Medicaid Benefits: Prescription Drugs
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2018
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limits on Services | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 51 No - 0 NR - 0 | 2018 data limited to CN | Yes - 36 | Yes - 32 | Included in "Limits on Services" for 2018 | Not included in 2018 survey |
| Alabama | Yes | CN | $0 to $3.90 dependent on drug cost | Yes-not specified | - | - |
| Alaska | Yes | CN | $.50 to $3.50 | Must be prior authorized | - | - |
| Arizona | Yes | CN | $2.30 per prescription for beneficiaries with Transitional Medical Assistance | No | - | - |
| Arkansas | Yes | CN | $0.50 to $3.00 based on cost | up to 31 day supply per prescription drug and state has quantity limits | - | - |
| California | Yes | CN | $1.00 per outpatient drug prescription | 6 prescriptions per month with some exceptions | - | - |
| Colorado | Yes | CN | $3.00 per prescription or refill | Each drug may be subject to utilization controls per the Preferred Drug List or Appendix P criteria | - | - |
| Connecticut | Yes | CN | No | No | - | - |
| Delaware | Yes | CN | $0.50 for prescription costing $10.00 or less; $1.00 for prescription costing $10.01-$25.00; $2.00 for prescription costing $25.01-$50.00; $3.00 for prescription costing $50.01 or more. Never to pay > $15.00 in a month. | Prescribed by licensed physician obtained from licensed pharmacy for medically accepted indication, medically necessary and produced by pharmaceutical manufacturer. | - | - |
| District of Columbia | Yes | CN | $1.00 per prescription | Certain drugs and drugs not listed on the PDL require a prior authorization | - | - |
| Florida | Yes | CN | No | Day and Amount Limits may apply | - | - |
| Georgia | Yes | CN | $0.50 to $3.00 | No | - | - |
| Hawaii | Yes | CN | No | Listed in the Hawaii Medicaid Drug Formulary | - | - |
| Idaho | Yes | CN | No | No | - | - |
| Illinois | Yes | CN | NR | NR | - | - |
| Indiana | Yes | CN | $3.00 per prescription | Prior authorization required for specified drugs. Age, Quantity and Step Therapy limits also apply. | - | - |
| Iowa | Yes | CN | NR | NR | - | - |
| Kansas | Yes | CN | $3.00 per prescription | Limits on Opioids, Benzodiazepines, Butorphanol, Calcitriol, Carisoprodol, Fentanyl, Ketorolac Products, Nabilone, Narcotic Analgesics, Tramadol and Skeletal Muscle Relaxants, Pregabalin, Proton Pump Inhibitor Drugs, Sleep Aids, Smoking Cessation Products, Tapentadol, Triptans | - | - |
| Kentucky | Yes | CN | Generic prescription drug $1.00; Preferred brand name drug $4.00 | Limitations on amount of controlled substance dispensed | - | - |
| Louisiana | Yes | CN | $0.50 -$3.00 based on ingredient cost with federally recognized exemptions. Additional copayment exemptions on USPSTF recommendations | Quantity limits; diagnosis code on selected agents; standard is 30 day supply or 100 dosage units, whichever is greater | - | - |
| Maine | Yes | CN | $3.00 per prescription, up to $30/month; no copay required for mail orders | 2 brand prescriptions per month unless no generic equivalent | - | - |
| Maryland | Yes | CN | $1 for generic and preferred brand name drugs; $3 for other brand name drugs | NR | - | - |
| Massachusetts | Yes | CN | $1.00/selected generic prescription drug, $3.65/other generic or brand prescription drug,up to a maximum of $250/year. | No | - | - |
| Michigan | Yes | CN | $1.00 per preferred drug or $3.00 per non-preferred drug | Coverages defined in policy and Michigan Pharmaceutical Product List (MPPL). | - | - |
| Minnesota | Yes | CN | $3.00 copay for non-preferred drugs, $1.00 copay for preferred drugs. Copays are limited to $12 per month. No copays are assessed for certain mental health drugs. | No | - | - |
| Mississippi | Yes | CN | $3 per prescription | 2 Brand/5 prescription limit per month | - | - |
