little Rock, AR 72203-1437 248 Chapman Road, Suite 100
T: 501/683-4120 Newark, DE 19702
F: 501/683-4124 T: 302/453-8453
E-mail: suzette.bridges@arkansas.gov F: 302/454-0224
E-mail: cynthia.denemark@eds.com
Internet address: www.dmap.state.de.us
A-3
DISTRICT OF COLUMBIA IDAHO

Carolyn C. Rachel-Price, R.Ph. Tami Eide, Pharm.D., B.C.P.S., F.A.S.H.P.
Pharmacy Director Pharmacy Unit Supervisor
Department of Health Department of Health and Welfare
Medical Assistance Administration Division of Medicaid
825 North Capitol Street, NE, Suite 5136 3232 Elder Street
Washington, DC 20002 Boise, ID 83705
T: 202/442-9078 T: 208/364-1831
F: 202/442-4790 F: 208/364-1864
E-mail: carolyn.rachel@dc.gov E-mail: eidet@dhw.idaho.gov
Internet address: http://dc.fhsc.com Internet address: www.medicaidpharmacy.idaho.gov
FLORIDA ILLINOIS
Jerry F. Wells Lisa D. Voils, Manager
Bureau Chief Drug Coverage Policy
Medicaid Pharmacy Services Department of Healthcare and Family Services
Agency for Healthcare Administration Services 201 S. Grand Avenue East
2728 Mahan Drive, MS 38 Springfield, IL 62763
Tallahassee, FL 32308 T: 217/782-2570
T: 850/487-4441 F: 217/782-5672
F: 850/922-0685 E-mail: lisa.voils@illinois.gov
E-mail: wellsj@ahca.myflorida.com Internet address: www.hfs.illinois.gov
Internet address: www.ahca.myflorida.com
INDIANA
GEORGIA
Marc Shirley, R.Ph.
Jerry L. Dubberly, Pharm.D., M.B.A. Pharmacy Operations Manager
Director, Pharmacy Services Family and Social Services Administration
Department of Community Health Office of Medicaid Policy and Planning
Division of Medical Assistance Indiana State Government Center South-Rm. W382
2 Peachtree Street, N.W., 37th Floor 402 West Washington Street
Atlanta, GA 30303 Indianapolis, IN 46204-2739
T: 404/656-4044 T: 317/232-4343
F: 404/656-8366 F: 317/232-7382
E-mail: jdubberly@dch.ga.gov E-mail: mshirley@fssa.state.in.us
Internet address: www.dch.georgia.gov
Note: All requests for information by, or on behalf of drug
manufacturers must be made ONLY to: PDL@FSSA.state.in.us.
HAWAII Phone requests will not be accepted.

Pharmacy Consultant IOWA
Department of Human Services Susan L. Parker, Pharm.D.
Med-Quest Division Pharmacy Consultant
601 Kamokila Boulevard, Room 506B Department of Human Services
P.O. Box 700190 1305 East Walnut Street
Honolulu, HI 96707 Des Moines, IA 50131
T: 808/692-8116 T: 515/725-1226
F: 808/692-8131 F: 515/725-1360
Internet address: www.med-quest.us E-mail: sparker2 @dhs.state.ia.us
Internet address: www.ime.state.ia.us
A-4
KANSAS MARYLAND
Dr. Margaret Smith Jeffrey C. Gruel
Pharmacy Program Manager Director
Kansas Health Policy Authority Maryland Pharmacy Program
900 SW Jackson, Suite 900 DHMH, Office of Operations, Eligibility, and
Topeka, KS 66612 Pharmacy
T: 785/296-4753 201 West Preston Street, Room 408
F: 785/296-4813 Baltimore, MD 21201
Internet address: www.khpa.ks.gov T: 410/767-1455
F: 410/333-5398
KENTUCKY E-mail: gruelj@dhmh.state.md.us
Internet address: www.dhmh.state.md.us/mma/mpap
Nici Gaines
Pharmacy Director
Department for Medicaid Services MASSACHUSETTS
CHR Building, 6 W-A
Paul L. Jeffrey
Director of Pharmacy
Frankfort, KY 40621
Office of Medicaid
T: 502/564-7940
F: 502/564-1351
Boston, MA 02111
T: 617/210-5319
Internet address: www.chs.ky.us/dms
F: 617/210/5865
LOUISIANA Internet address: www.mass.gov/masshealth/pharmacy
Pharmacy Director MICHIGAN
Department of Health and Hospitals
Pharmacy Benefits Management Unit Trish O’Keefe
Bienville Building Pharmacy Director
628 North Fourth Street, 7th Floor MDCH/Medical Services Administration
Baton Rouge, LA 70821 400 South Pine Street, P.O. Box 30479
T: 225/342-9768 Lansing, MI 48909-7979
F: 225/342-1980 T: 517/335-5181
E-mail: mterrebo@dhh.la.gov F: 517/241-8135
Internet address: www.lamedicaid.com or E-mail: okeefet@michigan.gov
www.dhh.la.gov Internet address: www.michigan.gov/mdch
MAINE
MINNESOTA
Bruce McClanahan
Pharmacy Unit Manager Kristin C. Young
Department of Health and Human Services Pharmacy Program Manager
Office of MaineCare Department of Human Services
11 SHS, 442 Civic Center Drive 540 Cedar Street
Augusta, ME 04330 St. Paul, MN 55155
T: 207/287-4018 T: 651/431-2504
F: 207/287-8601 F: 651/431-7426
E-mail: bruce.mcclanahan@maine.gov E-mail: kristin.young@state.mn.us
Internet address: www.mainecarepdl.org Internet address: www.dhs.mn.us/provider/pharm
A-5
MISSISSIPPI NEVADA
Judith P. Clark, R.Ph. Mary G. Griffith
Pharmacy Director Division of Health Care Financing and Policy
Division of Medicaid Pharmacy Program
Walter Sillers Building, 10th Floor 1100 E. Williams Street
550 High Street Carson City, NV 89701
Jackson, MS 39201 775/684-3751
T: 601/359-5253 E-mail: mary.griffith@dhcfp.nv.gov
F: 601/359-9555 Internet address: www.dhcfp.state.nv.us
E-mail: phipc@medicaid.state.ms.us
Internet address: www.dom.state.ms.us
NEW HAMPSHIRE
Pharmacy Administrator
MISSOURI
George L. Oestreich, Pharm.D., M.P.A. 129 Pleasant Street, Annex Building
Deputy Director, Clinical Services Concord, NH 03301
Department of Social Services T: 603/271-4210
Division of Medical Services F: 603/271-8701
205 Jefferson Street, 10th Floor Internet address:
P.O. Box 6500 www.dhhs.state.nh.us/DHHS/MEDICAIDPROGRAM/
T: 573/751-6961
F: 573/522-8514 NEW JERSEY
E-mail: George.L.Oestreich@dss.mo.gov Vacant
Internet address: www.dss.mo.gov/dms Pharmaceutical Services
MONTANA Division of Medical Assistance and Health Services
Wendy C. Blackwood Office of Utilization Management
Pharmacy Program Officer P.O. Box 712
Department of Public Health and Human Services Trenton, NJ 08619
Acute Services Bureau Internet address: www.state.nj.us
1400 Broadway, P.O. Box 202951
Helena, MT 59602 NEW MEXICO
T: 406/444-2738
Julie A. McKeay
F: 406/444-1861
Pharmacy Program Administrator
E-mail: wblackwood@mt.gov
Internet address: www.mtmedicaid.org
P.O. Box 2348
NEBRASKA Santa Fe, NM 87504-2348
Barbara Mart T: 505/827-6202
Pharmacy Consultant F: 505/827-3196
Department of Health and Human Services E-mail: julie.mckeay@state.nm.us
Finance and Support/Medicaid Division
301 Centennial Mall South, 5th Floor - NSOB
P.O. Box 95026
T: 402/471-9301
F: 402/471-9092
Internet address: www.hhs.state.ne.us/med/pharm
A-6
NEW YORK OKLAHOMA

Linda J. Jones, Director Nancy J. Nesser, D.Ph., J.D.
Bureau of Pharmacy Policy and Operations Pharmacy Director
Office of Health Insurance Programs Oklahoma Health Care Authority
Department of Health 4545 N. Lincoln Boulevard, Suite 124
99 Washington Avenue Oklahoma City, OK 73105
Albany, NY 12210 T: 405/522-7325
T: 518/474-9219 F: 405/530-3235
F: 518/473-5508 E-mail: Nancy.Nesser@okhca.org
E-mail: ljm07@health.state.ny.us Internet address: www.okhca.org
Internet address: www.nyhealth.gov
OREGON
NORTH CAROLINA
Debbie L. Bishop
Tom D’Andrea, R.Ph., M.B.A. Pharmacy Program Manager
Chief of Pharmacy and Ancillary Services Department of Human Resources
Department of Health and Human Services Division of Medical Assistance Programs
Division of Medical Assistance 500 Summer Street, NE, E-35
1985 Umstead Drive Salem, OR 97301-1077
Raleigh, NC 27699-2501 F: 503/947-1119
T: 919/855-4300 E-mail: debbie.l.bishop@state.or.us
F: 919/715-1255 Internet address: www.dhs.state.or.us/healthplan
E-mail: tom.dandrea@ncmail.net
Internet address: www.dhhs.state.nc.us/dma
PENNSYLVANIA
Terri Cathers
NORTH DAKOTA
Director of Pharmacy Programs
Brendan K. Joyce, Pharm.D., R.Ph. Department of Public Welfare
Administrator, Pharmacy Services 49 Beech Drive, 2nd Floor, Room 228
Department of Human Services Harrisburg, PA 17110-3591
600 East Boulevard Avenue T: 717/346-8156
Department 325 F: 717/346-8171
Bismarck, ND 58505-0250 E-mail: c-tcathers@state.pa.us
T: 701/328-4023 Internet address:
F: 701/328-1544 www.dpw.state.pa.us/Health/MAPharmProg
E-mail: sojoyb@nd.gov
Internet address: www.state.nd.us/humanservices RHODE ISLAND
Paula J. Avarista, R.Ph., M.B.A.
OHIO
Chief of Pharmacy
Robert P. Reid, R.Ph. Department of Human Services
Administrator, Pharmacy Services Unit 600 New London Avenue
Department of Job and Family Services Cranston, RI 02920
Bureau of Health Plan Policy T: 401/462-6390
P.O. Box 182709 F: 401/462-6336
Columbus, OH 43218-2709 E-mail: pavarista@dhs.ri.gov
T: 614/466-6420 Internet address: www.dhs.state.ri.us
F: 614/466-2908
E-mail: reidr@odjfs.state.oh.us
Internet address: www.jfs.ohio.gov
A-7
SOUTH CAROLINA UTAH

James M. Assey, R.Ph., Director RaeDell E. Ashley, R.Ph.
Division of Pharmacy and DME Services Pharmacy Director
Department of Health & Human Services Utah Medicaid
P.O. Box 8206 Department of Health
Columbia, SC 29202-8206 Division of Health Care Financing
T: 803/898-2876 288 North 1460 West
F: 803/255-8353 P.O. Box 143102
E-mail: asseyj@scdhhs.gov Salt Lake City, UT 84114
Internet address: http://southcarolina.fhsc.com T: 801/538-6495
F: 801/538-6099
SOUTH DAKOTA E-mail: rashley@.utah.gov
Internet address: www.health.utah.gov/medicaid
Pharmacy Consultant
VERMONT
South Dakota Medicaid
700 Governors Drive Ann E. Rugg
Pierre, SD 57501 Deputy Director
T: 605/773-3495 Office of Vermont Health Access
F: 605/773-5246 312 Hurricane Lane, Suite 200
E-mail: Mark.Petersen@state.sd.us Williston, VT 05495
Internet address: www.dss.sd.gov/medicaidservices T: 802/879-5911
F: 802/879-5919
TENNESSEE E-mail: ann.rugg@ahs.state.vt.us
Internet address: www.ovha.state.vt.us
Jeffrey G. Stockard, D.Ph.
Associate Pharmacy Director
VIRGINIA
Bureau of TennCare
310 Great Circle Road H. Bryan Tomlinson, II, Director
Nashville, TN 37243 Division of Health Care Services
615/507-6496 Department of Medical Assistance Services
E-mail: jeff.stockard@state.tn.us 600 East Broad Street, Suite 1300
Internet address: www.tennessee.gov/tenncare Richmond, VA 23219
T: 804/371-7398
TEXAS F: 804/786-0973
E-mail: Bryan.Tomlinson@dmas.virginia.gov
Andy Vasquez, Director Internet address: www.dmas.virginia.gov
Vendor Drug Program
Health and Human Services Commission
WASHINGTON
Medicaid and CHIP Division
11209 Metric Boulevard – H630 Siri A. Childs, Pharm.D.
Austin, TX 78758 Pharmacy Administrator
T: 512/491-1843 Health and Recovery Services Administration, DSHS
F: 512/491-1959 626 8th Avenue, SE
E-mail: Andy.Vasquez@hhsc.state.tx.us P.O. Box 45506
Internet address: www.hhsc.state.tx.us Olympia, WA 98504-5506
T: 360/725-1564
F: 360/586-8827
Internet address: http://maa.dshs.wa.gov/pharmacy
A-8
WEST VIRGINIA
Peggy A. King, R.Ph.
Director of Pharmacy Services
350 Capitol St., Room 251
Charleston, WV 25301-3707
T: 304/558-1700
F: 304/558-1542
E-mail: pking@wvdhhr.org
Internet address: www.wvdhhr.org/bms/pharmacy
WISCONSIN
Carrie L. Gray
Wisconsin Medicaid
P.O. Box 309
Madison, WI 53702
T: 608/266-3901
F: 608/266-1096
Internet address:
www.dhfs.state.wi.gov/medicaid/pharmacy
WYOMING
Medicaid Pharmacist
Cheyenne, WY 82002
T: 800/438-5785
F: 307/777-8623
E-mail: abrown@state.wy.us
Internet address:
www.health.wyo.gov/healthcarefin/pharmacy
A-9
NEW BRAND NAME PRODUCT CONTACT INFORMATION

ALABAMA COLORADO
Stephanie Frawley Cathy Traugott, R.Ph., J.D.
FDB Contract Administrator Pharmacy Supervisor
Alabama Medicaid Agency Department of Health Care Policy and Financing
501 Dexter Avenue, P.O. Box 5624 1570 Grant Street
Montgomery, AL 36103-5624 Denver, CO 80203
T: 334/353-4592 T: 303/866-2468
F: 334/353-7014 F: 303/866-3552
E-mail: stephanie.frawley@medicaid.alabama.gov E-mail: catherine.traugott@state.co.us
ALASKA CONNECTICUT
Dave Campana, R.Ph. James Zakszewski, R.Ph.
Pharmacy Program Manager Pharmacy Consultant
Division of Health Care Services Department of Social Services
4501 Business Park Blvd., Suite 24 Medical Operations Unit
Anchorage, AK 99503 25 Sigourney Street
T: 907/334-2425 Hartford, CT 06106-5033
F: 907/561-1684 T: 860/424-5150
E-mail: david.campana@alaska.gov F: 860/951-9544
E-mail: james.zakszewski@ct.gov
ARIZONA
DELAWARE
Contact health plans directly.
Joli Martini
ARKANSAS Pharmacist Consultant – Clinical Reviews
DSS/EDS
Pamela Ford, Pharm.D., Pharmacist II 248 Chapman Road, Suite 100
Department of Human Services Newark, DE 19702
Division of Medical Services T: 302/453-8453
P.O. Box 1437, Slot S 415 F: 302/454-0224
Little Rock, AR 72203-1437 E-mail: joli.martini@eds.com
T: 501/683-4120
F: 501/683-4124
E-mail: Pamela.ford@arkansas.gov DISTRICT OF COLUMBIA
CALIFORNIA Pharmacy Director
J. Kevin Gorospe, Pharm.D. Medical Assistance Administration
Chief, Pharmacy Policy Unit 825 North Capitol Street, NE, Suite 5136
California Department of Health Care Services Washington, DC 20002
Medi-Cal Policy Division T: 202/442-9078
Pharmacy Contracting and Policy Section F: 202/442-4790
1501 Capitol Avenue E-mail: carolyn.rachel@dc.gov
P.O. Box 997413, MS 4604
T: 916/552-9500
F: 916/552-9563
A-10
FLORIDA ILLINOIS
Jerry F. Wells Lisa D. Voils, Manager
Bureau Chief Drug Coverage Policy
Medicaid Pharmacy Services Illinois Department of Healthcare and Family
Agency for Health Care Administration Services
2728 Mahan Drive, MS 38 201 S. Grand Avenue East
Tallahassee, FL 32308 Springfield, IL 62763
T: 850/487-4441 T: 217/782-2570
F: 850/922-0685 F: 217/782-5672
E-mail: wellsj@ahca.myflorida.com E-mail: lisa.voils@illinois.gov
GEORGIA INDIANA
Emily Baker Marc Shirley, R.Ph.
Director of Clinical Programs Pharmacy Operations Manager
Georgia Medicaid Clinical Information Family and Social Services Administration
c/o NorthStar HealthCare Consulting Office of Medicaid Policy and Planning
1120 Powers Place Room W382
Alpharetta, GA 30004 Indiana State Government Center South
T: 404/308-2285 402 West Washington Street
F: 877/295-0836 Indianapolis, IN 46204-2739
E-mail: GAMedicaid@nhc-llc.com T: 317/232-4343
F: 317/232-7382
HAWAII Note: All manufacturer inquiries and/or submissions must be in
electronic format and sent to PDL@fssa.state.in.us. Paper copies
Lynn S. Donovan, R.Ph. will not be accepted and should not be mailed to any of the involved
Pharmacy Consultant parties, including OMPP, ACS, or the Therapeutic Committee.
Visit: http://indianapbm.com/downloads/T-
Department of Human Services committe%20PDL%20submission%20Form1-5-04.pdf for
Med-Quest Division necessary forms.
601 Kamokila Boulevard, Suite 506B
Kapolei, HI 96707 IOWA
T: 808/692-8116
F: 808/692-8131 Chad Bissell, Pharm.D.
Clinical Pharmacy Manager
IDAHO
100 Army Post Road
Mary Wheatley, R.Ph. Des Moines, IA 50315
Pharmacy Services Specialist T: 515/725-1271
Department of Health and Welfare F: 515/725-1358
Division of Medicaid E-mail: info@iowamedicaidpdl.com
3232 Elder
Boise, ID 83705 KANSAS
T: 208/364-1832
Dr. Margaret Smith
F: 208/364-1864
E-mail: wheatlem@dhw.idaho.gov
Topeka, KS 66612
T: 785-296-4753
F: 785/296-4813
A-11
KENTUCKY MASSACHUSETTS
Nici Gaines Christopher T. Burke
Pharmacy Director Program Analyst
Department for Medicaid Services Office of Medicaid
CHR Building, 6 W-A 600 Washington Street, Suite 5000
275 East Main Street Boston, MA 02111
Frankfort, KY 40621 T: 617/210-5592
T: 502/564-7940 F: 617/210-5865
F: 502/564-1351 E-mail: Christopher.Burke@state.ma.us
MICHIGAN
LOUISIANA
Trish O’Keefe
Mary J. Terrebonne, Pharm.D. Pharmacy Director
Pharmacy Director MDCH/Medical Services Administration
Department of Health & Hospitals 400 South Pine Street
Pharmacy Benefits Management Unit P.O. Box 30479
Bienville Building Lansing, MI 48909-7979
628 N. Fourth Street, 7th Floor T: 517/335-5181
P.O. Box 91030 F: 517/241-8135
Baton Rouge, LA 70821 E-mail: okeefet@michigan.gov
T: 225/342-9768
F: 225/342-1980 MINNESOTA
E-mail: mterrebo@dhh.la.gov Mary Claire Woheltz, Pharm.D.
Clinical Pharmacist
MAINE Department of Human Services
540 Cedar Street
Bruce McClanahan St. Paul, MN 55155
Pharmacy Unit Manager T: 651/431-2410
Office of MaineCare Services E-mail: mary.c.woheltz@state.mn.us
11 SHS, 442 Civic Center Drive
Augusta, ME 04330
T: 207/287-4018 MISSISSIPPI
F: 207/287-8601
E-mail: bruce.mcclanahan@maine.gov Judith P. Clark, R.Ph.
Pharmacy Director
MARYLAND Division of Medicaid
Walter Sillers Building, 10th Floor
Frank Tetkoski, P.D., Chief 550 High Street
Division of Pharmacy Services Jackson, MS 39201
DHMH T: 601/359-5253
Office of Operations, Eligibility, and Pharmacy F: 601/359-9555
Division of Pharmacy Services E-mail: phipc@medicaid.state.ms.us
Baltimore, MD 21201
T: 410/767-1460
F: 410/333-5398
E-mail: tetkoskif@dhmh.state.md.us
A-12
MISSOURI NEW HAMPSHIRE

Rhonda A. Driver Lisè C. Farrand, R.Ph.
Clinical Pharmacist Pharmaceutical Services Specialist
Department of Social Services Office of Medicaid Business and Policy
Division of Medical Services 129 Pleasant Street, Annex Building
205 Jefferson Street, 10th Floor Concord, NH 03301
P.O. Box 6500 T: 603/271-4419
Jefferson City, MO 65102- 6500 F: 603/271-8701
T: 573/751-6961 E-mail: lfarrand@dhhs.state.nh.us
F: 573/522-8514
E-mail: Rhonda.Driver@dss.mo.gov
NEW JERSEY
MONTANA Open Formulary – Contact Not Required
Wendy C. Blackwood
Pharmacy Program Officer NEW MEXICO
Department of Public Health and Human Services
Acute Services Bureau Julie A. McKeay
1400 Broadway Pharmacy Program Administrator
P.O. Box 202951 Human Services Department
Helena, MT 59602 Medical Assistance Division
T: 406/444-2738 P.O. Box 2348
F: 406/444-1861 Santa Fe, NM 87504-2348
E-mail: wblackwood@mt.gov T: 505/827-6202
F: 505/827-3196
NEBRASKA E-mail: julie.mckeay@state.nm.us
Barbara Mart NEW YORK

Pharmacy Consultant
Department of Health and Human Services Carl Cioppa, Pharm.D.
Finance and Support/Medicaid Division Pharmacy Operations Manager
301 Centennial Mall South Office of Health Insurance Programs
5th Floor-NSOB Department of Health
P.O. Box 95026 99 Washington Avenue
Lincoln, NE 68509-5026 Albany, NY 12210
T: 402/471-9301 T: 518/474-3209
F: 402/471-9092 F: 518/473-5508
E-mail: barbara.mart@hhss.ne.gov E-mail: ctc01@health.state.ny.us
NEVADA
Mary Griffith
Pharmacy Program
1100 E. Williams Street
775/684-3751
E-mail: mary.griffith@dhcfp.state.nv.us
A-13
NORTH CAROLINA OREGON

Tom D’Andrea, R.Ph., M.B.A. Debbie L. Bishop
Chief of Pharmacy and Ancillary Services Pharmacy Program Manager
Department of Health and Human Services Department of Human Services
Division of Medical Assistance Division of Medical Assistance Programs
1985 Umstead Drive, 2501 Mail Service Center 500 Summer Street, NE, E-35
Raleigh, NC 27699 Salem, OR 97301-1077
T: 919/855-4300 T: 503/945-6291
F: 919/715-1255 F: 503/947-1119
E-mail: tom.dandrea@ncmail.net E-mail: debbie.l.bishop@state.or.us
PENNSYLVANIA
NORTH DAKOTA
Terri Cathers
Brendan K. Joyce, Pharm.D., R.Ph. Director of Pharmacy Programs
Administrator, Pharmacy Services Department of Public Welfare
Department of Human Services 49 Beech Drive, 2nd Floor, Room 228
600 East Boulevard Avenue Harrisburg, PA 17110-3591
Department 325 T: 717/346-8156
Bismarck, ND 58505-0250 F: 717/346-8171
T: 701/328-4023 E-mail: c-tcathers@state.pa.us
F: 701/328-1544
E-mail: sojoyb@nd.gov RHODE ISLAND
Paula J. Avarista, R.Ph., M.B.A.
OHIO Chief of Pharmacy
Robert P. Reid, R.Ph. Department of Human Services
Administrator, Pharmacy Services Unit 600 New London Avenue
Department of Job and Family Services Cranston, RI 02920
Bureau of Health Plan Policy T: 401/462-6390
P.O. Box 182709 F: 401/462-6336
Columbus, OH 4321-2709 E-mail: pavarista@dhs.ri.gov
T: 614/466-6420
F: 614/466-2908 SOUTH CAROLINA
E-mail: reidr@odjfs.state.oh.us James M. Assey, R.Ph., Director
Division of Pharmacy and DME Services
Department of Health & Human Services
OKLAHOMA P.O. Box 8206
Rodney Ramsey Columbia, SC 29202-8206
Drug Reference Coordinator T: 803/898-2876
Oklahoma Health Care Authority F: 803/255-8353
4545 North Lincoln, Suite 124 E-mail: asseyj@scdhhs.gov
T: 405/522-7492 SOUTH DAKOTA
F: 405/530-7119 Mark E. Petersen, R.Ph.
E-mail: Rodney.Ramsey@okhca.org Pharmacy Consultant
South Dakota Medicaid
700 Governors Drive
Pierre, SD 57501
T: 605/773-3495
F: 605/773-5246
E-mail: Mark.Petersen@state.sd.us
A-14
TENNESSEE VIRGINIA
Jeffrey G. Stockard, D.Ph. Keith T. Hayashi
Associate Pharmacy Director Pharmacist
Bureau of TennCare Department of Medical Assistance Services
310 Great Circle Road 600 East Broad Street, Suite 1300
Nashville, TN 37243 Richmond, VA 23219
T: 615/507-6496 T: 804/225-2773
F: 615/253-5481 F: 804/786-0973
E-mail: jeff.stockard@state.tn.us E-mail: Keith.Hayashi@dmas.virginia.gov
TEXAS WASHINGTON
JoAnn Foster Siri A. Childs, Pharm D.
Formulary Pharmacist Pharmacy Administrator
Texas Health and Human Services Commission Health and Recovery Services Administration,
Vendor Drug Program DSHS
11209 Metric Boulevard, H630 628 8th Avenue, SE
Austin, TX 78758 P.O. Box 45506
T: 512/491-1156 Olympia, WA 98504-5506
F: 512/491-1961 T: 360/725-1564
E-mail: JoAnn.Foster@hhsc.state.tx.us F: 360/586-8827
UTAH
Jennifer Zeleny, CPhT WEST VIRGINIA
Division of Health Care Financing Peggy A. King, R.Ph.
Utah Medicaid Director of Pharmacy Services
Department of Health Department of Health and Human Resources
288 North 1460 West Bureau for Medical Services
P.O. Box 143102 350 Capitol Street, Room 251
Salt Lake City, UT 84114 Charleston, WV 25301-3707
T: 801/538-6339 T: 304/558-1700
F: 801/538-6099 F: 304/558-1542
E-mail: jzeleny@utah.gov E-mail: pking@wvdhhr.org
VERMONT
WISCONSIN
Diane Neal
Carrie L Gray
Clinical Pharmacist
MedMetrics Health Partners
Wisconsin Medicaid
312 Hurricane Lane
Williston, VT 05495
P.O. Box 309
T: 802/879-5605
Madison, WI 53702
F: 802/879-5919
T: 608/266-3901
E-mail: diane.neal@medmetricshp.com
F: 608/266-1096
A-15
WYOMING
Medicaid Pharmacist
Cheyenne, WY 82002
T: 800/438-5785
F: 307/777-8623
A-16
PRIOR AUTHORIZATION CONTACTS
ALABAMA CALIFORNIA
Kelli D. Littlejohn, R.Ph. J. Kevin Gorospe, Pharm.D.
Director of Pharmacy Chief, Pharmacy Policy Unit
Alabama Medicaid Agency California Department of Health Care Services
501 Dexter Avenue Medi-Cal Policy Division
P.O. Box 5624 Pharmacy Policy and Contracting Section
Montgomery, AL 36103-5624 1501 Capitol Avenue
T: 334/353-4525 P.O. Box 997413, MS 4604
F: 334/353-7014 Sacramento, CA 95899-7417
E-mail: kelli.littlejohn@medicaid.alabama.gov T: 916/552-9500
F: 916/552-9563
ALASKA
Dave Campana, R.Ph.
COLORADO
Division of Health Care Services Kimberly Eggert
4501 Business Park Blvd., Suite 24 Pharmacist
Anchorage, AK 99503 Department of Health Care Policy and Financing
T: 907/334-2425 1570 Grant Street
F: 907/561-1684 Denver, CO 80203
E-mail: david.campana@alaska.gov T: 303/866-3176
F: 303/866-3552
E-mail: kimberly.eggert@state.co.us
ARIZONA
Prior authorization is conducted at the plan level.
Within Federal and State guidelines, individual CONNECTICUT
managed care and pharmacy benefit management Emily C. Piddock
organizations make formulary/drug decisions. Pharmacy Consultant
ARKANSAS 25 Sigourney Street
Suzette Bridges, Pharm.D., Administrator Hartford, CT 06106-5033
Pharmacy Program T: 860/424-5813
Division of Medical Services F: 860/951-9544
Department of Human Services E-mail: emily.piddock@ct.gov
P.O. Box 1437, Slot S 415
Little Rock, AR 72203-1437
T: 501/683-4120 DELAWARE
F: 501/683-4124 Cynthia R. Denemark, R.Ph.
E-mail: suzette.bridges@arkansas.gov Director of Pharmacy Services
DSS/EDS
248 Chapman Road, Suite 100
Newark, DE 19702
T: 302/453-8453
F: 302/454-0224
A-17
DISTRICT OF COLUMBIA IDAHO

Robert Faller
Medical Program Specialist
Pharmacy Director
Department of Health and Welfare
Division of Medicaid
3232 Elder Street
825 North Capitol Street, NE, Suite 5136
Boise, ID 83705
T: 208/364-1850
T: 202/442-9078
F: 208/364-1864
F: 202/442-4790
E-mail: fallerr@dhw.idaho.gov
E-mail: carolyn.rachel@dc.gov
ILLINOIS
FLORIDA
Lisa D. Voils, Manager
Talisa Hardyl, Pharm.D. Drug coverage Policy
Pharmacy Program Manager Illinois Department of Healthcare and Family
Agency for Health Care Administration Services
2728 Mahan Drive, MS 38 201 S. Grand Avenue East
Tallahassee, FL 32308 Springfield, IL 62763
T: 850/487-4441 T: 217/782-2570
F: 850/922-0685 F: 217/782-5672
E-mail: hardyt@ahca.myflorida.com E-mail: lisa.voils@illinois.gov
GEORGIA INDIANA
Emily Baker ACS State Healthcare
Director of Clinical Programs 365 Northridge Road, Suite 400
Georgia Medicaid Clinical Information Atlanta, GA 30350
c/o NorthStar HealthCare Consulting T: 866/879-0106
1120 Powers Place F: 866/759-4100
Alpharetta, GA 30004 E-mail: PDL@fssa.state.in.us
T: 404/308-2285
F: 877/295-0836 Note: All manufacturer inquiries and/or submissions must be in
electronic format and sent to PDL@fssa.state.in.us. Paper copies
E-mail: GAMedicaid@nhc-llc.com will not be accepted and should not be mailed to any of the involved
parties, including OMPP, ACS, or the Therapeutic Committee.
Visit: http://indianapbm.com/downloads/T-
committe%20PDL%20submission%20Form1-5-04.pdf for
HAWAII necessary forms.
Pharmacy Consultant IOWA
Department of Human Services Chad Bissell, Pharm.D.
Med-Quest Division Clinical Pharmacy Manager
601 Kamokila Boulevard, Suite 506B Iowa Medicaid Enterprise
Kapolei, HI 96707 100 Army Post Road
T: 808/692-8116 Des Moines, IA 50315
F: 808/692-8131 T: 515/725-1271
F: 515/725-1010
E-mail: info@iowamedicaidpdl.com
A-18
KANSAS MARYLAND
Dr. Margaret Smith Tuong A. Nguyen, Pharm.D.
Pharmacy Program Manager Pharmacist Consultant
Kansas Health Policy Authority Maryland Pharmacy Program
900 SW Jackson, Suite 900 DHMH, Office of Operations, Eligibility, and
Topeka, KS 66612 Pharmacy
T: 785/296-4753 201 W. Preston Street, Room 409
F: 785/296-4813 Baltimore, MD 21201
T: 410/767-5701
F: 410/333-5398
KENTUCKY E-mail: nguyent@dhmh.state.md.us
Nici Gaines
Pharmacy Director MASSACHUSETTS
Department for Medicaid Services
CHR Building, 6 W-A Paul L. Jeffrey
275 East Main Street Director of Pharmacy
Frankfort, KY 40621 Office of Medicaid
T: 502/564-7940 600 Washington Street, Suite 5000
F: 502/564-1351 Boston, MA 02111
E-mail: nici.gaines@ky.gov T: 617/210-5319
F: 617/210-5865
LOUISIANA Internet address:
www.mass.gov/masshealth/pharmacy
Pharmacy Director
Department of Health & Hospitals
MICHIGAN
Pharmacy Benefits Management Unit
Bienville Building First Health Services Corporation
628 N. Fourth Street, 7th Floor 4300 Cox Road
P.O. Box 91030 Glen Allen, VA 23060
Baton Rouge, LA 70821 T: 800/884-2822
T: 225/342-9768 F: 804/527-6849
F: 225/342-1980
E-mail: mterrebo@dhh.la.gov MINNESOTA
Mary Claire Woheltz, Pharm.D.
MAINE
Clinical Pharmacist
Brenda McCormick, Director Department of Human Services
Health Care Management Division 540 Cedar Street
Department of Health and Human Services St. Paul, MN 55155
442 Civic Center Drive T: 651/431-2510
Augusta, ME 04333 F: 651/431-7426
T: 207/287-8419 E-mail: mary.c.woheltz@state.mn.us
F: 207/287-6533
E-mail: Brenda.McCormick@maine.gov
A-19
MISSISSIPPI NEVADA
Judith P. Clark, R.Ph. Mary Griffith
Pharmacy Director Division of Health Care Financing and Policy
Division of Medicaid Pharmacy Program
Walter Sillers Building, 10th Floor 1100 E. Williams Street
550 High Street Carson City, NV 89701
Jackson, MS 39201 T: 775/684-3751
T: 601/359-5253 F: 775/684-3762
F: 601/359-9555 E-mail: mary.griffith@dhcfp.nv.gov
E-mail: phipc@medicaid.state.ms.us
NEW HAMPSHIRE
MISSOURI
Robert C. Coppola, Pharm.D.
Rhonda A. Driver Account Manager
Clinical Pharmacist First Health Services Corporation
Department of Social Services 17 Chenell Drive
Division of Medical Services Concord, NH 03301
205 Jefferson Street, 10th Floor T: 603/224-2083
P.O. Box 6500 F: 603/224-6690
Jefferson City, MO 65102- 6500 E-mail: coppolro@fhsc.com
T: 573/751-6961
F: 573/522-8514
E-mail: Rhonda.Driver@dss.mo.gov NEW JERSEY
Dalia S. Hanna, Pharm. D.
MONTANA MEP Manager
Unisys
Wendy C. Blackwood 3705 Quakerbridge Road
Pharmacy Program Officer Trenton, NJ 08619-1288
Department of Public Health and Human Services T: 609/631-6686
Acute Services Bureau F: 609/588-5508
1400 Broadway E-mail: dalia.hanna@unisys.com
P.O. Box 202951
Helena, MT 59620-2951
T: 406/444-2738 NEW MEXICO
F: 406/444-1861 John Erb, Pharm. D..
E-mail: wblackwood@mt.gov Pharmacist
NEBRASKA Medical Assistance Division
Barbara Mart P.O. Box 2348
Pharmacy Consultant Santa Fe, NM 87504-2348
Finance and Support/Medicaid Division F: 505/827-3196
301 Centennial Mall South E-mail: JohnN.Erb@state.nm.us
5th Floor-NSOB
P.O. Box 95026
T: 402/471-9301
F: 402/471-9092
A-20
NEW YORK OKLAHOMA

Linda J. Jones, Director Ronald Graham, D.Ph.
Pharmacy Policy and Operations Manager, Operations/DUR
Bureau of Program Guidance University of Oklahoma, College of Pharmacy
Office of Health Insurance Programs ORI W-4403
NY Department of Health P.O. Box 26901
99 Washington Avenue Oklahoma City, OK 73190
Albany, NY 12210 T: 405/271-6614
T: 518/474-9219 F: 405/271-2615
F: 518/473-5508 E-mail: ronald-graham@ouhsc.edu
E-mail: ljm07@health.state.ny.us
OREGON
NORTH CAROLINA
Debbie L. Bishop
Lisa Week, Pharm.D. Pharmacy Program Manager
Pharmacy Manager Division of Medical Assistance Programs
Department of Health and Human Services Department of Human Resources
Division of Medical Assistance 500 Summer Street, NE, E-35
1985 Umstead Drive, 2501 Mail Service Center Salem, OR 97301-1077
Raleigh, NC 27699-2501 T: 503/945-6291
T: 919/855-4300 F: 503/947-1119
F: 919/715-1255 E-mail: debbie.l.bishop@state.or.us
E-mail: lisa.weeks@ncmail.net
PENNSYLVANIA
NORTH DAKOTA
Terri Cathers
Brendan K. Joyce, Pharm.D., R.Ph. Director of Pharmacy Programs
Administrator, Pharmacy Services Department of Public Welfare
Department of Human Services 49 Beech Drive, 2nd Floor, Room 228
600 East Boulevard Avenue Harrisburg, PA 17110-3591
Department 325 T: 717/346-8156
Bismarck, ND 58505-0250 F: 717/346-8171
T: 701/328-4023 E-mail: c-tcathers@state.pa.us
F: 701/328-1544
RHODE ISLAND
OHIO Paula J. Avarista, R.Ph., M.B.A.
Robert P. Reid, R.Ph. Chief of Pharmacy
Administrator, Pharmacy Services Unit Department of Human Services
Department of Job and Family Services 600 New London Avenue
Bureau of Health Plan Policy Cranston, RI 02920
P.O. Box 182709 T: 401/462-6390
Columbus, OH 43218-2709 F: 401/462-6336
T: 614/466-6420 E-mail: pavarista@dhs.ri.gov
F: 614/466-2908
A-21
SOUTH CAROLINA UTAH

James M. Assey, R.Ph., Director Jennifer Zeleny, CPhT
Division of Pharmacy and DME Services Department of Health
Department of Health & Human Services Division of Health Care Financing
P.O. Box 8206 Utah Medicaid
Columbia, SC 29202-8206 288 North 1460 West
T: 803/898-2876 P.O. Box 143102
F: 803/255-8353 Salt Lake City, UT 84114
E-mail: asseyj@scdhhs.gov T: 801/538-6339
F: 801/538-6099
E-mail: jzeleny@utah.gov
SOUTH DAKOTA
VERMONT
Pharmacy Consultant
South Dakota Medicaid The State of Vermont does not meet with
700 Governors Drive representatives from the pharmaceutical industry.
Pierre, SD 57501
T: 605/773-3495 VIRGINIA
F: 605/773-5246 Debra Moody
E-mail: Mark.Petersen@state.sd.us Clinical Manager
4300 Cox Road
TENNESSEE Richmond, VA 23060
Jeffrey G. Stockard, D.Ph. T: 804/956-7431
Associate Pharmacy Director F: 804/273-6961
Bureau of TennCare E-mail: moodyde@fhsc.com
Nashville, TN 37243 WASHINGTON
T: 615/507-6496 Siri A. Childs, Pharm.D.
E-mail: jeff.stockard@state.tn.us Pharmacy Administrator
Health and Recovery Administration, DSHS
TEXAS 805 Plum Street, SE
JoAnn Foster P.O. Box 45506
Formulary Pharmacist Olympia, WA 98504-5506
Texas Health and Human Services Commission T: 360/725-1564
Vendor Drug Program F: 360/586-8827
11209 Metric Boulevard, H630 E-mail: childsa@dshs.wa.gov
Austin, TX 78758
T: 512/491-1156 WEST VIRGINIA
F: 512/491-1961 Stephen Small, R.Ph., M.S.
E-mail: Joann.Foster@hhsc.state.tx.us Director, Rational Drug Therapy Program
West Virginia University School of Pharmacy
Robert C. Byrd Health Sciences Center
P.O. Box 9511
Morgantown, WV 26506-9511
T: 800/847-3859
F: 800/531-7787
E-mail: ssmall@hsc.wvu.edu
A-22
WISCONSIN
Carrie L. Gray
Wisconsin Medicaid
P.O. Box 309
Madison, WI 53702
T: 608/266-3901
F: 608/266-1096
WYOMING
Medicaid Pharmacist
Cheyenne, WY 82002
T: 800/438-5785
F: 307/777-8623
A-23
DUR CONTACT INFORMATION

State Contact Contractor
Tiffany D. Minnifield Tiffany D. Minnifiels
Associate Director Associate Director
Pharmacy Administrative Services Pharmacy Administrative Services
501 Dexter Avenue
ALABAMA
P.O. Box 5624
Contracted DUR
T: 334/353-4596
F: 334/353-7014
E-mail:
tiffany.minnifield@mediciad.alabama.gov

Edward Bako, R.Ph. Not Available
Medicaid Pharmacist
ALASKA
4501 Business Park Blvd., Ste. 24
In-House and
Anchorage, AK 99503
Contracted DUR
T: 907/334-2654
F: 907/561-1684
E-mail: edward.bako@alaska.gov
Within Federal and State guidelines,

ARIZONA individual managed care and pharmacy
DUR is conducted at benefit management organizations make
the plan level. formulary/drug decisions.