| Missouri | Yes | CN | $0.50-$2.00 based on ingredient cost | No | - | - |
| Montana | Yes | CN | $4.00 per prescription for preferred brand drugs; $8.00 per prescription for non-preferred brand drug | 34 day limit on medications except 90 day limit on maintenance medication. Restrictions to quantity per day per guidelines. Opioid daily quantity limits. | - | - |
| Nebraska | Yes | CN | $3.00 per brand prescriptions, $2.00 per generic prescription | No | - | - |
| Nevada | Yes | CN | NR | NR | - | - |
| New Hampshire | Yes | CN | $0, $1.00, and $2.00 dependent upon FPL, drug, if waiver recipient and preferred drug status | PDL and clinical prior authorization requirements for some drugs | - | - |
| New Jersey | Yes | CN | No | clinical criteria review, prior authorization, quantity limits | - | - |
| New Mexico | Yes | CN | No | No | - | - |
| New York | Yes | CN | NR | NR | - | - |
| North Carolina | Yes | CN | copay can vary based on Medicaid or Health Choice but usually copay is $3.00 | Preferred Drug List and Clinical Criteria. See website at: https://www.nctracks.nc.gov/content/public/providers/pharmacy/pa-drugs-criteria-new-format.html | - | - |
| North Dakota | Yes | CN | $3.00 per prescription fill for brand names only | No | - | - |
| Ohio | Yes | CN | Select Brands $2.00 copay; Drugs requiring prior authorization $3.00 copay | No | - | - |
| Oklahoma | Yes | CN | $4.00 copay per prescription | 6 per month limit; up to 2 brand name | - | - |
| Oregon | Yes | CN | No | Limit on day supply and preferred drug list. Includes a number of prior authorization limits | - | - |
| Pennsylvania | Yes | CN | $1.00 for generic and $3.00 for brand prescription drugs | No | - | - |
| Rhode Island | Yes | CN | No | Generics first policy. PA process for certain high cost/new medications. | - | - |
| South Carolina | Yes | CN | NR | NR | - | - |
| South Dakota | Yes | CN | $1 for generic drugs, $3.30 for brand name drugs | Drugs identified by P&T may require a prior auth. | - | - |
| Tennessee | Yes | CN | $1.50 for generic drugs, $3 for brand name drugs | Non-exempt adults limited to 5 prescriptions per month, up to two of which may be brand names. Additional drugs may be covered outside the limit in certain circumstances. | - | - |
| Texas | Yes | CN | No | 3 Rxs/month for most drug classes; smoking cessation products not limited; non-preferred drugs on the formulary require PA; drug utilization management policies applicable to some drugs | - | - |
| Utah | Yes | CN | $4.00 per prescription | Preferred Drug List is in place. | - | - |
| Vermont | Yes | CN | $1.00-$3.00 depending on cost | Coverage of certain drugs limited to specific conditions, such as amphetamines for narcolepsy cataplexy syndrome only; drugs prescribed for continued regular use must be dispensed in 30 to 90-day supplies unless prescriber states otherwise; maintenance drugs dispensed in 90-day quantities after first fill; prescribers and pharmacists must adhere to state’s Generic Drug Law and, where law permits substitution, dispense lowest-priced equivalent in stock; program will not pay if recipient refuses the substitution | - | - |
| Virginia | Yes | CN | $1 for brand, $3 for brand in FFS | Many drugs on the PDL are subject to utilization management controls | - | - |
| Washington | Yes | CN | No | Preferred drug list, prior authorization, Step Therapy - Washington implemented a single preferred drug list across all Medicaid managed care programs and the Fee-for-Service program. Many prescription drugs have quantity limits as well as require prior authorization. | - | - |
| West Virginia | Yes | CN | Pharmacy copays are based off the cost of drug and range from $0-$3.00 for those drugs over $50 in allowed charges | NR | - | - |