Pamela Ford, Pharm.D. Kendra Griffin
Pharmacist II Director, Retrospective DUR
Arkansas Department of Human Services Health Information Design
Division of Medical Services 391 Industry Drive
ARKANSAS
Pharmacy Program Auburn, AL 36832
Contracted DUR
P.O. Box 1437, Slot 415 T: 205/402-9530
Little Rock, AR 72203-1437 F: 205/402-9531
T: 501/683-4120 E-mail:
F: 501/683-4124 kendra.griffin@hdisolutions.com
E-mail: pamela.ford@arkansas.gov
A-24

J. Kevin Gorospe, Pharm.D. J. Kevin Gorospe, Pharm.D.
Chief, Pharmacy Policy Unit Chief, Pharmacy Policy Unit
California Department of Health Care
Services
CALIFORNIA Medi-Cal Policy Division
In-House and Pharmacy Contracting and Policy Section
Contracted DUR 1501 Capitol Avenue
P.O. Box 997413, MS 4604
T: 916/552-9500
F: 916/552-9563

Kimberly Eggert Kimberly Eggert
Pharmacist Pharmacist
Deptartment of Health Care Policy and
COLORADO Financing
Contracted DUR 1570 Grant Street
Denver, CO 80203
T: 303/866-3176
F: 303/866-3552
E-mail: kimberly.eggert@state.co.us

James R. Zakszewski, R.Ph. Anthony Ganter
Pharmacy Consultant Account Manager
Department of Social Services ACS State Healthcare
CONNECTICUT Medical Operations Unit 365 Northridge Road, Suite 400
Contracted DUR 25 Sigourney Street Atlanta, GA 30350
Hartford, CT 06106-5033 T: 866/322-5960
T: 860/424-5150 F: 866/246-8510
F: 860/951-9544 E-mail: anthony.ganter@acs-inc.com
E-mail: james.zakszewski@ct.gov

Cynthia R. Denemark, R.Ph. Cynthia R. Denemark, R.Ph.
Director of Pharmacy Services Director of Pharmacy Services
DSS/EDS DSS/EDS
DELAWARE
248 Chapman Road, Suite 100
Contracted DUR
Newark, DE 19702
T: 302/453-8453
F: 302/454-0224
A-25

Carolyn C. Rachel-Price, R.Ph. Jeffrey Dzieweczynski, R.Ph., M.S.
Pharmacy Director Clinical Manager
Department of Health ACS State Healthcare
DISTRICT OF
Medical Assistance Administration 750 First Street, NE, Suite 1020
COLUMBIA
825 North Capitol Street, NE Washington, DC 20002
Contracted DUR
Washington, DC 20002 T: 202/906-8353
T: 202/442-9078 F: 202/906-8399
F: 202/442-4790 E-mail: jeffrey.dzieweczynski@acs-
E-mail: carolyn.rachel@dc.gov inc.com

Linda G. Barnes, R.Ph. Heritage Information Systems
FLORIDA
Contracted DUR
T: 850/487-4441
F: 850/922-0685
E-mail: barnesl@ahca.myflorida.com

Patricia Zeigler-Jeter, R.Ph., M.P.A. Emily Baker, Director
DUR Coordinator-Rebate Pharmacist Clinical Programs
Department of Community Health Georgia Medicaid Clinical Information
GEORGIA Division of Medical Assistance c/o NorthStar HealthCare Consultants
Contracted DUR 2 Peachtree St. NW, 37th Floor 1120 Powers Place
Atlanta, GA 30303 Alpharetta, GA 30004
T: 404/656-4044 T: 404/308-2285
F: 404/657-5461 F: 877/295-0836
E-mail: pjeter@dch.ga.gov E-mail: GAMedicaid@nhc-llc.com
State Contact
Kathleen Kang-Kaulupali
Pharmacy Consultant
HAWAII
Med-Quest Division
In-House DUR
601 Kamokila Boulevard, Room 506-B
Kapolei, HI 90707
T: 808/692-8065
F: 808/692-8131
A-26

Tami Eide, Pharm.D., BCPS, FASHP Vaughn Culbertson, Pharmacist
Pharmacy Unit Supervisor Project Director
Department of Health and Welfare Idaho Drug Utilization Review
Division of Medicaid Idaho State U. - College of Pharmacy
IDAHO
3232 Elder Street 970 South 5th Street
Contracted DUR
Boise, ID 83705 Campus Box 8288
T: 208/364-1821 Pocatello, ID 83209-8288
F: 208/364-1864 T: 208/282-4597
E-mail: eidet@dhw.idaho.gov F: 208/282-4305
E-mail: vculb@pharmacy.isu.edu
State Contact
Drug Coverage policy
ILLINOIS Services
In-House DUR 201 S. Grand Avenue East
T: 217/782-2570
F: 217/782-5672
E-mail: lisa.voils@illinois.gov

DUR Board Secretary ACS State Healthcare
Office of Medicaid Policy and Planning 365 Northridge Road, Suite 400
Indiana State Government Center Atlanta, GA 30350
INDIANA
South-Room W382 T: 866/322-5960
Contracted DUR
402 West Washington Street F: 866/759-4100
T: 317/232-4307
F: 317/232-7382

Shelly Larson Shelly Larson
Director Director
Iowa Medicaid Enterprise Iowa Medicaid Enterprise
IOWA
100 Army Post Road
Contracted DUR
T: 515/725-1295
F: 515/725-1355
E-mail: slarson@dhs.state.ia.us
State Contact
Anne S. Ferguson, R.Ph.
DUR Director
KANSAS Kansas Health Policy Authority
In-House DUR 900 SW Jackson, Suite 900
Topeka, KS 66612
T: 785/274-7788
F: 785/296-4813
A-27
State Contact
Nici Gaines
Pharmacy Director
KENTUCKY CHR Building, 6 W-A
In-House DUR 275 East Main Street
Frankfort, KY 40621
T: 502/564-7940
F: 502/564-1351
E-mail: nici.gaines@ky.gov.us

Mary J. Terrebonne, Pharm.D. Shelly Delaville
Pharmacy Director Pharmacist
Department of Health and Hospitals Unisys
Pharmacy Benefits Management Unit 8591 United Plaza Blvd., Suite 300
LOUISIANA Bienville Building Baton Rouge, LA 70809
Contracted DUR 628 N. Fourth Street, 7th Floor T: 225/237-3227
P.O. Box 91030 F: 225/237-3334
Baton Rouge, LA 70821 E-mail: shelly.delaville@unisys.com
T: 225/342-9768
F: 225/342-1980
E-mail: mterrebo@dhh.state.la.us
State Contact
Kim Rackleff
Goold Health Systems
5 Community Drive
MAINE
P.O. Box 708
In-House DUR
T: 207/622-7153
F: 207/623-5125
E-mail: krackleff@ghsinc.com

Philip H. Cogan, Chief Philip H. Cogan, Chief
Clinical Pharmacy Services Division Clinical Pharmacy Services Division
DHMH
Office of Operations, Eligibility, and
MARYLAND
Pharmacy
In-House and
Contracted DUR
201 W. Preston St., Room 408
Baltimore, MD 21201
T: 410/767-5878
F: 410/333-5398
E-mail: coganp@dhmh.state.md.us
A-28

Paul L. Jeffrey Paul L. Jeffrey
Director of Pharmacy Director of Pharmacy
Office of Medicaid
MASSACHUSETTS
Contracted DUR
Boston, MA 02111
T: 617/210-5319
F: 617/210-5865

MDCH/Medical Services Administration First Health Services Corp.
Office of Medical Affairs 4300 Cox Rd.
MICHIGAN
400 S. Pine Street Glen Allen, VA 23060
In-House and
P.O. Box 30479 T: 800/884-2822
Contracted DUR
Lansing, MI 48909-7979 F: 804/527-6849
T: 517/335-5181
F: 517/241-8135
State Contact
Mary Beth Reinke, Pharm.D., M.S.A.
DUR Coordinator
Minnesota Dept. of Human Services
MINNESOTA
540 Cedar Street
In-House DUR
St. Paul, MN 55155
T: 651/431-2505
F: 651/431-7426
E-mail: mary.beth.reinke@state.mn.us

Paige Black Clayton, Pharm.D. Dennis Smith
Pharmacist Project Manager
Division of Medicaid Heritage Information Design
Walter Sillers Building, 10th Floor P.O. Box 320506
MISSISSIPPI
550 High Street Flowood, MS 39232
Contracted DUR
Jackson, MS 39201 T: 601/709-0000
T: 601/359-5253 F: 800/459-2135
F: 601/359-9555 E-mail:
E-mail: phpbc@medicaid.state.ms.us dennis.smith@hidsolutions.com

Tisha A. Honse Tisha A. Honse
DUR Coordinator DUR Coordinator
Div. of Medical Services
MISSOURI
205 Jefferson Street, 10th Floor
Contracted DUR
P.O. Box 6500
T: 573/751-6961
F: 573/522-8514
E-mail: Tisha.A.House@dss.mo.gov
A-29

Mark Eichler, R.Ph., FASCP Mark Eichler, R.Ph.
Pharmacy Programs Director Mountain-Pacific Quality Health
Mountain-Pacific Quality Health Foundation Foundation
MONTANA
3404 Cooney Drive
Contracted DUR
Helena, MT 59602
T: 406/457-5818
F: 406/443-7014
E-mail: meichler@mpqhf.org

Marcia Meuting Marcia Meuting
DUR Director DUR Director
Nebraska Pharmacists Association Nebraska Pharmacists Association
NEBRASKA
6221 South 58th Street, Suite A
Contracted DUR
Lincoln, NE 68516
T: 402/420-1500
F: 402/420-1406
E-mail: marcia@npharm.org

Mary Griffith Steve Espy, R.Ph.
Division of Health Care Financing and Policy Director of Drug Utilization
Pharmacy Program Health Info. Design, Inc.
NEVADA
1100 E. Williams Street 1550 Pumphrey Avenue
Contracted DUR
Carson City, NV 89701 Auburn, AL 36832
T: 775/684-3751 T: 205/402-9530
F: 775/684-3762 F: 205/402-9531
E-mail: mary.griffith@dhcfp.nv.gov

Lise C. Farrand, R.Ph. Robert Coppola, Pharm.D.
Pharmaceutical Services Specialist Account Manager
Office of Medicaid Business and Policy First Health Services Corp.
NEW HAMPSHIRE
129 Pleasant Street, Annex Building 17 Chenell Dirve
Contracted DUR
Concord, NH 03301 Concord, NH 03301
T: 603/271-4419 T: 603/224-2083
F: 603/271-8701 F: 603/224-6690
E-mail: lfarrand@dhhs.state.nh.us E-mail: coppolro@fhsc.com
State Contact
Kaye S. Morrow
Division of Medical Assistance and Health
NEW JERSEY Services
In-House DUR Office of Provider Relations
P.O Box 712
Trenton, NJ 08619
T: 609/631-2396
F: 609/588-3889
A-30
State Contact
John Erb, Pharm.D.
Pharmacist
NEW MEXICO Medical Assistance Division
In-House DUR P.O. Box 2348
Sante Fe, NM 87504-2348
T: 505/827-3129
F: 505/827-3196
E-mail: JohnN.Erb@state.nm.us
State Contact
Lydia J. Kosinski, R.Ph., Manager
Recipient Activities and Utilization Review
Office of Medicaid Inspector General
NEW YORK NYS Dept. of Health
In-House DUR 800 North Pearl Street
Albany, NY 12204
T: 518/474-6866
F: 518/473-5332
E-mail: ljk02@health.state.ny.us
State Contact
Glenda Adams, Pharm.D.
DUR Coordinator
Department of Human Resources
Division of Medical Assistance
NORTH CAROLINA
1985 Umstead Drive
In-House DUR
2501 Mail Services Center
Raleigh, NC 27699
T: 919/855-4300
F: 919/715-1255
E-mail: Glenda.Adams@ncmail.net
State Contact
Administrator, Pharmacy Services
North Dakota Department of Human Services
NORTH DAKOTA
600 E. Boulevard Avenue, Dept. 325
In-House DUR
T: 701/328-4023
F: 701/328-1544
State Contact
Margaret Scott, R.Ph.
Pharmacologist
OHIO
P.O. Box 182709
In-House DUR
T: 614/466-9689
F: 614/466-2866
A-31

Ronald Graham, D.Ph. Ronald Graham, D.Ph.
Manager, Operations/DUR Manager, Operations/DUR
University of Oklahoma University of Oklahoma
College of Pharmacy College of Pharmacy
OKLAHOMA
ORI W-4403
Contracted DUR
P.O. Box 26901
T: 405/271-6614
F: 405/271-2615
E-mail: ronald-graham@ouhsc.edu

Kathy L. Ketchum, R.Ph., M.P.A-H.A. Kathy L. Ketchum, R.Ph., M.P.A-H.A.
Medicaid Program Coordinator Medicaid Program Coordinator
OREGON Oregon State University College of Pharmacy
Contracted DUR 500 Summer Street, NE
Salem, OR 97301
T: 503/947-5220
E-mail: ketchumk@ohsu.edu
State Contact
Terri Cathers
Director of Pharmacy Programs
PENNSYLVANIA
49 Beech Drive, 2nd Floor, Room 228
In-House DUR
T: 717/346-8156
F: 717/346-8171
E-mail: c-tcathers@state.pa.us

Paula J. Avarista, R.Ph., M.B.A. Health Information Design
Chief of Pharmacy
Departrment of Human Services
RHODE ISLAND
600 New London Avenue
Contracted DUR
Cranston, RI 02920
T: 401/462-6390
F: 401/462-6336
E-mail: pavarista@dhs.ri.gov
State Contact
James M. Assey, R.Ph., Director
Division of Pharmacy and DME Services
Department of Health & Human Services
SOUTH CAROLINA
P.O. Box 8206
In-House DUR
T: 803/898-2876
F: 803/255-8353
E-mail: asseyj@scdhhs.gov
A-32
State Contact
Connie Hohn
Rebate Coordinator
SOUTH DAKOTA
700 Governors Drive
In-House DUR
Pierre, SD 57501
T: 605/773-5013
F: 605/773-4855
E-mail: Connie.Hohn@state.sd.us

Jeffery G. Stockard, D.Ph. First Health Services Corporation
Associate Pharmacy Director 4300 Cox Road
Bureau of TennCare Glen Allen, VA 23060
TENNESSEE
310 Great Circle Road T: 800/884-2822
Contracted DUR Nashville, TN 37243 F: 804/273-6961
615/507-6496
E-mail: jeff.stockard@state.tn.us

Don Valdes, R.Ph, Manager Don Valdes, R.Ph., Manager
DUR/Formulary DUR/Formulary
Texas Health and Human Services
Commision
TEXAS
Medicaid and CHIP Division
Contracted DUR
11209 Metric Boulevard, Building H630
Austin, TX 78758
T: 512/491-1157
F: 512/491-1962
E-mail: Don.Valdes@hhsc.state.tx.us
State Contact
Tim Morley
Pharmacist
Utah Medicaid
UTAH Division of Health Care Financing
In-House DUR 288 North 1460 West
P.O. Box 143102
T: 801/538-6293
F: 801/538-6099
E-mail: tmorley@utah.gov
A-33

Diane Neal Diane Neal
Clinical Pharmacist Clinical Pharmacist
MedMetrics Health Partners
VERMONT
312 Hurricane Lane, Suite 200
Contracted DUR
Williston, VT 05495
T: 802/879-5605
F: 802/879-5919
E-mail: diane.neal@medmetricshp.com

Rachel E. Cain, Pharm.D. Donna Johnson
Clinical Pharmacist Clinical Manager – Virginia Medicaid
Deparment of Medical Asistance Services First Health Services Corporation
VIRGINIA
600 East Broad Street, Suite 1300 4300 Cox Road
Contracted DUR
Richmond, VA 23219 Glen Allen, VA 23060
T: 804/783-2873 804/290-4833
F: 804/786-0973 E-mail:
E-mail: Rachel.Cain@dmas.virginia.gov donnajohnson@firsthealth.com
State Contact
Nicole N. Nguyen, Pharm.D.
Clinical Pharmacist
DSHS
WASHINGTON
626 8th Avenue, SE
In-House DUR
P.O. Box 45506
T: 360/725-1757
F: 360/586-8827
E-mail: nguyen@dshs.wa.gov

Vicki M. Cunningham, R.Ph. Craig Boon, Director
DUR Coordinator Account Management
Department of Health and Human Services ACS-Heritage Information Systems
WEST VIRGINIA Bureau for Medical Services 2810 N. Parham Road, Suite 210
In-House and Office of Pharmacy Services Richmond, VA 23294
Contracted DUR 350 Capitol Street, Room 251 T: 804/965-8293
Charleston, WV 25301-3707 F: 804/397-0687
T: 304/558-1700 E-mail: craigb@heritage-info.com
F: 304/558-1542
E-mail: vickicunningham@wvdhhr.org
A-34

Michael Mergener, R.Ph., Ph.D. Michael Mergener, R.Ph. Ph.D.
Chief Pharmacist Chief Pharmacist
APS Healthcare APS Healthcare
WISCONSIN 10 East Doty St., Suite 210
Contracted DUR Madison, WI 53702
T: 608/258-3350
F: 608/258-3359
E-mail: mergema@dhfs.state.wi.us

Aimee Lewis, Pharm.D. Aimee Lewis, Pharm.D.
DUR Manager DUR Manager
University of Wyoming School of Pharmacy University of Wyoming School of
WYOMING 1000 East University Avenue Pharmacy
Contracted DUR Department Box 3375
Laramie, WY 82071
T: 307/766-6750
F: 307/788-3160
E-mail: alewis@uwyo.edu
A-35
CLAIMS SUBMISSION CONTACT
ALABAMA COLORADO
Susan Jones Susan Pfau
Fiscal Agent Liaison (EDS) ACS State Healthcare
Alabama Medicaid Agency 600 17th Street
501 Dexter Avenue Suite 600 North
P.O. Box 5624 Denver, CO 80202
Montgomery, AL 36103-5624 T: 800/237-0757
T: 334/242-5553 F: 303/534-0439
F: 334/242-7014
E-mail: susan.jones@medicaid.alabama.gov
CONNECTICUT
Ellen Arce
ALASKA
Pharmacy Manager
First Health Services Corporation EDS
4300 Cox Road 195 Scott Swamp Road
Glen Allen, VA 23060 Farmington, CT 06032
800/965-7400 860/255-3822
E-mail: ellen.arce@eds.com
ARIZONA
DELAWARE
Del Swan
Pharmacy Program Administrator Cynthia R. Denemark, R.Ph.
AHCCCS Director of Pharmacy Services
701 East Jefferson Street DSS/EDS
MD 8000 248 Chapman Rd, Suite 100
Phoenix, AZ 85034 Newark, DE 19702
T: 602/417-4726 T: 302/453-8453
F: 602/254-1769 F: 302/454-0224
E-mail: del.swan@azahcccs.gov E-mail: cynthia.denemark@eds.com
ARKANSAS DISTRICT OF COLUMBIA

John Herzog Kathryn Novak
Account Manager Account Manager
EDS First Health Services Corporation
500 President Clinton Ave., Suite 400 4300 Cox Road
Little Rock, AR 72201 Glen Allen, VA 23060
T: 501/374-6608 T: 443/263-8669
F: 501/372-2971 F: 443/263-7062
E-mail: john.herzog@eds.com E-mail: kathryn.novak@fhsc.com
CALIFORNIA
EDS
P.O. Box 13029
MS 4604
916/636-1000
A-36
FLORIDA INDIANA
Kevin Whittington EDS
Clinical Program Coordinator 950 N. Meridian Street
ACS State Healthcare Suite 1150
904 Roswell Road Indianapolis, IN 46204
Roswell, GA 800/577-3240
850/201-1111
IOWA
GEORGIA
Sandy Pranger, R.Ph.
SXC POS Account Manager
2441 Warrenville Road Iowa Medicaid Enterprise
Suite 610 100 Army Post Road
Lisle, IL 60532-37101 Des Moines, IA 50315
T: 630/577-3100 T: 515/725-1272
F: 630/577-3101 F: 515/725-1357
HAWAII
Ulka Pandya KANSAS
Account Manager EDS
ACS State Healthcare 3600 SW Topeka Boulevard
365 Northridge Road, Suite 400 Suite 204
Atlanta, GA 30350 Topeka, KS 66611
Attn: Hawaii Medicaid T: 785/274-4200
T: 808/952-5564 F: 785/267-7687
F: 888/725-7559
E-mail: ulka.pandya@acs-inc.com
KENTUCKY
Nici Gaines
IDAHO
Pharmacy Director
EDS Department for Medicaid Services
P.O. Box 23 CHR Building, 6 W-A
Boise, ID 83707 275 East Main Street
T: 208/395-2000 Frankfort, KY 40621
F: 208/395-2030 T: 502/564-7940
F: 502/564-1351
ILLINOIS E-mail: nici.gaines@ky.gov
Illinois Dept. of Healthcare and Family Services

201 S. Grand Avenue East LOUISIANA
Springfield, IL 62763 Carol Simpson
T: 217/782-2570 Project Manager
F: 217/782-5672 Unisys
8591 United Plaza Blvd., Ste. 300
T: 225/237-3391
F: 225/237-3334
E-mail: carol.simpson@unisys.com
A-37
MAINE MISSISSIPPI
Marcia Pykare Chris Bryan
Goold Health Systems Pharmacy Services Manager
5 Community Drive ACS State Healthcare
P.O. Box 708 385-B Highland Colony Parkway
Augusta, ME 04332-0708 Ridgeland, MS 39157
T: 207/622-7153 T: 601/206-9595
F: 207/623-5125 F: 601/572-3200
E-mail: mpykare@ghsinc.com E-mail: chris.bryan@acs-inc.com
MARYLAND MISSOURI
James Demery Diane Twehous
Manager, Pharmacy Services Account Manager
DHMH Infocrossing Health Care Services, Inc.
Office of Operations, Eligibility, and Pharmacy 905 Weathered Rock Rd.
Division of Claims Processing Jefferson City, MO 65109
201 W. Preston St. 573/635-2434
Baltimore, MD 21201
T: 401/767-6028
MONTANA
F: 410/333-5398
E-mail: demeryj@dhmh.state.md.us Brett Jakovac
Executive Account Manager
MASSACHUSETTS
34 N. Last Chance Gulch, Suite 200
ACS State Healthcare Helena, MT 59601
365 Northridge Road, Suite 400 T: 406/457-9555
Atlanta, GA 30350 F: 406/442-2819
T: 800/358-2381 E-mail: brett.jakovac@acs-inc.com
F: 770/730-5198
NEBRASKA
MICHIGAN
George Jackson
First Health Services Corporation Account Manager
4300 Cox Road ACS State Healthcare
Glen Allen, VA 23060 365 Northridge Road
F: 804-527-6849 Atlanta, GA 30350
T: 770/901-5002 ext. 5034
MINNESOTA F: 888/772-2250
E-mail: george.jacksoniii@acs-inc.com
Larry Woods
Health Care Operations
NEVADA
Minnesota Dept. of Human Services
540 Cedar Street First Health Services Corporation
St. Paul, MN 51555 P.O. Bos 30042
651/431-3082 Reno, NV 89520-3042
877/638-3472
E-mail: nevadamedicaid@fhsc.som
A-38
NEW HAMPSHIRE NORTH DAKOTA

Sherrill Bryant Brendan K. Joyce, Pharm.D., R.Ph.
Plan Administrator Administrator, Pharmacy Services
First Health Services Corp. North Dakota Department of Human Services
4300 Cox Road 600 East Boulevard Avenue, Department 325
Glen Allen, VA 23060 Bismarck, ND 58505-0250
T: 800/884-2822 T: 701/328-4023
F: 804/965-7647 F: 701/328-1544
E-mail: bryantsh@fhsc.com E-mail: sojoyb@nd.gov
NEW JERSEY OHIO

Mark Nemerson F. Joseph Brown
Administrative Analyst ACS State Healthcare
Department of Human Services 375 Northridge Road
Division of Medical Assistance and Health Services Suite 400
P.O. Box 712 Atlanta, GA 30350
Trenton, NJ 08619 800/358-2381
T: 609/588-3404
F: 609/588-3889
OKLAHOMA
E-mail: mark.nemerson@dhs.state.nj.us
EDS
2401 N.W. 23rd Street, Suite 11
NEW MEXICO
ACS State Healthcare 405/416-6794
365 Northridge Road
Northridge Center One, Suite 400
OREGON
Atlanta, GA 30350
T: 800/365-4944 Bill Milne, R.Ph.
F: 770/730-5198 Account Manager
P.O. Box 181
NEW YORK
Canby, OR 97013
eMedNY T: 503/391-1980
Computer Sciences Corporation F: 503/391-1979
Attn: eMedNY Webmaster
One CSC Way
PENNSYLVANIA
800/343-9000 EDS
E-mail: general@emedny.org 225 Grandview Avenue
Camp Hill, PA 17011
717/731-1250
NORTH CAROLINA
(All contacts with contractor must be
Sharon Greeson, R.Ph. made through State agency.)
Pharmacy Director
EDS RHODE ISLAND
4905 Waters Edge Dr.
Raleigh, NC 27606 EDS
T: 919/816-4475 171 Service Avenue
F: 919/816-4399 Building 1, Suite 100
E-mail: sharon.greeson@eds.com Warwick, RI 02886
401/784-3879
A-39
SOUTH CAROLINA VIRGINIA

First Health Services Corporation Doug Davis
4300 Cox Road Claims Processing Administrator
Glen Allen, VA 23060 First Health Services Corporation
T: 804/965-7778 4300 Cox Road
T: 804/273-6961 Glen Allen, VA 23060
804/965-7400
SOUTH DAKOTA
WASHINGTON
Pharmacy Consultant Joann Fulton
South Dakota Medicaid Acting Claims Processing Office Chief
700 Governors Drive Health and Recovery Services Administrator, DSHS
Pierre, SD 57501 P.O. Box 45560
T: 605/773-3495 Olympia, WA 98504
F: 605/773-5246 360/725-1239
E-mail: Mark.Petersen@state.sd.us E-mail: fultojc@dshs.wa.gov
TENNESSEE WEST VIRGINIA

First Health Services Corporation Eric N. Sears, R.Ph.
4300 Cox Road Pharmacy Benefits Manager
Glen Allen, VA 23060 Unisys Corporation
T: 804/965-7451 1600 Pennsylvania Avenue
F: 804/290-4831 Charleston, WV 25302
T: 304/348-3200
F: 304/353-6314
TEXAS
E-mail: eric.sears@unisys.com
4300 Cox Road
WISCONSIN
804/965-7400 EDS
6406 Bridge Road
UTAH
T: 608/221-4746
Brenda Bryant, Assistant Director F: 608/221-4567
Division of Health Care Financing
WYOMING
288 North 1460 West, P.O. Box 143102
Salt Lake City, UT 84116 ACS State Healthcare
F: 801-536-0473 365 Northridge Road
E-mail: bbryant@utah.gov Atlanta, GA 30350
T: 866/322-5960
F: 888/335-8459
VERMONT
Medmetric Health Partners
100 Century Drive
Worcester, MA 01606
A-40
PRESCRIPTION PRICE UPDATING CONTACTS
ALABAMA COLORADO
Stephanie Frawley Catherine Traugott, R.Ph., J.D.
FBD contract Administrator Pharmacy Supervisor
Alabama Medicaid Agency Department of Health Care Policy and Financing
501 Dexter Avenue 1570 Grant Street
P.O. Box 5624 Denver, CO 80203
Montgomery, AL 36103-5624 T: 303/866-2468
T: 334/353-4592 F: 303/866-3552
F: 334/353-7014 E-mail: catherine.traugott@state.co.us
E-mail: stephanie.frawley@medicaid.alabama.gov
CONNECTICUT
ALASKA
Mark Synol
Dave Campana, R.Ph. Staff Pharmacist
Pharmacy Program Manager EDS
Division of Health Care Services 195 Scott Swamp Road
4501 Business Park Blvd., Suite 24 Farmington, CT 06032
Anchorage, AK 99503 860/255-3886
T: 907/273-3224 E-mail: mark.synol@eds.com
F: 907/561-1684
E-mail: david.campana@alaska.gov
DELAWARE
ARIZONA
Director of Pharmacy Services
Del Swan 248 Chapman Road, Suite 100
Pharmacy Program Administrator Newark, DE 19702
AHCCCS T: 302/453-8453
701 East Jefferson Street F: 302/454-0224
MD 8000 E-mail: cynthia.denemark@eds.com
Phoenix, AZ 85034
T: 602/417-4726
DISTRICT OF COLUMBIA
F: 602/254-1769
E-mail: del.swan@azahcccs.gov Carolyn C. Rachel-Price, R.Ph.
Pharmacy Director
ARKANSAS
First DataBank 825 North Capitol Street, NE, Suite 5136
1111 Bayhill Drive, Suite 350 Washington, DC 20002
San Bruno, CA 94066 T: 202/442-9078
T: 650/588-5454 F: 202/442-4790
F: 650/588-4003 E-mail: carolyn.rachel@dc.gov
CALIFORNIA
EDS Federal Corporation
P.O. Box 13029, MS 4604
916/636-1000
A-41
FLORIDA INDIANA
First DataBank First DataBank
1111 Bayhill Drive, Suite 350 1111 Bayhill Drive, Suite 350
San Bruno, CA 94066 San Bruno, CA 94066
T: 650/588-5454 T: 650/588-5454
F: 650/827-5454 F: 650/588-4003
GEORGIA IOWA
Amy Guenette Sandy Pranger, R.Ph.
Vice President for Clinical Products POS Account Manager
SXC Iowa Medicaid Enterprise
2441 Warrenville Road 100 Army Post Road
Lisle, IL 60532-3642 Des Moines, IA 50315
T: 630/577-3120 T: 515/725-1272
F: 630/577-3101 F: 515/725-1357
E-mail: amy.guenette@sxc.com E-mail: sprange@dhs.state.ia.com
HAWAII KANSAS
ACS State Healthcare Dr. Margaret Smith
365 Northridge Road, Suite 400 Pharmacy Program Manager
Atlanta, GA 30350 Kansas Health Policy Authority
Attn: Hawaii Medicaid 900 SW Jackson, Suite 900
T: 800/358-2381 Topeka, KS 66612
F: 770/730-5198 T: 785/296-4753
F: 785/296-4813
IDAHO
KENTUCKY
David Mendoza
Pharmacy Tech. Nici Gaines
Department of Health and Welfare Pharmacy Director
Division of Medicaid Department for Medicaid Services
3232 Elder Street CHR Building, 6 W-A
Boise, ID 83705 275 East Main Street
T: 208/364-1838 Frankfort, KY 40621
F: 208/364-1864 T: 502/564-7940
E-mail: mendozad@idhw.idaho.gov F: 502/564-1351
ILLINOIS
LOUISIANA
Drug Coverage Policy Maggie Vick
Illinois Department of Health and Family Services Unisys
201 S. Grand Avenue East 8591 United Plaza Blvd., Ste. 300
Springfield, IL 67263 Baton Rouge, LA 70809
T: 217/782-2570 T: 225/216-6251
F: 217/782-5672 F: 225/216-6334
E-mail: lisa.voils@illinois,gov E-mail: margaret.vick@unisys.com
A-42
MAINE MISSISSIPPI
Marcia Pykare Terri R. Kirby, R.Ph., Pharmacist
Goold Health Systems Division of Medicaid
5 Community Drive Walter Sillers Building, 10th Floor
P.O. Box 708 550 High Street
Augusta, ME 04332-0708 Jackson, MS 39201
T: 207/622-7153 T: 601/359-5253
F: 207/623-5125 F: 601/359-9555
E-mail: mpykare@ghsinc.com E-mail: phtrk@medicaid.state.ms.us
MARYLAND MISSOURI
Frank Tetkoski, P.D., Chief First DataBank
Division of Pharmacy Services 1111 Bayhill Drive, Suite 350
DHMH, Office of Operations, Eligibility, and San Bruno, CA 94066
Pharmacy T: 650/588-5454
201 West Preston Street, Room 409 F: 650/827-4510
Baltimore, MD 21201
T: 410/767-1460
MONTANA
F: 410/333-5398
E-mail: tetkoskif@dhmh.state.md.us First DataBank
San Bruno, CA 94066
MASSACHUSETTS
T: 650/588-5454
First DataBank F: 650/827-4578
San Bruno, CA 94066
NEBRASKA
T: 650/588-5454
F: 650/827-4578 Barbara Mart, Pharmacy Consultant
Finance and Support/Medicaid Division
MICHIGAN
301 Centennial Mall South, 5th Floor-NSOB
First Health Services Corporation P.O. Box 95026
4300 Cox Road Lincoln, NE 68509-5026
Glen Allen, VA 23060 T: 402/471-9301
T: 800/884-2822 F: 402/471-9092
F: 804/527-6849 E-mail: barbara.mart@hhss.ne.gov
MINNESOTA NEVADA
First DataBank First DataBank
1111 Bay Hill Drive, Suite 350 1111 Bayhill Drive, Suite 350
San Bruno, CA 94066 San Bruno, CA 94066
T: 800/633-3453 T: 650/588-5454
F: 650/588-4003 F: 650/827-4578
A-43
NEW HAMPSHIRE NORTH CAROLINA

Robert Coppola, Pharm.D. Tom D’Andrea, R.Ph., M.B.A.
Account Manager Chief of Pharmacy and Ancillary Services
First Health Services Corp. Department of Health and Human Services
17 Chenell Drive Division of Medical Assistance
Concord, NH 03301 1985 Umstead Drive
T: 603/224-2083 2501 Mail Service Center
F: 603/224-6690 Raleigh, NC 27699
E-mail: coppolro@fhsc.com T: 919/855-4300
F: 919/715-1255
NEW JERSEY E-mail: Tom.Dandrea@ncmail.net
First DataBank
NORTH DAKOTA
San Bruno, CA 94066 Brendan K. Joyce, Pharm.D., R.Ph.
T: 650/588-5454 Administrator, Pharmacy Services
F: 650/827-4578 North Dakota Department of Human Services
600 East Boulevard Avenue
NEW MEXICO Dept. 325
Bismark, ND 58505-0250
Julie A. McKeay T: 701/328-4023
Pharmacy Program Administrator F: 701/328-1544
Human Services Department E-mail: sojoyb@nd.gov
P.O. Box 2348
OHIO
Santa Fe, NM 87504-2348
T: 505/827-6202 First DataBank
F: 505/827-3196 1111 Bayhill Drive, Suite 350
E-mail: julie.mckeay@state.nm.us San Bruno, CA 94066
T: 650/588-5454
NEW YORK F: 650/827-4578
Carl T. Cioppa, Pharm.D.