| Wisconsin | Yes | CN | Generics and compounded products are $1.00. Brand name products are $3.00, with a maximum of $12 per member, per provider, per calendar month | Some items may require prior approval; restrict quantities/days supply; or monitor prescription refill limits | - | - |
| Wyoming | Yes | CN | $0.65 per prescription for generic drugs and $3.65 for brand name drugs | Utilization is managed through a Preferred Drug List, Dosage Limitation Chart, and Additional Therapeutic Criteria Chart which can be found at www.wymedicaid.org | - | - |
2012
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 56 No - 0 | Yes - 43 No - 13 | ||||
| Alabama | Yes | CN | $.50-$3/Rx depending on drug cost | 4 brand Rxs/month except brand antipsychotics and antiretrovirals up to 10 Rxs/month, no limit on generic Rxs and limited OTCs are covered | Multiple source drugs paid lesser of FUL, state MAC, EAC (AAC or WAC+9.2%) or charge plus dispensing fee; other drugs paid EAC (AAC or WAC+9.2%) or charge plus dispensing fee; hemophilia factor drugs paid ASP+6%; dispensing fee is $10.64 | |
| Alaska | Yes | CN | $2/Rx | Specified drugs | WAC+8%, plus a dispensing fee dependent on total prescription volume ($12.12 to $26.74) | |
| American Samoa | Yes | See territory-specific FN | Prospective payment/Rx based on prior year cost | |||
| Arizona | Yes | CN & MN | $2.30/Rx | OTCs covered only if medically appropriate and less costly than a prescription Rx | AWP-15.25%, plus $1.35 dispensing fee | |
| Arkansas | Yes | CN & MN | $.50-$3/Rx depending on drug cost | 6 Rxs/month except for family planning and for persons in nursing facilities or participating in HCBS waivers | More than 3 prescriptions per month for non-institutionalized beneficiaries | EAC/AWP-14% for brand Rx, EAC/AWP-20% for generic Rx, plus $5.51 dispensing fee for each, additional $2.00 dispensing fee for generic Rx with no FUL or state MAC |
| California | Yes | CN & MN | $1/Rx | 6 Rxs/month with some exceptions | AWP-17%, plus $7.25 dispensing fee, non-traditional pharmacies receive an $8.00 dispensing fee | |
| Colorado | Yes | CN | $1/generic or multi-source Rx, $3/brand or single source Rx | Products not on PDL and other specified products | Lesser of charge, FUL, state MAC (AAC+51.5% non-rural and AAC+233% rural) or WAC+2.6% for brand Rx and WAC-0.1% for generic Rx, plus $4.00 dispensing fee, non-traditional pharmacies receive a $1.89 dispensing fee | |
| Connecticut | Yes | CN & MN | 30 day supply for acute conditions, 30 day supply or 240 dosage units for chronic conditions, nutritional supplement coverage restricted by diagnosis, only limited OTCs covered | AWP-14% for brand Rx, AWP-40% for generic Rx, plus $3.15 dispensing fee | ||
| Delaware | Yes | CN | $.50-$3/Rx depending on drug cost, up to $15/month | Rx must be generic unless DAW | AWP-14.5% by retail pharmacies, AWP-18% by non-traditional pharmacies, plus $3.65 dispensing fee for each | |
| District of Columbia | Yes | CN & MN | $1/Rx | Coverage of brand products requires prescriber to specify brand necessary or medically necessary | Specified drugs and injectables including Percodan and Dalmane | WAC+3%, plus $4.50 dispensing fee |
| Florida | Yes | CN & MN | Step therapy required for some drugs not on PDL, selected OTCs covered | Specified drugs | Lower of AWP-16.4% or WAC+1.5%, plus $3.73 dispensing fee | |
| Georgia | Yes | CN & MN | $.50-$3 depending on payment rate | 5 Rxs or refills/month | Specified drugs | AWP-11%, plus $4.63 dispensing fee to for profit retail pharmacies, dispensing fee $.30 less to non-profit pharmacies |
| Guam | Yes | CN | Adult vitamins limited to pregnancy supplements | AWP plus $4.40 dispensing fee | ||
| Hawaii | Yes | CN & MN | Specified drugs | WAC+0%, plus $5 dispensing fee | ||
| Idaho | Yes | CN | Specified drugs including amphetamines, high cost and therapeutic-equivalent drugs | Lesser of charge, FUL, state MAC, AAC or WAC, plus dispensing fee dependent on total prescription claims volume ($11.51 to $15.11) | ||
| Illinois | Yes | CN & MN | $2/generic Rx or OTC product, $3.80/brand Rx | 3 brand Rxs/month | WAC+0%, plus $5.50 dispensing fee for generic Rx and $2.40 for brand Rx | |
| Indiana | Yes | CN | $3/Rx | Specified drugs | AWP-16% for brand Rx, AWP-20% for generic Rx, plus $3.00 dispensing fee for each | |
| Iowa | Yes | CN & MN | $1/generic and preferred brand Rx, $2-$3/non-preferred brand Rx depending on payment | Specified drugs | AWP-17% for specialty drugs and AWP-12% for other drugs, plus $6.20 dispensing fee | |
| Kansas | Yes | CN & MN | $3/Rx | 4 single-source Rxs/month, adult vitamins limited to pregnancy supplements | Specified drugs | WAC+4.6% for single source brand Rx, WAC+8.6% for generic Rx, plus $3.40 dispensing fee for each |
| Kentucky | Yes | A, B & C - See state-specific FN | $1/generic Rx; $2/preferred brand Rx; 5% of payment up to $20 for non-preferred brand Rx; annual out-of-pocket expense capped at $225 | 4 Rxs/month including up to 3 brand Rxs | Specified drugs, including amphetamines and OTCs | WAC+3.2% for generic Rx and WAC+2% for brand Rx, plus $5.00 dispensing fee |
| Louisiana | Yes | CN & MN | $.50-$3/Rx depending on drug cost | 4 Rxs/month, overrides possible, limit not applicable to residents in institutions | Specified drugs | AWP-13.5% for independent pharmacies, AWP-15% for chain stores, plus $5.77 dispensing fee for each |
| Maine | Yes | CN & MN | $3/Rx, up to $30/month, no copayment required for mail order Rxs | Generic and therapeutically equivalent products required over brand, 2 brand Rxs/month unless no generic equivalent, some products exempted from limit | Specified products | AWP-16% or WAC+0.8% for brand Rx , AWP-13% or WAC+4.4% for generic Rx, plus $3.35 dispensing fee for each in urban areas and 55-65 cents higher in rural areas; AWP-20% or WAC-4% for brand Rx and AWP-60% or WAC-52% for generic Rx through mail order pharmacy, plus $2.50 dispensing fee for each |
| Maryland | Yes | CN & MN | $1/Rx for generic, preferred brand or HIV/AIDS drug, $3/Rx for non-preferred brand | Specified quantity limits and clinical criteria for selected drugs | Specified drugs and drug therapies | Lower of FUL, IDC (See state-specific FN) or EAC (AWP-12%, WAC+8% or DP+8%), plus $3.51 dispensing fee for generic or preferred brand Rx by traditional pharmacies or $2.56 dispensing fee for non-preferred Rx; non-traditional pharmacies paid $4.46 dispensing fee for generic or preferred brand Rx and $3.51 for non-preferred Rx but only one dispensing fee/month |
| Massachusetts | Yes | CN & MN | $1/selected generic Rx or selected OTCs, $3.65/other generic or brand Rx or other specified OTCs up to a maximum of $250/year | Specified drugs and drug classes | Specified drugs and drug classes | Lesser of charge, FUL, state MAC or WAC+5% plus $3.00 dispensing fee for most products |
| Michigan | Yes | CN & MN | $1/generic Rx, $3/brand Rx | AWP-13.5% for independent pharmacies, AWP-15.1% for chain stores, plus $2.75 dispensing fee for each, non-traditional pharmacies paid $3.00 dispensing fee | ||
| Minnesota | Yes | A & B - See state-specific FN | A - $1/generic Rx, $3/brand Rx, up to $12/month, antipsychotic Rxs not subject to copayments; B - $3/Rx with no cap and no exceptions - See state-specific FN | Non-preferred and brand Rx when generic available | WAC+4% for rural independent pharmacies and WAC+2% for others, plus $3.65 dispensing fee; specialty drug products paid less - See state-specific FN | |
| Mississippi | Yes | CN | $3/Rx | Generic products required if available unless brand product preferred, 5 Rxs/month including 2 brand Rxs, 5 brand Rxs/month for HIV/AIDS, limit not applicable to nursing facility residents | Specified drugs | AWP-12% or WAC+9% for brand or single source generic Rx plus $3.91 dispensing fee; AWP-25% for generic Rx plus $4.91 dispensing fee; non-traditional pharmacies paid $3.91 dispensing fee |