OKLAHOMA
Pharmacy Operations Manager
Department of Health First DataBank
Office of Health Insurance Programs 1111 Bayhill Drive, Suite 350
99 Washington Avenue San Bruno, CA 94066
Albany, NY 12210 800/633-3453
T: 518/486-3209
F: 518/473-5508
OREGON
E-mail: ctc02@health.state.ny.us
Debbie L. Bishop
Division of Medical Assistance Programs
500 Summer Street, NE, E-35
Salem, OR 97301-1077
T: 503/945-6291
F: 503/947-1119
E-mail: debbie.l.bishop@state.or.us
A-44
PENNSYLVANIA TEXAS
Terri Cathers Betty Wasko, Formulary Analyst
Director of Pharmacy Programs Texas Health and Human Services Commission
Department of Public Welfare Vendor Drug Program
49 Beech Drive, 2nd Floor, Room 228 11209 Metric Boulevard, H630
Harrisburg, PA 17110-3591 Austin, TX 78758
T: 717/346-8164 512/491-1155
F: 717/346-8171 E-mail: Emma.Wasko@hhsc.state.tx.us
UTAH
RHODE ISLAND
Paula J. Avarista, R.Ph., M.B.A. Pharmacy Director
Chief of Pharmacy Utah Medicaid
Department of Human Services Department of Health
600 New London Avenue Division of Health Care Financing
Cranston, RI 02919 P.O. Box 143102
T: 401/462-6390 Salt Lake City, UT 84114
F: 401/462-6336 T: 801/538-6495
E-mail: pavarista@dhs.ri.gov F: 801/538-6099
E-mail: rashley@utah.gov
SOUTH CAROLINA
VERMONT
First DataBank
1111 Bayhill Drive, Suite 350 Bob Rase
San Bruno, CA 94066 Medmetrics Health Partners
T: 650/588-5454 10975 Benson Drive, Suite 100
F: 650/872-4578 Overland Park, KS 62210
E-mail: editorialservices@firstdatabank.com 913/451-9466
SOUTH DAKOTA VIRGINIA

Mark E. Petersen, R.Ph. Keith T. Hayashi
Pharmacy Consultant Pharmacist
South Dakota medicaid Department of Medical Assistance Services
700 Governors Drive 600 East Broad Street, Suite 1300
Pierre, SD 57501 Richmond, VA 23219
T: 605/773-3495 T: 804/225-2773
F: 605/773-5246 F: 804/786-0973
E-mail: mark.petersen@state.sd.us E-mail: Keith.Hayashi@virginia.gov
TENNESSEE WASHINGTON
First DataBank Johnna Ziegler
1111 Bayhill Drive, Suite 350 Cost Reimbursement Analyst
San Bruno, CA 94066 Health and Recovery and Services Administration
T: 650/588-5454 DSHS
F: 650/588/6867 P.O. Box 45510
360/725-1841
E-mail: zieglje@dshs.wa.gov
A-45
WEST VIRGINIA
Eric N. Sears, R.Ph.
Pharmacy Benefits Manager
Unisys Corporation
1600 Pennsylvania Avenue
T: 304/348-3200
F: 304/353-6314
E-mail: eric.sears@unisys.com
WISCONSIN
Carrie L. Gray
Wisconsin Medicaid
Madison, WI 53702
T: 608/266-3901
F: 608/266-1096
WYOMING
First DataBank
San Bruno, CA 94066
T: 800/633-3453
F: 650/588-4003
A-46
MEDICAID DRUG REBATE CONTACTS
ALABAMA CALIFORNIA
Lynn M. Abrell Craig Miller
Associate Director Chief, Drug Rebate and Vision Section
Drug Rebate Department of Health Care Services
Alabama Medicaid Agency Medi-Cal Policy Division
501 Dexter Avenue Pharmacy Contracting and Policy Section
P.O. Box 5624 1501 Capitol Avenue
Montgomery, AL 36103-5624 P.O. Box 997417, MS 4604
T: 334/242-2326 Sacramento, CA 95899-7417
F: 334/353-7014 T: 916/552-9500
E-mail: lynn.abrell@medicaid.alabama.gov F: 916/552-9563
E-mail: cmiller@dhs.ca.gov
ALASKA
Dave Campana, R.Ph. COLORADO
Vince Sherry
Drug Rebate Manager
4501 Business Park Blvd., Suite 24
Anchorage, AK 99503
1570 Grant Street
T: 907/334-2425
Denver, CO 80203
F: 907/561-1684
T: 303/866-5408
E-mail: david.campana@alaska.gov
F: 303/866-3552
E-mail: vince.sherry@state.co.us
ARIZONA
Del Swan CONNECTICUT
Pharmacy Program Administrator Evelyn A. Dudley
AHCCCS Pharmacy Manager
701 East Jefferson Street Department of Social Services
MD 8000 Medical Operations Unit
Phoenix, AZ 85034 25 Sigourney Street
T: 602/417-4726 Hartford, CT 06106-5033
F: 602/254-1769 T: 860/424-5654
E-mail: del.swan@ahcccs.gov F: 860/951-9544
E-mail: evelyn.dudley@ct.gov
ARKANSAS
Suzette Bridges, Pharm.D., Administrator DELAWARE
Pharmacy Program Cynthia R. Denemark, R.Ph.
Department of Human Services Director of Pharmacy Services
Division of Medical Services DSS/EDS
Pharmacy Program 248 Chapman Road, Suite 100
P.O. Box 1437, Slot 415 Newark, DE 19702
Little Rock, AR 72203-1437 T: 302/453-8453
T: 501/683-4120 F: 302/454-0224
F: 501/683-4124 E-mail: cynthia.denemark@eds.com
E-mail: suzette.bridges@arkansas.gov
A-47
DISTRICT OF COLUMBIA ILLINOIS

Jeffrey Dzieweczynski, R.Ph., M.S. Jeff Naber
Clinical Manager Bureau of Budget and Cash Management
ACS State Healthcare IL Department of Healthcare and Family Services
750 First Street, NE, Suite 1020 2200 Churchill Road, Bldg A-1
Washington, DC 20002 Springfield, IL 62702
T: 202/906-8353 T: 217/524-7161
F: 202/906-8399 F: 217/785-4174
E-mail: jeffrey.dzieweczynski@acs-inc.com E-mail: jeff.naber@illinois.gov
FLORIDA INDIANA
Carla G. Sims Demetrius Murphy
Rebate Coordinator Senior Accounting Rebate Specialist
Agency for Health Care Administration ACS State Healthcare
2728 Mahan Dr., MS 38 365 Northridge Rd., Suite 400
Tallahassee, FL 32308 Atlanta, GA 30350
T: 850/487-4441 T: 770/901-5002 ext. 3291
F: 850/922-0685 F: 866/759-4100
E-mail: simsc@ahca.myflorida.com E-mail: demitrius.murphy@acs-inc.com
GEORGIA
IOWA
Patricia Zeigler-Jeter, M.P.A., R.Ph.
Sandy Pranger, R.Ph.
DUR Coordinator-Rebate Pharmacist
POS Account Manager
100 Army Post Road
2 Peachtree St., NW, 37th Floor
Atlanta, GA 30303
T: 515/725-1272
T: 404/656-4044
F: 515/725-1357
F: 404/657-5461
E-mail: pjeter@dch.ga.gov
KANSAS
HAWAII
Anne S. Ferguson, R.Ph.
Joseph Braun
Drug Rebate Program Manager
Drug Rebate Supervisor
Topeka, KS 66612
Atlanta, GA 30350
T: 785/296-7778
Attn: Hawaii Medicaid
F: 785/296-4813
800/358-4122
KENTUCKY
IDAHO
Nici Gaines, Pharmacy Director
Larry Tisdale
Program Supervisor
CHR Building, 6 W-A
3rd Party Recovery Unit
275 E. Main Street
3232 Elder Street
Frankfort, KY 40621
Boise, ID 83705
T: 502/564-7940
208/287-1141
F: 502/564-1351
E-mail: tisdale@dhw.idaho.gov
A-48
LOUISIANA MINNESOTA
Amanda Caire Jarvis P. Jackson, R.Ph.
UNO Rebate Manager Drug Rebate Coordinator
University of New Orleans Department of Human Services
1201 Capitol Access Road, 6th Floor 540 Cedar Street
P.O. Box 91030 St. Paul, MN 55155-3853
Baton Rouge, LA 70821 T: 651/431-2543
T: 225/342-0427 F: 651/431-7426
F: 225/342-1980 E-mail: jarvis.jackson@state.mn.us
E-mail: acaire@dhh.la.gov
MISSISSIPPI
MAINE
Christopher Yount
Rossi Rowe, Director DRAMS Business Analyst
Third Party Liability ACS State Healthcare
Department of Health and Human Services 385-B Highland Colony Parkway
Office of MaineCare Services Ridgeland, MS 39157
11 SHS, 442 Civic Center Drive T: 601/206-2904
Augusta, ME 04333 F: 601/572-3200
T: 207/287-1838 E-mail: christopher.yount@acs-inc.com
F: 207/287-1788
E-mail: rossi.rowe@maine.gov
MISSOURI
MARYLAND Jacqueline K. Hickman
Medicaid Unit Supervisor
Dorine B. Rascoe
Accountant
DHMS, Office of Operations, Eligibility, and
205 Jefferson Street, 10th Floor
Pharmacy
P.O. Box 6500
201 West Preston, Street, Room 409
Baltimore, MD 21201
T: 573/526-5664
T: 410/767-6992
F: 573/522-4650
F: 410/333-5398
E-mail: Jacqueline.K.Hickman@dss.mo.gov.
E-mail: rascoed@dhmh.state.md.us
MASSACHUSETTS MONTANA
Emily Toohey Betty DeVaney
ACS State Healthcare Drug Rebate Coordinator
260 Franklin Street, 10th Floor Dept. of Public Health and Human Services
Boston, MA 02110 Medicaid Services Bureau
T: 617/423-9841 1400 Broadway
F: 617/423-9846 P.O. Box 202951
E-mail: emily.toohey@acs-inc.com Helena, MT 59620-2951
T: 406/444-3457
F: 406/444-1861
MICHIGAN
E-mail: bdevaney@mt.gov
4300 Cox Road
T: 800/884-2822
F: 804/527-6849
A-49
NEBRASKA NEW MEXICO

Karen Jaques Sherry Montoya, Pharmacist
Accountant II Human Services Department
HHSS-Finance and Support Medical Assistance Division
301 Centennial Mall South P.O. Box 2348
NSOB, 5th Floor Santa Fe, NM 87504-2348
P.O. Box 95026 T: 505/827-7777
Lincoln, NE 68509 F: 505/827-3196
T: 402/471-9397 E-mail: sherry.montoya@state.nm.us
F : 402/471-7783
E-mail: karen.jaques@hhss.ne.gov
NEW YORK
NEVADA Joseph A. Maiello, M.S., R.Ph.
Pharmacy Rebate Manager
Mary Griffith
Office of Health Insurance Programs
NYS Department of Health
Pharmacy Program
99 Washington Ave.
1100 E. Williams Street
Albany, NY 12210
T: 518/486-3209
T: 775/684-3751
F: 518/473-5508
F: 775/684-3762
E-mail: jam22@health.state.ny.us
E-mail: mary.griffith@dhcfp.nv.gov
NORTH CAROLINA
NEW HAMPSHIRE
Sharon Greeson, R.Ph..
John Cox
Pharmacy Director
Rebate Pharmacist
EDS
First Health Services Corp.
4905 Waters Edge Drive
4300 Cox Road
Raleigh, NC 27606
T: 919/816-4475
T: 800/884-2822
F: 919/816-4399
F: 804/965-7647
E-mail: sharon.greeson@eds.com
E-mail: coxjo@fhsc.com
NORTH DAKOTA
NEW JERSEY
Kaye S. Morrow
Administrator, Pharmacy Services
600 East Boulevard Ave, Department 325
Division of Medical Assistance and Health Services
Office of Provider Relations
T: 701/328-4023
P.O. Box 712
F: 701/328-1544
Trenton, NJ 08619
T: 609/588-2396
F: 609/588-3889
A-50
OHIO SOUTH CAROLINA

Robert P. Reid, R.Ph. Noelle Wriston
Administrator, Pharmacy Services Unit Accountant/Fiscal Analyst II
Department of Job and Family Services Department of Health & Human Services
Bureau of Health Plan Policy P.O. Box 8206
P.O. Box 182709 Columbia, SC 29202-8206
Columbus, OH 43218-2709 803/898-1085
T: 614/466-6420 E-mail: wriston@scdhhs.gov
F: 614/466-2908
SOUTH DAKOTA
Connie Hohn, Rebate Coordinator
OKLAHOMA
Tom Simonson 700 Governors Drive
Drug Rebate Manager Pierre, SD 57501
Oklahoma Health Care Authority T: 605/773-5013
4545 N. Lincoln Blvd, Suite 124 F: 605/773-4855
Oklahoma City, OK 73105 E-mail: connie.hohn@state.sd.us
T: 405/522-7327
F: 405/522-3236
TENNESSEE
E-mail: Tom.Simonson@okhca.org
Sybil Creekmore
Accounting Manager
OREGON Bureau of TennCare
Debbie. L. Bishop 310 Great Circle Road
Pharmacy Program Manager Nashville, TN 37243
Division of Medical Assistance Programs 615/507-6622
Department of Human Services E-mail: sybil.creekmore@state.tn.us
500 Summer Street, NE, E-35
Salem, OR 97301-1077 TEXAS
T: 503/945-6291
F: 503/947-1119 Pollett Jones-Reasonover
Claims Rebate Administrator
Health and Human Services Commission
PENNSYLVANIA Medicaid and CHIP Divison
Terri Cathers 11209 Metric Boulevard, H630
Director of Pharmacy Programs Austin, TX 78758
Department of Public Welfare T: 512/491-1158
49 Beech Drive, 2nd Floor, Room 228 F: 512/491-1967
Harrisburg, PA 17110-3591 E-mail: Polett.Jones-Reasonover@hhsc.state.tx.us
T: 717/346-8156
F: 717/346-8171 UTAH
Pharmacy Director
RHODE ISLAND Utah Medicaid
Dawn Rousseau, Rebate Analyst Department of Health
EDS Division of Health Care Financing
171 Service Avenue, Building 1, Suite 100 P.O. Box 143102
Warwick, RI 02886 Salt Lake City, UT 84114
T: 401/784-8825 T: 801/538-6495
F: 401/941-7712 F: 801/538-6099
E-mail: dawn.rousseau@eds.com E-mail: rashley@utah.gov
A-51
VERMONT WYOMING
Christine Dapkiewicz Sheila McInerney
EDS TPL Manager
312 Hurricane Lane, Suite 100 ACS State Healthcare
Williston, VT 05495 P.O. Box 667
T: 802/879-4450 Cheyenne, WY 82001
F: 802/878-3440 T: 800/251-1268
F: 307/772-8405
VIRGINIA E-mail: sheila.mcinerney@acs-inc.com
John Cox
Rebate Pharmacist
4300 Cox Road
T: 804/965-6791
F: 804/217-7911
E-mail: john.cox@firsthealth.com
WASHINGTON
Connie L. Riddle
DSHS
P.O. Box 45503
Lacey, WA 98504-5503
360/725-1243
E-mail: riddle1@dshs.wa.gov
WEST VIRGINIA
Gail J. Goodnight, R.Ph.
Rebate Coordinator
T: 304/558-1700
F: 304/558-1542
E-mail: gailgoodnight@wvdhhr.org
WISCONSIN
Ellen Orsburne
Medicaid Systems Analyst
Bureau of Systems and Operations
Wisconsin Medicaid
One West Wilson Street
P.O. Box 309
Madison, WI 53702
608/267-7939
E-mail: orsbuer@dhfs.state.wi.us
A-52
STATE OFFICIALS
ALABAMA ALASKA AMERICAN SAMOA

Governor Governor Governor
Honorable Bob Riley Honorable Sarah Palin Honorable Togiola T.A. Tulafono
State Capitol State Capitol Executive Office Building
600 Dexter Avenue P.O. Box 110001 Pago Pago, AS 96799
Montgomery, AL 36103 Juneau, AK 99811-0001 T: 684/633-4116
T: 334/242-7100 T: 907/465-3500 F: 684/633-2269
F: 334/353-0004 F: 907/465-3532 Internet address: www.asg-
E-mail: E-mail: governor@gov.state.ak.us gov.net/001GOVERNORSPAGE.h
governor@governor.state.al.us Internet address: tm and americansamoa.gov/
Internet address: www.gov.state.ak.us
www.governor.state.al.us Single State Agency Director
Single State Agency Director Mr. Uto'ofili Asofa'afetai Maga,
Single State Agency Director Ms. Karleen Jackson, Commissioner Director
Ms. Carol Herrmann-Steckel Department of Health and Social Department of Health
Commissioner Services American Samoa Government
Alabama Medicaid Agency P.O. Box 110601 Territory of American Samoa,
501 Dexter Avenue 350 Main Street, Room 229 Pago Pago, AS 96799
P.O. Box 5624 Juneau, AK 99811-0601 T: 684/633-4606
Montgomery, AL 36103-5624 T: 907/465-3030 F: 684/633-5379
T: 334/242-5600 F: 907/465-3068 Internet address:
F: 334/242-0597 E-mail: americansamoa.gov/departments/de
E-mail: karleen_jackson@health.state.ak.us pts/health.htm
ALmedicaid@medicaid.state.al.us Internet address:
Internet address: www.hss.state.ak.us Medicaid Director
www.medicaid.state.al.us Mr. Andy Puletasi, Medicaid
Medicaid Director Program Director
Medicaid Director Mr. Jerry Fuller, Director LBJ Tropical Medical Center
Ms. Carol Herrmann-Steckel Division of Medical Assistance Pago Pago, AS 96799
Commissioner Department of Health Care Services T: 684/633-4590
Alabama Medicaid Agency P.O. Box 110601 F: (011) 684/633-1869
501 Dexter Avenue Juneau, AK 99811-0601
P.O. Box 5624 T: 907/465-1617
Montgomery, AL 36103-5624 F: 907/465-3068
T: 334/242-5600 E-mail:
F: 334/242-0597 jerry_fuller@health.state.ak.us
E-mail: Internet address:
Almedicaid@medicaid.state.al.us www.hss.state.ak.us/dhcs
Internet address:
www.medicaid.state.al.us
A-53
ARIZONA ARKANSAS CALIFORNIA

Honorable Janet Napolitano Honorable Mike Beebe Honorable Arnold Schwarzenegger
State Capitol State Capitol Building State Capitol, First Floor
1700 W. Washington Room 250 Sacramento, CA 958l4
Phoenix, AZ 85007 Little Rock, AR 72201 T: 916/445-2841
T: 602/542-4331 T: 501/682-2345 F: 916/445-4633
F: 602/542-1381 F: 501/682-3597 E-mail: governor@governor.ca.gov
E-mail: azgov@azgov.state.az.us E-mail: mike.beebe@state.ar.us Internet address:
Internet address: Internet address: www.governor.ca.gov
www.governor.state.az.us www.arkansas.gov/governor
Single State Agency Director
Single State Agency Director Single State Agency Director Ms. Sandra Shewry, Director
Mr. Anthony D. Rodgers, Director Mr. John Selig, Director Department of Health Services
Arizona Health Care Cost Department of Human Services 1501 Capitol Avenue
Containment System (AHCCCS) P.O. Box 1437, Slot 201 Sacramento, CA 95899
80l East Jefferson Street Little Rock, AR 72203-1437 T: 916/440-7400
Phoenix, AZ 85034 T: 501/682-8999 F: 916/440-7404
T: 602/417-4111 F: 501/682-6836 E-mail: sshewry@dhs.ca.gov
F: 602/252-6536 E-mail: John.Selig@arkansas.gov Internet address: www.dhs.ca.gov
E-mail: anthony.rodgers@ Internet address:
ahcccs.state.az.us www.arkansas.gov/dhhs/ Medicaid Director
Internet address: Mr. Stan Rosenstein
www.ahcccs.state.az.us Medicaid Director Deputy Director
Mr. Roy Jeffus, Director Medical Care Services
Medicaid Director Division of Medical Services Department of Health Services
Mr. Anthony D. Rodgers, Director Dept. of Human Services 1501 Capitol Avenue, 6th Floor
Arizona Health Care Cost P.O. Box 1437, Slot 5401 MS 0004
Containment System (AHCCCS) 700 Main Street P.O. Box 942732
801 East Jefferson Street Little Rock, AR 72203-1437 Sacramento, CA 95814
Phoenix, AZ 85034 T: 50l/682-8740 T: 916/440-7800
T: 602/417-4111 F: 501/682-1197 F: 916/440-7805
F: 602/252-6536 E-mail: E-mail: Upareja@dhs.ca.gov
E-mail: anthony.rodgers@ roy.jeffus@medicaid.state.ar.us Internet address: www.medi-
ahcccs.state.az.us Internet address: cal.ca.gov
Internet address: www.medicaid.state.ar.us
www.ahcccs.state.az.us
A-54
COLORADO CONNECTICUT DELAWARE

Honorable Bill Ritter Honorable M. Jodi Rell Honorable Ruth Ann Minner
State Capitol Executive Office of the Governor Tatnall Building
Room 136 State Capitol, Room 210 William Penn Street
Denver, CO 80203-1792 Hartford, CT 06l06 Dover, DE 19901
T: 303/866-2471 T: 860/566-4840 T: 302/744-4101
F: 303/866-2003 F: 820/524-7396 F: 302/739-2775
E-mail: governor.ritter@state.co.us E-mail: governor.rell@po.state.ct.us E-mail: gminner@state.de.us
Internet address: Internet address: Internet address:
www.colorado.gov/governor www.ct.gov/governorrel www.state.de.us/governor
Single State Agency Director Single State Agency Director Single State Agency Director
Ms. Karen Beye Mr. Michael P. Starkowski Mr. Vincent P. Meconi, Secretary
Executive Director Commissioner Department of Health and Social
Department of Human Services Department of Social Services Services
l575 Sherman Street 25 Sigourney Street 1901 North DuPont Highway
Denver, CO 80203-1714 Hartford, CT 06106-5033 New Castle, DE l9720
T: 303/866-5700 T: 860/424-5008 T: 302/255-9040
F: 303/866-4047 F: 860/566-2022 F: 302/255-4429
E-mail: Karen.Beye@state.co.us E-mail: E-mail: vmeconi@state.de.us
Internet address: michael.starkowski@po.state.ct.us Internet address:
www.cdhs.state.co.us Internet address: www.ct.gov/dss www.dhss.delaware.gov/dhss/
Medicaid Director Medicaid Director Medicaid Director

Ms. Barbara Prehmus Mr. David Parella, Director Mr. Harry Hill
Director Medical Care Administration Director
Office of Medical Assistance Department of Social Services Division of Mediciad and Medical
Department of Health Care Policy 25 Sigourney Street Assistance
and Financing Hartford, CT 06106 Department of Health and Social
1570 Grant Street T: 860/424-5116 Services
Denver, CO 80203-1818 F: 860/424-5114 Lewis Building
T: 303/866-5929 E-mail: 1901 North DuPont Highway
F: 303/866-3476 david.parrella@po.state.ct.us New Castle, DE 19720
E-mail: Internet address: www.ct.gov.dss T: 302/255-9500
barbara.prehmus@state.co.us F: 302/255-4454
Internet address: E-mail: harry.hill@state.de.us
www.chcpf.state.co.us Internet address:
www.dhss.delaware.gov/dhss/
A-55
DISTRICT OF COLUMBIA FLORIDA GEORGIA

Mayor Governor Governor
Honorable Adrian M. Fenty Honorable Charles Crist Honorable Sonny Purdue
John A. Wilson Building The State Capitol 203 State Capitol
1350 Pennsylvania Avenue, NW Tallahassee, FL 32399-0001 Atlanta, GA 30334
Washington, DC 20004 T: 850/488-7146 T: 404/656-l776
T: 202/727-2980 F: 850/487-0801 F: 404/657-7332
F: 202/727-6561 E-mail: governor@myflorida.com E-mail: governor@gov.state.ga.us
E-mail: mayor@dc.gov Internet address: www.flgov.com/ Internet address:
Internet address: www.dc.gov www.gov.state.ga.us/
Single State Agency Director Dr. Andrew Agwunobi Single State Agency Director
Dr. Gregory A. Pane Agency for Health Care Dr. Rhonda Medows,
Department of Health Administration Commissioner
825 North Capitol Street, NE 2727 Mahan Drive, Mail Stop 1 Department of Community of
Fourth Floor Tallahassee, FL 32308 Health
Washington, DC 20002 T: 850/922-3809 2 Peachtree Street, NW
T: 202/442-5000 F: 850/488-0043 Suite 4043
F: 202/442-4788 E-mail: Atlanta, GA 30303-3159
E-mail: gregory.pane@dc.gov agwunoba@ahca.myflorida.com T: 404/656-4507
Internet address: Internet address: F: 404/651-6880
www.dchealth.dc.gov www.fdhc.state.fl.us/ E-mail: dbevelle@hch.state.ga.us
Internet address:
Medicaid Director Medicaid Director www.dch.state.ga.us
Mr. Robert Maruca Mr. Thomas W. Arnold
Senior Deputy Director Deputy Secretary Medicaid Director
Medical Assistance Administration Agency for Health Care Mr. Mark Trail, Director
Department of Health Administration Department of Community Health
825 North Capitol Street, NE 2727 Mahan Drive Medical Assistance Division
Fifth Floor Tallahassee, FL 32308 2 Peachtree Street, NW
Washington, DC 20002 T: 850/413-9660 Suite 3733
T: 202/442-5988 F: 850/488-2520 Atlanta, GA 30303
F: 202/442-4790 E-mail: T: 404/656-1502
E-mail: robert.maruca@dc.gov thomas.arnold@myflorida.com F: 866/283-0128
Internet address: Internet address: E-mail: mtrail@dma.state.ga.us
www.dchealth.dc.gov www.fdhc.state.fl.us/Medicaid Internet address:
www.dch.state.ga.us
A-56
GUAM HAWAII IDAHO

Honorable Felix Comacho Honorable Linda Lingle Honorable C.L. “Butch” Otter
Adelup Complex State Capitol P.O. Box 83720
P.O. Box 2950 415 S. Beretania Street Boise, ID 83720-0034
Agana, GU 96932 Honolulu, HI 968l3 T: 208/334-2100
T: 671/479-2002 T: 808/586-0034 F: 208/334-3454
F: 671/479-2009 F: 808/586-0006 E-mail: governor@gov.state.id.us
E-mail: governor@mail.gov.gu E-mail: governor.lingle@hawaii.gov Internet address: www.idaho.gov
Internet address: Internet address: and gov.idaho.gov/
www.guamgovernor.net/ www.hawaii.gov/gov/
Single State Agency Director Single State Agency Director Mr. Richard Armstrong, Director
Mr. Arthur San Agustin, Acting Ms. Lillian B. Koller, Director Department of Health and Welfare
Director Department of Human Services 450 West State Street
Dept. of Public Health and Social 1390 Miller Street, Room 209 Boise, ID 83720-0036
Services Honolulu, HI 96813 T: 208/334-5500
123 Chalan Kareta, Route 10, T: 808/586-4997 F: 208/334-6558
Mangilao, Guam 96923 F: 808/586/4890 E-mail:
T: 671/735-7102 E-mail: lillian.b.koller@hawaii.gov armstrongr@idhw.state.id.us
F: 671/734-5910 Internet address: Internet address:
E-mail: www.hawaii.gov/dhs/ www.healthandwelfare.idaho.gov
director@dphss.govguam.net
Internet address: Medicaid Director Medicaid Director
www.dphss.govguam.net/ Mr. Wesley Mun Ms. Leslie Clement, Administrator
Acting Administrator Division of Medicaid
Medicaid Director Med-Quest Division Department of Health and Welfare
Ms. Ma Theresa Arcangel Department of Human Services Americana Building
Administrator 601 Kamokila Blvd., Room 518 3232 Elder Street
Bureau of Health Care Financing Kapolei, HI 96707 Boise, ID 83705
Department of Public Health and (P.O. Box 399 T: 208/334-5747
Social Services Honolulu, HI 96809-0339) F: 208/364-1811
P.O. Box 28l6 T: 808/692-8050 E-mail: clementl@idwh.state.id.us
Agana, GU 96932 F: 808/692-8155 Internet address:
T: 671/735-7282 E-mail: www.healthandwelfare.idaho.gov
F: 671/734-6860 wmun@medicaid.dhs.state.hi.us
Internet address:
www.med-quest.us
A-57
ILLINOIS INDIANA IOWA

Governor
Governor Governor
Honorable Mitch Daniels
Honorable Rod Blagojevich Honorable Chet Culver
State House, Room 206
207 State Capitol Building State Capitol Building
Springfield, IL 62706 Des Moines, IA 503l9
T: 2l7/782-6830 T: 5l5/28l-5211
T: 3l7/232-4567
F: 217/524-4049 F: 515/281-6611
F: 317/232-3443
E-mail: governor@state.il.us E-mail: igov.contact@Iowa.gov
E-mail: mdaniels@gov.state.in.us
Internet address: Internet address:
Internet address: www.in.gov/gov
www.illinois.gov/gov/ www.governor.iowa.gov
Single State Agency Director Single State Agency Director
Mr. Mitch Roob, Secretary
Mr. Barry Maram, Director Mr. Kevin Concannon, Director
Family and Social Services
Department of Healthcare and Department of Human Services
Administration
Family Services Hoover State Office Building
Room 461, Mail Stop 25
201 South Grand Avenue, East Fifth Floor
P.O. Box 7083
Third Floor Des Moines, IA 503l9-0114
Springfield, IL 62794 T: 5l5/28l-5452
T: 2l7/782-1200 F: 515/281-4980
T: 317/233-4454
F: 217/524-7120 E-mail: kconcan@dhs.state.ia.us
F: 317/233-4693
E-mail: directorhfs@illinois.gov Internet address:
E-mail: mitch.roob@fssa.in.gov
Internet address: www.dhs.state.ia.us
Internet address:
www.hfs.illinois.gov/
www.state.in.us/fssa
Medicaid Director
Medicaid Director (Medical Mr. Eugene Gessow
Medicaid Director Medicaid Director
Operations)
Jeffrey Wells, M.D., M.H.A.
Theresa Eagleson Wyatt, Medicaid Division of Medical Services
Director of Medicaid
Administrator Department of Human Services
Office of Medicaid Policy and
Medical Programs Hoover State Office Building
Planning
Department of Healthcare and Fifth Floor
Family & Social Services Admin.
Family Services Des Moines, IA 503l9-0114
Executive Office/ Room W382
20l S. Grand Ave., East, 3rd Floor T: 5l5/725-1121
Springfield, IL 62763-0001 MailStop 25
F: 515/725-1010
T: 2l7/782-2570 402 W. Washington Street
E-mail: egessow@dhs.state.ia.us
F: 217/524-5672 Indianapolis, IN 46204-2739
Internet address:
E-mail: directorhfs@illinois.gov T: 317/234-2407
www.dhs.state.ia.us
Internet address: F: 317/233-4693
www.hfs.illinois.gov/medical E-mail: jeffrey.wells@fssa.in.gov
Internet address:
www.in.gov/fssa/disability/medicaid
/index.html
A-58
KANSAS KENTUCKY LOUISIANA

Honorable Kathleen Sebelius Honorable Ernie Fletcher Honorable Kathleen Blanco
2nd Floor State Capitol Building State Capitol
State Capitol Building 700 Capitol Avenue P.O. Box 94004
Topeka, KS 66612-1590 Frankfort, KY 4060l Baton Rouge, LA 70804
T: 785/296-3232 T: 502/564-2611 T: 225/342-7015
F: 785/296-7973 F: 502/564-2517 F: 225/342-7099
E-mail: governor@ks.gov E-mail: governor@mail.state.ky.us Internet address:
Internet address: Internet address: www.gov.louisiana.gov/
www.governor.ks.gov www.governor.ky.gov
Single State Agency Director Single State Agency Director Mr. Frederick P. Cerise, M.D.
Mr. Don Jordan, Secreatry Mr. Mark D. Birdwhistell, Secretary Secretary
Kansas Department of Social and Cabinet for Health and Family Department of Health and
Rehabilitation Services Services Hospitals
Docking State Office Building 275 East Main Street, 5W-A P.O. Box 629
915 SW Harrison Street, 6th Floor Frankfort, KY 40621 Baton Rouge, LA 70821-0629
Topeka, KS 66612 T: 502/564-7042 T: 225/342-9500
T: 785/296-3271 F: 502/564-7091 F: 225/342-5568
F: 785/296-2173 E-mail: mark.birdwhistell@ky.gov E-mail: bgulotta@dhh.la.gov
www.srskansas.org chfs.ky.gov/agencies/os/ www.dhh.louisiana.gov/

Mr. Andrew Allison, PhD, Mr. Glenn Jennings, Acting Mr. Jerry Phillips, Director
Medicaid Director and Commissioner Bureau of Health Services
Deputy Director Cabinet for Health and Family Financing
Kansas Health Policy Authority Services Department of Health and
900 SW Jackson Street Department for Medicaid Services Hospitals
Suite 900-N Sixth Floor P.O. Box 91030
Topeka, KS 66612 275 East Main Street, 6W-A Baton Rouge, LA 70821-9030
T: 785/368-8162 Frankfort, KY 40621 T: 225/342-3891
F: 785/296-4813 T: 502/564-4321 F: 225/342-9508
E-mail: F: 502/564-0509 E-mail: jphillips2@dhh.la.gov
Andrew.allison@khpa.ks.gov E-mail: anna.dunn@ky.gov Internet address:
Internet address: Internet address: chfs.ky.gov/dms/ www.dhh.louisiana.gov/
www.khpa.ks.gov/
A-59
MAINE MARYLAND MASSACHUSETTS

Honorable John Baldacci Honorable Martin O’Malley Honorable Deval Patrick
1 State House Station State House Executive Office, State House
Augusta, Maine 04333-0001 Annapolis, MD 21401 Room 360
T: 207/287-3531 T: 410/974-3901 Boston, MA 02133
F: 207/287-1034 F: 410/974-3275 T: 617/725-4000
E-mail: governor@state.me.us E-mail: governor@gov.state.md.us F: 617/727-9725
Internet address: Internet address: E-mail: goffice@state.ma.us
www.maine.gov/governor/baldacci www.gov.state.md.us Internet address:
/index.shtml www.mass.gov
Single State Agency Director Mr. John M. Colmers Single State Agency Director
Ms. Brenda Harvey Secretary Dr. JudyAnn Bigby, MD, Secretary
Commissioner Department of Health & Mental Health and Human Services
Department of Health & Human Hygiene Executive Office
Services Herbert R. O'Connor Building One Ashburton Place, Room 1109
State House Station 11 201 West Preston Street Boston, MA 02108
221 State Street Fifth Floor T: 617/727-7600
Augusta, ME 04333-0011 Baltimore, MD 21201 F: 617/573-1890
T: 207/287-3707 T: 410/767-6505 E-mail:
F: 207/287-3005 F: 410/767-6489 JudyAnn.Bigby@state.ma.us
E-mail: E-mail: ktobias@dhmh.state.md.us Internet address:
Brenda.Harvey@maine.gov Internet address: www.mass.gov/eohhs
Internet address: www.dhmh.state.md.us
www.maine.gov/dhhs/index.shtml Medicaid Director
Medicaid Director Mr. Tom Dehner,
Medicaid Director Mr. John G. Folkemer Medicaid Director
Mr. Tony Marple, Acting Director Deputy Secretary Office of Medicaid
Bureau of Medical Services Health Care Financing One Ashburton Place, Room 1109
Office of MaineCare Services Department of Health & Mental Room 1109
Department of Health & Human Hygiene Boston, MA 02108
Services 201 West Preston Street, 2nd Floor T: 617/573-1770
State House Station 11 Baltimore, MD 21201 F: 617/573-1894
442 Civic Center Drive T: 410/767-4073 E-mail:
Augusta, ME 04333-0011 F: 410/767-7687 tdehner@nt.dma.state.ma.us
T: 207/287-2674 E-mail: Internet address:
F: 207/287-2675 folkemerj@dhmh.state.md.us www.state.ma.us/dma
E-mail: Tony.Marple@maine.gov Internet address:
Internet address: www.dhmh.state.md.us
www.maine.gov/dhhs/bms
A-60
MICHIGAN MINNESOTA MISSISSIPPI

Honorable Jennifer Granholm Honorable Tim Pawlenty Honorable Haley Barbour
P.O. Box 30013 130 State Capitol State Capitol
Lansing, MI 48909 St. Paul, MN 55155-1099 P.O. Box 139
T: 5l7/373-3400 T: 651/296-3391 Jackson, MS 39205
F: 517/335-6863 F: 651/296-2089 60l/359-3150
E-mail: www.michigan.gov/gov E-mail: tim.pawlenty@state.mn.us Internet address:
Internet address: Internet address: http://www.governorbarbour.com/
www.michigan.gov/gov www.governor.state.mn.us
Single State Agency Director Single State Agency Director Mr. Donald Taylor
Ms. Janet Olszewski Mr. Cal Ludeman Executive Director
Director Commissioner Department of Human Services
Michigan Department of Minnesota Department of Human 750 North State Street
Community Health Services Jackson, MS 39202
201 Townsend Street P.O. Box 64998 T: 601/359-4500
Lansing, MI 48933 St. Paul, MN 55164-0998 F: 601/359-4477
T: 517/373-3740 T: 651/431-2907 E-mail: dtaylor@mdhs.state.ms.us
F: 517/373-4288 F: 651/431-7443 Internet address:
E-mail: norris@michigan.gov E-mail: www.mdhs.state.ms.us
Internet address: commissioner.dhs@state.mn.us
www.michigan.gov/mdch Internet address: Medicaid Director
www.dhs.state.mn.us Dr. Robert Robinson
Medicaid Director Executive Director
Mr. Paul Reinhart Medicaid Director Division of Medicaid
Medicaid Director Ms. Christine Bronson Suite 801, Robert E. Lee Building
Michigan Department of Medicaid Director 239 North Lamar Street
Community Health Minnesota Department of Human Jackson, MS 39201-1399
400 S. Pine Street Services T: 601/359-9562
Lansing, MI 48933 P.O. Box 64998 F: 601/359-6048
T: 517/241-7882 St. Paul, MN 55164-0998 E-mail:
F: 517/335-5007 T: 651/431-2914 exblr@medicaid.state.ms.us
E-mail: reinhartp1@michigan.gov F: 651/431-7443 Internet address:
Internet address: E-mail: www.mdhs.state.ms.us
www.michigan.gov/mdch christine.bronson@state.mn.us
Internet address:
www.dhs.state.mn.us
A-61
MISSOURI MONTANA NEBRASKA

Honorable Matt Blunt Honorable Brian Schweitzer Honorable Dave Heineman
State Capitol Building, Room 216 Office of the Governor P.O. Box 94848
P.O. Box 720 State Capitol Lincoln, NE 68509-4848
Jefferson City, MO 65102-0720 P.O. Box 200801 T: 402/471-2244
T: 573/751-3222 Helena, MT 59620-0801 F: 402/471-6031
F: 573/751-1495 T: 406/444-3111 E-mail:
E-mail: F: 406/444-4151 www.gov.state.ne.us/mail/govmail.
http://www.gov.mo.gov/constituent E-mail: governor@mt.gov html
form.htm Internet address: Internet address:
Internet address: www.gov.mo.gov www.governor.mt.gov www.gov.state.ne.us/
Single State Agency Director Single State Agency Director Single State Agency Director
Ms. Deborah Scott, Director Ms. Joan Miles, Director Mr. Scot Adams, Director
Department of Social Services Department of Public Health and Nebraska Department of Health
Broadway State Office Building Human Services and Human Services System
221 West High Street P.O. Box 4210 Finance and Support
P.O. Box 1527 111 N. Sanders P.O. Box 95044
Jefferson City, MO 65102-1527 Helena, MT 59604-4210 Lincoln, NE 68509-5044
T: 573/751-4815 T: 406/444-5622 T: 402/471-2306
F: 573/751-3203 F: 406/444-1970 F: 402/471-9449
E-mail: dscott@mail.state.mo.us E-mail: jmiles@mt.gov E-mail:
Internet address: www.dss.mo.gov Internet address: kelly.ostrander@hhss.ne.gov
http://www.dphhs.mt.gov/ Internet address:
Medicaid Director www.hhss.ne.gov
Mr. Steven Renne, Interim Director Medicaid Director
Division of Medical Services Mr. John Chappuis Medicaid Director
Department of Social Services Medicaid Director Ms. Vivianne Chaumont
615 Howerton Court Division of Health Policy and Director
P.O. Box 6500 Services Division of Medicaid and Long-
Jefferson City, MO 65102-6500 Department of Public Health and Term Care
T: 573/751-6922 Human Services Nebraska Department of Health
F: 573/751-6564 P.O. Box 4210 and Human Services
Internet address: 111 N. Sanders P.O. Box 95026
www.dss.mo.gov Helena, MT 59604-4210 301 Centennial Mall South
T: 406/444-4084 Lincoln, NE 68509-5026
F: 406/444-1861 T: 402/471-3121
E-mail: jchappuis@mt.gov F: 402/471-9092
Internet address: Internet address:
http://www.dphhs.mt.gov/ www.hhss.ne.gov/med/medprog.
htm
A-62
NEVADA NEW HAMPSHIRE NEW JERSEY

Honorable Jim Gibbons Honorable John Lynch Honorable Jon S. Corzine
State Capitol Office of the Governor Governor
101 N. Carson Street State House 125 West State Street
Carson City, NV 89701 Room 208 State House CN-001
T: 702/684-5670 107 North Main Street Trenton, NJ 08625
F: 775/684-5683 Concord, NH 03301-4990 T: 609/292-6000
E-mail: T: 603/271-2121 F: 609/292-3454
gov.state.nv.us/ContactUs_NORT F: 603/271-5686 E-mail:
H.htm E-mail: governorlynch@nh.gov www.state.nj.us/governor/govmail.
Internet address: Internet address: html
www.gov.state.nv.us http://www.nh.gov/governor/ Internet address:
www.state.nj.us/governor
Mr. Mike Willden, Director Mr. John Stephen, Commissioner Single State Agency Director
Department of Health and Human Department of Health and Human Ms. Jennifer Velez,
Services Services Acting Commissioner
4126 Technology Way, Room 100 129 Pleasant Street Department of Human Services
Carson City, NV 89706-2009 Concord, NH 03301-3857 P.O. Box 700
T: 775/684-4000 T: 603/271-4334 Trenton, NJ 08625-0700
F: 775/684-4010 F: 603/271-4912 T: 609/292-3717
E-mail: nvdhhs@dhhs.nv.gov E-mail: jstephen@dhhs.state.us F: 609/292-3824
Internet address: www.dhhs.nv.gov Internet address: E-mail:
www.dhhs.state.nh.us/DHHS/ DHS_Commissioner@dhs.state.nj.
Medicaid Director DHHS_SITE/default.htm us
Mr. Charles Duarte, Administrator Internet address:
Division of Health Care Financing Medicaid Director www.state.nj.us/humanservices
and Policy Mr. Norman Cordell, Director
1100 East William Street, Suite Medicaid Business & Policy Medicaid Director
116 Department of Health and Human Mr. John R. Guhl, Director
Carson City, NV 89710 Services Division of Medical Assistance and
T: 775/684-3676 129 Pleasant Street Health Services
F: 775/687-3893 Concord, NH 03301-3857 Department of Human Services
E-mail: cduarte@dhhs.nv.gov T: 603/271-8166 Quakerbridge Plaza
Internet address: dhcfp.state.nv.us F: 603/271-4727 P.O. Box 712
E-mail: Trenton, NJ 08625-0712
www.dhhs.state.nh.us/DHHS/OMB T: 609/588-2600
P/CONTACT+INFO/default.htm F: 609/588-3583
Internet address: E-mail: john.guhl@dhs.state.nj.us
www.dhhs.state.nh.us/DHHS/MEDI Internet address:
CAIDPROGRAM/default.htm www.state.nj.us/humanservices/
dmahs/index.html
A-63
NEW MEXICO NEW YORK NORTH CAROLINA

Honorable Bill Richardson Honorable Eliot Spitzer Honorable Mike Easley
Office of the Governor Executive Chamber Office of the Governor
State Capitol State Capitol 116 West Jones Street
Suite 400 Albany, NY 12224 20301 Mail Service Center
Santa Fe, NM 87501 T: 5l8/474-7516 Raleigh, NC 27699-0301
T: 505/476-2200 F: 518/474-3767 T: 919/733-4240
F: 505/476-2226 E-mail: T: 919/733-5811
E-mail: gov@gov.state.nm.us www.state.ny.us/governor/contact/in F: 919/733-2120
Internet address: dex.html E-mail:
www.governor.state.nm.us Internet address: www.governor.state.nc.us/email.as
www.ny.gov/governor/ p?to=1
Single State Agency Director Internet address:
Ms. Pamela Hyde, J.D. Single State Agency Director www.governor.state.nc.us
Secretary Richard F. Daines, M.D.
New Mexico Human Services Assistant Secretary Single State Agency Director
Department Health Policy and Medical Mr. Dempsey E. Baenton
P.O. Box 2348 Assistance Secretary
Santa Fe, NM 87504-2348 NYS Department of Health Department of Health and Human
T: 505/827-7750 Empire State Plaza, Services
F: 505/827-6286 Corning Tower Building 2001 Mail Service Center
E-mail: marty.eckert@state.nm.us Albany, NY 12237 Raleigh, NC 27699-2001
Internet address: T: 518/474-2011 T: 919/733-4534
www.hsd.state.nm.us F: 518/474-5450 F: 919/715-4645
E-mail: rfd02@health.state.ny.us E-mail:
Medicaid Director Internet address: www.nyhealth.gov dempsey.benton@ncmail.net
Ms. Carolyn Ingram, Director Internet address:
Medical Assistance Division Medicaid Director www.dhhs.state.nc.us
New Mexico Human Services Ms. Deborah Bachrach
Department Medicaid Director Medicaid Director
P.O. Box 2348 NYS Department of Health Dr. L. Allen Dobson
Santa Fe, NM 87504-2348 Empire State Plaza Assistant Secretary
T: 505/827-3106 Corning Tower Building, Health Policy & Medical
F: 505/827-3185 Room 1466 Assistance
E-mail: Albany, NY 12237 Division of Medical Assistance
carolyn.ingram@state.nm.us T: 518/474-3018 Department of Health and Human
Internet address: F: 518/486-6852 Services
www.hsd.state.nm.us/mad/ E-mail: dsb10@health.state.ny.us 1985 Umstead Drive
Internet address : 2501 Mail Service Center
www.health.state.ny.us/health_care/ Raleigh, NC 27699-2501
medicaid T: 919/855-4100
F: 919/733-6608
E-mail: allen.dobson@ncmail.net
Internet address:
www.dhhs.state.nc.us/dma
A-64
NORTH DAKOTA NORTHERN MARIANA OHIO

Governor ISLANDS Governor
Honorable John Hoeven Governor Honorable Ted Strickland
Department 101 Honorable Benigno Repeki Fitial 77 South High Street, 30th Floor
600 East Boulevard Avenue Office of the Governor Columbus, OH 43215-6117
Bismarck, ND 58505-0001 Commonwealth of the Northern T: 614/466-3555
T: 701/328-2200 Mariana Islands F: 614/466-9354
F: 701/328-2205 Juan S. Atalig Memorial Building E-mail:
E-mail: governor@nd.gov Isa Drive, Capitol Hill apps.das.ohio.gov/govpublic/conta
Internet address: Caller Box 10007 ct.aspx
http://governor.nd.gov/ Saipan, MP 96950 Internet address:
T: 670/664-2200 governor.ohio.gov/
Single State Agency Director F: 670/664-2211
Ms. Carol K. Olson, Executive Internet address: www.gov.mp/ Single State Agency Director
Director Ms. Helen E. Jones-Kelley,
Department of Human Services Single State Agency Director Director
600 East Boulevard Avenue, Mr. Kelvin Villagomez Ohio Department of Job and
Dept. 325 Secretary for Health Services Family Services
Bismarck, ND 58505-0250 Department of Public Health 30 East Broad Street, 32nd Floor
T: 701/328-2538 Commonwealth of the Northern Columbus, OH 43215-3414
F: 701/328-1545 Mariana Islands T: 614/466-6282
E-mail: dhseo@state.nd.us P.O. Box 500-409 F: 614/466-2815
Internet address: Saipan, MP 96950-0409 E-mail: kellyl@odjfs.state.oh.us
www.nd.gov/humanservices/ T: 670/234-8950 Internet address: www.jfs.ohio.gov
E-mail: jkvsaipan@cnmidph.net
Medicaid Director Internet: www.dphsaipan.com Medicaid Director
Ms. Maggie Anderson Ms. Cristal A. Thomas
Director Medicaid Director Medicaid Program Director
Division of Medical Services Ms. Helen Sablan Deputy Director
Department of Human Services Medicaid Administrator Ohio Health Plans
600 East Boulevard Avenue Department of Public Health Ohio Department of Job and
Dept. 325 Commonwealth of the Northern Family Services
Bismarck, ND 58505-0261 Mariana Islands 30 East Broad Street, 31st Floor
T: 701/328-1603 P.O. Box 409 CK Columbus, OH 43215-3414
F: 701/328-1544 Saipan, MP 96950 T: 614/466-4443
E-mail: dhsmed@state.nd.us T: 670/664-4884 F: 614/752-3986
Internet address: F: 670/664-4885 E-mail:
www.nd.gov/humanservices/servic thomac02@odjfs.state.oh.us
es/medicalserv/ Internet address:
www.jfs.ohio.gov/ohp
A-65
OKLAHOMA OREGON PENNSYLVANIA

Honorable Brad Henry Honorable Ted Kulongoski Honorable Edward G. Rendell
212 State Capitol State Capitol 225 Main Capitol Building
2300 N. Lincoln Boulevard 900 Court Street NE Harrisburg, PA 17120
Oklahoma City, OK 73105 Salem, OR 97301-4047 T: 717/787-2500
T: 405/521-2342 T: 503/378-3111 F: 717/772-8284
F: 405/521-3353 F: 503/378-8970 E-mail:
E-mail: E-mail: http://sites.state.pa.us/PA_Exec/Go
www.gov.ok.gov/message.php www.governor.state.or.us/Gov/conta vernor/govmail.html
Internet address: ct_us.shtml Internet address:
www.gov.ok.gov/index.php Internet address: http:www.governor.state.pa.us/
www.governor.state.or.us
Mr. Mike Fogarty, J.D. Single State Agency Director Ms. Estelle B. Richman, Secretary
Chief Executive Officer Mr. Bruce Goldberg, Director Department of Public Welfare
Oklahoma Health Care Authority Office of the Director Health and Welfare Building
4545 North Lincoln Boulevard Department of Human Services P.O. Box 2675
Suite 124 500 Summer Street, NE, E15 Harrisburg, PA 17105-2675
Oklahoma City, OK 73105 Salem, OR 97301-1097 T: 717/787-2600
T: 405/522-7300 T: 503/945-5944 F: 717/772-2062
F: 405/522-7187 F: 503/378-2897 E-mail: ra-dpwsecretarynet
E-mail: fogartym@ohca.state.ok.us E-mail: bruce.goldberg@state.or.us @state.pa.us
www.ohca.state.ok.us www.oregon.gov/DHS www.dpw.state.pa.us/

Ms. Lynn Mitchell, M.D., M.P.H. Mr. Jim Edge Mr. Michael Nardone
Medical Director Interim Assistant DHS Director Acting Deputy Secretary
Oklahoma Health Care Authority Division of Medical Assistance Office of Medical Assistance
4545 North Lincoln Boulevard Programs Programs
Suite 124 Department of Human Services Department of Public Welfare
Oklahoma City, OK 73105 500 Summer Street, NE, E49 Health and Welfare Building,
T: 405/522-7365 Salem, OR 97301-1079 Room 515
F: 405/530-3218 T: 503/945-5772 P.O. Box 2675
E-mail: mitchelll@ohca.state.ok.us F: 503/373-7689 Harrisburg, PA 17105-2675
Internet address: E-mail: jim.edge@state.or.us T: 717/787-1870
www.ohca.state.ok.us Internet address: F: 717/787-4639
www.oregon.gov/DHS/healthplan/in Internet address:
dex.shtml www.dpw.state.pa.us/omap
A-66
PUERTO RICO RHODE ISLAND SOUTH CAROLINA

Honorable Aníbal S. Acevedo-Vilá Honorable Don Carcieri Honorable Mark Sanford
Office of the Governor Office of the Governor P.O. Box 12267
La Fortaleza State House, Room 115 Columbia, SC 29211
P.O. Box 9020082 Providence, RI 02903 T: 803/734-2100
San Juan, PR 00902-0082 T: 401/222-2080 F: 803/734-5167
T: 787/721-7000 F: 401/222-8096 E-mail:
F: 787/721-5072 E-mail: http://www.scgovernor.com/Contac
Internet address: www.governor.state.ri.us/webform/i t.asp
http://fortaleza.govpr.org/ nquirytest.php Internet address:
Internet address: www.scgovernor.com/
Single State Agency Director www.governor.state.ri.us/
Dr. Rosa Pérez Perdomo, M.D., Single State Agency Director
Ph.D. Single State Agency Director Ms. Susan B. Bowling
Secretary Mr. Gary Alexander, Director Acting Director
Department of Health Department of Human Services Department of Health and Human
P.O. Box 70184 600 New London Avenue Services
San Juan, PR 00936-0184 Cranston, RI 02920 1801 Main Street
787/274-7676 T: 401/462-2121 P.O. Box 8206
Internet address: F: 401/462-6504 Columbia, SC 29201-8206
www.salud.gov.pr/ E-mail: galexand@dhs.ri.gov T: 803/898-2500
Internet address: F: 803/255-8235
Medicaid Director www.dhs.state.ri.us/ E-mail: bowlings@scdhhs.gov
Ms. Wendy Matos, Ph.D. Internet address:
Executive Director Medicaid Director www.dhhs.state.sc.us/dhhsnew/ind
Office of Economic Assistance Mr. John C. Young, C.P.M. ex.asp
Medically Indigent Deputy Director
Department of Health Division of Medical Services Medicaid Director
P.O. Box 70184 Department of Human Services Mr. Robert Kerr, Director
San Juan, PR 00936-0184 600 New London Avenue Department of Health and Human
T: 787/250-0453 Cranston, RI 02920 Services
F: 787/250-0990 T: 401/462-3575 1801 Main Street
E-mail: wematos@salud.gov. F: 401/462-6338 P.O. Box 8206
E-mail: Jyoung@dhs.ri.gov Columbia, SC 29202-8206
Internet address: T: 803/898-2504
www.dhs.state.ri.us/ F: 803/255-8235
E-mail: malonel@dhhs.state.sc.us
Internet address:
www.dhhs.state.sc.us/dhhsnew/ind
ex.asp
A-67
SOUTH DAKOTA TENNESSEE TEXAS

Honorable Mike Rounds Honorable Phil Bredesen Honorable Rick Perry
500 East Capitol State Capitol, First Floor Office of the Governor
Pierre, SD 57501 Nashville, TN 37243-0001 State Capitol
T: 605/773-3212 T: 615/741-2001 P.O. Box 12428
F: 605/773-4711 F: 615/532-9711 Austin, Texas 78711-2428
E-mail: governor@state.sd.us E-mail: phil.bredesen@state.tn.us Office of the Governor
Internet address: Internet address: Austin, Texas 78701
www.state.sd.us/governor www.tennesseeanytime.org/governo T: 512/463-2000
r F: 512/463-1849
Single State Agency Director E-mail:
Ms. Deborah L. Bowman, Single State Agency Director www.governor.state.tx.us/contact
Secretary Ms. Virginia “Gina” Lodge, Internet address:
Department of Social Services Commissioner www.governor.state.tx.us/
Richard F. Kneip Building Department of Human Services
700 Governors Drive 400 Deaderick Street, 15th Floor Single State Agency Director
Pierre, SD 57501-2291 Nashville, TN 37248-0001 Mr. Albert Hawkins,
T: 605/773-3165 T: 615/313-4700 Commissioner
F: 605/773-4855 F: 615/741-4165 Health and Human Services
E-mail: dssinfo@state.sd.us E-mail: Commission
Internet address: gina.lodge@state.tn.us P.O. Box 13247
www.state.sd.us/social Internet address: Austin, TX 78711
www.state.tn.us/humanserv T: 5l2/424-6502
Medicaid Director F: 512/424-6587
Mr. Larry Iverson Medicaid Director E-mail:
Medicaid Director Mr. Darin Gordon, Deputy laura.ozuna@hhsc.state.tx.us
Medical Services Commissioner Internet address:
Department of Social Services Bureau of TennCare www.hhsc.state.tx.us/
Richard F. Kneip Building Citizen’s Plaza Building, 12th Floor
700 Governors Drive 310 Great Circle Road Medicaid Director
Pierre, SD 57501-2291 Nashville, TN 37243 Mr. Chris Traylor
T: 605/773-3495 T: 615/507-6443 Associate Commissioner
F: 605/773-5246 F: 615/313-6639 Medicaid / CHIP, H-100
E-mail: medical@state.sd.us E-mail: tenn.care@state.tn.us Health and Human Services
Internet address: Internet address: Commission
www.state.sd.us/social/medical tennessee.gov/tenncare/index.htm 1100 West 49th Street
Mail Code H100
P.O. Box 85200
Austin, TX 78708-5200
T: 512/491-1867
F: 512/491-1977
E-mail: contact@hhsc.state.tx.us
Internet address:
www.hhsc.state.tx.us/medicaid/ind
ex.html
A-68
VIRGINIA
UTAH VERMONT
Governor
Governor Governor
Honorable Tim Kaine
Honorable John Huntsman Honorable James Douglas
Office of the Governor
Office of the Governor 109 State Street
Patrick Henry Building, 3rd Floor
Utah East Office Building Montpelier, VT 05609-0101
1111 East Broad Street
Suite E220 T: 802/828-3333
P.O. Box 142220 F: 802/828-3339
Mailing Address:
Salt Lake City, UT 84114-2220 Internet address:
P.O. Box 1475
T: 801/538-1000 www.vermont.gov/governor
F: 801/538-1528
T: 804/786-2211
E-mail: governor@utah.gov Single State Agency Director
F: 804/692-0121
Internet address: Mr. Cynthia LaWare, Secretary
E-mail:
www.utah.gov/governor Agency of Human Services
www.governor.virginia.gov/About
103 South Main Street
TheGovernor/contactGovernor.cfm
Single State Agency Director Waterbury, VT 05671-0201
Internet address:
Mr. David Sundwall, M.D. T: 802/241-2220
www.governor.virginia.gov/
Executive Director F: 802/241-2979
Department of Health E-mail: mary.collins@state.vt.us
Ms. Marilyn B. Tavenner,
Salt Lake City, UT 84114-1000 www.ahs.state.vt.us
Secretary
T: 801/538-6111
Health and Human Resources
F: 801/538-6306 Medicaid Director
Patrick Henry Building
E-mail: davidsundwall@utah.gov Mr. Joshua Slen, Medicaid Director 1111 East Broad Street
Internet address: Agency of Human Services P.O. Box 1475
www.health.utah.gov Office of Vermont Health Access Richmond, VA 23219
103 South Main Street T: 804/786-7765
Medicaid Director Waterbury, VT 05676-1201 F: 804/371-6984
Mr. Michael T. Hales, Director T: 802/879-5900 E-mail: shhr@gov.state.va.us
Department of Health F: 802/879-5962 Internet address:
Division of Health Care Financing E-mail: joshuas@path.state.vt.us www.hhr.virginia.gov/
Salt Lake City, UT 84114-3101 www.dsw.state.vt.us Medicaid Director
T: 801/538-6406 Mr. Patrick Finnerty, Director
F: 801/538-6099 Department of Medical Assistance
E-mail: mthales@utah.gov Services
Internet address: 600 East Broad Street
www.health.utah.gov/medicaid Suite 1300
Richmond, VA 23219
T: 804/786-4231
F: 804/371-4981
E-mail:
Patrick.Finnerty@dmas.state.va.us
Internet address:
www.dmas.virginia.gov/
A-69
VIRGIN ISLANDS WASHINGTON WEST VIRGINIA

John P. deJongh, Jr. Honorable Christine Gregoire Honorable Joe Manchin III
Office of the Governor Office of the Governor State Capitol
Government House, 21-22 P.O. Box 40002 1900 Kanawha Boulevard, E.
Kongens Gade Olympia, WA 98504-0002 Charleston, WV 25305
Charlotte Amalie T: 360/902-4111 T: 304/558-2000
St. Thomas, VI 00802 F: 360-753-4110 F: 304/342--7025
T: 340/774-0001 E-mail: E-mail: Governor@WVGov.org
F: 340/776-4912 http://www.governor.wa.gov/contact Internet address: www.wvgov.org/
E-mail: rcanton@govhouse.gov.vi /govemail.htm
Internet address: Internet address: Single State Agency Director
www.governordejongh.com www.governor.wa.gov Ms. Martha Yeager Walker
www.usvi.org Secretary
www.legvi.org Single State Agency Director Department of Health and Human
Ms. Robin Arnold-Williams Resources
Single State Agency Director Secretary State Capitol Complex, Building 3,
Ms. Phyllis L. Wallace, Ed.D., MS Department of Social and Health Room 206
Acting Commissioner of Health Services Charleston, WV 25305
Virgin Islands Department of P.O. Box 45010 T: 304/558-0684
Health Olympia, WA 98504-5010 F: 304/558-1130
48 Sugar Estate T: 360/902-7800 E-mail:
St. Thomas, VI 00802 F: 360/902-7848 marthaywalker@wvdhhr.org
T: 340/774-0117 E-mail: arnolr@dshs.wa.gov Internet address: www.wvdhhr.org/
www1.dshs.wa.gov/ Medicaid Director
Medicaid Director Ms. Marsha K. Morris
Ms. Priscilla Berry Quetel, Medicaid Director Bureau for Medical Services
Executive Director Mr. Doug Porter Department of Health and Human
Bureau of Health Insurance and Assistant Secretary Resources
Medical Assistance Health and Recovery Services 350 Capital Street – Room 251
Department of Health Administration Charleston, WV 25301-3706
3730 Estate Altona, Suite 302 P.O. Box 45507 T: 304/558-1700
Frostco Center Olympia, WA 98504-5100 F: 304/558-1509
Charlotte Amalie T: 360/725-1867 E-mail: medcomm@wvdhhr.org
St. Thomas, VI 00802 F: 360/586-9551 Internet address:
T: 340/774-4624 E-mail: portejd@dshs.wa.gov www.wvdhhr.org/bms
E-mail: prisrena@viaccess.net www.fortress.wa.gov/dshs/maa
A-70
WISCONSIN WYOMING
Governor Governor
Honorable Jim Doyle Honorable Dave Freudenthal
Office of the Governor State Capitol, Room 124
115 East State Capitol Cheyenne, WY 82002-0010
Madison, WI 53702 T: 307/777-7434
T: 608/266-1212 F: 307/632-3909
F: 608/267-8983 E-mail: governor@state.wy.us
E-mail: Internet address:
www.wisgov.state.wi.us/contact.as wyoming.gov/governor
p?locid=19
Internet address: Single State Agency Director
www.wisgov.state.wi.us/ Dr. Brent Sherard, Director
Single State Agency Director 401 Hathaway Building
Mr. Kevin R. Hayden, Secretary Cheyenne, WY 82002
Department of Health and Family T: 307/777-7656
Services F: 307/777-7439
One West Wilson Street, Room E-mail: wdh@state.wy.us
650 Internet address:
Madison, WI 53703 wdhfs.state.wy.us/main/index.asp
T: 608/266-9622
F: 608/266-7882 Medicaid Director
E-mail: Mr. Greg Gruman, Ph.D.
Kevin.Hayden@wisconsin.gov State Medicaid Agent
Internett address: Wyoming Department of Health
www.dhfs.state.wi.us/ 6101 Yellow Stone Rd. Suite 210
Cheyenne, WY 82002
Medicaid Director T: 307/777-7531
Mr. Jason A. Helgerson F: 307/777-6964
State Medicaid Director E-mail: ggruman@state.wy.us
Division of Health Care Financing Internet address:
Department of Health and Family wdh.state.wy.us/healthcarefin/medic
Services aid/changes.html
One West Wilson Street, Room
350
P.O. Box 309
T: 608/266-2522
F: 608/266-1096
E-mail: HelgeJA@dhfs.state.wi.us
Internet address:
www.dhfs.state.wi.us/
A-71
CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)

REGIONAL OFFICES
ASSOCIATE REGIONAL ADMINISTRATORS - MEDICAID
Region I Charolotte Yeh Connecticut, Maine, Massachusetts,

Boston Regional Office John F. Kennedy Federal Bldg. New Hampshire, Rhode Island,
Government Center, Room 2325 Vermont
Boston, MA 02203-0003
617/565-1188
Region II Jim Kerr New Jersey, New York, Puerto Rico,
New York Regional Office 26 Federal Plaza, 38th Floor Virgin Islands
New York, NY 10278
212/616-2205
Region III Nancy O’Connor Delaware, District of Columbia,
Philadelphia Regional Office The Public Ledger Building, Suite 216 Maryland, Pennsylvania, Virginia,
150 S. Independence Mall West West Virginia
Philadelphia, PA 19106
215/861-4140
Region IV Roger Perez Alabama, Florida, Georgia, Kentucky,
Atlanta Regional Office Atlanta Federal Center Mississippi, North Carolina, South
61 Forsyth Street, SW, Suite 4T20 Carolina, Tennessee
Atlanta, GA 30303-8909
404/562-7500
Region V Jackie Garner Illinois, Indiana, Michigan,
Chicago Regional Office 233 North Michigan Avenue Minnesota, Ohio, Wisconsin
Suite 600
Chicago, IL 60601-5519
312/886-6432
Region VI Randy Farris Arkansas, Louisiana, New Mexico,
Dallas Regional Office 1301 Young Street, Room 714 Oklahoma, Texas
Dallas, TX 75202
214/767-6423
Region VII Tom Lenz Iowa, Kansas, Missouri, Nebraska
Kansas City Regional Office Richard Bolling Federal Building
601 East 12th Street, Room 235
Kansas City, MO 64106-2808
816/426-5233
Region VIII Mark Gilbert Colorado, Montana, North Dakota,
Denver Regional Office Colorado State Bank Building South Dakota, Utah, Wyoming
1600 Broadway, Suite 700
Denver, CO 80202-4367
303/844-2111
Region IX Jeff Flick Arizona, California, Hawaii, Guam
San Francisco Regional Office 90 Seventh Street. Suite 5W Nevada, and Pacific Islands
San Francisco, CA 94103-6706
415/744-3501
Region X John Hammarlund Alaska, Idaho, Oregon, Washington
Seattle Regional Office 2201 6th Avenue, MS-40
Seattle, WA 98121-2500
206/615-2306
Source: CMS, Central Office, Centers for Medicaid and State Operations, as of September 2007.
A-72
Appendix B:
Medicaid Program Statistics -
CMS MSIS Tables
B-1
B-2
Medicaid Program Statistics -- MSIS Report
The CMS MSIS Report is an annual report designed to collect State-reported statistical summary data
on eligibles, recipients, services, and expenditures during a Federal fiscal year (i.e., October l through
September 30). The data reported for a given year represent recipients of service and the amount of
payments for claims adjudicated during the year. The data reflect bills adjudicated during the year
rather than the services used during the year.
Historically, States summarized and reported the data processed through their Medicaid claims
processing and payment operations unless they opted to participate in the Medicaid Statistical
Information System (MSIS) project. Prior to Federal fiscal year 1999, MSIS was a voluntary
program and those States participating in the MSIS project provide data tapes from their claims
processing systems to HCFA in lieu of HCFA-2082 tables. However, in accordance with the
Balanced Budget Act of 1997, all claims processed on or after January 1, 1999, must be submitted
electronically in the MSIS format.
The MSIS Report is the primary CMS source on recipients’ use of services and the associated
payments for these services. However, the new reporting requirements have resulted in a lag in the
timely release of MSIS summary tables. The most recent MSIS service utilization information
available from CMS is for FY 2004. In addition, Puerto Rico and the U.S. territories have been
excluded from the tables and the National totals.
In an effort to provide more recent recipient information as well as to maintain continuity with
previous version of the Compilation, we have compiled ten tables from the MSIS data system for
inclusion in this Appendix. The first two tables provide national level summary information on total
expenditures and total number of recipients by type of service for FY 2003 and FY 2004. The
remaining tables present State-by-State and national level data, including some trend information, on
total Medicaid recipients, total Medicaid payments, number of prescription drug recipients, and
Medicaid prescription drug payments.
B-3
B-4
Total U.S. Medical Assistance Recipients By Type of Service

Percent Percent Percent
Service FY 2003 of Total* FY 2004 of Total* Change 2003-2004
Capitated Payment Services 27,574,367 53.1% 29,527,913 53.7% 7.1%
Pharmaceuticals 26,075,011 50.2% 27,548,578 50.1% 5.7%
Physicians 22,857,218 44.0% 23,611,570 42.9% 3.3%
Hospital Outpatient 15,510,542 29.8% 15,887,813 28.9% 2.4%
Lab/X-ray 14,687,064 28.3% 15,875,351 28.9% 8.1%
Other Care 11,741,797 22.6% 12,387,284 22.5% 5.5%
Clinic 10,162,022 19.6% 11,102,371 20.2% 9.3%
Dental 8,509,824 16.4% 9,036,990 16.4% 6.2%
PCCM Services 7,541,745 14.5% 8,547,877 15.5% 13.3%
Personal Support Services 6,022,040 11.6% 6,254,143 11.4% 41.9%
Other Practitioners 5,746,278 11.1% 5,932,735 10.8% 3.2%
Hospital Inpatient 5,217,106 10.0% 5,425,463 9.9% 4.0%
Nursing Facility 1,690,846 3.3% 1,708,675 3.1% 1.1%
Home Health Care 1,183,764 2.3% 1,145,949 2.1% -3.2%
Sterilizations 159,949 0.3% 174,187 0.3% 8.9%
Mental Health Facility 104,529 0.2% 116,619 0.2% 11.6%
ICF-Mentally Retarded 113,984 0.2% 113,883 0.2% -0.1%
Unknown 87,718 0.2% 80,941 0.1% -7.7%
Total Unduplicated
Recipients* 51,971,173 55,002,107 5.80%
*Percentages are based on amount of services provided. These do not reflect recipients' use of multiple services. Puerto Rico and the U.S.
Territories are not included in these national totals.
B-5
Total U.S. Medical Assistance Payments By Type of Service
Percent of Percent of Percent

Service FY 2003 Total* FY 2004 Total* Change 2003-2004
Capitated Payment Services $37,405,402,095 16.0% $42,600,856,112 16.5% 13.9%
Nursing Facility $40,381,022,223 17.3% $42,007,526,640 16.3% 4.0%
Pharmaceuticals $33,714,314,456 14.5% $39,475,607,168 15.3% 17.1%
Hospital Inpatient $31,549,248,411 13.5% $34,914,457,404 13.6% 10.7%
Other Care $21,809,259,794 9.4% $24,950,515,340 9.7% 14.4%
Personal Support Services $17,245,382,598 7.4% $18,494,193,344 7.2% 7.2%
ICF-Mentally Retarded $10,861,243,599 4.7% $11,192,580,251 4.3% 3.1%
Hospital Outpatient $9,251,889,428 4.0% $10,260,565,755 4.0% 10.9%
Physicians $9,209,880,046 3.9% $10,060,699,732 3.9% 9.2%
Clinic $7,312,110,849 3.1% $8,335,938,704 3.2% 14.0%
Home Health Care $4,403,905,141 1.9% $4,565,865,727 1.8% 3.7%
Dental $2,594,893,174 1.1% $2,867,259,819 1.1% 10.5%
Lab/X-Ray $2,365,005,639 1.0% $2,694,862,125 1.0% 13.9%
Mental Health Facility $2,143,131,041 0.9% $2,326,391,089 0.9% 8.6%
Unknown $1,702,298,783 0.7% $1,344,018,721 0.5% -21.0%
Other Practitioners $882,313,595 0.4% $950,539,160 0.4% 7.7%
PCCM Services $208,303,118 0.1% $499,758,200 0.2% 139.9%
Sterilization $166,394,202 0.1% $206,800,018 0.1% 24.3%
Total Payments* $233,205,998,192 $257,748,435,309 10.50%
*Sum of percentages will not equal 100% due to payments for sterilizations and “unknown.” Puerto Rico and the U.S. Territories are not
included in these national totals.
B-6
2004 Baseline Data

Drug $ as a
State Total Payments Drug Payments Total Recipients Drug Recipients % of Total $
National Total $257,748,435,309 $39,475,607,168 55,002,107 27,548,578 15.3%
Alabama $3,856,624,429 $597,327,339 808,192 543,088 15.5%
Alaska $904,557,756 $116,327,805 118,005 76,203 12.9%
Arizona $3,888,008,156 $4,530,961 1,070,317 8,013 0.1%
Arkansas $2,358,152,529 $396,483,799 707,792 422,930 16.8%
California $27,443,631,984 $4,611,537,385 10,014,373 3,173,781 16.8%
Colorado $2,398,974,577 $294,954,808 503,485 239,881 12.3%
Connecticut $3,695,687,112 $445,816,745 500,952 120,373 12.1%
Delaware $800,099,395 $120,225,182 157,306 104,380 15.0%
District of Columbia $1,269,371,462 $102,118,065 157,650 35,939 8.0%
Florida $12,834,434,692 $2,458,521,754 2,952,363 1,350,741 19.2%
Georgia $6,944,469,214 $1,156,607,078 1,928,820 1,276,736 16.7%
Hawaii $861,761,796 $110,739,727 218,397 41,918 12.9%
Idaho $990,209,718 $159,792,134 206,462 139,491 16.1%
Illinois $10,796,139,208 $1,684,843,071 2,031,777 1,488,375 15.6%
Indiana $4,342,598,411 $738,171,688 946,212 469,260 17.0%
Iowa $2,205,524,237 $366,931,835 382,887 273,391 16.6%
Kansas $1,860,136,019 $280,750,753 365,078 183,107 15.1%
Kentucky $3,923,759,382 $812,180,180 860,508 537,941 20.7%
Louisiana $4,039,097,496 $900,611,528 1,108,054 804,196 22.3%
Maine $2,366,282,600 $304,330,901 293,966 223,450 12.9%
Maryland $4,594,329,962 $429,074,160 750,287 213,731 9.3%
Massachusetts $7,776,024,456 $967,418,472 1,074,050 583,820 12.4%
Michigan $7,696,785,150 $777,599,687 1,799,058 624,745 10.1%
Minnesota $4,575,111,805 $363,035,295 697,929 213,727 7.9%
Mississippi $3,312,060,122 $666,491,588 725,637 581,702 20.1%
Missouri $4,886,664,657 $1,133,878,803 1,140,194 550,572 23.2%
Montana $584,752,191 $96,711,936 112,642 70,441 16.5%
Nebraska $1,345,629,686 $225,374,331 244,275 193,596 16.7%
Nevada $805,569,471 $128,676,465 237,015 90,740 16.0%
New Hampshire $822,246,561 $128,650,584 119,207 91,392 15.6%
New Jersey $6,622,936,246 $1,007,400,013 959,843 310,150 15.2%
New Mexico $2,277,653,128 $129,922,833 474,303 104,871 5.7%
New York $37,273,255,429 $4,598,090,640 4,712,211 2,724,003 12.3%
North Carolina $7,388,008,367 $1,555,955,045 1,512,608 1,071,753 21.1%
North Dakota $477,445,701 $59,815,955 78,324 46,768 12.5%
Ohio $11,374,733,796 $1,870,162,977 1,896,173 1,083,593 16.4%
Oklahoma $2,335,120,746 $396,855,999 653,777 421,476 17.0%
Oregon $2,152,757,267 $230,841,512 559,004 204,821 10.7%
Pennsylvania $10,055,362,936 $902,868,589 1,834,651 428,586 9.0%
Rhode Island $1,530,945,956 $162,380,466 207,621 58,153 10.6%
South Carolina $4,014,695,264 $651,239,970 856,715 611,557 16.2%
South Dakota $579,796,034 $83,907,246 127,783 71,736 14.5%
Tennessee $6,971,053,079 $2,337,847,829 1,654,656 1,196,000 33.5%
Texas $13,214,404,197 $2,202,193,332 3,603,539 2,679,025 16.7%
Utah $1,355,982,016 $192,049,879 307,059 191,562 14.2%
Vermont $744,334,990 $163,436,410 148,921 118,375 22.0%
Virginia $3,574,171,786 $578,855,766 732,009 314,942 16.2%
Washington $4,930,041,261 $653,547,751 1,109,110 448,290 13.3%
West Virginia $2,019,557,347 $360,089,285 376,680 289,762 17.8%
Wisconsin $4,314,127,932 $707,084,087 896,468 395,711 16.4%
Wyoming $363,357,597 $51,347,525 67,762 49,784 14.1%
B-7
Medicaid Payments and Recipients, 2004
State Total Payments Total Recipients Payments Per Recipient

National Total $257,748,435,309 55,002,107 $4,686
Alabama $3,856,624,429 808,192 $4,772
Alaska $904,557,756 118,005 $7,665
Arizona $3,888,008,156 1,070,317 $3,633
Arkansas $2,358,152,529 707,792 $3,332
California $27,443,631,984 10,014,373 $2,740
Colorado $2,398,974,577 503,485 $4,765
Connecticut $3,695,687,112 500,952 $7,377
Delaware $800,099,395 157,306 $5,086
District of Columbia $1,269,371,462 157,650 $8,052
Florida $12,834,434,692 2,952,363 $4,347
Georgia $6,944,469,214 1,928,820 $3,600
Hawaii $861,761,796 218,397 $3,946
Idaho $990,209,718 206,462 $4,796
Illinois $10,796,139,208 2,031,777 $5,314
Indiana $4,342,598,411 946,212 $4,589
Iowa $2,205,524,237 382,887 $5,760
Kansas $1,860,136,019 365,078 $5,095
Kentucky $3,923,759,382 860,508 $4,560
Louisiana $4,039,097,496 1,108,054 $3,645
Maine $2,366,282,600 293,966 $8,050
Maryland $4,594,329,962 750,287 $6,123
Massachusetts $7,776,024,456 1,074,050 $7,240
Michigan $7,696,785,150 1,799,058 $4,278
Minnesota $4,575,111,805 697,929 $6,555
Mississippi $3,312,060,122 725,637 $4,564
Missouri $4,886,664,657 1,140,194 $4,286
Montana $584,752,191 112,642 $5,191
Nebraska $1,345,629,686 244,275 $5,509
Nevada $805,569,471 237,015 $3,399
New Hampshire $822,246,561 119,207 $6,898
New Jersey $6,622,936,246 959,843 $6,900
New Mexico $2,277,653,128 474,303 $4,802
New York $37,273,255,429 4,712,211 $7,910
North Carolina $7,388,008,367 1,512,608 $4,884
North Dakota $477,445,701 78,324 $6,096
Ohio $11,374,733,796 1,896,173 $5,999
Oklahoma $2,335,120,746 653,777 $3,572
Oregon $2,152,757,267 559,004 $3,851
Pennsylvania $10,055,362,936 1,834,651 $5,481
Rhode Island $1,530,945,956 207,621 $7,374
South Carolina $4,014,695,264 856,715 $4,686
South Dakota $579,796,034 127,783 $4,537
Tennessee $6,971,053,079 1,654,656 $4,213
Texas $13,214,404,197 3,603,539 $3,667
Utah $1,355,982,016 307,059 $4,416
Vermont $744,334,990 148,921 $4,998
Virginia $3,574,171,786 732,009 $4,883
Washington $4,930,041,261 1,109,110 $4,445
West Virginia $2,019,557,347 376,680 $5,361
Wisconsin $4,314,127,932 896,468 $4,812
Wyoming $363,357,597 67,762 $5,362
B-8
Drug Payments and Recipients, 2004
State Total Drug Payments Total Drug Recipients Drug Payments Per Recipient
National Total $39,475,607,168 27,548,578 $1,433
Alabama $597,327,339 543,088 $1,100
Alaska $116,327,805 76,203 $1,527
Arizona $4,530,961 8,013 $565
Arkansas $396,483,799 422,930 $937
California $4,611,537,385 3,173,781 $1,453
Colorado $294,954,808 239,881 $1,230
Connecticut $445,816,745 120,373 $3,704
Delaware $120,225,182 104,380 $1,152
District of Columbia $102,118,065 35,939 $2,841
Florida $2,458,521,754 1,350,741 $1,820
Georgia $1,156,607,078 1,276,736 $906
Hawaii $110,739,727 41,918 $2,642
Idaho $159,792,134 139,491 $1,146
Illinois $1,684,843,071 1,488,375 $1,132
Indiana $738,171,688 469,260 $1,573
Iowa $366,931,835 273,391 $1,342
Kansas $280,750,753 183,107 $1,533
Kentucky $812,180,180 537,941 $1,510
Louisiana $900,611,528 804,196 $1,120
Maine $304,330,901 223,450 $1,362
Maryland $429,074,160 213,731 $2,008
Massachusetts $967,418,472 583,820 $1,657
Michigan $777,599,687 624,745 $1,245
Minnesota $363,035,295 213,727 $1,699
Mississippi $666,491,588 581,702 $1,146
Missouri $1,133,878,803 550,572 $2,059
Montana $96,711,936 70,441 $1,373
Nebraska $225,374,331 193,596 $1,164
Nevada $128,676,465 90,740 $1,418
New Hampshire $128,650,584 91,392 $1,408
New Jersey $1,007,400,013 310,150 $3,248
New Mexico $129,922,833 104,871 $1,239
New York $4,598,090,640 2,724,003 $1,688
North Carolina $1,555,955,045 1,071,753 $1,452
North Dakota $59,815,955 46,768 $1,279
Ohio $1,870,162,977 1,083,593 $1,726
Oklahoma $396,855,999 421,476 $942
Oregon $230,841,512 204,821 $1,127
Pennsylvania $902,868,589 428,586 $2,107
Rhode Island $162,380,466 58,153 $2,792
South Carolina $651,239,970 611,557 $1,065
South Dakota $83,907,246 71,736 $1,170
Tennessee $2,337,847,829 1,196,000 $1,955
Texas $2,202,193,332 2,679,025 $822
Utah $192,049,879 191,562 $1,003
Vermont $163,436,410 118,375 $1,381
Virginia $578,855,766 314,942 $1,838
Washington $653,547,751 448,290 $1,458
West Virginia $360,089,285 289,762 $1,243
Wisconsin $707,084,087 395,711 $1,787
Wyoming $51,347,525 49,784 $1,031
B-9
Drug Payment Trends, Percent Change 2003-2004
State 2003 2004 Percent Change

National Total $33,714,314,456 $39,475,607,168 17.1%
Alabama $537,070,779 $597,327,339 11.2%
Alaska $99,756,988 $116,327,805 16.6%
Arizona $4,139,726 $4,530,961 9.5%
Arkansas $325,829,229 $396,483,799 21.7%
California $4,019,645,375 $4,611,537,385 14.7%
Colorado $251,367,181 $294,954,808 17.3%
Connecticut $402,380,645 $445,816,745 10.8%
Delaware $110,942,313 $120,225,182 8.4%
District of Columbia $82,817,543 $102,118,065 23.3%
Florida $2,062,349,922 $2,458,521,754 19.2%
Georgia $1,003,853,892 $1,156,607,078 15.2%
Hawaii $96,404,644 $110,739,727 14.9%
Idaho $137,360,436 $159,792,134 16.3%
Illinois $1,258,646,834 $1,684,843,071 33.9%
Indiana $655,689,109 $738,171,688 12.6%
Iowa $325,270,012 $366,931,835 12.8%
Kansas $235,117,999 $280,750,753 19.4%
Kentucky $693,988,604 $812,180,180 17.0%
Louisiana $783,761,071 $900,611,528 14.9%
Maine $278,812,700 $304,330,901 9.2%
Maryland $380,007,833 $429,074,160 12.9%
Massachusetts $938,275,647 $967,418,472 3.1%
Michigan $753,841,353 $777,599,687 3.2%
Minnesota $336,444,933 $363,035,295 7.9%
Mississippi $568,265,605 $666,491,588 17.3%
Missouri $953,324,877 $1,133,878,803 18.9%
Montana $86,637,045 $96,711,936 11.6%
Nebraska $197,698,309 $225,374,331 14.0%
Nevada $110,070,582 $128,676,465 16.9%
New Hampshire $117,004,510 $128,650,584 10.0%
New Jersey $757,754,210 $1,007,400,013 32.9%
New Mexico $108,079,641 $129,922,833 20.2%
New York $4,000,289,361 $4,598,090,640 14.9%
North Carolina $1,263,258,395 $1,555,955,045 23.2%
North Dakota $56,433,414 $59,815,955 6.0%
Ohio $1,569,067,697 $1,870,162,977 19.2%
Oklahoma $290,182,401 $396,855,999 36.8%
Oregon $251,539,420 $230,841,512 -8.2%
Pennsylvania $769,962,791 $902,868,589 17.3%
Rhode Island $141,126,655 $162,380,466 15.1%
South Carolina $559,908,608 $651,239,970 16.3%
South Dakota $72,883,705 $83,907,246 15.1%
Tennessee $1,772,766,619 $2,337,847,829 31.9%
Texas $1,921,877,468 $2,202,193,332 14.6%
Utah $146,490,144 $192,049,879 31.1%
Vermont $129,301,879 $163,436,410 26.4%
Virginia $506,529,241 $578,855,766 14.3%
Washington $597,415,127 $653,547,751 9.4%
West Virginia $339,840,738 $360,089,285 6.0%
Wisconsin $610,280,050 $707,084,087 15.9%
Wyoming $42,551,196 $51,347,525 20.7%
B-10
Rankings Based on Drug Payments
% of Total 2004 Medicaid