| Missouri | Yes | CN | $.50-$2/Rx depending on ingredient cost | Lower of FUL, state MAC, AWP-10.43% or WAC+10%, plus base dispensing fee of $4.84 and enhanced dispensing fee of $4.82; generic product preferred incentive fee is $4.00 | ||
| Montana | Yes | A & B - See state-specific FN | $1-$5/Rx depending on drug cost, up to $25 max per month | Selected OTC products covered with Rx | Specified drugs | Lesser of FUL, state MAC, AWP-15% or WAC+2% plus dispensing fee between $2 and $4.94 for brand Rx and non-preferred generics or $6.40 for preferred products |
| Nebraska | Yes | CN & MN | $2/generic Rx, $3/brand Rx | Specified drugs | WAC+6.8%, plus dispensing fee of $4.45 | |
| Nevada | Yes | CN | Quantity limits established for many drug products | Specified drugs | Lesser of FUL, State MAC or WAC+2%, plus $4.76 dispensing fee | |
| New Hampshire | Yes | CN & MN | $1/generic Rx, $2/brand or compound Rx | Specified drugs | EAC: AWP-16% or WAC+0.8%, plus $1.75 dispensing fee | |
| New Jersey | Yes | CN & MN - See state-specific FN | OTC products covered in limited medically necessary circumstances | Specified drugs including nutritional supplements and methadone | WAC-1%, plus pharmacy specific dispensing fee of $3.73-$3.99 depending on services provided, non-traditional pharmacies receive a capitated dispensing fee | |
| New Mexico | Yes | CN | A - $3/Rx, B - $5/Rx - see state-specific FN | Rx must be generic unless DAW or other specified drug, mail order dispensing permitted, A - OTCs not covered except for certain allergy medications | WAC+6%, Direct Price+6% or SWP-14%, plus $2.50 dispensing fee; if a generic product is dispensed in place of a prescribed brand the fee is $3.65 | |
| New York | Yes | CN & MN | $1/generic Rx or for preferred or less costly brand Rx , $3/brand Rx, $.50/OTC product | Beneficiary Specific Utilization Thresholds apply - see state-specific FN | Specified drugs | AWP-17% for brand Rx, AWP-25% for generic Rx, plus $3.50 dispensing fee for brand Rx or $3.50 dispensing fee for generic Rx |
| North Carolina | Yes | CN & MN | $3/Rx | Non-preferred and specified high cost drugs | FUL, state MAC, AWP-11.67% or WAC+6%, plus a tiered dispensing fee based on provider's generic dispensing rate and $3.00 dispensing fee for brand Rx; AWP-17% or WAC+2.2% for most specialty medications | |
| North Dakota | Yes | CN & MN | $3/brand Rx | Adult vitamins limited to pregnancy supplements or for specified medical conditions, smoking cessation products limited | WAC+8% or DP+8%, plus $4.60 dispensing fee for brand Rx and $5.60 for generic Rx | |
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | Non-preferred drugs | |||
| Ohio | Yes | CN | $2/selected brand Rx, $3/Rx if prior approval required | Specified drugs | WAC+7% (or AWP-14.4% if WAC unknown), plus $1.80 dispensing fee for non-compounded Rx | |
| Oklahoma | Yes | CN | $.65-$3.50/Rx, depending on allowable drug cost with no copayment required for preferred generic drugs | 6 Rxs/month including up to 2 brand Rxs, HCBS waiver participants have higher limits | AWP-12%, plus $4.02 dispensing fee | |
| Oregon | Yes | A & B - See state-specific FN | A - $1/non-preferred PDL generic or generic in non-PDL class costing more than $10; $3/brand Rx | Specified drugs including nutritional supplements, growth hormones and anti-ulcer drugs | Estimated acquisition cost using AAC or WAC plus dispensing fee based on annual claims volume of each pharmacy ($9.68 to $14.01) | |
| Pennsylvania | Yes | CN & MN | $1/generic Rx, $3/brand Rx | CN: 6 Rxs/month, with both an automated and manual exceptions process; MN - limited to birth control drugs but nursing facility residents have no limitations | Lower of AWP-14% or WAC+3.2% for brand Rx, lower of FUL, State MAC, AWP-25% or WAC+0% for generic, plus $2.00 dispensing fee ($3.00 for compound Rx), $.50 dispensing fee if Medicaid is secondary payer | |