State 2004 Payments Ranking Drug Payments 2003 Payments Ranking
California $4,611,537,385 1 11.7% $4,019,645,375 1
New York $4,598,090,640 2 11.7% $4,000,289,361 2
Florida $2,458,521,754 3 6.2% $2,062,349,922 3
Texas $2,337,847,829 4 5.9% $1,772,766,619 5
Tennessee $2,202,193,332 5 5.6% $1,921,877,468 4
Ohio $1,870,162,977 6 4.7% $1,569,067,697 6
North Carolina $1,684,843,071 7 4.3% $1,258,646,834 8
Illinois $1,555,955,045 8 3.9% $1,263,258,395 7
Georgia $1,156,607,078 9 2.9% $1,003,853,892 9
Missouri $1,133,878,803 10 2.9% $953,324,877 10
Massachusetts $1,007,400,013 11 2.6% $757,754,210 14
Louisiana $967,418,472 12 2.5% $938,275,647 11
Pennsylvania $902,868,589 13 2.3% $769,962,791 13
New Jersey $900,611,528 14 2.3% $783,761,071 12
Michigan $812,180,180 15 2.1% $693,988,604 16
Kentucky $777,599,687 16 2.0% $753,841,353 15
Indiana $738,171,688 17 1.9% $655,689,109 17
Wisconsin $707,084,087 18 1.8% $610,280,050 18
Washington $666,491,588 19 1.7% $568,265,605 20
Mississippi $653,547,751 20 1.7% $597,415,127 19
South Carolina $651,239,970 21 1.7% $559,908,608 21
Alabama $597,327,339 22 1.5% $537,070,779 22
Virginia $578,855,766 23 1.5% $506,529,241 23
Connecticut $445,816,745 24 1.1% $402,380,645 24
Maryland $429,074,160 25 1.1% $380,007,833 25
West Virginia $396,855,999 26 1.0% $290,182,401 30
Minnesota $396,483,799 27 1.0% $325,829,229 28
Arkansas $366,931,835 28 0.9% $325,270,012 29
Iowa $363,035,295 29 0.9% $336,444,933 27
Oklahoma $360,089,285 30 0.9% $339,840,738 26
Maine $304,330,901 31 0.8% $278,812,700 31
Oregon $294,954,808 32 0.8% $251,367,181 33
Colorado $280,750,753 33 0.7% $235,117,999 34
Kansas $230,841,512 34 0.6% $251,539,420 32
Nebraska $225,374,331 35 0.6% $197,698,309 35
Utah $192,049,879 36 0.5% $146,490,144 36
Rhode Island $163,436,410 37 0.4% $129,301,879 39
Idaho $162,380,466 38 0.4% $141,126,655 37
Vermont $159,792,134 39 0.4% $137,360,436 38
New Hampshire $129,922,833 40 0.3% $108,079,641 43
Delaware $128,676,465 41 0.3% $110,070,582 42
Nevada $128,650,584 42 0.3% $117,004,510 40
New Mexico $120,225,182 43 0.3% $110,942,313 41
Alaska $116,327,805 44 0.3% $99,756,988 44
Hawaii $110,739,727 45 0.3% $96,404,644 45
Montana $102,118,065 46 0.3% $82,817,543 47
District of Columbia $96,711,936 47 0.2% $86,637,045 46
South Dakota $83,907,246 48 0.2% $72,883,705 48
North Dakota $59,815,955 49 0.2% $56,433,414 49
Wyoming $51,347,525 50 0.1% $42,551,196 50
Arizona $4,530,961 51 0.0% $4,139,726 51
B-11
Drugs as a Percentage of Total Payments, 2004
State Drug Payments Total Payments Percent of Total Payments

National Total $39,475,607,168 $257,748,435,309 15.3%
Alabama $597,327,339 $3,856,624,429 15.5%
Alaska $116,327,805 $904,557,756 12.9%
Arizona $4,530,961 $3,888,008,156 0.1%
Arkansas $396,483,799 $2,358,152,529 16.8%
California $4,611,537,385 $27,443,631,984 16.8%
Colorado $294,954,808 $2,398,974,577 12.3%
Connecticut $445,816,745 $3,695,687,112 12.1%
Delaware $120,225,182 $800,099,395 15.0%
District of Columbia $102,118,065 $1,269,371,462 8.0%
Florida $2,458,521,754 $12,834,434,692 19.2%
Georgia $1,156,607,078 $6,944,469,214 16.7%
Hawaii $110,739,727 $861,761,796 12.9%
Idaho $159,792,134 $990,209,718 16.1%
Illinois $1,684,843,071 $10,796,139,208 15.6%
Indiana $738,171,688 $4,342,598,411 17.0%
Iowa $366,931,835 $2,205,524,237 16.6%
Kansas $280,750,753 $1,860,136,019 15.1%
Kentucky $812,180,180 $3,923,759,382 20.7%
Louisiana $900,611,528 $4,039,097,496 22.3%
Maine $304,330,901 $2,366,282,600 12.9%
Maryland $429,074,160 $4,594,329,962 9.3%
Massachusetts $967,418,472 $7,776,024,456 12.4%
Michigan $777,599,687 $7,696,785,150 10.1%
Minnesota $363,035,295 $4,575,111,805 7.9%
Mississippi $666,491,588 $3,312,060,122 20.1%
Missouri $1,133,878,803 $4,886,664,657 23.2%
Montana $96,711,936 $584,752,191 16.5%
Nebraska $225,374,331 $1,345,629,686 16.7%
Nevada $128,676,465 $805,569,471 16.0%
New Hampshire $128,650,584 $822,246,561 15.6%
New Jersey $1,007,400,013 $6,622,936,246 15.2%
New Mexico $129,922,833 $2,277,653,128 5.7%
New York $4,598,090,640 $37,273,255,429 12.3%
North Carolina $1,555,955,045 $7,388,008,367 21.1%
North Dakota $59,815,955 $477,445,701 12.5%
Ohio $1,870,162,977 $11,374,733,796 16.4%
Oklahoma $396,855,999 $2,335,120,746 17.0%
Oregon $230,841,512 $2,152,757,267 10.7%
Pennsylvania $902,868,589 $10,055,362,936 9.0%
Rhode Island $162,380,466 $1,530,945,956 10.6%
South Carolina $651,239,970 $4,014,695,264 16.2%
South Dakota $83,907,246 $579,796,034 14.5%
Tennessee $2,337,847,829 $6,971,053,079 33.5%
Texas $2,202,193,332 $13,214,404,197 16.7%
Utah $192,049,879 $1,355,982,016 14.2%
Vermont $163,436,410 $744,334,990 22.0%
Virginia $578,855,766 $3,574,171,786 16.2%
Washington $653,547,751 $4,930,041,261 13.3%
West Virginia $360,089,285 $2,019,557,347 17.8%
Wisconsin $707,084,087 $4,314,127,932 16.4%
Wyoming $51,347,525 $363,357,597 14.1%
B-12
Drugs as a Percentage of Total Payments, 1998 – 2004*
State 1998 1999 2000 2001 2002 2003 2004

National Total 9.5% 10.8% 11.8% 12.7% 13.3% 14.5% 15.3%
Alabama 12.4% 16.6% 13.9% 13.3% 14.2% 15.5% 15.5%
Alaska 10.0% 9.9% 11.3% 11.9% 12.1% 11.9% 12.9%
Arizona 0.1% 0.1% 0.1% 0.2% 0.2% 0.1% 0.1%
Arkansas 11.0% 13.4% 13.6% 14.4% 13.9% 14.7% 16.8%
California 10.9% 11.9% 13.5% 14.1% 14.4% 15.6% 16.8%
Colorado 7.7% 8.0% 8.5% 9.1% 9.3% 11.1% 12.3%
Connecticut 7.7% 8.3% 9.3% 10.3% 11.0% 12.0% 12.1%
Delaware 9.9% 11.6% 12.5% 13.6% 15.4% 14.8% 15.0%
District of Columbia 5.6% 5.9% 7.0% 7.5% 6.6% 6.9% 8.0%
Florida 16.4% 16.3% 18.4% 17.4% 17.7% 18.6% 19.2%
Georgia 12.3% 14.3% 16.2% 17.3% 15.6% 18.7% 16.7%
Hawaii 7.8% 8.4% 9.8% 12.0% 11.7% 12.8% 12.9%
Idaho 12.9% 13.2% 14.1% 14.8% 15.4% 15.8% 16.1%
Illinois 9.4% 10.6% 10.8% 11.5% 13.4% 13.4% 15.6%
Indiana 12.7% 13.7% 15.6% 16.7% 17.1% 16.6% 17.0%
Iowa 11.4% 12.4% 13.2% 13.9% 15.0% 16.3% 16.6%
Kansas 13.0% 12.7% 13.7% 13.9% 14.7% 14.6% 15.1%
Kentucky 13.2% 13.8% 15.9% 18.5% 19.1% 19.5% 20.7%
Louisiana 14.8% 16.0% 18.2% 19.3% 21.1% 21.7% 22.3%
Maine 16.3% 12.1% 13.4% 14.0% 14.6% 13.4% 12.9%
Maryland 6.0% 6.7% 7.4% 8.1% 8.7% 8.6% 9.3%
Massachusetts 10.8% 12.0% 12.6% 13.8% 14.9% 14.7% 12.4%
Michigan 8.6% 6.8% 7.7% 11.4% 11.4% 11.6% 10.1%
Minnesota 5.9% 6.1% 6.8% 7.0% 6.6% 7.2% 7.9%
Mississippi 16.1% 17.2% 20.5% 22.7% 22.7% 22.1% 20.1%
Missouri 14.9% 17.2% 18.4% 18.8% 19.6% 21.6% 23.2%
Montana 11.7% 13.4% 14.0% 14.7% 14.6% 16.2% 16.5%
Nebraska 12.3% 13.2% 14.1% 14.8% 15.7% 15.4% 16.7%
Nevada 7.5% 8.8% 10.0% 10.6% 12.5% 12.5% 16.0%
New Hampshire 9.1% 12.3% 12.4% 13.2% 13.3% 14.9% 15.6%
New Jersey 10.1% 11.2% 12.4% 12.9% 12.5% 12.6% 15.2%
New Mexico 4.8% 4.2% 4.6% 4.7% 5.2% 5.3% 5.7%
New York 5.6% 7.6% 9.1% 10.0% 10.8% 11.4% 12.3%
North Carolina 11.6% 14.3% 16.4% 17.6% 17.7% 19.4% 21.1%
North Dakota 8.1% 9.1% 10.6% 11.5% 12.2% 12.7% 12.5%
Ohio 10.5% 12.0% 12.4% 13.9% 14.5% 15.3% 16.4%
Oklahoma - 11.7% 11.1% 10.8% 12.0% 13.6% 17.0%
Oregon 6.4% 7.7% 9.5% 11.8% 12.6% 11.9% 10.7%
Pennsylvania 8.6% 9.9% 8.4% 9.0% 8.4% 8.1% 9.0%
Rhode Island 6.7% 8.5% 8.4% 9.6% 10.1% 10.5% 10.6%
South Carolina 11.1% 10.5% 12.1% 14.2% 13.5% 15.4% 16.2%
South Dakota 8.7% 10.0% 11.1% 12.3% 12.6% 13.4% 14.5%
Tennessee 0.0% 0.0% 0.0% 0.0% 12.1% 32.5% 33.5%
Texas 11.5% 11.7% 12.1% 13.8% 14.3% 15.3% 16.7%
Utah 11.1% 10.5% 10.5% 11.0% 11.6% 12.2% 14.2%
Vermont 12.4% 16.0% 19.2% 19.6% 19.0% 20.1% 22.0%
Virginia 13.4% 14.9% 15.4% 15.4% 15.0% 15.9% 16.2%
Washington 12.0% 11.8% 16.0% 17.1% 12.6% 13.2% 13.3%
West Virginia 12.0% 14.6% 15.5% 16.4% 17.4% 18.6% 17.8%
Wisconsin 10.5% 12.4% 11.8% 12.2% 12.6% 15.6% 16.4%
Wyoming 8.9% 11.2% 12.8% 13.3% 13.6% 13.1% 14.1%
*Hawaii did not report on time for FY 1999 and was excluded from the national totals for those years. Hawaii also did not report for FY 2000.
CMS included their FY 1999 data in the FY 2000 MSIS Report. Oklahoma did not report for FY 1998 and was excluded from the national total
for that year.
Source: CMS, HCFA-2082 Report, FY 1998 and MSIS Reports, FY 1999 – FY 2004.
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Total Drug Recipients
State 1998* 1999 2000 2001 2002 2003 2004

National Total 19,324,605 19,428,344 20,324,675 21,910,532 24,424,493 26,075,011 27,548,578
Alabama 395,290 405,330 438,529 464,695 500,789 527,855 543,088
Alaska 43,734 52,070 60,273 65,278 70,550 75,501 76,203
Arizona 56,796 5,545 7,034 9,761 7,805 7,616 8,013
Arkansas 262,907 280,552 290,749 321,920 356,233 432,556 422,930
California 2,644,430 2,252,441 2,491,537 2,489,050 2,651,229 2,868,468 3,173,781
Colorado 147,033 151,537 160,265 143,167 153,520 197,128 239,881
Connecticut 108,331 108,754 113,101 116,785 123,704 119,698 120,373
Delaware 69,027 73,093 78,167 85,350 125,461 99,634 104,380
District of Columbia 57,733 37,862 38,129 35,324 45,216 34,424 35,939
Florida 1,014,372 991,927 1,078,631 1,165,866 1,245,841 1,309,456 1,350,741
Georgia 805,923 843,353 882,309 978,404 1,076,904 1,222,323 1,276,736
Hawaii 32,222 35,837 37,316 39,288 39,320 41,748 41,918
Idaho 86,775 81,980 92,776 112,357 125,537 133,592 139,491
Illinois 959,472 966,790 1,013,387 1,068,687 1,199,933 1,227,361 1,488,375
Indiana 323,811 361,661 420,071 464,975 490,386 459,938 469,260
Iowa 215,173 213,144 212,178 221,690 245,711 258,417 273,391
Kansas 155,875 153,054 158,334 158,515 157,618 165,599 183,107
Kentucky 429,102 366,051 425,721 476,774 489,416 512,351 537,941
Louisiana 552,481 551,698 581,356 628,574 689,973 758,388 804,196
Maine 137,816 143,548 149,262 194,288 224,664 245,562 223,450
Maryland 176,403 159,779 163,410 171,747 181,101 204,994 213,731
Massachusetts 613,186 671,741 671,716 671,756 659,626 640,437 583,820
Michigan 589,818 436,848 435,723 551,680 577,785 610,641 624,745
Minnesota 203,220 184,075 179,879 187,854 190,577 201,366 213,727
Mississippi 368,609 375,573 415,925 478,409 526,923 547,268 581,702
Missouri 353,902 412,597 447,068 472,645 493,230 526,991 550,572
Montana 58,641 59,182 58,918 63,352 67,365 74,400 70,441
Nebraska 145,408 155,136 166,031 178,634 194,889 196,184 193,596
Nevada 50,903 48,534 51,170 58,699 71,950 76,745 90,740
New Hampshire 70,339 71,039 73,313 73,489 78,861 85,787 91,392
New Jersey 309,849 301,022 299,356 305,962 296,059 297,997 310,150
New Mexico 96,637 55,018 67,239 75,892 122,098 99,931 104,871
New York 1,803,428 2,024,870 2,173,856 2,458,197 2,567,595 2,623,805 2,724,003
North Carolina 764,886 812,234 827,389 907,741 949,795 1,015,932 1,071,753
North Dakota 37,675 37,780 38,964 39,758 44,428 47,738 46,768
Ohio 702,143 796,720 777,632 934,632 997,246 1,054,737 1,083,593
Oklahoma - 222,456 221,985 252,025 276,111 302,424 421,476
Oregon 148,258 174,931 193,924 223,580 242,865 240,228 204,821
Pennsylvania 580,749 520,221 416,498 461,114 464,848 404,586 428,586
Rhode Island 44,852 49,277 49,809 50,411 53,729 57,605 58,153
South Carolina 401,611 446,893 474,470 542,768 576,136 614,417 611,557
South Dakota 46,588 50,780 53,666 58,212 64,948 68,361 71,736
Tennessee^ 1 0 0 0 916,968 1,175,224 1,196,000
Texas 1,894,447 1,853,348 1,852,828 1,917,398 2,153,316 2,475,742 2,679,025
Utah 126,953 130,682 133,224 136,719 152,268 160,312 191,562
Vermont 58,037 89,547 103,635 109,578 112,227 115,381 118,375
Virginia 383,880 377,588 344,877 334,008 319,196 325,047 314,942
Washington 274,463 301,907 339,611 385,408 423,758 438,618 448,290
West Virginia 267,398 274,894 262,675 269,174 276,338 285,582 289,762
Wisconsin 221,508 224,165 267,417 262,238 309,795 361,969 395,711
Wyoming 32,510 33,280 33,342 36,704 42,652 46,947 49,784
Note: Recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs.
*Oklahoma did not report for FY 1998. They are excluded from the national total for that year.
^Until 2002, Tennessee did not report drug recipients because beneficiaries are enrolled in managed care & receive pharmaceutical benefits through these
plans.
Source: CMS, HCFA-2082 Report, FY1998 and MSIS Report, FY 1999 – FY 2004.
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Appendix C:
Medicaid Rebate Law
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NOTE: This section is current through September 20, 2007.
TITLE 42 - THE PUBLIC HEALTH AND WELFARE

CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS
Sec. 1396r-8. Payment for covered outpatient drugs1
a. Requirement for rebate agreement
(1) In general
In order for payment to be available under section 1396b(a) of this subchapter or under part B of
subchapter XVIII for covered outpatient drugs of a manufacturer, the manufacturer must have entered
into and have in effect a rebate agreement described in subsection (b) of this section with the
Secretary, on behalf of States (except that, the Secretary may authorize a State to enter directly into
agreements with a manufacturer), and must meet the requirements of paragraph (5)(with respect to
drugs purchased by a covered entity on or after the first day of the first month that begins after
November 4, 1992) and paragraph (6). Any agreement between a State and a manufacturer prior to
April 1, 1991, shall be deemed to have been entered into on January 1, 1991, and payment to such
manufacturer shall be retroactively calculated as if the agreement between the manufacturer and the
State had been entered into on January 1, 1991. If a manufacturer has not entered into such an
agreement before March 1, 1991, such an agreement, subsequently entered into, shall become effective
as of the date on which the agreement is entered into or, at State option, on any date thereafter on or
before the first day of the calendar quarter that begins more than 60 days after the date of the
agreement is entered into.
(2) Effective date

Paragraph (1) shall first apply to drugs dispensed under this subchapter on or after January 1, 1991.
(3) Authorizing payment for drugs not covered under rebate agreements
Paragraph (1), and section 1396b(i)(10)(A) of this title, shall not apply to the dispensing of a single
source drug or innovator multiple source drug if (A)(i) the State has made a determination that the
availability of the drug is essential to the health of beneficiaries under the State Plan for medical
assistance; (ii) such drug has been given a rating of 1-A by the Food and Drug Administration; and
(iii)(I) the physician has obtained approval for use of the drug in advance of its dispensing in
accordance with a prior authorization program described in subsection (d) of this section, or (II) the
Secretary has reviewed and approved the State’s determination under subparagraph (A); or (B) the
Secretary determines that in the first calendar quarter of 1991, there were extenuating circumstances.
(4) Effect on existing agreements

In the case of a rebate agreement in effect between a State and a manufacturer on November 5, 1990,
such agreement, for the initial agreement period specified therein, shall be considered to be a rebate
agreement in compliance with this section with respect to that State, if the State agrees to report to the
Secretary any rebates paid pursuant to the agreement and such agreement provides for a minimum
aggregate rebate of 10 percent of the State’s total expenditures under the State Plan for coverage of the
manufacturer’s drugs under this subchapter. If, after the initial agreement period, the State establishes
to the satisfaction of the Secretary that an agreement in effect on November 5, 1990, provides for
rebates that are at least as large as the rebates otherwise required under this section, and the State
agrees to report any rebates under the agreement to the Secretary, the agreement shall be considered to
be a rebate agreement in compliance with the section for the renewal periods of such agreement.
1
This is section 1927 of the Social Security Act. It is codified as Section 1396r-8 of Title 42 of the United States Code.
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(5) Limitation on prices of drugs purchased by covered entities
(A) Agreement with Secretary

A manufacturer meets the requirements of this paragraph if the manufacturer has entered into
an agreement with the Secretary that meets the requirements of section 256b of this title with
respect to covered outpatient drugs purchased by a covered entity on or after the first day of
the first month that begins after November 4, 1992.
(B) “Covered entity” defined

In this subsection, the term “covered entity” means an entity described in section
256b(b)(a)(4) of this title and a children’s hospital described in section 1395ww(d)(1)(B)(iii)
of this title which meets the requirements of clauses (i) and (iii) of section 256b(b)(4)(L) of
this title and which would meet requirements of clauses (ii) of such section if that clause were
applied by taking into account the percentage of care provided by the hospital to patients
eligible for medical assistance under a State plan under this title.
(C) Establishment of alternative mechanism to ensure against duplicate discounts or rebates

If the Secretary does not establish a mechanism under section 256b(a)(5)(A) of this title within
12 months of November 4, 1992, the following requirements shall apply:
(i) Entities
Each covered entity shall inform the single State agency under section 1396a(a)(5) of this
title when it is seeking reimbursement from the State Plan for medical assistance
described in section 1396d(a)(12) of this title with respect to a unit of any covered
outpatient drug which is subject to an agreement under section 256b(a) of this title.
(ii) State agency

Each such single State agency shall provide a means by which a covered entity shall
indicate on any drug reimbursement claims form (or format, where electronic claims
management is used) that a unit of the drug that is the subject of the form is subject to an
agreement under section 256b of this title, and not submit to any manufacturer a claim for
a rebate payment under subsection (b) of this section with respect to such a drug.
(D) Effect of subsequent amendments

In determining whether an agreement under subparagraph (A) meets the requirements of
section 256b of this title, the Secretary shall not take into account any amendments to such
section that are enacted after November 4, 1992.
(E) Determination of compliance

A manufacturer is deemed to meet the requirements of this paragraph if the manufacturer
establishes to the satisfaction of the Secretary that the manufacturer would comply (and has
offered to comply) with the provisions of section 256b of this title (as in effect immediately
after November 4, 1992) and would have entered into an agreement under such section (as
such section was in effect at such time), but for a legislative change in such section after
November 4, 1992.
(6) Requirements relating to master agreements for drugs procured by Department of Veterans Affairs
and certain other Federal agencies
(A) In general
A manufacturer meets the requirements of this paragraph if the manufacturer complies with
the provisions of section 8126 of title 38, including the requirement of entering into a master
agreement with the Secretary of Veterans Affairs under such section.
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(B) Effect of subsequent amendments

In determining whether a master agreement described in subparagraph (A) meets the
requirements of section 8126 of title 38, the Secretary shall not take into account any
amendments to such section that are enacted after November 4, 1992.
(C) Determination of compliance

A manufacturer is deemed to meet the requirements of this paragraph if the manufacturer
establishes to the satisfaction of the Secretary that the manufacturer would comply (and has
offered to comply) with the provisions of section 8126 of title 38, (as in effect immediately
after November 4, 1992) and would have entered into an agreement under such section (as
such section was in effect at such time), but for a legislative change in such section after
November 4, 1992.
(7) Requirement for submission of utilization data for certain physician administered drugs.
(A) Single source drugs.

In order for payment to be available under section 1396b(a) for a covered outpatient drug that
is a single source drug that is physician administered under this subchapter (as determined by
the Secretary), and that is administered on or after January 1, 2006, the State shall provide for
the collection and submission of such utilization data and coding (such as J-codes and
National Drug Code numbers) for each such drug as the Secretary may specify as necessary to
identify the manufacturer of the drug in order to secure rebates under this section for drugs
administered for which payment is made under this subchapter.
(B) Multiple source drugs

(i) Identification of most frequently administered multiple source drugs.-- Not later than
January 1, 2007, the Secretary shall publish a list of the 20 physician administered
multiple source drugs that the Secretary determines have the highest dollar volume of
physician administered drugs dispensed under this subchapter. The Secretary may modify
such list from year to year to reflect changes in such volume.
(ii) Requirement.-- In order for payment to be available under section 1396b(a) for a
covered outpatient drug that is a multiple source drug that is physician administered (as
determined by the Secretary), that is on the list published under clause (i), and that is
administered on or after January 1, 2008, the State shall provide for the submission of
such utilization data and coding (such as J-codes and National Drug Code numbers) for
each such drug as the Secretary may specify as necessary to identify the manufacturer of
the drug in order to secure rebates under this section.
(C) Use of NDC codes.

Not later than January 1, 2007, the information shall be submitted under subparagraphs (A)
and (B)(ii) using National Drug Code codes unless the Secretary specifies that an alternative
coding system should be used.
(D) Hardship waiver.

The Secretary may delay the application of subparagraph (A) or (B)(ii), or both, in the case of
a State to prevent hardship to States which require additional time to implement the reporting
system required under the respective subparagraph.
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b. Terms of rebate agreement
(1) Periodic rebates
(A) In general
A rebate agreement under this subsection shall require the manufacturer to provide, to each
State Plan approved under this subchapter, a rebate for a rebate period in an amount specified
in subsection (c) of this section for covered outpatient drugs of the manufacturer dispensed
after December 31, 1990, for which payment was made under the State Plan for such period.
Such rebate shall be paid by the manufacturer not later than 30 days after the date of receipt of
the information described in paragraph (2) for the period involved.
(B) Offset against medical assistance

Amounts received by a State under this section (or under an agreement authorized by the
Secretary under subsection (a)(1) of this section or an agreement described in subsection (a)(4)
of this section) in any quarter shall be considered to be a reduction in the amount expended
under the State Plan in the quarter for medical assistance for purposes of section 1396b(a)(1)
of this title.
(2) State provision of information
(A) State responsibility

Each State agency under this subchapter shall report to each manufacturer not later than 60
days after the end of each rebate period and in a form consistent with a standard reporting
format established by the Secretary, information on the total number of units of each dosage
form and strength and package size of each covered outpatient drug dispensed after December
31, 1990, for which payment was made under the Plan during the period, and shall promptly
transmit a copy of such report to the Secretary.
(B) Audits
A manufacturer may audit the information provided (or required to be provided) under
subparagraph (A). Adjustments to rebates shall be made to the extent that information
indicates that utilization was greater or less than the amount previously specified.
(3) Manufacturer provision of price information
(A) In general. -- Each manufacturer with an agreement in effect under this section shall report
to the Secretary –
(i) not later than 30 days after the last day of each month of a rebate period under the
agreement—
(I) on the average manufacturer price (as defined in subsection (k)(1) of this section)
for customary prompt pay discounts extended to wholesalers, for covered outpatient
drugs for the rebate period under the agreement (including for all such drugs that are
sold under a new drug application approved under section 355(c) of title 21); and
(II) for single source drugs and innovator multiple source drugs (including all such
drugs that are sold under a new drug application approved under section 355(c) of title
21), on the manufacturer’s best price (as defined in subsection (c)(1)(C) of this
section) for such drugs for the rebate period under the agreement;
(ii) not later than 30 days after the date of entering into an agreement under this section on
the average manufacturer price (as defined in subsection (k)(1) of this section) as of
October 1, 1990 for each of the manufacturer’s covered outpatient drugs (including for
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such drugs that are sold under a new drug application approved under section 355(c) of
title 21); and
(iii) for calendar quarters beginning on or after January 1, 2004, in conjunction with
reporting required under clause (i) and by National Drug Code (including package size)—
(I) the manufacturer’s average sales price (as defined in section 1395w-3a(c) of this
title) and the total number of units specified under section 1395w-3a(b)(2)(A) of this
title;
(II) if required to make payment under section 1395w-3a of this title, the
manufacturer’s wholesale acquisition cost, as defined in subsection (c)(6) of such
section; and
(III) information on those sales that were made at a nominal price or otherwise
described in section 1395w-3a(c)(2)(B) of this title;
for a drug or biological described in subparagraph (C), (D), (E), or (G) of section 1395u(o)(1)
or section 1395rr(b)(13)(A)(ii) of this title.
Information reported under this subparagraph is subject to audit by the Inspector General of
the Department of Health and Human Services. Beginning July 1, 2006, the Secretary shall
provide on a monthly basis to States under subparagraph (D)(iv) the most recently reported
average manufacturer prices for single source drugs and for multiple source drugs and shall,
on at least a quarterly basis, update the information posted on the website under subparagraph
(D)(v), and, for calendar quarters beginning on or after January 1, 2007 and only with respect
to the information described in subclause (III), for covered outpatient drugs.
(B) Verification surveys of average manufacturer price and manufacturer’s average sales price
The Secretary may survey wholesalers and manufacturers that directly distribute their covered
outpatient drugs, when necessary, to verify manufacturer prices reported under subparagraph
(A). The Secretary may impose a civil monetary penalty in an amount not to exceed $100,000
on a wholesaler, manufacturer, or direct seller, if the wholesaler, manufacturer, or direct seller
of a covered outpatient drug refuses a request for information about charges or prices by the
Secretary in connection with a survey under this subparagraph or knowingly provides false
information. The provisions of section 1320a-7a of this title (other than subsections (a) (with
respect to amounts of penalties or additional assessments) and (b)) shall apply to a civil money
penalty under this subparagraph in the same manner as such provisions apply to a penalty or
proceeding under section 1320a-7a(a) of this title.
(C) Penalties
(i) Failure to provide timely information
In the case of a manufacturer with an agreement under this section that fails to provide
information required under subparagraph (A) on a timely basis, the amount of the penalty
shall be increased by $10,000 for each day in which such information has not been
provided and such amount shall be paid to the Treasury, and, if such information is not
reported within 90 days of the deadline imposed, the agreement shall be suspended for
services furnished after the end of such 90-day period and until the date such information
is reported (but in no case shall such suspension be for a period of less than 30 days).
(ii) False information

Any manufacturer with an agreement under this section that knowingly provides false
information is subject to a civil money penalty in an amount not to exceed $100,000 for
each item of false information. Such civil money penalties are in addition to other
penalties as may be prescribed by law. The provisions of section 1320a-7a of this title
(other than subsections (a) and (b)) shall apply to a civil money penalty under this
subparagraph in the same manner as such provisions apply to a penalty or proceeding
under section 1320a-7a(a) of this title.
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(D) Confidentiality of information

Notwithstanding any other provision of law, information disclosed by manufacturers or
wholesalers under this paragraph or under an agreement with the Secretary of Veterans Affairs
described in subsection (a)(6)(A)(ii) of this section is confidential and shall not be disclosed
by the Secretary or the Secretary of Veterans Affairs or a State agency (or contractor
therewith) in a form which discloses the identity of a specific manufacturer or wholesaler,
prices charged for drugs by such manufacturer or wholesaler, except-
(i) as the Secretary determines to be necessary to carry out this section;
(ii) to permit the Comptroller General to review the information provided;
(iii) to permit the Director of the Congressional Budget Office to review the information
provided;
(iv) to States to carry out this subchapter; and
(v) to the Secretary to disclose (through a website accessible to the public) average
manufacturer prices.
The previous sentence shall also apply to information disclosed under section 1395w-
102(d)(2) or 1395w-104(c)(2)(E) of this title, and drug pricing data reported under the first
sentence of section 1395w-141(i)(1) of this title.
(4) Length of agreement
(A) In general
A rebate agreement shall be effective for an initial period of not less than 1 year and shall be
automatically renewed for a period of not less than one year unless terminated under
subparagraph (B).
(B) Termination
(i) By the Secretary
The Secretary may provide for termination of a rebate agreement for violation of the
requirements of the agreement or other good cause shown. Such termination shall not be
effective earlier than 60 days after the date of notice of such termination. The Secretary
shall provide, upon request, a manufacturer with a hearing concerning such a termination,
but such hearing shall not delay the effective date of the termination.
(ii) By a manufacturer
A manufacturer may terminate a rebate agreement under this section for any reason. Any
such termination shall not be effective until the calendar quarter beginning at least 60 days
after the date the manufacturer provides notice to the Secretary.
(iii) Effectiveness of termination

Any termination under this subparagraph shall not affect rebates due under the agreement
before the effective date of its termination.
(iv) Notice to States

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
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The provisions of this subparagraph shall apply to the terminations of agreements

described in section 256b(a)(1) of this title and master agreements described in section
8126(a) of title 38.
(C) Delay before reentry

In the case of any rebate agreement with a manufacturer under this section which is
terminated, another such agreement with the manufacturer (or a successor manufacturer) may
not be entered into until a period of 1 calendar quarter has elapsed since the date of the
termination, unless the Secretary finds good cause for an earlier reinstatement of such an
agreement.
(D) Emergency services furnished by non-contract providers’ delay before entry

Any provider of emergency services that does not have in effect a contract with a Medicaid
managed care entity that establishes payment amounts for services furnished to a beneficiary
enrolled in the entity's Medicaid managed care plan must accept as payment in full no more
than the amounts (less any payments for indirect costs of medical education and direct costs of
graduate medical education) that it could collect if the beneficiary received medical assistance
under this subchapter other than through enrollment in such an entity. In a State where rates
paid to hospitals under the State Plan are negotiated by contract and not publicly released, the
payment amount applicable under this subparagraph shall be the average contract rate that
would apply under the State Plan for general acute care hospitals or the average contract rate
that would apply under such Plan for tertiary hospitals.
(c) Determination of amount of rebate
(1) Basic rebate for single source drugs and innovator multiple source drugs
(A) In general
Except as provided in paragraph (2), the amount of the rebate specified in this subsection for a
rebate period (as defined in subsection (k)(8) of this section) with respect to each dosage form
and strength of a single source drug or an innovator multiple source drug shall be equal to the
product of -
(i) the total number of units of each dosage form and strength paid for under the State Plan
in the rebate period (as reported by the State); and
(ii) subject to subparagraph (B)(ii), the greater of -

(I) the difference between the average manufacturer price and the best price (as
defined in subparagraph (C)) for the dosage form and strength of the drug, or
(II) the minimum rebate percentage (specified in subparagraph (B)(i)) of such average
manufacturer price for the rebate period.
(B) Range of rebates required

(i) Minimum rebate percentage
For purposes of subparagraph (A)(ii)(II), the “minimum rebate percentage” for rebate
periods beginning -
(I) after December 31, 1990, and before October 1, 1992, is 12.5 percent;
(II) after September 30, 1992, and before January 1, 1994, is 15.7 percent;
(III) after December 31, 1993, and before January 1, 1995, is 15.4 percent;
(IV) after December 31, 1994, and before January 1, 1996, is 15.2 percent; and
(V) after December 31, 1995, is 15.1 percent.
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(ii) Temporary limitation on maximum rebate amount

In no case shall the amount applied under subparagraph (A)(ii) for a rebate period
beginning -
(I) before January 1, 1992, exceed 25 percent of the average manufacturer price; or
(II) after December 31, 1991, and before January 1, 1993, exceed 50 percent of the
average manufacturer price.
(C) “Best price” defined

For purposes of this section
(i) In general
The term “best price” means, with respect to a single source drug or innovator multiple
source drug of a manufacturer (including the lowest price available to any entity for any
such drug of a manufacturer that is sold under a new drug application approved under
section 355(c) of title 21), the lowest price available from the manufacturer during the
rebate period to any wholesaler, retailer, provider, health maintenance organization,
nonprofit entity, or governmental entity within the United States, excluding
(I) any prices charged on or after October 1, 1992, to the Indian Health Service, the
Department of Veterans Affairs, a State home receiving funds under section 1741 of
title 38, the Department of Defense, the Public Health Service, or a covered entity
described in subsection (a)(5)(B) of this section (including inpatient prices charged to
hospitals described in section 256b(a)(4)(L) of this title;
(II) any prices charged under the Federal Supply Schedule of the General Services
Administration;
(III) any prices used under a State pharmaceutical assistance program;
(IV) any depot prices and single award contract prices, as defined by the Secretary, of
any agency of the Federal Government;
(V) the prices negotiated from drug manufacturers for covered discount card drugs
under an endorsed discount card program under section 1395w-141 of this title; and
(VI) any prices charged which are negotiated by a prescription drug plan under part D
of subchapter XVIII, by an MA-PD plan under part C of such subchapter with respect
to covered part D drugs or by a qualified retiree prescription drug plan (as defined in
section 1395w-132(a)(2)) with respect to such drugs on behalf of individuals entitled
to benefits under part A or enrolled under part B of such title.
(ii) Special rules

The term “best price”
(I) shall be inclusive of cash discounts, free goods that are contingent on any purchase
requirement, volume discounts, and rebates (other than rebates under this section);
(II) shall be determined without regard to special packaging, labeling, or identifiers on
the dosage form or product or package;
(III) shall not take into account prices that are merely nominal in amount; and
(IV) in the case of a manufacturer that approves, allows, or otherwise permits any
other drug of the manufacturer to be sold under a new drug application approved
under section 355(c) of title 21, shall be inclusive of the lowest price for such
authorized drug available from the manufacturer during the rebate period to any
manufacturer, wholesaler, retailer, provider, health maintenance organization,
nonprofit entity, or governmental entity within the United States, excluding those
prices described in subclauses (I) through (IV) of clause (i).
(iii) Application of auditing and recordkeeping requirements

With respect to a covered entity described in section 256b(a)(4)(L) of this title, any drug
purchased for inpatient use shall be subject to the auditing and recordkeeping
requirements described in section 256b(a)(5)(C) of this title.
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(D) Limitation on sales at a nominal price

(i) In general
For purposes of subparagraph (C)(ii)(III) and subsection (b)(3)(A)(iii)(III), only sales by a
manufacturer of covered outpatient drugs at nominal prices to the following shall be
considered to be sales at a nominal price or merely nominal in amount:
(I) A covered entity described in section 256b(a)(4) of this title.
(II) An intermediate care facility for the mentally retarded.
(III) A State-owned or operated nursing facility.
(IV) Any other facility or entity that the Secretary determines is a safety net provider
to which sales of such drugs at a nominal price would be appropriate based on the
factors described in clause (ii).
(ii) Factors
The factors described in this clause with respect to a facility or entity are the following:
(I) The type of facility or entity.
(II) The services provided by the facility or entity.
(III) The patient population served by the facility or entity.
(IV) The number of other facilities or entities eligible to purchase at nominal prices in
the same service area.
(iii) Non-application
Clause (i) shall not apply with respect to sales by a manufacturer at a nominal price of
covered outpatient drugs pursuant to a master agreement under section 8126 of title 38,
United States Code.
(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, 1900, 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”.
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(3) Rebate for other drugs
(A) In general
The amount of the rebate paid to a State for a rebate period with respect to each dosage form
and strength of covered outpatient drugs (other than single source drugs and innovator
multiple source drugs) shall be equal to the product of
(i) the applicable percentage (as described in subparagraph (B)) of the average
manufacturer price for the dosage form and strength for the rebate period; and
(ii) the total number of units of such dosage form and strength dispensed after December
31, 1990, for which payment was made under the State Plan for the rebate period.
(B) Applicable percentage defined

For purposes of subparagraph (A)(i), the “applicable percentage” for rebate periods beginning
(i) before January 1, 1994, is 10 percent; and
(ii) after December 31, 1993, is 11 percent.
(d) Limitations on coverage of drugs
(1) Permissible restrictions
(A) A State may subject to prior authorization any covered outpatient drug. Any such prior
authorization program shall comply with the requirements of paragraph (5).
(B) A State may exclude or otherwise restrict coverage of a covered outpatient drug if -
(i) the prescribed use is not for a medically accepted indication (as defined in subsection
(k)(6) of this section);
(ii) the drug is contained in the list referred to in paragraph (2);
(iii) the drug is subject to such restrictions pursuant to an agreement between a

manufacturer and a State authorized by the Secretary under subsection (a)(1) of this section
or in effect pursuant to subsection (a)(4) of this section; or
(iv) the State has excluded coverage of the drug from its formulary established in
accordance with paragraph (4).
(2) List of drugs subject to restriction

The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or
otherwise restricted:
(A) Agents when used for anorexia, weight loss, or weight gain.
(B) Agents when used to promote fertility.
(C) Agents when used for cosmetic purposes or hair growth.
(D) Agents when used for the symptomatic relief of cough and colds.
(E) Agents when used to promote smoking cessation.
(F) Prescription vitamins and mineral products, except prenatal vitamins and fluoride
preparations.
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(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.
(K) Agents when used for the treatment of sexual or erectile dysfunction, unless such agents
are used to treat a condition, other than sexual or erectile dysfunction, for which the agents
have been approved by the Food and Drug Administration.
(3) Update of drug listings

The Secretary shall, by regulation, periodically update the list of drugs or classes of drugs described in
paragraph (2) or their medical uses, which the Secretary has determined, based on data collected by
surveillance and utilization review programs of State medical assistance programs, to be subject to
clinical abuse or inappropriate use.
(4) Requirements for formularies

A State may establish a formulary if the formulary meets the following requirements:
(A) The formulary is developed by a committee consisting of physicians, pharmacists, and

other appropriate individuals appointed by the Governor of the State (or, at the option of the
State, the State’s drug use review board established under subsection (g)(3) of this section).
(B) Except as provided in subparagraph (C), the formulary includes the covered outpatient
drugs of any manufacturer which has entered into and complies with an agreement under
subsection (a) of this section (other than any drug excluded from coverage or otherwise
restricted under paragraph (2)).
(C) A covered outpatient drug may be excluded with respect to the treatment of a specific
disease or condition for an identified population (if any) only if, based on the drug’s labeling
(or, in the case of a drug the prescribed use of which is not approved under the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 301 et seq.) but is a medically accepted indication, based
on information from the appropriate compendia described in subsection (k)(6) of this section),
the excluded drug does not have a significant, clinically meaningful therapeutic advantage in
terms of safety, effectiveness, or clinical outcome of such 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.
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(5) Requirements of prior authorization programs

A State Plan under this subchapter may require, as a condition of coverage or payment for a covered
outpatient drug for which Federal financial participation is available in accordance with this section,
with respect to drugs dispensed on or after July 1, 1991, the approval of the drug before its dispensing
for any medically accepted indication (as defined in subsection (k)(6) of this section) only if the
system providing for such approval –
(A) provides response by telephone or other telecommunication device within 24 hours of a

request for prior authorization; and
(B) except with respect to the drugs on the list referred to in paragraph (2), provides for the
dispensing of at least 72-hour supply of a covered outpatient prescription drug in an
emergency situation (as defined by the Secretary).
(6) Other permissible restrictions

A State may impose limitations, with respect to all such drugs in a therapeutic class, on the minimum
or maximum quantities per prescription or on the number of refills, if such limitations are necessary to
discourage waste, and may address instances of fraud or abuse by individuals in any manner
authorized under this chapter.
(e) Treatment of pharmacy reimbursement limits
(1) In general
During the period beginning on January 1, 1991, and ending on
December 31, 1994 –
(A) a State may not reduce the payment limits established by regulation under this subchapter
or any limitation described in paragraph (3) with respect to the ingredient cost of a covered
outpatient drug or the dispensing fee for such a drug below the limits in effect as of January 1,
1991, and
(B) except as provided in paragraph (2), the Secretary may not modify by regulation the
formula established under sections 447.331 through 447.334 of title 42, Code of Federal
Regulations, in effect on November 5, 1990, to reduce the limits described in subparagraph
(A).
(2) Special rule

If a State is not in compliance with the regulations described in paragraph (1)(B), paragraph (1)(A)
shall not apply to such State until such State is in compliance with such regulations.
(3) Effect on State maximum allowable cost limitations

This section shall not supersede or affect provisions in effect prior to January 1, 1991, or after
December 31, 1994, relating to any maximum allowable cost limitation established by a State for
payment by the State for covered outpatient drugs, and rebates shall be made under this section
without regard to whether or not payment by the State for such drugs is subject to such a limitation or
the amount of such a limitation.
(4) Establishment of upper payment limits

Subject to paragraph (5), the Secretary shall establish a Federal upper reimbursement limit for each
multiple source drug for which the FDA has rated three or more (or effective January 1, 2007, two or
more) products therapeutically and pharmaceutically equivalent, regardless of whether all such
additional formulations are rated as such and shall use only such formulations when determining any
such upper limit.
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(5) Use of AMP in upper payment limits.

Effective January 1, 2007, in applying the Federal upper reimbursement limit under paragraph (4) and
section 447.332(b) of title 42 of the Code of Federal Regulations, the Secretary shall substitute 250
percent of the average manufacturer price (as computed without regard to customary prompt pay
discounts extended to wholesalers) for 150 percent of the published price.
(f) Survey of retail prices, State payment and utilization rates and performance rankings
(1) Survey of retail prices.
(A) Use of vendor.

The Secretary may contract services for
(i) the determination on a monthly basis of retail survey prices for covered outpatient
drugs that represent a nationwide average of consumer purchase prices for such drugs, net
of all discounts and rebates (to the extent any information with respect to such discounts
and rebates is available); and
(ii) the notification of the Secretary when a drug product that is therapeutically and
pharmaceutically equivalent and bioequivalent becomes generally available.
(B) Secretary response to notification of availability of multiple source products.

If contractor notifies the Secretary under subparagraph (A)(ii) that a drug product described in
such subparagraph has become generally available, the Secretary shall make a determination,
within 7 days after receiving such notification, as to whether the product is now described in
subsection (e)(4).
(C) Use of competitive bidding

In contracting for such services, the Secretary shall competitively bid for an outside vendor
that has a demonstrated history in
(i) surveying and determining, on a representative nationwide basis, retail prices for
ingredient costs of prescription drugs;
(ii) working with retail pharmacies, commercial payers, and States in obtaining and
disseminating such price information; and
(iii) collecting and reporting such price information on at least a monthly basis.
In contracting for such services, the Secretary may waive such provisions of the Federal
Acquisition Regulation as are necessary for the efficient implementation of this
subsection, other than provisions relating to confidentiality of information and such other
provisions as the Secretary determines appropriate.
(D) Additional provisions.

A contract with a vendor under this paragraph shall include such terms and conditions as the
Secretary shall specify, including the following:
(i) The vendor must monitor the marketplace and report to the Secretary each time there is
a new covered outpatient drug generally available.
(ii) The vendor must update the Secretary no less often than monthly on the retail survey
prices for covered outpatient drugs.
(iii) The contract shall be effective for a term of 2 years.
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(E) Availability of information to the States.

Information on retail survey prices obtained under this paragraph, including applicable
information on single source drugs, shall be provided to States on at least a monthly basis. The
Secretary shall devise and implement a means for providing access to each State agency
designated under section 1396a(a)(5) with responsibility for the administration or supervision
of the administration of the State plan under this title of the retail survey price determined
under this paragraph.
(2) Annual State report.

Each State shall annually report to the Secretary information on
(A) the payment rates under the State plan under this subchapter for covered outpatient drugs;
(B) the dispensing fees paid under such plan for such drugs; and
(C) utilization rates for non-innovator multiple source drugs under such plan.
(3) Annual State performance rankings.
(A) Comparative analysis.

The Secretary annually shall compare, for the 50 most widely prescribed drugs identified by
the Secretary, the national retail sales price data (collected under paragraph (1)) for such drugs
with data on prices under this subchapter for each such drug for each State.
(B) Availability of information.

The Secretary shall submit to Congress and the States full information regarding the annual
rankings made under subparagraph (A).
(4) Appropriation.
Out of any funds in the Treasury not otherwise appropriated, there is appropriated to the Secretary of
Health and Human Services $5,000,000 for each of fiscal years 2006 through 2010 to carry out this
subsection.
(g) Drug use review
(1) In general
(A) In order to meet the requirement of section 1396b(i)(10)(B) of this title, a State shall
provide, by not later than January 1, 1993, for a drug use review program described in
paragraph (2) for covered outpatient drugs in order to assure that prescriptions (i) are
appropriate, (ii) are medically necessary, and (iii) are not likely to result in adverse medical
results. The program shall be designed to educate physicians and pharmacists to identify and
reduce the frequency of patterns of fraud, abuse, gross overuse, or inappropriate or medically
unnecessary care, among physicians, pharmacists, and patients, or associated with specific
drugs or groups of drugs, as well as potential and actual severe adverse reactions to drugs
including education on therapeutic appropriateness, overutilization and underutilization,
appropriate use of generic products, therapeutic duplication, drug-disease contraindications,
drug-drug interactions, incorrect drug dosage or duration of drug treatment, drug-allergy
interactions, and clinical abuse/misuse.
(B) The program shall assess data on drug use against predetermined standards, consistent
with the following:
(i) compendia which shall consist of the following:
(I) American Hospital Formulary Service Drug Information;
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(II) United States Pharmacopeia-Drug Information (or its successor publications);

(III) the DRUGDex information System; and
(ii) the peer-reviewed medical literature.
(C) The Secretary, under the procedures established in section 1396b of this title, shall pay to
each State an amount equal to 75 per centum of so much of the sums expended by the State
Plan during calendar years 1991 through 1993 as the Secretary determines is attributable to the
statewide adoption of a drug use review program which conforms to the requirements of this
subsection.
(D) States shall not be required to perform additional drug use reviews with respect to drugs
dispensed to residents of nursing facilities which are in compliance with the drug regimen
review procedures prescribed by the Secretary for such facilities in regulations implementing
section 1396r of this title, currently at section 483.60 of title 42, Code of Federal Regulations.
(2) Description of program

Each drug use review program shall meet the following requirements for covered outpatient drugs:
(A) Prospective drug review

(i) The State plan shall provide for a review of drug therapy before each prescription is
filled or delivered to an individual receiving benefits under this subchapter, typically at the
point-of-sale or point of distribution. The review shall include screening for potential
drug therapy problems due to therapeutic duplication, drug-disease contraindications,
drug-drug interactions (including serious interactions with nonprescription or over-the-
counter drugs), incorrect drug dosage or duration of drug treatment, drug-allergy
interactions, and clinical abuse/misuse. Each State shall use the compendia and literature
referred to in paragraph (1)(B) as its source of standards for such review.
(ii) As part of the State’s prospective drug use review program under this subparagraph
applicable State law shall establish standards for counseling of individuals receiving
benefits under this subchapter by pharmacists which includes at least the following:
(I) The pharmacist must offer to discuss with each individual receiving benefits under
this subchapter or caregiver of such individual (in person, whenever practicable, or
through access to a telephone service which is toll-free for long-distance calls) who
presents a prescription, matters which in the exercise of the pharmacist’s professional
judgment (consistent with State law respecting the provision of such information), the
pharmacist deems significant including the following:
(aa) The name and description of the medication.
(bb) The route, dosage form, dosage, route of administration, and duration of drug
therapy.
(cc) Special directions and precautions for preparation, administration and use by
the patient.
(dd) Common severe side or adverse effects or interactions and therapeutic
contraindications that may be encountered, including their avoidance, and the
action required if they occur.
(ee) Techniques for self-monitoring drug therapy.
(ff) Proper storage.
(gg) Prescription refill information.
(hh) Action to be taken in the event of a missed dose.
(II) A reasonable effort must be made by the pharmacist to obtain, record, and
maintain at least the following information regarding individuals receiving benefits
under this subchapter:
(aa) Name, address, telephone number, date of birth (or age) and gender.
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(bb) Individual history where significant, including disease state or states, known
allergies and drug reactions, and a comprehensive list of medications and relevant
devices.
(cc) Pharmacist comments relevant to the individual’s drug therapy.
Nothing in this clause shall be construed as requiring a pharmacist to provide consultation
when an individual receiving benefits under this subchapter or caregiver of such individual
refuses such consultation, or to require verification of the offer to provide consultation or a
refusal of such offer.
(B) Retrospective drug use review

The program shall provide, through its mechanized drug claims processing and information
retrieval systems (approved by the Secretary under section 1396b(r) of this title) or otherwise,
for the ongoing periodic examination of claims data and other records in order to identify
patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, among
physicians, pharmacists and individuals receiving benefits under this subchapter, or associated
with specific drugs or groups of drugs.
(C) Application of standards

The program shall, on an ongoing basis, assess data on drug use against explicit predetermined
standards (using the compendia and literature referred to in paragraph (1)(B) as the source of
standards for such assessment) including but not limited to monitoring for therapeutic
appropriateness, overutilization and underutilization, appropriate use of generic products,
therapeutic duplication, drug-disease contraindications, drug-drug interactions, incorrect drug
dosage or duration of drug treatment, and clinical abuse/misuse and, as necessary, introduce
remedial strategies, in order to improve the quality of care and to conserve program funds or
personal expenditures.
(D) Educational program

The program shall, through its State drug use review board established under paragraph (3),
either directly or through contracts with accredited health care educational institutions, State
medical societies or State pharmacists associations/societies or other organizations as
specified by the State, and using data provided by the State drug use review board on common
drug therapy problems, provide for active and ongoing educational outreach programs
(including the activities described in paragraph (3)(C)(iii) of this subsection) to educate
practitioners on common drug therapy problems with the aim of improving prescribing or
dispensing practices.
(3) State drug use review board
(A) Establishment
Each State shall provide for the establishment of a drug use review board (hereinafter referred
to as the “DUR Board”) either directly or through a contract with a private organization.
(B) Membership
The membership of the DUR Board shall include health care professionals who have
recognized knowledge and expertise in one or more of the following:
(i) The clinically appropriate prescribing of covered outpatient drugs.
(ii) The clinically appropriate dispensing and monitoring of covered outpatient drugs.
(iii) Drug use review, evaluation, and intervention.
(iv) Medical quality assurance.
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The membership of the DUR Board shall be made up at least 1/3 but no more than 51 percent
licensed and actively practicing physicians and at least 1/3 licensed and actively practicing
pharmacists.
(C) Activities
The activities of the DUR Board shall include but not be limited to the following:
(i) Retrospective DUR as defined in paragraph (2)(B).
(ii) Application of standards as defined in paragraph (2)(C).
(iii) Ongoing interventions for physicians and pharmacists, targeted toward therapy
problems or individuals identified in the course of retrospective drug use reviews
performed under this subsection. Intervention programs shall include, in appropriate
instances, at least:
(I) information dissemination sufficient to ensure the ready availability to physicians
and pharmacists in the State of information concerning its duties, powers, and basis
for its standards;
(II) written, oral, or electronic reminders containing patient-specific or drug-specific
(or both) information and suggested changes in prescribing or dispensing practices,
communicated in a manner designed to ensure the privacy of patient-related
information;
(III) use of face-to-face discussions between health care professionals who are experts
in rational drug therapy and selected prescribers and pharmacists who have been
targeted for educational intervention, including discussion of optimal prescribing,
dispensing, or pharmacy care practices, and follow-up face-to-face discussions; and
(IV) intensified review or monitoring of selected prescribers or dispensers.
The Board shall re-evaluate interventions after an appropriate period of time to determine if
the intervention improved the quality of drug therapy, to evaluate the success of the
interventions and make modifications as necessary.
(D) Annual report

Each State shall require the DUR Board to prepare a report on an annual basis. The State shall
submit a report on an annual basis to the Secretary which shall include a description of the
activities of the Board, including the nature and scope of the prospective and retrospective
drug use review programs, a summary of the interventions used, an assessment of the impact
of these educational interventions on quality of care, and an estimate of the cost savings
generated as a result of such program. The Secretary shall utilize such report in evaluating the
effectiveness of each State’s drug use review program.
(h) Electronic claims management
(1) In general
In accordance with chapter 35 of title 44 (relating to coordination of Federal information policy), the
Secretary shall encourage each State agency to establish, as its principal means of processing claims
for covered outpatient drugs under this subchapter, a point-of-sale electronic claims management
system, for the purpose of performing on-line, real time eligibility verifications, claims data capture,
adjudication of claims, and assisting pharmacists (and other authorized persons) in applying for and
receiving payment.
(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
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financial participation under section 1396b(a)(3)(A)(i) of this title (at a matching rate of 90
percent) if the State acquires, through applicable competitive procurement process in the State,
the most cost-effective telecommunications network and automatic data processing services
and equipment; and
(B) the Secretary may permit, in the procurement described in subparagraph (A) in the
application of part 433 of title 42, Code of Federal Regulations, and parts 95, 205, and 307 of
title 45, Code of Federal Regulations, the substitution of the State’s request for proposal in
competitive procurement for advance planning and implementation documents otherwise
required.
(i) Annual report
(1) In general
Not later than May 1 of each year the Secretary shall transmit to the Committee on Finance of the
Senate, the Committee on Energy and Commerce of the House of Representatives, and the
Committees on Aging of the Senate and the House of Representatives a report on the operation of this
section in the preceding fiscal year.
(2) Details
Each report shall include information on –
(A) ingredient costs paid under this subchapter for single source drugs, multiple source drugs,
and nonprescription covered outpatient drugs;
(B) the total value of rebates received and number of manufacturers providing such rebates;
(C) how the size of such rebates compare with the size of rebates offered to other purchasers
of covered outpatient drugs;
(D) the effect of inflation on the value of rebates required under this section;
(E) trends in prices paid under this subchapter for covered outpatient drugs; and
(F) Federal and State administrative costs associated with compliance with the provisions of
this subchapter.
(j) Exemption of organized health care settings
(1) Covered outpatient drugs dispensed by health maintenance organizations, including Medicaid
managed care organizations that contract under section 1396b(m) of this title, are not subject to the
requirements of this section.
(2) The State Plan shall provide that a hospital (providing medical assistance under such Plan) that
dispenses covered outpatient drugs using drug formulary systems, and bills the Plan no more than the
hospital’s purchasing costs for covered outpatient drugs (as determined under the State Plan) shall not
be subject to the requirements of this section.
(3) Nothing in this subsection shall be construed as providing that amounts for covered outpatient
drugs paid by the institutions described in this subsection should not be taken into account for
purposes of determining the best price as described in subsection (c) of this section.
(k) Definitions
In this section -
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(1) Average manufacturer price.
(A) In general.
Subject to subparagraph (B), the term “average manufacturer price” means, with respect to a
covered outpatient drug of a manufacturer for a rebate period, the average price paid to the
manufacturer for the drug in the United States by wholesalers for drugs distributed to the retail
pharmacy class of trade.
(B) Exclusion of customary prompt pay discounts extended to wholesalers.

The average manufacturer price for a covered outpatient drug shall be determined without
regard to customary prompt pay discounts extended to wholesalers.
(C) Inclusion of Section 355(c) drugs.

In the case of a manufacturer that approves, allows, or otherwise permits any drug of the
manufacturer to be sold under a new drug application approved under section 355(c) of title
21, such term shall be inclusive of the average price paid for such drug by wholesalers for
drugs distributed to the retail pharmacy class of trade.
(2) Covered outpatient drug

Subject to the exceptions in paragraph (3), the term “covered outpatient drug” means -
(A) of those drugs which are treated as prescribed drugs for purposes of section 1396d(a)(12)
of this title, a drug which may be dispensed only upon prescription (except as provided in
paragraph (5)), and -
(i) which is approved for safety and effectiveness as a prescription drug under section 505
or 507 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355, 357) or which is
approved under section 505(j) of such Act (21 U.S.C. 355(j));
(ii)(I) which was commercially used or sold in the United States before October 10, 1962,
or which is identical, similar, or related (within the meaning of section 310.6(b)(1) of title
21 of the Code of Federal Regulations) to such a drug, and (II) which has not been the
subject of a final determination by the Secretary that it is a “new drug” (within the
meaning of section 201(p) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C.
321(p))) or an action brought by the Secretary under section 301, 302(a), or 304(a) of such
Act (21 U.S.C. 331, 332(a), 334(a)) to enforce section 502(f) or 505(a) of such Act (21
U.S.C. 352(f), 355(a)); or
(iii)(I) which is described in section 107(c)(3) of the Drug Amendments of 1962 and for
which the Secretary has determined there is a compelling justification for its medical need,
or is identical, similar, or related (within the meaning of section 310.6(b)(1) of title 21 of
the Code of Federal Regulations) to such a drug, and (II) for which the Secretary has not
issued a notice of an opportunity for a hearing under section 505(e) of the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 355(e)) on a proposed order of the Secretary to
withdraw approval of an application for such drug under such section because the
Secretary has determined that the drug is less than effective for some or all conditions of
use prescribed, recommended, or suggested in its labeling; and
(B) a biological product, other than a vaccine which -

(i) may only be dispensed upon prescription,
(ii) is licensed under section 262 of this title, and
C-21
(iii) is produced at an establishment licensed under such section to produce such product;
and
(C) insulin certified under section 506 of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 356).
(3) Limiting definition

The term “covered outpatient drug” does not include any drug, biological product, or insulin provided
as part of, or as incident to and in the same setting as, any of the following (and for which payment
may be made under this subchapter as part of payment for the following and not as direct
reimbursement for the drug):
(A) Inpatient hospital services.
(B) Hospice services.
(C) Dental services, except that drugs for which the State Plan authorizes direct
reimbursement to the dispensing dentist are covered outpatient drugs.
(D) Physicians’ services.
(E) Outpatient hospital services.
(F) Nursing facility services and services provided by an intermediate care facility for the
mentally retarded.
(G) Other laboratory and x-ray services.
(H) Renal dialysis.
Such term also does not include any such drug or product for which a National Drug Code number is
not required by the Food and Drug Administration or a drug or biological used for a medical
indication which is not a medically accepted indication. Any drug, biological product, or insulin
excluded from the definition of such term as a result of this paragraph shall be treated as a covered
outpatient drug for purposes of determining the best price (as defined in subsection (C)(1)(C) of this
section) for such drug, biological product, or insulin.
(4) Nonprescription drugs

If a State Plan for medical assistance under this subchapter includes coverage of prescribed drugs as
described in section 1396d(a)(12) and permits coverage of drugs which may be sold without a
prescription (commonly referred to as “over-the-counter” drugs), if they are prescribed by a physician
(or other person authorized to prescribe under State law), such a drug shall be regarded as a covered
outpatient drug.
(5) Manufacturer
The term “manufacturer” means any entity which is engaged in -
(A) the production, preparation, propagation, compounding, conversion, or processing of

prescription drug products, either directly or indirectly by extraction from substances of
natural origin, or independently by means of chemical synthesis, or by a combination of
extraction and chemical synthesis, or
(B) in the packaging, repackaging, labeling, relabeling, or distribution of prescription drug

products.
C-22
Such term does not include a wholesale distributor of drugs or a retail pharmacy licensed under State
law.
(6) Medically accepted indication

The term “medically accepted indication” means any use for a covered outpatient drug which is
approved under the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 301 et seq.) or the use of which
is supported by one or more citations included or approved for inclusion in any of the compendia
described in subsection (g)(1)(B)(i) of this section.
(7) Multiple source drug; innovator multiple source drug; noninnovator multiple source drug; single
source drug
(A) Defined
(i) Multiple source drug
The term “multiple source drug” means, with respect to a rebate period, a covered
outpatient drug (not including any drug described in paragraph (5)) for which there is at
least 1 other drug product which -
(I) is 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), is pharmaceutically equivalent and
bioequivalent, as defined in subparagraph (C) and as determined by the Food and
Drug Administration, and
(III) is 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
distributors operating under the new drug application.
(B) Exception
Subparagraph (A)(i)(II) shall not apply if the Food and Drug Administration changes by
regulation the requirement that, for purposes of the publication described in subparagraph
(A)(i)(I), in order for drug products to be rated as therapeutically equivalent, they must be
pharmaceutically equivalent and bioequivalent, as defined in subparagraph (C).
(C) Definitions
For purposes of this paragraph -
(i) drug products are pharmaceutically equivalent if the products contain identical amounts
of the same active drug ingredient in the same dosage form and meet compendial or other
applicable standards of strength, quality, purity, and identity;
C-23
(ii) drugs are bioequivalent if they do not present a known or potential bioequivalence
problem, or, if they do present such a problem, they are shown to meet an appropriate
standard of bioequivalence; and
(iii) a drug product is considered to be sold or marketed in a State if it appears in a

published national listing of average wholesale prices selected by the Secretary, provided
that the listed product is generally available to the public through retail pharmacies in that
State.
(8) Rebate period

The term “rebate period” means, with respect to an agreement under subsection (a) of this section, a
calendar quarter or other period specified by the Secretary with respect to the payment of rebates
under such agreement.
(9) State agency

The term “State agency” means the agency designated under section 1396a(a)(5) of this title to
administer or supervise the administration of the State Plan for medical assistance.
C-24
Appendix D:
Federal Upper Limits for
Multiple Source Products
D-1
The following list of multiple source drugs meets the criteria set forth in 42 CFR 447.332 and
§1927(e) of the Social Security Act, as amended by OBRA 1993. The development of the current
Federal Upper Limit (FUL) listing has been accomplished by computer. Payments for multiple source
drugs identified and listed in the accompanying addendum must not exceed, in the aggregate, payment
levels determined by applying to each drug entity a reasonable dispensing fee (established by the State
and specified in the State Plan), plus an amount based on the limit per unit which CMS has determined
to be equal to a 150 percent applied to the lowest price listed (in package sizes of 100 units, unless
otherwise noted) in any of the published compendia of cost information of drugs. Issued by CMS on
November 20, 2001 the initial listing was based on data current as of April 2001 from the First Data
Bank (Blue Book), Medi-Span, and the Red Book. The listing was revised to reflect additional
changes (i.e., additions, deletions, pricing changes) through December 19, 2006. The list does not
reference the commonly known brand names. However, brand names are included in the FUL listing
provided to the State agencies in electronic format. The FUL price list is in pdf format at:
http://www.cms.hhs.gov/FederalUpperLimits/Downloads/ChangesMadeToTransmittal37.pdf.
In accordance with current policy, Federal financial participation will not be provided for any drug on
the FUL listing for which the Food and Drug Administration (FDA) has issued a notice of an
opportunity for a hearing as a result of the Drug Efficacy Study and Implementation (DESI) program
and which has been found to be less than effective or is identical, related, or similar (IRS) to the DESI
drug. The DESI drug is identified by the FDA or reported by the drug manufacturer for purposes of
the Medicaid drug rebate program.
As required by the Deficit Reduction Act of 2005 (DRA – P.L. 109-171), CMS is developing and
implementing a new methodology for calculating the FUL based on average manufacturer prices. As
a result of ongoing activities related to this new methodology, CMS has not posted updated FUL data
on its website since December 19, 2006. The original November 20, 2001 list has been amended
below with all changes to be implemented no later than January 19, 2007. It is anticipated that
updated FUL data will be released on or about December 30, 2007.
Generic Name Upper Limit per Unit (Source)

Acebutolol Hydrochloride
Eq 200 mg base, Capsule, Oral, 100 $0.3567 B
Eq 400 mg base, Capsule, Oral, 100 0.5315 B
Acetaminophen; Butalbital; Caffeine

500 mg; 50mg; 40 mg, Tablet, Oral, 100 0.6870 B
Acetaminophen; Codeine Phosphate

300 mg; 15 mg, Tablet, Oral, 100 0.1500 R
300 mg; 30 mg, Tablet, Oral, 100 0.2137 B
Acetaminophen; Hydrocodone Bitartrate

500 mg; 5 mg, Capsule, Oral, 100 0.1943 B
500 mg /15 ml; 7.5 mg/15 ml Elixir, Oral, 473 ml 0.0633 R
500 mg, 2.5 mg, Tablet, Oral, 100 0.2190 B
500 mg; 7.5 mg, Tablet, Oral, 100 0.1739 B
D-2

750 mg; 7.5 mg, Tablet, Oral, 100 0.1407 R
Acetaminophen; Oxycodone Hydrochloride

500 mg; 5 mg, Capsule, Oral, 100 0.2248 B
Acetaminophen; Pentazocine Hydrochloride

650 mg; Eq 25 mg base, Tablet, Oral, 100 0.8517 R
Acetaminophen; Propoxyphene Hydrochloride

Acetaminophen; Propoxyphene Napsylate

Acetylcysteine
10%, Solution, Inhalation, Oral, 10 ml 0.9780 B
Acyclovir
200 mg, Capsule, Oral, 100 0.1478 B
400 mg, Tablet, Oral, 100 0.2334 B
800 mg, Tablet, Oral, 100 0.4667 B
Albuterol Sulfate
Eq 0.083% base, Solution, Inhalation, 3ml 0.1150 B
Eq 0.5% base, Solution, Inhalation, 20 ml 0.2333 B
4 mg, Tablet, Oral, 100 0.1425 B
Alclometasone Dipropionate
0.05%, Cream, Topical, 45 gm 0.8283 B
0.05%, Ointment, Topical, 45 gm 0.8283 B
Allopurinol
100 mg, Tablet, Oral, 100 0.0784 B
300 mg, Tablet, Oral, 100 0.1013 B
Alprazolam
0.25 mg, Tablet, Oral, 100 0.0614 R
0.5 mg, Tablet, Oral, 100 0.0698 B
0.5 mg, Tablet, Extended Release, Oral, 60 1.9343 B
1 mg, Tablet, Extended Release, Oral, 60 2.4065 B
2 mg, Tablet, Oral, 100 0.1745 R
Amantadine Hydrochloride
50 mg/5 ml, Syrup, Oral, 480 ml 0.0656 M
D-3
Amiloride Hydrochloride; Hydrochlorothiazide

Eq 5 mg Anhydrous; 50 mg, Tablet, Oral, 100 0.0675 B
Amiodarone Hydrochloride
200 mg, Tablet, Oral, 60 1.6875 B
Amitriptyline Hydrochloride
10 mg, Tablet, Oral, 100 0.0608 B
25 mg, Tablet, Oral, 100 0.0653 B
50 mg, Tablet, Oral, 100 0.0666 B
75 mg, Tablet, Oral, 100 0.1425 B
100 mg, Tablet, Oral, 100 0.1500 R
150 mg, Tablet, Oral, 100 0.2430 B
Amoxicillin
500 mg, Capsule, Oral, 100 0.1302 R
125 mg/5 ml, Powder for Reconstitution, Oral, 150 0.0194 B
250 mg/5 ml, Powder for Reconstitution, Oral, 100 0.0281 B
Amoxicillin; Clavulanic Acid

200 mg/5 ml; 28.5 mg/5 ml, Powder for Reconstitution, Oral, 100 0.2850 B
400 mg/5 ml; 57 mg/5 ml, Powder for Reconstitution, Oral, 100 0.5347 B
Ampicillin/Ampicillin Trihydrate
Anagrelide Hydrochloride
0.5 mg, Capsule, Oral, 100 0.4395 B
Aspirin; Butalbital; Caffeine

325 mg; 50 mg; 40 mg, Tablet, Oral, 100 0.2400 R
Aspirin; Carisoprodol
Aspirin; Carisoprodol; Codeine Phosphate

325 mg; 200 mg; 16 mg, Tablet, Oral, 100 1.8375 B
Atenolol
25 mg, Tablet, Oral, 100 0.0975 B
50 mg, Tablet, Oral, 100 0.1058 B
100 mg, Tablet, Oral, 100 0.1943 B
Atenolol; Chlorthalidone
D-4
Atropine Sulfate; Diphenoxylate Hydrochloride

0.025 mg; 2.5 mg, Tablet, Oral, 100 0.1088 B
Baclofen
10 mg, Tablet, Oral, 100 0.4492 B
20 mg, Tablet, Oral, 100 0.8438 B
Benazepril Hydrochloride
10 mg, Tablet, Oral, 100 0.4905 R
20 mg, Tablet, Oral, 100 0.4905 R
40 mg, Tablet, Oral, 100 0.4905 R
Benazepril Hydrochloride; Hydrochlorothiazide

Benzonatate
Benztropine Mesylate
0.5 mg, Tablet, Oral, 100 0.1227 B
Betamethasone Dipropionate
Eq 0.05% base, Cream, Topical, 15 gm 0.2330 B
Eq 0.05% base, Lotion, Topical, 60 ml 0.1500 B
Betamethasone Dipropionate; Clotrimazole

0.05%; 1%, Cream, Topical, 15 gm 1.4820 B
0.05%; 1%, Lotion, Topical, 30 gm 1.8115 B
Betamethasone Valerate
Bethanechol Chloride
10 mg, Tablet, Oral, 100 0.9171 R
25 mg, Tablet, Oral, 100 1.7079 R
50 mg, Tablet, Oral, 100 1.9565 R
Bisoprolol Fumarate; Hydrochlorothiazide

D-5
Brimonidine Tartrate
0.2%, Solution/Drops, Ophthalmic, 5 ml 4.5000 B
Brompheniramine Maleate/Dextromethorphan Hydrobromide/

Pseudoephedrine Hydrochloride
2 mg/10 mg/30 mg per 5 ml, Syrup, Oral, 480 ml 0.0387 B
Bumetanide
0.5 mg, Tablet, Oral, 100 0.1743 B
Buspirone Hydrochloride
10 mg, Tablet, Oral, 100 0.3942 B
Captopril
12.5 mg, Tablet, Oral, 100 0.0232 B
50 mg, Tablet, Oral, 100 0.0390 B
100 mg, Tablet, Oral, 100 0.1080 B
Captopril; Hydrochlorothiazide
Carbamazepine
100 mg, Tablet, Chewable, Oral, 100 0.1965 R
200 mg, Tablet, Oral, 100 0.1500 R
Carbidopa; Levodopa
Carisoprodol
350 mg, Tablet, Oral, 100 0.3743 B
Carteolol Hydrochloride
1%, Solution/Drops, Ophthalmic, 10 ml 3.6775 R
Cefadroxil/Cefadroxil Hemihydrate
Cefprozil
125 mg/5 ml, Suspension, Oral, 100 0.4080 B
250 mg/5ml, Suspension, Oral, 100 0.7394 B
D-6
Cefuroxime Axetil
250 mg, Tablet, Oral, 20 2.5425 B
500 mg, Tablet, Oral, 20 4.7475 B
Cephalexin
Eq 250 mg base, Capsule, Oral, 100 0.1835 R
Chlordiazepoxide Hydrochloride
Chlorhexidine Gluconate
0.12%, Solution, Dental, 480 ml 0.0109 B
Chlorpropamide
100 mg, Tablet, Oral, 100 0.2325 B
250 mg, Tablet, Oral, 100 0.4917 B
Chlorzoxazone
500 mg, Tablet, Oral, 100 0.0757 B
Cholestyramine
Eq 4 gm Resin/Packet, Powder, Oral, 60 1.2767 B
Ciclopirox
Cilostazol
100 mg, Tablet, Oral, 60 1.0388 B
Cimetidine
200 mg, Tablet, Oral, 100 0.1313 B
300 mg, Tablet, Oral, 100 0.1313 B
400 mg, Tablet, Oral, 100 0.1071 R
800 mg, Tablet, Oral, 100 0.2775 B
Cimetidine Hydrochloride
Eq 300 mg base/ 5 ml Solution, Oral, 240 ml 0.1139 B
Ciprofloxacin Hydrochloride
0.3%, Solution/Drops, Ophthalmic, 5ml 7.5690 B
250 mg, Tablet, Oral, 100 0.3750 B
500 mg, Tablet, Oral, 100 0.4500 B
750 mg, Tablet, Oral, 100 0.4800 B
D-7
Citalopram Hydrobromide
EQ 10 mg base/5 ml, Solution, Oral, 240 ml 0.4231 B
10 mg, Tablet, Oral, 100 0.2963 B
20 mg, Tablet, Oral, 100 0.3090 B
40 mg, Tablet, Oral, 100 0.3224 B
Clarithromycin
250 mg, Tablet, Oral, 60 2.3725 B
500 mg, Tablet, Oral, 60 2.3725 B
Clindamycin Hydrochloride
Clindamycin Phosphate
Eq 1% base, Lotion, Topical, 60 ml 0.7988 B
Eq 1% base, Solution, Topical, 60 ml 0.2060 R
1%, Swab, Topical, 60 0.6300 B
Clobetasol Propionate
Clomiphene Citrate
Clomipramine Hydrochloride
Clonazepam
0.5 mg, Tablet, Oral, 100 0.2455 B
Clonidine Hydrochloride
0.1 mg, Tablet, Oral, 100 0.0968 B
0.2 mg, Tablet, Oral, 100 0.1350 B
0.3 mg, Tablet, Oral, 100 0.1830 B
Clorazepate Dipotassium
3.75 mg, Tablet, Oral, 100 0.8350 B
7.5 mg, Tablet, Oral, 100 1.0388 B
15 mg, Tablet, Oral, 100 1.4094 B
Clotrimazole
1%, Solution, Topical, 10 ml 0.4725 B
Cromolyn Sodium
4%, Solution/ Drops, Ophthalmic, 10 ml 3.3750 B
D-8
Cyclobenzaprine Hydrochloride
10 mg, Tablet, Oral, 100 0.1302 B
Demeclocycline Hydrochloride
150 mg, Tablet, Oral, 100 9.4950 B
300 mg, Tablet, Oral, 48 17.1875 B
Desipramine Hydrochloride
25 mg, Tablet, Oral, 100 0.2835 B
50 mg, Tablet, Oral, 100 0.5339 B
75 mg, Tablet, Oral, 100 1.0304 B
100 mg, Tablet, Oral, 100 1.3539 B
150 mg, Tablet, Oral, 50 1.9617 B
Desonide
0.05%, Cream, Topical, 100 0.2337 B
0.05%, Lotion, Topical, 59 ml 0.5441 R
Dexamethasone; Neomycin Sulfate; Polymyxin B Sulfate

0.1%; Eq 3.5 mg base/gm; 10,000 units/gm, Ointment, Ophthalmic, 3 gm 1.0714 B
Dextroamphetamine Sulfate
10 mg, Tablet, Oral, 100 0.3435 B
Diazepam
10 mg, Tablet, Oral, 100 0.0573 B
Diclofenac Potassiuim
50 mg, Tablet, Oral, 100 0.8625 B
Diclofenac Sodium
50 mg, Tablet, Delayed Release, Oral, 100 0.4748 R
75 mg, Tablet, Delayed Release, Oral, 100 0.5850 R
Dicyclomine Hydrochloride
20 mg, Tablet, Oral, 100 0.1185 B
Digoxin
0.125 mg, Tablet, Oral, 100 0.2132 B
0.25 mg, Tablet, Oral, 100 0.2132 B
D-9
Diltiazem Hydrochloride
30 mg, Tablet, Oral, 100 0.1019 B
60 mg, Tablet, Oral, 100 0.1114 B
90 mg, Tablet, Oral, 100 0.2312 B
120 mg, Tablet, Oral, 100 0.2331 B
Diphenhydramine Hydrochloride
12.5 mg/5 ml, Elixir, Oral, 120 ml 0.0137 B
Dipivefrin Hydrochloride
Dipyridamole
25 mg, Tablet, Oral, 100 0.2978 B
50 mg, Tablet, Oral, 100 0.4796 B
75 mg, Tablet, Oral, 100 0.6417 B
Disopyramide Phosphate
Doxazosin Mesylate
Doxepin Hydrochloride
Eq 10 mg base/ml, Concentrate, Oral, 120 ml 0.1145 R
Doxycycline Hyclate
Eq 100 mg base, Tablet, Oral, 50 0.1287 B
Doxycycline Hydrochloride
Enalapril Maleate
2.5 mg, Tablet, Oral, 100 0.4334 B
10 mg, Tablet, Oral, 100 0.6863 B
20 mg, Tablet, Oral, 100 0.9150 B
D-10
Erythromycin
2%, Solution, Topical, 60 ml 0.0687 B
2%, Gel, Topical, 30 gm 0.6250 B
0.5%, Ointment, Ophthalmic, 3 gm 1.0714 B
Estazolam
Estradiol
0.5 mg, Tablet, Oral, 100 0.1791 B
Estropipate
0.75 mg, Tablet, Oral, 100 0.2754 B
1.5 mg, Tablet, Oral, 100 0.3450 B
Ethinyl Estradiol; Norgestimate