| Puerto Rico | Yes | CN & MN | $.50/Rx | Specified high cost drugs and drugs not in plan formulary | Service is included in payment made to Pharmacy Benefit Manager and excluded from the capitated rate paid to managed care plans | |
| Rhode Island | Yes | See state-specific FN | Generic drugs must be dispensed rather than brand products with few exceptions | Specified drugs and injectables | Lower of WAC, FUL, State MAC or charge, plus $3.40 dispensing fee for traditional pharmacies and $2.85 dispensing fee for non-traditional pharmacies | |
| South Carolina | Yes | CN | $3.40/Rx | 4 Rxs/month or up to 10 Rxs/month with defined overrides | AWP-16% or WAC+.8%, plus $3.00 dispensing fee | |
| South Dakota | Yes | CN | $1/generic Rx, $3.30/brand Rx | Adult vitamins limited to pregnancy supplements, OTCs not covered except insulin | Specified OTC products | AWP-15% or State MAC, plus $4.30 dispensing fee for traditional pharmacies and $5.10 dispensing fee for non-traditional pharmacies |
| Tennessee | Yes | A, B & C - See state-specific FN | $3/brand Rx | 5 Rxs/month including up to 2 brand Rxs, specified additional drugs covered outside limit, OTCs not covered except for prenatal vitamins, barbiturates and benzodiazepines not covered | Reimbursement rates established and paid by pharmacy benefits manager - see state-specific FN | |
| Texas | Yes | CN & MN | 3 Rxs/month with some exceptions | Non-preferred or clinically specified products | Lower of EAC (AWP-15% or WAC+12%) or charge, plus an EAC-adjusted dispensing fee with both a fixed and variable component | |
| Utah | Yes | A, B & C - See state-specific FN | A - $3/Rx up to $15/month, B - $3/Rx, C - $5/generic or preferred brand Rx and 25% cost for others | A & B - limited OTCs covered, C - 4 Rxs/month and limited OTCs covered | AWP-17.4%, plus $3.90 dispensing fee for urban pharmacies or $4.40 dispensing fee for rural pharmacies | |
| Vermont | Yes | A & B - See state-specific FN | A - $1-$3/Rx, depending on drug cost; B - $1-$2/Rx, depending on household income and drug cost | A & B - Rxs for chronic conditions must be at least 30-day supply, adult vitamins limited to specified conditions and products, lowest price generic equivalent product must be dispensed | Specified drugs | AWP-14.2%, plus $4.75 dispensing fee for in-state pharmacies; higher fee paid for compound prescriptions; dispensing fees limited to 1/drug/25 days for LTC residents; mail order pharmacies paid slightly lower rates |
| U.S. Virgin Islands | Yes | CN | Rxs must be dispensed by public health operated or contracted pharmacies | Acquisition cost plus dispensing fee | ||
| Virginia | Yes | CN & MN | $1/generic Rx, $3/brand Rx | Rx must be generic unless DAW or brand has preferred status on drug list | Specified drugs | AWP-13.1%, plus $3.75 dispensing fee to traditional pharmacies |
| Washington | Yes | CN & MN | 90 day supply required for selected maintenance drugs, only limited OTC cough and cold products covered | Specified drugs | AWP-14% to traditional pharmacies or AWP-19% to mail order contractors for drugs available from fewer than 5 labelers or manufacturers, AWP-50% to traditional pharmacies or AWP-15% to mail order contractors for multi-source drugs, plus a dispensing fee to traditional pharmacies dependent on Medicaid volume (low and unit dose: $5.25, med: $4.56, high: $4.24), $3.25 dispensing fee to mail order contractors | |
| West Virginia | Yes | A, B & C | $.50-$3/Rx depending on drug cost | A - 4 Rxs/month; A, B & C - 34-day supply, limits based on gender, age and drug quantity; specified OTCs covered | Specified drugs including vitamins, acute dosing of anti-ulcer drugs beyond 90 days and amphetamines | Lower of FUL, State MAC, charge or,AWP-30%, plus $5.30 dispensing fee for generic Rx; lower of FUL, charge or AWP-15%, plus $2.50 dispensing fee for brand Rx; 340b providers paid cost plus $8.25 dispensing fee; dispensing fee $1.00 more for compound Rxs |