Etodolac
400 mg, Tablet, Oral, 100 0.3923 R
500 mg, Tablet, Oral, 100 0.7500 R
Famotidine
20 mg, Tablet, Oral, 100 0.1500 B
40 mg, Tablet, Oral, 100 0.3000 B
Flecainide Acetate
50 mg, Tablet, Oral, 100 0.8610 B
100 mg, Tablet, Oral, 100 1.4070 B
150 mg, Tablet, Oral, 100 1.9328 B
Fluconazole
100 mg, Tablet, Oral, 30 0.8825 B
200 mg, Tablet, Oral, 30 1.4075 B
Fluocinonide
0.05%, Cream, Topical, 60 gm 0.0790 R
0.05%, Gel, Topical, 60 gm 0.4965 R
0.05%, Solution, Topical, 60 ml 0.2483 R
Fluocinonide Emulsified Base (Fluocinonide-E)

0.05%, Cream, Topical, 60 gm 0.2453 R
D-11
Fluoxetine Hydrochloride
40 mg Capsule, Oral, 30 4.0125 B
20 mg/5ml, Solution, Oral, 120 ml 0.7500 R
10 mg, Tablets, Oral, 30 0.6000 B
Fluphenazine Hydrochloride
2.5 mg, Tablet, Oral, 100 0.2775 B
10 mg, Tablet, Oral, 100 0.5099 R
Flurazepam Hydrochloride
Flurbiprofen
100 mg, Tablet, Oral, 100 0.2438 B
Flurbiprofen Sodium
0.03%, Solution/Drops, Ophthalmic, 2ml 4.0679 B
Fluticasone Propionate
0.05% Cream, Topical, 30 gm 1.1110 B
Fluvoxamine Maleate
25 mg, Tablet, Oral, 100 1.0883 R
50 mg, Tablet, Oral, 100 1.0830 R
100 mg, Tablet, Oral, 100 1.1775 R
Folic Acid
Furosemide
10 mg/ml, Solution, Oral, 60 ml 0.1300 B
20 mg, Tablet, Oral, 100 0.0563 B
40 mg, Tablet, Oral, 100 0.0599 B
80 mg, Tablet, Oral, 100 0.1043 B
Gabapentin
600 mg, Tablet, Oral, 100 2.4704 B
800 mg, Tablet, Oral, 100 2.9586 B
Gemfibrozil
600 mg, Tablet, Oral, 500 0.3800 B
D-12
Gentamicin Sulfate
Eq 0.1% base, Ointment, Topical, 15 gm 0.2000 B
Eq 0.3% base, Solution/Drops, Ophthalmic, 5 ml 0.5700 B
Glimepiride
Glipizide
10 mg, Tablet, Oral, 100 0.1192 B
Glyburide
1.25 mg, Tablet, Oral, 100 0.1244 R
1.5 mg, Tablet, Oral, 100 0.1875 R
2.5 mg, Tablet, Oral, 100 0.1893 R
Glyburide; Metformin Hydrochloride

1.25mg; 250 mg, Tablet, Oral, 100 0.8405 B
2.5 mg; 500 mg, Tablet, Oral, 100 1.0026 B
Gramicidin; Neomycin Sulfate; Polymyxin B Sulfate

0.025 mg/ml; Eq 1.75 mg base/ml; 10,000 units/ml
Solution/Drops, Ophthalmic, 10 ml 2.0250 B
Guanfacine Hydrochloride
Halobetasol Propionate
Haloperidol Lactate
Eq 2 mg base/ml, Concentrate, Oral, 120 ml 0.1369 B
Hydrochlorothiazide
25 mg, Tablet, Oral, 1000 0.0577 R
50 mg, Tablet, Oral, 1000 0.1019 R
Hydrochlorothiazide; Propranolol Hydrochloride

D-13
Hydrochlorothiazide; Spironolactone
Hydrochlorothiazide; Triamterene
25 mg; 37.5 mg, Capsule, Oral, 100 0.3177 B
25 mg; 37.5 mg, Tablet, Oral, 100 0.1683 R
Hydrocortisone
0.5%, Cream, Topical, 30 gm 0.0510 M
1%, Cream, Topical, 30 gm 0.0572 B
1%, Lotion, Topical, 120 ml 0.0572 B
2.5%, Lotion, Topical, 59 ml 0.6814 B
Hydrocortisone Valerate
0.2%, Ointment, Topical, 45 gm 0.6583 R
Hydroxychloroquine Sulfate
200 mg, Tablet, Oral, 100 0.8535 B
Hydroxyzine Hydrochloride
10 mg/5 ml, Syrup, Oral, 480 ml 0.0159 B
10 mg, Tablet, Oral, 100 0.4865 R
25 mg, Tablet, Oral, 100 0.6744 B
50 mg, Tablet, Oral, 100 0.8222 B
Hydroxyzine Pamoate
Eq 25 mg HCL, Capsule, Oral, 100 0.1150 B
Eq 50 mg HCL, Capsule, Oral, 100 0.1572 B
Ibuprofen
400 mg, Tablet, Oral, 100 0.0493 B
600 mg, Tablet, Oral, 100 0.0573 B
800 mg, Tablet, Oral, 100 0.0590 B
Imipramine Hydrochloride
10 mg, Tablet, Oral, 100 0.2643 B
25 mg, Tablet, Oral, 100 0.3551 B
50 mg, Tablet, Oral, 100 0.4604 B
Indapamide
1.25 mg, Tablet, Oral, 100 0.1035 B
2.5 mg, Tablet, Oral, 100 0.1125 B
Ipratropium Bromide
0.02%, Solution for Inhalation, 2.500 ml, 25s 0.1080 R
D-14
Isoniazid
100 mg, Tablet, Oral, 100 0.0561 B
300 mg, Tablet, Oral, 100 0.0890 B
Isosorbide Dinitrate
10 mg, Tablet, Oral, 100 0.0228 R
20 mg, Tablet, Oral, 100 0.0558 B
Isosorbide Mononitrate
10 mg, Tablet, Oral, 100 0.6110 R
20 mg, Tablet, Oral, 100 0.4950 B
Ketoconazole
200 mg, Tablet, Oral, 100 2.2500 R
Ketorolac Tromethamine
10 mg, Tablet, Oral, 100 0.6773 M
Labetalol Hydrochloride
100 mg, Tablet, Oral, 100 0.2157 B
200 mg, Tablet, Oral, 100 0.3582 B
300 mg, Tablet, Oral, 100 0.5363 B
Lactulose
10 gm/15 ml, Solution, Oral, 480 ml 0.0219 B
Leflunomide
Levobunolol Hydrochloride
Levothyroxine Sodium
0.025 mg, Tablet, Oral, 100 0.2318 B
0.05 mg, Tablet, Oral, 100 0.2633 B
0.075 mg, Tablet, Oral, 100 0.2910 B
0.088 mg, Tablet, Oral, 100 0.2955 B
0.1 mg, Tablet, Oral, 100 0.2985 B
0.112 mg, Tablet, Oral, 100 0.3443 B
0.125 mg, Tablet, Oral, 100 0.3495 B
0.15 mg, Tablet, Oral, 100 0.3600 B
0.175 mg, Tablet, Oral, 100 0.4275 B
0.2 mg, Tablet, Oral, 100 0.4418 B
0.3 mg, Tablet, Oral, 100 0.6023 B
D-15
Lidocaine Hydrochloride
2%, Solution, Oral, 100 ml 0.0315 R
Lisinopril
2.5 mg, Tablet, Oral, 100 0.3855 B
10 mg, Tablet, Oral, 100 0.5970 B
20 mg, Tablet, Oral, 100 0.6390 B
30 mg, Tablet, Oral, 100 0.9038 B
40 mg, Tablet, Oral, 100 0.9345 B
Lisinopril; Hydrochlorothiazide
Lithium Carbonate
300 mg, Capsule, Oral, 1000 0.1382 B
Lorazepam
0.5 mg, Tablet, Oral, 100 0.4350 B
Lovastatin
Meclizine Hydrochloride
12.5 mg, Tablet, Oral, 100 0.0599 B
25 mg, Tablet, Oral, 100 0.0420 B
Medroxyprogesterone Acetate
2.5 mg, Tablet, Oral, 100 0.2025 B
10 mg, Tablet, Oral, 100 0.3787 B
Megestrol Acetate
20 mg, Tablet, Oral, 100 0.3489 B
40 mg, Tablet, Oral, 100 0.6755 B
Meloxicam
7.5 mg, Tablet, Oral, 100 0.2100 B
15 mg, Tablet, Oral, 100 0.2850 B
D-16
Meperidine Hydrochloride
50 mg, Tablet, Oral, 100 0.5370 B
100 mg, Tablet, Oral, 100 1.0347 B
Metformin Hydrochloride
500 mg, Tablet, Oral, 100 0.3557 B
750 mg, Tablet, Oral, 100 1.1498 B
850 mg, Tablet, Oral, 100 0.3863 B
1000 mg, Tablet, Oral, 100 0.4597 B
Methazolamide
25 mg, Tablet, Oral, 100 0.3150 R
50 mg, Tablet, Oral, 100 0.4650 R
Methenamine Mandelate
1 gm, Tablet, Oral, 100 0.2923 B
Methimazole
10 mg, Tablet, Oral, 100 0.7176 R
Methocarbamol
500 mg, Tablet, Oral, 100 0.1463 B
750 mg. Tablet, Oral, 100 0.1792 B
Methotrexate Sodium
Eq 2.5 mg base, Tablet, Oral, 100 1.2637 B
Methylphenidate Hydrochloride
10 mg, Tablet, Oral, 100 0.4224 B
20 mg, Tablet, Oral, 100 0.6180 B
Methylprednisolone
Metoclopramide
10 mg, Tablet, Oral, 100 0.1095 B
Metoclopramide Hydrochloride
Eq 5 mg base/5 ml, Solution, Oral, 480 ml 0.0155 B
Metolazone
2.3 mg, Tablet, Oral, 100 0.8910 B
10 mg, Tablet, Oral, 100 1.3425 B
D-17
Metoprolol Tartrate
25 mg, Tablet, Oral, 100 0.0720 B
50 mg, Tablet, Oral, 100 0.0500 B
100 mg, Tablet, Oral, 100 0.0690 B
Metronidazole
250 mg, Tablet, Oral, 100 0.0849 B
500 mg, Tablet, Oral, 100 0.2184 B
Mexiletine Hydrochloride
Midazolam Hydrochloride
Eq 2 mg base/ml/Syrup, Oral, 118 ml 0.8263 B
Minocycline Hydrochloride
Minoxidil
2.5 mg, Tablet, Oral, 100 0.3170 B
10 mg, Tablet, Oral, 100 0.6965 B
Mirtazapine
Mometasone Furoate
Mupirocin
2%, Ointment, Topical, 22 gm 1.8839 B
Nadolol
20 mg, Tablet, Oral, 100 0.4650 B
40 mg, Tablet, Oral, 100 0.4289 B
80 mg, Tablet, Oral, 100 0.8025 B
Naltrexone Sodium
50 mg, Tablet, Oral, 100 4.0400 B
Naphazoline Hydrochloride
0.1%, Solution/Drops, Ophthalmic, 15 ml 0.3140 R
D-18
Naproxen
250 mg, Tablet, Oral, 100 0.1044 R
375 mg, Tablet, Oral, 100 0.1383 R
500 mg, Tablet, Oral, 100 0.1805 B
Niacin
500 mg, Tablet, Oral, 100 0.0390 B
Nicardipine Hydrochloride
Nizatidine
Nortriptyline Hydrochloride
Nystatin
100,000 units/gm, Cream, Topical, 30 gm 0.0755 B
100,000 units/gm, Ointment, Topical, 15 gm 0.1019 B
100,000 Units/Gram, Powder, Topical, 15 gm 1.7480 B
Nystatin; Triamcinolone Acetonide

100,000 units/gm; 0.1%, Cream, Topical, 30 gm 0.0975 B
Ofloxacin
0.3%, Soultion/Drops, Ophthalmic, 5 ml 6.7470 B
Omeprazole
10 mg, Capsule, Delayed Release Pellets, Oral, 100 3.5463 B
20 mg, Capsule, Delayed Release Pellets, Oral, 100 3.9790 B
Oxaprozin
600 mg, Tablet, Oral, 100 0.6758 B
Oxazepam
Oxybutynin Chloride
5 mg/5 ml, Syrup, Oral, 473 ml 0.0825 R
D-19
Oxycodone Hydrochloride
20 mg/ml, Concentrate, Oral, 30 ml 0.9500 B
15 mg, Tablet, Oral, 100 0.6695 M
30 mg, Tablet, Oral, 100 1.3094 M
Paroxetine Hydrochloride
Penicillin V Potassium
250 mg, Tablet, Oral, 100 0.2112 B
500 mg, Tablet, Oral, 100 0.3590 B
Pentoxifylline
Perphenazine
16 mg, Tablet, Oral, 100 1.3833 B
Phenytoin
125 mg/5 ml, Suspension, Oral, 237 ml 0.1521 B
Piroxicam
Polymyxin B Sulfate; Trimethoprim Sulfate

10,000 units/ml; Eq 1 mg base/ml, Solution/Drops, Ophthalmic, 10 ml 1.2360 B
Potassium Chloride
8 MEQ, Tablet, Extended Release, Oral, 100 0.1044 B
Pravastatin Sodium
D-20
Prednisolone
15 mg/5 ml, Syrup, Oral, 480 ml 0.2081 B
Prednisolone Acetate
1%, Suspension/Drops, Ophthalmic, 10 ml 1.6950 B
Prednisone
10 mg, Tablet, Oral, 100 0.0615 B
20 mg, Tablet, Oral, 100 0.0804 B
Primidone
250 mg, Tablet, Oral, 100 0.8055 R
Probenecid
500 mg, Tablet, Oral, 100 0.7059 B
Prochlorperazine Maleate
Promethazine Hydrochloride
12.5 mg, Suppository, Rectal, 12 0.9612 B
25 mg, Suppository, Rectal, 12 1.0362 B
Propafenone Hydrochloride
150 mg, Tablet, Oral, 100 1.1049 B
225 mg, Tablet, Oral, 100 1.5624 B
Propranolol Hydrochloride
10 mg, Tablet, Oral, 100 0.0585 B
20 mg, Tablet, Oral, 100 0.0705 B
40 mg, Tablet, Oral, 100 0.0848 B
80 mg, Tablet, Oral, 100 0.1020 B
Pseudoephedrine Hydrochloride; Tripolidine Hydrochloride

Pyridostigmine Bromide
60 mg, Tablet, Oral, 100 0.5832 B
Ranitidine Hydrochloride
Eq 150 mg base, Tablet, Oral, 100 0.1088 R
Ribavirin
D-21
Rifampin
Rimantadine Hydrochloride
100 mg, Tablet, Oral, 100 1.5120 B
Selegiline Hydrochloride
Selenium Sulfide
2.5%, Lotion/Shampoo, Topical, 120 ml 0.0750 B
Silver Sulfadiazine
1%, Cream, Topical, 400 gm 0.0591 B
Sotalol Hydrochloride (Does Not Apply to the “AF” Versions)

80 mg, Tablet, Oral, 100 1.7850 B
120 mg, Tablet, Oral, 100 2.3550 B
160 mg, Tablet, Oral, 100 2.9250 B
240 mg, Tablet, Oral, 100 3.9750 B
Spironolactone
25 mg, Tablet, Oral, 100 0.3000 B
Sucralfate
1 gm, Tablet, Oral, 100 0.3690 B
Sulfacetamide Sodium
10%, Solution/Drops, Opthalmic, 15 ml 0.1530 B
Sulfamethoxazole; Trimethoprim
Sulfasalazine
500 mg, Tablet, Oral, 100 0.1565 B
Sulindac
150 mg, Tablet, Oral, 100 0.3317 B
200 mg, Tablet, Oral, 100 0.4289 B
Tamoxifen Citrate
Temazepam
D-22
Terazosin Hydrochloride
Terconazole
0.4%, Cream, Vaginal, 45 gm 0.9650 B
Tetracycline Hydrochloride
Theophylline
200 mg, Tablet, Extended Release, Oral, 100 0.2160 R
300 mg, Tablet, Extended Release, Oral, 100 0.2625 R
Thiothixene
Ticlopidine Hydrochloride
250 mg, Tablet, Oral, 60 0.2732 B
Timolol Maleate
Tizanidine Hydrochloride
Tobramycin
Torsemide
100 mg, Tablet, Oral, 100 2.9175 B
Tramadol Hydrochloride
50 mg, Tablet, Oral, 100 0.3068 B
Trazodone Hydrochloride
50 mg, Tablet, Oral, 100 0.0742 R
100 mg, Tablet, Oral, 100 0.1140 B
150 mg, Tablet, Oral, 100 0.3113 B
D-23
Tretinoin
Triamcinolone Acetonide
Triazolam
0.125 mg, Tablet, Oral, 100 0.3012 B
0.25 mg, Tablet, Oral, 10 0.3251 B
Trihexyphenidyl Hydrochloride
Trimethobenzamide Hydrochloride
Tropicamide
1%, Solution/Drops, Ophthalmic, 15 ml 0.7000 B
Valproic Acid
250 mg/5 ml, Syrup, Oral, 480 ml 0.0594 M
Verapamil Hydrochloride
120 mg, Capsule, Extended Release, Oral, 100 0.8250 B
40 mg, Tablet, Oral, 100 0.1509 B
80 mg, Tablet, Oral, 100 0.0735 B
120 mg, Tablet, Oral, 100 0.1110 B
Warfarin Sodium
2.5 mg, Tablet, Oral, 100 0.5816 B
7.5 mg, Tablet, Oral, 100 0.8649 B
10 mg, Tablet, Oral, 100 0.8970 B
D-24
Zidovudine
300 mg, Tablet, Oral, 60 3.6503 B
Zonisamide
100 mg Capsule, Oral, 100 1.1742 B
D-25
D-26
Appendix E:
Glossary
E-1
E-2
GLOSSARY OF MEDICAL, MEDICAID,

AND MANAGED CARE TERMS
Term Definition
Access A patient’s ability to obtain medical care. The ease of access is determined
by components such as the availability of medical services and their
acceptability to the patient, the location of health care facilities,
transportation, hours of operation and affordability of care.
Actual Acquisition Cost (AAC) The pharmacist’s net payment made to purchase a drug product, after
taking into account such items as purchasing allowances, discounts, and
rebates.
Actual Charge The amount a physician or other provider actually bills a patient for a
particular medical service, procedure or supply in a specific instance. The
actual charge may differ from the usual, customary, prevailing, and/or
reasonable charge.
Acute Care Medical treatment rendered to individuals whose illnesses or health

problems are of a short-term or episodic nature. Acute care facilities are
those hospitals that mainly serve persons with short-term health problems.
Additional Drug Benefit List A list of pharmaceutical products approved by a health plan and employer
for dispensing in larger quantities than the standards covered under a
benefit package in order to facilitate long-term patient use. The list is
subject to periodic review and modification by the health plan. Also called
“drug maintenance list.”
Adjudication Processing a claim through a series of edits in order to determine proper

payment.
Administrative Costs The costs incurred by a carrier, such as an insurance company or HMO,
for services such as claims processing, billing and enrollment, and
overhead costs. Administrative costs can be expressed as a percentage of
premiums or on a per member per month basis. Additional costs that are
often expressed as administrative include those related to utilization
review, insurance marketing, medical underwriting, agents’ commissions,
premium collection, claims processing, insurer profit, quality assurance
activities, medical libraries and risk management.
Administrative Services Only An insurance arrangement requiring the employer to be at risk for the cost
(ASO) 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.
E-3
Term Definition
Aged For purposes of Medicare enrollment, persons 65 years of age or over are
considered to be aged. Medicaid eligibility is determined on the basis of
financial need for people who meet Supplemental Security Income (SSI)
eligibility criteria (aged, blind, or disabled individuals) and Temporary
Assistance for Needy Families (TANF) criteria (adults and children).
Eligibility determinations are made for an entire economic unit or “case”
(sometimes a family) based on whether or not one member of a case meets
the criteria. For example, an “aged” case could consist of a 66 year old
male and his 63 year old wife. In contrast, a disabled enrollee could be
over 65 years of age. May also be defined as “Elderly.”
Agency for Healthcare A Federal agency under Health and Human Services (HHS) whose
Research and Quality (AHRQ) purpose is to enhance the quality and effectiveness of health care 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
Children (AFDC) all States, AFDC recipiency may be used to establish Medicaid eligibility.
Now known as Temporary Assistance for Needy Families (TANF).
Allied Health Personnel Specially trained and licensed (when necessary) health workers other than
physicians, dentists, optometrists, chiropractors, podiatrists and nurses.
The term is sometimes used synonymously with paramedical personnel, all
health workers who perform tasks that must otherwise be performed by a
physician, or health workers who do not usually engage in independent
practice.
Allowable Charge The maximum fee that a third party will reimburse a provider for a given
service. An allowable charge may not be the same amount as either a
reasonable or customary charge.
Allowable Costs Charges for services rendered or supplies furnished by a health provider,
which qualify for an insurance reimbursement.
Ambulatory Care All types of health services that are provided on an outpatient basis, in
contrast to services provided in the home or to persons who are inpatients.
While many inpatients may be ambulatory, the term ambulatory care
usually implies that the patient must travel to a location to receive services
which do not require an overnight stay.
Ambulatory Surgery Any minor surgical procedures that can be performed at any type of
medical facility on an outpatient basis, i.e., not requiring an overnight stay.
American National Standards A nonprofit organization that coordinates the development of voluntary
Institute (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.
E-4
Term Definition
Ancillary Services Hospital services other than room, board, and professional services. They
may include X-rays, lab tests, or anesthesia.
Antitrust A legal term encompassing a variety of efforts on the part of government

to assure that sellers do not conspire to restrain trade or fix prices for their
goods or services in the market.
Any Willing Provider A requirement that a health insurance plan or a health maintenance
organization (HMO) must sign a contract for the delivery of health care
services with any provider in the area that would like to provide such
services to the plan’s or HMO’s enrollees, and can meet the terms of a
contract.
Assignee The person to whom the rights to a health insurance policy are assigned,
either in part or in whole, by the original policyholder.
Assignment of Benefits A method under which a claimant requests that his/her benefits under a
claim be paid to some designated person or institution, usually a physician
or hospital.
At-Risk Accepting prepayment as full coverage for a predetermined health care

benefit and assuming financial liability for any loss that occurs when
premiums paid are less than the cost of services provided.
Authorization As it applies to managed care, authorization is the approval of care, such as

hospitalization.
Average Cost Per Claim The average dollar amount of administrative and/or medical services
rendered for the unit of measure within each expenditure category. The
calculation is $amount / #of units.
Average Manufacturer Price The average price paid by wholesalers for products distributed to the retail
(AMP) class of trade.
Average Wholesale Price The published suggested wholesale price of a drug. It is often used by
(AWP) pharmacies as a cost basis for pricing prescriptions.
Barriers To Access Barriers to access can be financial (insufficient monetary resources),

geographic (distance to providers), organizational (lack of available
providers) and sociological (e.g., discrimination, language barriers). Efforts
to improve access often focus on providing/improving health coverage.
Behavioral Health Care Assessment and treatment of mental and/or psychoactive substance abuse
disorders.
Beneficiary An individual who receives benefits from or is covered by an insurance

policy or other health care financing program. Also known as a "member,"
"enrollee," "subscriber," or "insured."
Benefit A service provided under an insurance policy or prepayment plan.
Benefit Maximum Specifies a dollar limit for the total reimbursement of health care costs
during a benefit period.
Benefit Package Services an insurer, government agency, or health plan offers to a group or
individual under the terms of a contract.
E-5
Term Definition
Best Price For purposes of Medicaid rebate calculations, lowest price paid for a
product by any purchaser other than Federal agencies and State
pharmaceutical assistance programs.
Biological Equivalents Those chemical equivalents which, when administered in the same amounts,
will provide the same biological or physiological availability, as measured
by blood levels, urine levels, etc.
Blue Book (MDBT) The generic name for a widely used pricing guide entitled the American
Druggist First Databank Annual Directory of Pharmaceuticals. Brand
name and generic drugs are listed by product, manufacturer, National Drug
or Universal Price Codes, direct price and average wholesale price (AWP).
Other pricing guides are the Red Book and Medispan’s Pricing Guide.
Brand Name Name identifying a drug as the product of a specific pharmaceutical

company. Also known as proprietary trademark name.
Cafeteria Plan An employee benefit plan under which all participants are permitted to
choose among two or more benefit options according to their needs and/or
ability to pay. Also called a flexible benefit plan of “flex plan.”
Capitation A method of payment in which a health plan, such as an HMO or a

specific health care provider, receives a fixed amount for each person
eligible to receive services ($ per member per month), which is made
whether or not the covered person becomes an active patient and without
regard to the number and mix of services used by that patient.
Capitation Fund A fund based on the number of members multiplied by the budgeted or
capitated amount each member pays. Some HMOs, in lieu of reimbursing
physicians on a direct capitation basis, may establish such a fund.
Physicians are then reimbursed on a fee-for-service basis from the
capitation fund. The HMO monitors patient visits for over-utilization;
patients exceeding the norm are notified.
Card Programs The use of a drug benefit identification card which, when presented to a
participating pharmacy by employees or their dependents, usually entitles
them to receive the medication for a copay.
Care Coordinator A primary health care practitioner: (1) who provides primary care services
to an enrollee, (2) who is generally responsible for coordinating the
enrollee’s health care, and (3) with whom, other than in an emergency, a
patient must consult to obtain a referral to a specialist provider in order to
obtain the highest level of benefits available under a health plan. Care
coordinators are sometimes called “gatekeepers.”
Carve Out A decision to purchase separately a service that is typically a part of an

indemnity or HMO plan. Example: an HMO may “carve out” the
behavioral health benefits and select a specialized vendor to supply these
services on a stand-alone basis.
E-6
Term Definition
Case Management (1) A process whereby covered persons with specific health care needs are
identified and a plan designed to efficiently utilize health care 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 are aged, blind, or disabled
individuals or families and children who meet financial eligibility
requirements for TANF, Supplemental Security Income, or an optional
State supplement.
Center for Medicaid and State The agency within the Centers for Medicare and Medicaid Services (CMS)
Operations (CMSO) with responsibility for administering the Medicaid and The Children’s
Health Insurance Program (SCHIP).
Centers for Medicare and The government agency within the Department of Health and Human
Medicaid Services (CMS) Services which directs the Medicare and Medicaid programs (Titles XVIII
and XIX of the Social Security Act) and conducts research to support those
programs. Formerly known as the Health Care Financing Administration
(HCFA).
Certificate of Need (CON) A certificate issued by a government body, where required, to an

individual or organization proposing to construct or modify a health
facility, acquire major new medical equipment, or offer a new or different
health service. Such issuance recognizes that a facility or services, when
available, will meet the needs of those for whom it is intended.
Chain Pharmacy One of a group of pharmacies, usually three or more, under the same
management or ownership.
Charity Care Pools The assets of several funds combined to cover health care costs to the poor
and uninsured. The pools are established by organizations such as
hospitals and insurance companies to offset a portion of the cost for
providing health care to the indigent.
Chemical Equivalents Those multiple-source drug products containing identical amounts of the
same active ingredients, in equivalent dosage forms, and meeting existing
physical/chemical standards.
Chronic Care Care and treatment rendered to individuals whose health problems are of a
long-term and continuing nature. Rehabilitation facilities, nursing homes,
and mental hospitals may be considered chronic care facilities.
E-7
Term Definition
Claim Information on medical services provided that is submitted by a provider or

a covered person from which processing for payment to the provider or
covered person is made. The term generally refers to the liability for health
care services received by covered persons.
Claims Administration A carrier function involving the review of health insurance claims
submitted for payment, by individual claim or in the aggregate. Claims
administration, as it relates to professional review programs, is an
identification procedure, screening treatment or charge pattern, for
subsequent peer review and adjudication.
Claims Clearinghouse System A system which allows electronic claims submission through a single
source.
Claims Review The method by which an enrollee’s health care service claims are reviewed
before reimbursement is made. The purpose of this monitoring system is to
validate the medical appropriateness of the provided services and to be
sure the cost of the service is not excessive.
Clearinghouse Capability A company capable of submitting electronic and/or paper claims to several
third-party payers.
Clinical Indicator A tool or marker used to monitor and evaluate care to assure desirable
outcomes and to explain or prevent undesirable outcomes.
Clinical Outcome The status of the patient’s health, especially after receipt of medical care
services. Assessment of outcomes may be dependent upon targeted goals,
clinical markers, and the ability to provide objective measurements.
Clinical Practice Guidelines Guidelines that specify the appropriate course(s) of treatment for specified
health conditions.
Closed-Panel HMO Generally offers the services of a relatively limited number of health care
providers, e.g., physicians employed by the HMO. Staff- and group-model
HMOs are usually referred to as being in this category.
CMS MSIS Report The CMS MSIS Report, formerly the HCFA-2082 Report, is the basic
source of State-reported eligibility and claims data on the Medicaid
population, their characteristics, utilization, and payments. Through FY
1998, the HCFA-2082 was an annual State submitted report designed to
collect aggregate statistical data on Medicaid eligibles, recipients, services,
and expenditures during each federal fiscal year. States summarized and
reported the data processed through their own Medicaid claims processing
and payment systems unless they opted to participate in the Medicaid
Statistical Information System (MSIS) where the 2082 Report was
produced by CMS. State-by-State national summary tables were developed
based on the 2082 Reports. As a result of legislation enacted by The
Balanced Budget Act of 1997, States, beginning in FY 1999, are required
to submit all of their eligibility and claims data on a quarterly basis
through MSIS. The State requirement for completing the HCFA-2082
Report has been eliminated.
E-8
Term Definition
CMS-64 Report The CMS-64 Report is a product of the financial budget and grant system.
It is a statement of expenditures for the Medicaid program that States
submit to CMS 30 days after each quarter. The Report is an accounting
statement of actual expenditures made by the States for which they are
entitled to receive Federal reimbursement under Title XIX for that quarter.
Along with The CMS MSIS Report, it is one of the primary sources for
Medicaid statistical data.
Coinsurance The portion of covered health care 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.
Commercial Managed Care A health maintenance organization with a contract §1876 or a Medicare
Organization (Com-MCO) Advantage organization, a provider sponsored organization, or any private
or public organization which meets the requirements of §1902(w). They
provide comprehensive services to commercial and/or Medicare, as well as
Medicaid enrollees.
Community Rating A method of determining a premium structure that is influenced not by the
expected level of benefit utilization by specific groups, but by expected
utilization by the population as a whole. Most often based on the entire
population of a metropolitan statistical area (MSA). The intent is to spread
risk over a large number of covered lives.
Competitive Medical Plan A status granted by the Federal government to an organization meeting
(CMP) specified criteria, enabling that organization to obtain a Medicare risk
contract.
Compliance The degree to which patients follow treatment recommendations.
Comprehensive Benefits Plan A variation of the major medical plan which carries copayment
requirements, usually 10-20 percent of all health expenses and deductibles
ranging from $100 to $1,000.
Concurrent Drug Evaluation An electronic assessment of claims at the point of service to detect potential
problems that should be addressed prior to dispensing drugs to patients.
Consolidated Omnibus A Federal law that, among other things, requires employers to offer
Reconciliation Act (COBRA) continued health insurance coverage to certain employees and their
beneficiaries whose group health insurance coverage has been terminated.
Consumer Price Index (CPI) A price index constructed monthly by the U.S. Department of Labor using
retail prices of goods and services sold in large cities across the country.
Continuous Quality A formal process of constantly seeking better ways to achieve stated goals.
Improvement (CQI)
Continuum of Care A range of clinical services provided to an individual or group, which may
reflect treatment rendered during a single inpatient hospitalization, or care
for multiple conditions over a lifetime. The continuum provides a basis
for analyzing quality, cost and utilization over the long term.
E-9
Term Definition
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.
Copay/Copayment A cost-sharing arrangement in which a covered person pays a specified

charge for a specified service, such as $10 for an office visit. The covered
person is usually responsible for payment at the time the care is rendered.
Typical copayments are fixed or variable flat amounts for physician office
visits, prescriptions or hospital services. Some copayments are referred to
as coinsurance, with the distinguishing characteristics that copayments are
flat or variable dollar amounts and coinsurance is a defined percentage of
the charges for services rendered.
Cosmetic Procedures Those procedures which involve physical appearance, but which do not
correct or materially improve a physiological function and are not deemed
medically necessary.
Cost Sharing Any provision of a health insurance policy that requires the insured to pay
some portion of medical expenses. The general term includes deductibles,
copayments, and coinsurance.
Cost Shifting The redistribution of payment sources. Typically, cost shifting occurs
when one payer obtains a discount on provider services, and the providers
increase costs to another payer to make up the difference.
Cost-Based Reimbursement Payment by third-party insurers in which the amount is based on the cost to
the provider of delivering services.
Cost-Effectiveness Usually considered as a ratio, the cost-effectiveness of a drug or procedure,

for example, relates the cost of that drug or procedure to the health benefits
resulting from it. In health terms, it is often expressed as the cost per year
per life saved.
Counter Detailing A process of re-educating or influencing prescribers in a closed or

controlled HMO plan. Usually done in order to gain more compliance with
a formulary. In a counter-detailing program, techniques used by
pharmaceutical sales representatives are adapted to a “counter” objective,
i.e., to provide doctors with basic pharmacological information designed to
influence their prescribing habits.
Coverage Entire range of protection provided under an insurance contract.
Covered Expenses Medical and related costs, experienced by those covered under the policy,
that qualify for reimbursement under terms of the insurance contract.
Covered Services The specific services and supplies for which Medicaid will provide
reimbursement. Covered services under Medicaid consist of a
combination of mandatory and optional services within each State.
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Term Definition
Credentialing A process of review to approve a provider who applies to participate in a

health plan. Specific criteria and prerequisites are applied in determining
initial and ongoing participation in the health plan.
Customary Charge The charge a physician or supplier usually bills his patients for furnishing
a particular service or supply is called the customary charge.
Customary, Prevailing, and Method of reimbursement which limits payment to the lowest of the
Reasonable 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.
Deficit Reduction Act of 2005 Public Law 109-171, a law whose Medicaid provisions changed how
(DRA) manufacturers and pharmacies are reimbursed for prescribed drugs,
increased penalties on improper asset transfers to qualify for nursing home
care, and gave States new flexibility on greater cost sharing and benefit
restrictions. As of January 1, 2007, Medicaid payments for prescription
drugs are based on the “average manufacturer price (AMP),” not the
previous “average wholesale price (AWP).” The Federal Upper Limit
(FUL) is based on 250% of AMP for multiple source drugs, instead of
150% of the published price. The definition of AMP is also revised to
exclude customary prompt payment discounts to wholesalers. The
definition of “multiple source drugs” subject to the FUL includes drugs
with at least one generic equivalent, instead of the previous two.
Demand The amount of care a population seeks to obtain through the health delivery
system.
Dependent An individual who relies on an employee for support or obtains health

coverage through a spouse, parent, or grandparent who is the covered
person.
Depot Price The price(s) available to any depot of the Federal government, for
purchase of drugs from the manufacturer through the depot system of
procurement.
Diagnosis Center Freestanding or hospital-based facility that specializes in diagnosing

illnesses and injuries.
Diagnosis Related Group A system of classification for inpatient hospital services based on principal
(DRG) 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.
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Term Definition
Disability (1) Any condition that results in functional limitations that interfere with
an individual’s ability to perform his/her customary work and which
results in substantial limitation in one of more major life activities. (2)
Condition(s) that prevent or limit an individual’s ability to engage in
normal activities. These may be temporary.
Disability Income Insurance Type of health insurance that periodically pays a disabled subscriber to
replace income lost during the period of disability.
Disease Management An effort to improve patient outcomes and lower costs by organizing
managed care initiatives around patients with a particular disease or
condition.
Dismemberment Loss of body parts stemming from accidental physical injury.
Dispense As Written (DAW) A prescribing directive issued by physicians to indicate that the pharmacy
should not in any way alter a prescription. Such alterations are usually done
in order to substitute a generic drug for the brand name drug ordered.
Dispensing, Fill or Professional The amount paid to a pharmacy for each prescription, in addition to the
Fee negotiated formula for reimbursing ingredient cost.
Dispensing or Prescribing Limitations on the number of prescriptions per month, or the amount of
Limits medication that may be prescribed in a given time frame.
Disproportionate Share A disproportionate share hospital (DSH) is a hospital that serves a

Hospital (DSH) disproportionate number of low-income patients with special needs and
receives a payment adjustment for providing such services. In addition to
certain requirements for the provision of obstetrical services to individuals
entitled to medical assistance, a hospital is deemed to be a disproportionate
share hospital if 1) the hospital’s Medicaid inpatient utilization rate is at
least one standard deviation above the mean Medicaid inpatient utilization
rate for hospitals receiving Medicaid payments in the State, or 2) the
hospital’s low-income utilization rate exceeds 25 percent.
Drug Detailing Presenting information about a brand name drug product to prescribers to
educate them about its activity, uses, side effects, proper dosage and
administration, etc.
Drug Formulary A listing of prescription medications which are preferred for use by a health
plan and which may be dispensed through participating pharmacies to
covered persons. This list is subject to periodic review and modification by
the health plan. A plan that has adopted an “open or voluntary” formulary
allows coverage for both formulary and non-formulary medications. A plan
that has adopted a “closed, select or mandatory” formulary limits coverage
to those drugs in the formulary.
Drug Use Evaluation (DUE) Evaluations of prescribing patterns of prescribers to specifically determine
the appropriateness of drug therapy. There are three forms of DUE:
prospective (before or at the time of prescription dispensing), concurrent
(during the course of drug therapy), and retrospective (after the therapy has
been completed). Same as “Drug Utilization Review.”
Drug Utilization The prescribing, dispensing, administering and ingestion or use of

pharmaceutical products.
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Term Definition
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.
Dual Eligibles The term describes a population of low-income elderly and individuals
with disabilities who qualify for both Medicare and Medicaid coverage.
While Medicare covers basic health services, including physician and
hospital care, dual eligibles rely on Medicaid to pay Medicare premiums
and cost-sharing and to cover critical benefits Medicare does not cover,
such as long-term care. However starting in 2006, coverage of
prescription drugs for dual eligibles shifted from Medicaid to Medicare.
Early and Periodic Screening, The EPSDT program covers screening and diagnostic services to
Diagnostic, and Treatment determine physical or mental defects in recipients under age 21, as well as
(EPSDT) health care and other measures to correct or ameliorate any defects and
chronic conditions discovered.
Electronic Data Interchange The computer-to-computer exchange of business or other information. The
(EDI) 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 A Federal Act passed in 1974, that established new standards and
Security Act of 1974, Public reporting/disclosure requirements for employer-funded pension and health
Law 93-406 (ERISA) benefit programs. To date, self-funded health benefit plans operating under
ERISA have been held to be exempt from State insurance laws.
Enrollment The total number of covered persons in a health plan. Also refers to the
process by which a health plan signs up groups and individuals for
membership, or the number of enrollees who sign up in any one group.
Estimated Acquisition Cost An estimate of the price generally, and currently, paid by providers for a
(EAC) drug marketed or sold by a particular manufacturer or labeler in the
package size most frequently purchased by providers.
Exclusions Specific conditions or circumstances listed in the contract or employee

benefit plan for which the policy or plan will not provide benefit
payments.
Exclusivity Clause A part of a contract which prohibits physicians from contracting with more
than one health maintenance organization or preferred provider
organization.
Expenditures Under Medicaid, “expenditures” refers to an amount paid out by a State

agency for the covered medical expenses of eligible participants.
Experience Rating The process of setting rates based partially or in whole on previous claims
experience and projected required revenues for a future policy year for a
specific group or pool of groups.
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Term Definition
Experimental, Investigational Medical, surgical, psychiatric, substance abuse or other health care services,
or 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 health care 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 to freely
determine the number or spacing of their children.
Favorable Selection A tendency for utilization of health services in a population group to be

lower than expected or estimated.
Federal Financial Participation The technical term for Federal Medicaid matching funds paid to States for
allowable expenditures for Medicaid services or administrative costs.
Federal Medical Assistance The Federal Medical Assistance Percentage (FMAP) determines that
Percentage (FMAP) Federal government’s share of medical assistance expenditures under each
State’s Medicaid program. Each year, the FMAP is established by a
formula that compares the State's average per capita income level with the
national income average. States with a higher per capita income level are
reimbursed a smaller share of their costs. By law, the FMAP cannot be
lower than 50 percent or higher than 83 percent. The FMAP is defined in
Section 1933(d) of the Social Security Act.
Federal Poverty Level (FPL) The Federal government’s working definition of poverty is used as the
reference point for the income standard for Medicaid eligibility for certain
categories of beneficiaries. The Federal Poverty Level is the
administrative version of the poverty measure and is issued by the
Department of Health and Human Services (HHS). It is a simplification of
the poverty thresholds and is used in determining financial eligibility for
certain Federal programs. The FPL is also referred to as the Federal
poverty guidelines.
Federal Upper Limits (FUL) The upper limit amount that Medicaid can reimburse for a drug product if
there are three or more generic versions of the product rated
therapeutically equivalent and at least three suppliers listed in the current
editions of published national compendia. These limits are intended to
assure that the Federal government acts as a prudent buyer of drugs. The
upper limits program seeks to achieve savings by taking advantage of
current market prices.
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Term Definition
Federally Qualified Health Federally Qualified Health Centers are facilities or programs more
Center (FQHC) commonly known as Community Health Centers, Migrant Health Centers,
and Health Care for The Homeless. These centers may qualify as Medicaid
providers of services if: 1) The facility receives a grant under sections 329,
330, or 340 of The Public Health Services Act; 2) HRSA recommends,
and the HHS Secretary determines, that the facility meets the requirements
of the grant; or 3) The Secretary determines that a facility may qualify
through waivers of the requirements (such a waiver cannot exceed two
years).
Federally Qualified HMOs HMOs that meet certain Federally stipulated provisions aimed at
protecting consumers: e.g., providing a broad range of basic health
services, assuring financial solvency, and monitoring the quality of care.
HMOs must apply to the Federal government for qualification. The Office
of Prepaid Health Care of CMS administers the process.
Fee Maximum The maximum amount a participating provider may be paid for a specific
health care service provided to a covered person under a specific contract.
Sometimes called “fee max.”
Fee Schedule A listing of codes and related services with pre-established payment
amounts that could be percentages of billed charges, flat rates or maximum
allowable amounts.
Fee-for-Service The traditional health care payment system, under which physicians and
Reimbursement other providers receive a payment that does not exceed their billed charge
for each unit of service provided. Fees are paid as care is rendered.
First-Dollar Coverage Health policies that pay all or a portion of medical expenses upon
enrollment, without a deductible charge.
Fiscal Agent A contractor that processes or pays vendor claims on behalf of a Medicaid
agency.
Fiscal Intermediary The agent that has contracted with providers of service to process claims
for reimbursement under health care coverage. In addition to handling
financial matters, it may perform other functions such as providing
consultative services or serving as a center for communication with
providers and making audits of providers’ records.
Fiscal Year Any predetermined set of 12 months for which annual accounts are kept.
The Federal government’s fiscal year extends from Oct. 1 to the following
Sept. 30.
Fixed Fee An established “fee” schedule for pharmacy services allowed by certain
government and private third-party programs in lieu of cost-of-doing
business markups.
Formulary See “Drug Formulary.”
Free-Standing Hospital Any hospital that is not affiliated with a multihospital system.
Freedom-of-Choice (FOC) Legislation requiring managed care organizations to allow members to

choose providers whether or not they connect with the plans (often
coupled with “any willing provider” legislation).
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Term Definition
Gatekeeper See “Care Coordinator.”
Generic Drug A chemically equivalent copy of a brand name drug whose patent has
expired. Drug formulations must be of identical composition with respect
to the active ingredient (i.e., meet official standards of identity, purity, and
quality of active ingredient). Also called generic equivalent or non-
innovator multiple source drug.
Generic Equivalent See “Generic Drug.”
Generic Substitution Dispensing a generic drug in place of a brand name medication.
Global Target A financing method identical to a global budget except that no

enforcement mechanism is used to keep providers and hospitals within
budget (i.e., providers and hospitals will receive additional funding if their
costs exceed their budgeted payments).
HCFA 1500 A universal form developed by the government agency previously known
as the Health Care Financing Administration (HCFA, now CMS), for
providers of services to bill professional fees to health carriers.
Healthcare Common A listing of services, procedures and supplies offered by physicians and
Procedural Coding System other providers. HCPCS includes current procedural terminology (CPT)
(HCPCS) codes, national alphanumeric codes and local alphanumeric codes. The
national codes are developed by CMS in order to supplement CPT codes.
They include physician services not included in CPT as well as non-
physician services such as ambulance, physical therapy and durable medical
equipment. The local codes are developed by local Medicare carriers in
order to supplement the national codes. HCPCS codes are 5-digit codes, the
first digit a letter followed by four numbers. HCPCS codes beginning with
A through V are national; those beginning with W through Z are local.
Health Care Financing See “Centers for Medicare and Medicaid Services.”
Administration (HCFA)
Health Care Prepayment Plan A cost contract with the CMS that prepays a health plan a flat amount per
(HCPP) 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 Insurance Flexibility A Medicaid and State Children’s Health Insurance Program (SCHIP)
and Accountability (HIFA) demonstration waiver, using Section 1115 waiver authority, that offers
Waiver States greater flexibility in setting benefits and cost-sharing for some
groups of Medicaid beneficiaries. States can use the waiver to cut benefits
and /or increase cost-sharing for certain Medicaid beneficiaries and invest
resulting savings into expanding coverage of uninsured individuals
through Medicaid and SCHIP.
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Term Definition
Health Insurance Portability Public Law 104-191, a law which requires each State’s Medicaid
and Accountability Act of 1996 Management Information System (MMIS) to have the capacity to exchange
(HIPAA) data with the Medicare program and contains “administrative
simplification” provisions that require State Medicaid Programs to use
standard codes for electronic transactions relating to the processing of
health claims.
Health Insuring Organization An entity that provides for or arranges for the provision of care and
(HIO) contracts on a prepaid capitated risk basis to provide a comprehensive set of
services.
Health Maintenance (1) An entity that provides, offers or arranges for coverage of designated
Organizations (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 health care or otherwise assuring health care
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 health care purchases and
evaluating health plan performance. HEDIS 2007 is currently used and
distributed by NCQA (National Committee for Quality Assurance).
HMO - Group Model A health care model involving contracts with physicians organized as a
partnership, professional corporation, or other association. The health plan
compensates the medical group for contracted services at a negotiated rate,
and that group is responsible for compensating its physicians and
contracting with hospitals for care of their patients.
HMO - Individual Practice A health care model that contracts with physicians and other community
Association (IPA) health care 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 health care model that employs physicians to provide health care to its
members. All premiums and other revenues accrue to the HMO, which
compensates physicians by salary and incentive programs.
Home and Community-Based See “Section 1915(c) Waivers.”

Waivers
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Term Definition
Home Health Agency (HHA) A facility or program licensed, certified or otherwise authorized pursuant
to State and Federal laws to provide health care 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.
Innovator Multiple-Source An innovator multiple-source drug is a multiple source drug that was
Drug originally marketed under an original new drug application approved by
the FDA.
Inpatient Hospital Services Items and services furnished to a resident patient of a hospital by the
hospital. May include such items as: bed and board; nursing and related
services; diagnostic and therapeutic services; and medical or surgical
services.
Integrated Behavioral Health A carve-out benefit plan that combines independent managed care services
into what is designed as a seamless delivery system for behavioral health
concerns. Components could include employee assistance services, a
telephone counseling triage, utilization management, behavioral health
treatment networks, claims payment, and data management.
Integrated Delivery System A generic term referring to a joint effort of physician/hospital integration
for a variety of purposes. Some models of integration include physician-
hospital organization, group practice without walls, integrated provider
organization and medical foundation.
Intensive Care Skilled nursing services, usually in a hospital, prescribed by a physician

for individuals with serious medical conditions and delivered with the
guidance of a registered nurse.
Intergovernmental Transfer The transfer of non-Federal public funds from a local government (or
(IGT) locally owned hospital or nursing facility) to the State Medicaid agency, or
from another State agency (or State-owned hospital) to the State Medicaid
agency, usually for the purpose of providing the State share of a Medicaid
expenditure in order to draw down Federal matching funds.
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Term Definition
Intermediate Care Facility for The ICF/MR benefit is an optional Medicaid benefit for States. Section
the Mentally Retarded 1905(d) of the Social Security Act created this benefit to fund
(ICF/MR) "institutions" (4 or more beds) for people with mental retardation, and
specifies that these institutions must provide health and/or rehabilitative
services.
International Classification of A listing of diagnoses and identifying codes used by physicians for
Diseases, 9th Edition (Clinical reporting diagnoses of health plan enrollees. The coding and terminology
Modification) (ICD-9-CM) provide a 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 Professional and technical laboratory and radiological services ordered by
Services 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 health care for an individual stated by
an insurer. This amount serves as a cap on contractual liability and can be
exceeded only in rare and unusual circumstances.
Long-Term Care A set of health care, personal care and social services required by persons
who have lost, or never acquired, some degree of functional capacity (e.g.,
the chronically ill, aged, disabled, or retarded) in an institution or at home,
on a long-term basis. The term is often used more narrowly to refer only to
long-term institutional care such as that provided in nursing homes, homes
for the retarded and mental hospitals. Ambulatory services such home
health care, which can also be provided on a long-term basis, are seen as
alternatives to long-term institutional care.
Magnetic Resonance Imaging State-of-the-art machine used as a diagnostic tool, using magnetic fields to
produce comprehensive pictures of the anatomy.
Managed Care (1) A system of health care 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 health care;
(2) A systemized approach which seeks to ensure the provision of the right
health care at the right time, place and cost.
Managed Care Organization Broad term that encompasses various types of health plans, including
(MCO) 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.
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Term Definition
Maximum Allowable Cost, or A fixed maximum cost 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.
Means Testing The policy of basing eligibility for benefits upon an individual’s lack of
means, as measured by his or her income or resources. Means testing, by
definition, requires the disclosure of personal financial information by an
applicant as a condition of eligibility. Medicaid and SCHIP are means
tested programs.
Medicaid A Federally aided State-operated and administered program that provides

medical benefits for certain indigent or low-income persons in need of
health and medical care. The program, authorized by Title XIX of the
Social Security Act, is basically for the poor. It does not cover all of the
poor, however, but only persons who meet specified eligibility criteria.
Subject to broad Federal guidelines, States determine the benefits covered,
program eligibility, rates of payment for providers, and methods of
administering the program. Also referred to as State Medical Assistance
Programs.
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 Federally developed guidelines for a computer system designed to achieve
Information System (MMIS) national standardization of Medicaid claims processing, payment, review
and reporting for all health care claims.
Medicaid-only Managed Care An MCO that provides comprehensive services to Medicaid beneficiaries
Organization (Mcaid-MCO) but not commercial or Medicare enrollees.
Medicaid Statistical The information system developed by CMS to collect detailed data on
Information System (MSIS) eligibility, utilization, and payments for services covered by State Medicaid
programs.
Medical Assistance The term used in the Federal Medicaid statute (Title XIX of the Social
Security Act) to refer to payment for items and services covered under a
State’s Medicaid program.
Medical Care Advisory Committee A committee, consisting of physicians, other health professionals,
(MCAC) Medicaid beneficiaries, and the director of the public health or welfare
agency, appointed by the Medicaid agency director to participate in policy
development and administration of a State’s Medicaid program.
Medical Necessity The evaluation of health care 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 A non-taxable savings account used to cover medical expenses. Based
(MSA) loosely on the idea of individual retirement accounts.
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Term Definition
Medically Needy Under Medicaid, medically needy cases are aged, blind, or disabled
individuals or families and children who are not otherwise eligible for
Medicaid, and whose income resources are above the limits for eligibility
as categorically needy (TANF or SSI) but are within limits set under the
Medicaid State Plan.
Medicare 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. Initially, it consisted of two separate but
coordinated programs: hospital insurance (Part A) and supplementary
medical insurance (Part B). Recent legislation has expanded the Medicare
program to include an HMO option (Part C) and a prescription drug
benefit (Part D). See “Medicare Prescription Drug, Improvement and
Modernization Act of 2003.”
Medicare Beneficiary A person designated by the Social Security Administration as entitled to

receive Medicare benefits.
Medicare Payment Advisory A Federal commission established under the Balanced Budget Act of 1997
Commission (MedPAC) to 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 Prescription Drug, The Medicare Prescription Drug, Improvement, and Modernization Act
Improvement, and (Public Law 108-173), also known as the Medicare Modernization Act
Modernization Act of 2003 (MMA) was enacted December 8, 2003. It enacted the Prescription Drug
(MMA) Program (Medicare Part D) effective January 2006, under which Medicare
assumed responsibility for the prescription drug needs of beneficiaries
eligible for both Medicare and Medicaid. It also enacted the temporary
Medicare Prescription Drug Discount Card Program, effective June 2004-
December 2005. Many other amendments to the Medicare and Medicaid
programs were also enacted, including coverage of an initial preventive
physical examination, cardiovascular screening blood tests, and diabetes
screening tests. Health Savings Accounts were also authorized. Medicare
payment limits were established for certain hospital outpatient
departments.
Medicare Supplemental A policy guaranteeing that a health plan will pay a policyholder’s
Insurance 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.”
Medigap (Medicare See “Medicare Supplemental Insurance.”
Supplemental Insurance)
Members A participant in a health plan (member or eligible dependent). Also used to
describe an individual specified within a subscriber contract that may
receive health care services according to the terms of the subscriber
policy. Also known as "beneficiary," "enrollee," "subscriber," or
"insured."
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Term Definition
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 A contractual agreement that stipulates that a vendor must provide to a
or Clause particular payor the lowest prices that would be available to any purchaser.
The Federal government often invokes most favored nation clauses for
health care contracts.
Multiple-Source Drug A multiple-source drug is one that is marketed or sold by two or more
manufacturers or labelers, or a drug marketed or sold by the same
manufacturer or labeler under two or more different proprietary names or
under a proprietary name and without such a name.
National Committee for Quality A national organization founded in 1979 composed of 14 directors
Assurance (NCQA) representing consumers, purchasers, and providers of managed health care.
It accredits quality assurance programs in prepaid managed health care
organizations, and develops and coordinates programs for assessing the
quality of care and service in the managed care industry, including the
HEDIS quality measures.
National Drug Code (NDC) A national classification system for identification of drugs. Similar to the
Universal Product Code (UPC).
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.”
Nurse-Midwife Services Nurse-midwife services are those concerned with the management of care
of mothers and newborns throughout the maternity cycle. OBRA 1980
required that payment be made for providing nurse-midwife services to
categorically needy recipients to the extent that the nurse-midwife is
authorized to practice under State law or regulation. States are also
required to offer direct reimbursement to nurse-midwives as one of the
payment options. Nurse-midwives must be registered nurses who are either
certified by an organization recognized by the Secretary of HHS or who
have completed a program of study and clinical experience that has been
approved by the Secretary.
Nursing Facility (NF) 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.
Nursing Facility Services All services furnished to inpatients of, and billed for by, a formally
certified nursing facility that meets standards set by Secretary of DHHS.
Other Practitioners’ Services Health care services of licensed practitioners other than physicians and
dentists.
Out-of-Pocket Costs/Expenses The portion of payments for health services required to be paid by the
(OOPs) enrollee, including copayments, coinsurance and deductibles.
E-22
Term Definition
Out-of-Pocket Limit The total payments toward eligible expenses that a covered person funds for
him/herself and/or dependents: i.e., deductibles, copays and coinsurance -
as defined per the contract. Once this limit is reached, benefits will increase
to 100% for health services received during the rest of that calendar year.
Some out-of-pocket costs (e.g., mental health, penalties for non-
precertification, etc.) are not eligible for out-of-pocket limits.
Outcome Measures Assessments which gauge the effect or results of treatment for a particular
disease or condition. Outcome measures include such parameters as: the
patient’s perception of restoration of function, quality of life and functional
status, as well as objective measures of mortality, morbidity and health
status.
Outcomes Management Systematically improving health care results, typically by modifying

practices in response to data gleaned through outcomes measurement, then
remeasuring and remodifying - often in a formal program of continuous
quality improvement.
Outcomes Research Studies aimed at measuring the effect of a given product, procedure, or
medical technology on health or costs.
Outlier An observation in a distribution that is outside a certain range, often defined

as two or three standard deviations from the mean or exceeding a specific
percentile. Frequently refers to a case or hospital stay that is unusually long
or expensive for its type, or to a physician practice that uses an abnormally
high or low volume of resources.
Outpatient Services Outpatient services are medical and other services provided on a non-
resident basis (patients are not admitted to the facility) by a hospital or
other qualified facility, such as a mental health clinic, rural health clinic,
mobile X-ray unit, or freestanding dialysis unit. Such services include
outpatient physical therapy services, diagnostic X-ray and laboratory tests,
and X-ray and other radiation therapy.
Over-the-Counter (OTC) A drug product that does not require a prescription under Federal or State
law.
Participating Provider A provider who has contracted with the health plan to provide medical
services to covered persons. The provider may be a hospital, pharmacy,
other facility or a physician who has contractually accepted the terms and
conditions as set forth by the health plan.
Patient Health Status Survey Questionnaire used to solicit patient perceptions regarding the state of their
health. Questions may be general and address overall health status with
regard to a specific condition (e.g., an arthritic patient’s ability to make a
fist or an asthmatic patient’s ability to climb a flight of stairs).
Patient Satisfaction Survey Questionnaire used to solicit the perceptions the plan enrollees or patients
have regarding how a health plan meets their medical needs and how the
delivery of care is handled, (e.g., waiting time, access to treatments).
Payer A general term indicating the responsible party for the payment of medical
care service expenses. Payers may be patients, insurance companies,
government agencies, or a combination of these.
E-23
Term Definition
Pediatric Nurse Practitioner Services furnished as authorized under State law by a registered
and Family Nurse Practitioner professional nurse who meets a State’s advanced educational and clinical
Services practice requirements, whether or not the practitioner is under the
supervision of or associated with a physician or other health care provider.
Peer Review The evaluation of quality of total health care provided, by medical staff
with equivalent training.
Peer Review Organization An entity established by the Tax Equity and Fiscal Responsibility Act of
(PRO) 1982 (TERFA) to review quality of care and appropriateness of
admissions, readmissions and discharges for Medicare and Medicaid.
These organizations are held responsible for maintaining and lowering
admission rates, and reducing lengths of stay while insuring against
inadequate treatment. Also known as “Professional Standards Review
Organization.”
Personal Support Services Personal support services consist of a variety of services including personal
care, targeted case management, home and community-based care for
functionally disabled elderly, rehabilitative services, hospice services, and
nurse-midwife, nurse practitioner, and private duty nursing services.
Pharmacy And Therapeutics An organized panel of physicians and pharmacists from varying practice
(P&T) Committee specialties, who function as an advisory panel to the plan regarding the safe
and effective use of prescription medications. Often comprises 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.
Pharmaceutical Benefits An entity that is responsible for managing prescription benefits.

Manager (PBM)
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 A legal entity formed by a hospital and a group of physicians to further

Organization (PHO) mutual 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.
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Term Definition
Portability Requirement that health plans guarantee continuous coverage without

waiting periods for persons moving between plans.
Practice Guideline Systematically developed statements on medical practice that assist a

practitioner and a patient in making decisions about appropriate health care
for specific medical conditions. Managed care organizations frequently
use these guidelines to evaluate appropriateness and medical necessity of
care. Terms used synonymously include practice parameters, standard
treatment protocols and clinical practice guidelines.
Practice Parameters See “Practice Guidelines.”
Practice Variation An assessment of the patterns of a practitioner’s practice to determine if

the provider’s care is significantly different from others with similar
practices. If there is a significant difference, the practitioner’s practice is
analyzed to determine the reasons for the variation and whether that
practitioner’s practice patterns should be modified.
Pre-Certification Review See “Utilization Review.”
Pre-Existing Condition (PEC) Any medical condition that has been diagnosed or treated within a
specified period immediately preceding the covered person’s effective date
of coverage under the master group contract.
Preferred Provider A program in which contracts are established with providers of medical
Organization (PPO) care. Providers under such contracts are referred to as preferred providers.
Usually, the benefit contract provides significantly better benefits (fewer
copayments) for services received from preferred providers, thus
encouraging 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.
E-25
Term Definition
Preventive Care Comprehensive care emphasizing priorities for prevention, early detection
and early treatment of conditions, generally including routine physical
examinations, immunization and well person care.
Primary Care Basic or general health care traditionally provided by family practice,
pediatrics and internal medicine. See also “Secondary Care.”
Primary Care Case Managed care arrangements where primary care providers receive a per
Management (PCCM) capita management fee to coordinate a patient's care in addition to
reimbursement (fee-for-service or capitation) for the medical services they
provide.
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.
Program for All-Inclusive Care A program that provides prepaid, capitated comprehensive health care
for the Elderly (PACE) services to the frail elderly.
Prospective Financing Financing for health care services based on prices or budgets determined
prior to the delivery of service. Payments can be per unit of service, per
member, or per time period. In all its forms prospective financing differs
from cost-based reimbursement, under which a provider is paid for costs
incurred.
Protocol See “Practice Guidelines.”
Provider Network See “Network Plan.”
Providers A physician, hospital, group practice, nurse, nursing home, pharmacy or

any individual or group of individuals that provides a health care service.
Qualified Medicare Beneficiary An individual who qualifies for Medicare Part A, whose income does not
(QMB) exceed 100 percent of the Federal poverty level, and whose resources do
not exceed twice the SSI resource-eligibility standard. Medicaid coverage
of QMBs is limited to payments of their Medicare cost-sharing charges,
such as Medicare premiums, coinsurance, and copayment amounts.
Quality Assurance (QA) or A formal set of activities to review and affect the quality of services
Quality Improvement (QI) provided. 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.
E-26
Term Definition
Reasonable Charge In processing claims for Supplementary Medical Insurance benefits,

carriers use CMS guidelines to establish the reasonable charge for services
rendered. The reasonable charge is the lowest of: the actual charge billed
by the physician or supplier; the charge the physician or supplier
customarily bills his patients for the same services, and the prevailing
charge which most physicians or suppliers in that locality bill for the same
service. Increases in the physicians’ prevailing charge levels are
recognized only to the extent justified by an index reflecting changes in
the costs of practice and in general earnings.
Reasonable Cost In processing claims for health insurance benefits, intermediaries use CMS
guidelines to determine the reasonable cost incurred by the individual
providers in furnishing covered services to enrollees. The reasonable cost
is based on the actual cost of providing such services, including direct and
indirect costs of providers, excluding any costs that are unnecessary in the
efficient delivery of services covered by the insurance program.
Rebate A monetary amount that is returned to a payer from a prescription drug

manufacturer based upon utilization by a covered person or purchases by a
provider.
Recipient A recipient of Medicaid is an individual who has been determined to be

eligible for Medicaid and who has used medical services covered under
Medicaid.
Referral The process of sending a patient from one practitioner to another for health
care services. Health plans may require that designated primary care
providers authorize a referral for coverage of specialty services.
Restrictive Formulary A term often used synonymously with closed formulary. See “Drug
Formulary.”
Retrospective Review Determination of medical necessity and/or appropriate billing practice for
services already rendered.
Risk Responsibility for paying for or otherwise providing a level of health care
services based on an unpredictable need for these services.
Risk Contract (1) An agreement between a State Medicaid program and an HMO or
competitive medical plan requiring the HMO to furnish at a minimum all
Medicaid covered services to Medicaid eligible enrollees for an annually
determined, fixed monthly payment rate from the State government. The
HMO is then liable for services regardless of their extent, expense or
degree. (2) An agreement between a provider and payer, or intermediary,
on behalf of a payer, that requires the provider to furnish all specified
services for a specified enrollee for a set fee, usually prepaid, and for a set
period of time (usually one year). The provider is then liable for services
regardless of their extent, expense or degree. Such stated limitations for
such liability are stated in advance and may be subject to reinsurance.
E-27
Term Definition
Rural Health Clinic A rural health clinic is an outpatient facility which is primarily engaged in
furnishing physician and other medical and health services, which meets
certain other requirements designed to ensure the health and safety of the
individuals served by the clinic. The clinic must be located in an area that
is not urbanized as defined by the Census Bureau and that is designated by
the Secretary of DHHS either as an area with a shortage of personal health
services, or as a health manpower shortage area, and has filed an
agreement with the Secretary not to charge any individual or other person
for items or services for which such individual is entitled to have payment
made by Medicare, except for the amount of any deductible or coinsurance
amount applicable.
Secondary Care Services provided by medical specialists, such as cardiologists, urologists

and dermatologists, who generally do not have first contact with patients.
See also “Primary Care.”
Section 1115 Waivers Section 1115 of the Social Security Act grants the Secretary of Health and
Human Services broad authority to waive certain laws relating to Medicaid
for the purpose of conducting pilot, experimental or demonstration
projects. Section 1115 demonstration waivers allow States to change
provisions of their Medicaid programs, including: eligibility requirements,
the scope of services available, the freedom to choose a provider, a
provider’s choice to participate in a plan, the method of reimbursing
providers, and the statewide application of the program. Projects typically
run three to five years.
Section 1915(b) Waivers Section 1915(b) of the Social Security Act authorizes the Secretary of
Health and Human Services to waive compliance with certain portions of
the Medicaid statute that prevent a State from mandating Medicaid
beneficiaries obtain their care from a single provider or health plan.
Section 1915(b) waivers allow States to operate mandatory managed care
programs in all or portions of the State while continuing to receive Federal
Medicaid matching funds. Waivers must be approved by the Centers for
Medicare & Medicaid Services (CMS).
Section 1915(c) Waivers Section 1915(c) of the Social Security Act authorizes the Secretary of
Health and Human Services to allow State Medicaid programs to offer
special services to beneficiaries at risk of institutionalization in a nursing
facility or facility for the mentally retarded. These services, which would
otherwise not qualify for Federal matching funds, include case
management, homemaker/home health aide services, rehabilitation
services, and respite care. They also include, in the case of individuals,
with chronic mental illness, day treatment and partial hospitalization,
psychosocial rehabilitation, and clinic services. Also know as home and
community-based (HCBS) waivers.
Self-Referral Restrictions Restrictions on or prohibitions against providers referring patients to a

designated health service (e.g., pharmacies, clinical laboratories, and
outpatient surgery) in which the provider or the provider’s immediate
family member has a financial interest.
Sin Taxes Taxes imposed on items considered harmful to public health interests, such
as tobacco and alcohol.
E-28
Term Definition
Single-Source Drug A single-source drug is a covered outpatient drug which is produced or

distributed under an original new drug application approved by the FDA,
including a drug product marketed by any cross-licensed producers or
distributors operating under the new drug application.
Single State Agency The agency within State government designated as responsible for
administration of the State Medicaid Plan. The Single State Agency is not
required to administer the entire Medicaid program. It may delegate
certain functions or supervise other State agencies, private contractors, or
both.
Skilled Nursing Facility (SNF) See “Nursing Facility.”
Specified Low-Income These individuals are entitled to Medicare Part A, have income of greater
Medicare Beneficiary (SLMB) than 100% FPL, but less than 120% FPL and resources that do not exceed
Program twice the limit for SSI eligibility, and are not otherwise eligible for
Medicaid as a dual eligible. Medicaid pays their Medicare Part B
premiums only, but they are not eligible for Medicaid payment for their
Medicare cost-sharing obligations.
Spend-Down Under Medicaid, “spend-down” refers to a method by which an individual

establishes Medicaid eligibility by reducing gross income through
incurring medical expenses until net income (after medical expenses)
meets Medicaid financial requirements.
State Buy-In The term given to the process by which a State may provide
Supplementary Medical Insurance coverage for its needy eligible persons
through an agreement with the Federal government under which the State
pays the premiums for them.
State Children’s Health As part of the Balanced Budget Act of 1997, Congress created SCHIP as a
Insurance Program (SCHIP) Federal/State partnership with the goal of expanding health insurance to
children whose families earn too much money to be eligible for Medicaid,
but not enough money to purchase private insurance. SCHIP is designed
to provide coverage to "targeted low-income children." A "targeted low-
income child" is one who resides in a family with income below 200% of
the Federal Poverty Level (FPL) or whose family has an income 50%
higher than the State's Medicaid eligibility threshold. Unlike Medicaid,
SCHIP is a block grant awarded to the States each year. Children who are
eligible for Medicaid are not eligible for SCHIP.
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.
State Medical Assistance See “ Medicaid.”

Programs
State Pharmacy Assistance State authorized programs to provide pharmaceutical coverage or

Programs (SPAPs) assistance to low-income and/or persons with disabilities who do not
qualify for Medicaid. Also known as Expanded Drug Benefit Programs.
E-29
Term Definition
State Plan The Medicaid State Plan is a comprehensive written commitment by a

Medicaid agency to administer or supervise the administration of a
Medicaid program in accordance with Federal requirements.
State Plan Amendment A State that wishes to change its Medicaid eligibility criteria or its covered
benefits or its provider reimbursement rates must amend its State Medicaid
Plan to reflect the proposed change. The State must submit the State Plan
Amendment to CMS for approval.
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 A Federal cash assistance program for low-income aged, blind and
(SSI) disabled individuals established by Title XVI of the Social Security Act.
States may use SSI income limits to establish Medicaid eligibility.
Tax Equity and Fiscal The Federal law which created the current risk and cost contract provisions
Responsibility Act of 1982 under which health plans contract with CMS and which defined the primary
(TEFRA) and secondary coverage responsibilities of the Medicare program.
Temporary Assistance to Needy Federal-State welfare program which replaced Aid to Families with
Families (TANF) Dependent Children. Authorized by the 1996 Welfare Reform Act. States
may use TANF to establish Medicaid eligibility.
Therapeutic Alternatives Drug products containing different chemical entities but which should
provide similar treatment effects, the same pharmacological action or
chemical effect when administered to patients in therapeutically equivalent
doses.
Therapeutic Substitution Dispensing by a pharmacist of a product different from that which was
prescribed, but which is deemed to be therapeutically equivalent. In most
States such a practice requires the prescribing physician’s authorization
before the substitution may occur. A pharmacy and therapeutics committee
(P&T) most often approves the rationale for therapeutic equivalency prior
to such practice.
Third-Party Administrator An independent person or corporate entity (third party) that administers
(TPA) group benefits, claims and administration for a self-insured company/group.
A TPA does not underwrite the risk.
Third-Party Liability Under Medicaid, third-party liability exists if there is any entity (i.e., other
government programs or insurance) which is or may be liable to pay all or
part of the medical cost or injury, disease, or disability of an applicant or
recipient of Medicaid.
Total Quality Management See “Continuous Quality Improvement.”

(TQM)
Title XIX See “ Medicaid.”
E-30
Term Definition
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 A term used to refer to the commonly charged or prevailing fees for health
Reasonable Charges services within a geographic area. A fee is considered to be reasonable if
it falls within the parameters of the average or commonly charged fee for
the particular service within that specific community.
Utilization The extent to which the members of a covered group use a program or
obtain a particular service, or category of procedures, over a given period of
time. Usually expressed as the number of services used per year or per 100
or 1,000 persons eligible for the service.
Utilization Management (UM) A process of integrating review and case management of services in a
cooperative effort with other parties, including patients, providers, and
payers.
Utilization Review A formal assessment of the medical necessity, efficiency, and/or

appropriateness of health care services and treatment plans on a
prospective, concurrent or retrospective basis.
Vaccines for Children Program A program under which the Federal government, through the Centers for
(VCF) Disease Control and Prevention, purchases and distributes pediatric
vaccines to States at no charge and the State, in turn, arranges for the
immunization of Medicaid-eligible and uninsured children through public
and private physicians or other authorized providers.
Vendor A medical vendor is an institution, agency, organization, or individual

practitioner that provides health or medical products and/or services either
to a medical provider, who in turn interfaces with patients, or directly to
the public.
Vendor Payments In welfare programs, direct payments are made by the State to providers
such as physicians, pharmacists and health care institutions rather than to
the welfare recipient himself.
Waiver A rider or clause in a health insurance contract excluding an insurer’s

liability for some sort of pre-existing illness or injury. Also refers to a plan
amendment, such as a CMS waiver or State Plan modification.
Wholesale Acquisition Cost See “Average Wholesale Price” definition.

(WAC)
E-31
Term Definition
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).”
E-32
ACRONYMS
AABD Aid to Aged, Blind, and Disabled

AAC Actual Acquisition Cost
AHRQ Agency for Health Research and Quality
AIDS Acquired Immune Deficiency Syndrome
AMP Average Manufacturer Price
ANSI American National Standards Institute
ARF Area Resource File
ASO Administrative Services Only
AWP Average Wholesale Price
BBA Balanced Budget Act of 1997
BIPA Benefits Improvement and Protection Act
BLS Bureau of Labor Statistics
CHIP See SCHIP
CFR Code of Federal Regulations
CMP Competitive Medical Plan
CMS Centers for Medicare and Medicaid Services (formerly HCFA)
CMSO CMS’ Center for Medicaid and State Operations
CNAB Categorically Needy Aid to the Blind
CNAFDC Categorically Needy Aid to Families with Dependent Children
CNAPTD Categorically Needy Aid to the Permanently and Totally Disabled
CNOAA Categorically Needy Old Age Assistance
COBRA Consolidated Omnibus Reconciliation Act of 1985
COM-MCO Commercial Managed Care Organization
CON Certificate of Need
CPI Consumer Price Index
CPR Customary Prevailing, and Reasonable (charges)
CPT Current Procedural Terminology
CQI Continuous Quality Improvement
DAW Dispense As Written
DBA Doing Business As
DEFRA Deficit Reduction Act of 1984
DESI Drug Efficacy Study and Implementation
DHHS Department of Health and Human Services
DRA Deficit Reduction Act of 2005
DRGs Diagnostic Related Groupings
DSH Disproportionate Share Hospital
DUE Drug Use Evaluation
DUR Drug Utilization Review
EAC Estimated Acquisition Cost
E-33
EDI Electronic Data Interchange

EPSDT Early and Periodic Screening, Diagnostic and Treatment
ERISA Employee Retirement Income Security Act
ESRD End Stage Renal Disease
FDA Food and Drug Administration
FFP Federal Financial Participation
FFS Fee-for-Service
FMAP Federal Medical Assistance Percentage
FOC Freedom of Choice
FPL Federal Poverty Level
FQHC Federally Qualified Health Center
FUL Federal Upper Limits
FY Fiscal Year
HCFA Health Care Financing Administration (see CMS)
HCPCS Healthcare Common Procedural Coding System
HCPP Health Care Prepayment Plan
HEDIS Health Plan Employer Data and Information Set
HH Home Health
HIFA Health Insurance Flexibility and Accountability
HIO Health Insuring Organizations
HIPAA Health Insurance Portability and Accountability Act
HMO Health Maintenance Organization
HRSA Health Resources and Services Administration
ICF-MR Intermediate Care Facility for the Mentally Retarded
IGT Intergovernmental Transfer
IPA Individual Practice Association
MAC Maximum Allowable Cost
MAIC Maximum Allowable Ingredient Cost
MCAC Medical Care Advisory Committee
MCAID-MCO Medicaid-only Managed Care Organization
MCO Managed Care Organization
MMA Medicare Prescription Drug, Improvement and Modernization Act of
2003
MMIS Medicaid Management Information System
MNAB Medically Needy Aid to the Blind
MNAFDC Medically Needy Aid to Families with Dependent Children
MNAPTD Medically Needy Aid to the Permanently and Totally Disabled
MNOAA Medically Needy Old Age Assistance
MQC Medicaid Quality Control
MSA Medical Savings Account
MSIS Medicaid Statistical Information System
NDC National Drug Code
NF Nursing Facility
E-34
NP Nurse Practitioner
OACT Office of the Actuary
OASDI Old Age, Survivors, and Disability Insurance
OBRA Omnibus Budget Reconciliation Act
OHS Outpatient Hospital Services
OMB Office of Management and Budget
ORD Office of Research and Demonstrations
OT Occupational Therapy
OTC Over-the-Counter (drugs)
P&T Pharmacy and Therapeutics Committee
PA Physician’s Assistant or Prior Authorization
PACE Program for All-Inclusive Care for the Elderly
PBM Pharmaceutical Benefits Manager
PCCM Primary Care Case Management
PCF Program Characteristics File
PCP Primary Care Physician
PHP Prepaid Health Plan
PMPM Per Member Per Month
PHO Physician-Hospital Organization
POS Point-of-Service
PPO Preferred Provider Organization
PRO Peer Review Organization
ProPAC Prospective Payment Assessment Commission
PT Physical Therapy
QA/QI Quality Assurance/Quality Improvement
QMB Qualified Medicare Beneficiary
RHC Rural Health Clinic
RPH Registered Pharmacist
Rx Pharmaceutical
SCHIP State Children’s Health Insurance Program
SFO State Funds Only
SLMB Specified Low-Income Medicare Beneficiary
SPAPs State Pharmacy Assistance Plans
SSA Social Security Administration
SSI Supplemental Security Income
SSP State Supplemental Payments
TANF Temporary Assistance for Needy Families
TDOC Total Days of Care
TEFRA Tax Equity & Fiscal Responsibility Act
Title XIX Title XIX of The Social Security Act (See Medicaid)
TPA Third-Party Administrator
TQM Total Quality Management
E-35
UCR Usual, Customary and Reasonable

UM Utilization Management
UR Utilization Review
VCF Vaccines for Children Program
WAC Weighted Average Cost or Wholesale Acquisition Cost
E-36

Pharmaceutical Benefits Under State Medical Assistance Programs, 2007

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Pharmaceutical Benefits Under State Medical Assistance Programs, 2007

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Pharmaceutical Benefits

Under State Medical

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

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

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

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

SECTION 5: STATE PHARMACY PROGRAM PROFILES ......................................................... 5-1

SECTION 6: STATE PHARMACY ASSISTANCE PROGRAMS .................................................. 6-1

! Section 3: Consists of sociodemographic statistics, by age, race, insurance, income, and

! Section 6: Profiles State pharmaceutical assistance programs.

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

MEDICAID PROGRAM OVERVIEW

! TB-related services for TB infected persons;

CHARACTERISTICS OF BENEFITS PROVIDED

Inpatient Hospital Services

Outpatient Hospital Services

Rural Health Clinic Services

Other Laboratory and X-Ray Services

Nursing Facility Services

Early and Periodic Screening, Diagnostic and Treatment Services

! Appropriate immunizations. (If it is determined at the time of screening that

Family Planning Services

Home Health Services

Personal Support Services

retarded, or institution for mental disease. Services are authorized by a physician in

Pediatric Nurse Practitioner and Family Nurse Practitioner Services

Federally Qualified Health Center and Other Ambulatory Services

AMOUNT AND DURATION OF SERVICES

MEDICAID PAYMENT FOR SERVICES

Total Medicaid Eligibles by Maintenance Assistance Status, 20041

Source: CMS, MSIS Report, FY 2004.

Total Medicaid Eligibles by Age Group, 20041

Source: CMS, MSIS Report, FY 2004.

Total Medicaid Eligibles by Gender, 20041

Source: CMS, MSIS Report, FY 2004.

Total Medicaid Eligibles by Race/Ethnicity, 20041

Source: CMS, MSIS Report, FY 2004.

Total Medicaid Eligibles by Basis of Eligibility, 20041

Blind/ Foster Care BCCA BOE

Source: CMS, MSIS Report, FY 2004.

Total Medicaid Eligibles Per 1000 Population, 20041

Total State Total Eligibles per

Percent Percent Percent

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Federal Medical Assistance Percentage (FMAP),

Total Net Medical Total Average

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