| Wisconsin | Yes | CN & MN | $1/generic Rx and $3/brand Rx up to $12/month, $.50/OTC product, | Most drugs limited to 34 day supply with 100 day supply for some | Specified drugs | WAC+2% for brand Rx, WAC-3.8% for single source generics, SMAC for multi-source generics, plus $3.94 dispensing fee for generic Rx and $3.44 dispensing fee for brand Rx |
| Wyoming | Yes | CN | $.65/generic or preferred brand Rx, $3.65/non-preferred brand Rx | Non-preferred brand drugs, obesity products, OTC drugs | AWP-11%, plus $5.00 dispensing fee |
2010
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 56 No - 0 | Yes - 43 No - 13 | ||||
| Alabama | Yes | CN | Up to $3/Rx depending on eligibility and drug cost | 5 brand Rxs/month except brand antipsychotics and antiretrovirals up to 10 Rxs/month, unlimited generics and covered OTCs | Multiple source drugs paid lesser of FUL, state MAC, EAC (AAC or WAC+9.2%) or charge plus dispensing fee; other drugs paid EAC (AAC or WAC+9.2%) or charge plus dispensing fee; hemophilia factor drugs paid ASP+6%; dispensing fee is $10.64 | |
| Alaska | Yes | CN | $2/Rx | Specified drugs | WAC+8%, plus a dispensing fee dependent on Medicaid volume ($3.45 to $11.46) | |
| American Samoa | Yes | See territory-specific FN | Prospective payment/Rx based on prior year cost | |||
| Arizona | Yes | CN & MN | $2.30/Rx | OTCs covered only if medically appropriate and less costly than a prescription Rx | AWP-16%, plus $1.50 dispensing fee | |
| Arkansas | Yes | CN & MN | $.50-$3/Rx depending on drug cost | 6 Rxs/month except for family planning and for persons in nursing facilities or participating in HCBS waivers | More than 3 prescriptions per month for non-institutionalized beneficiaries | EAC/AWP-14% for brand Rx, EAC/AWP-20% for generic Rx, plus $5.51 dispensing fee for each, additional $2.00 dispensing fee for generic Rx with no FUL or state MAC |
| California | Yes | CN & MN | $1/Rx | 6 Rxs/month | AWP-17%, plus $7.25 dispensing fee, non-traditional pharmacies receive an $8.00 dispensing fee | |
| Colorado | Yes | CN | $1/generic or multi-source Rx, $3/brand or single source Rx | Products not on PDL and other specified products | AWP-14.5% for brand Rx, AWP-45% for generic Rx, plus $4.00 dispensing fee for each, non-traditional pharmacies receive a $1.89 dispensing fee | |
| Connecticut | Yes | CN & MN | 30 day supply for acute conditions, 30 day supply or 240 dosage units for chronic conditions, nutritional supplement coverage restricted by diagnosis, only limited OTCs covered | AWP-14% for brand Rx, AWP-40% for generic Rx, plus $3.15 dispensing fee | ||
| Delaware | Yes | CN | $.50-$3/Rx depending on drug cost, up to $15/month | Rx must be generic unless DAW | AWP-14% by retail pharmacies, AWP-16% by non-traditional pharmacies, plus $3.65 dispensing fee for each | |
| District of Columbia | Yes | CN & MN | $1/Rx | Specified drugs and injectables including Percodan and Dalmane | WAC+3%, plus $4.50 dispensing fee | |
| Florida | Yes | CN & MN | Step therapy required for some drugs not on PDL | Specified drugs | Lower of AWP-16.4% or WAC+4.75%, plus $3.73 dispensing fee, $7.50 dispensing fee for 340B pharmacies | |
| Georgia | Yes | CN & MN | $1-$3/Rx depending on drug cost and status | 5 Rxs or refills/month | Specified drugs | AWP-11%, plus $4.63 dispensing fee to for profit retail pharmacies, dispensing fee $.30 less to non-profit pharmacies |
| Guam | Yes | CN | Adult vitamins limited to pregnancy supplements | AWP plus $4.40 dispensing fee | ||
| Hawaii | Yes | CN & MN | Specified drugs | AWP-10.5%, plus $4.67 dispensing fee | ||
| Idaho | Yes | CN | Specified drugs including amphetamines, high cost and therapeutic-equivalent drugs | Lesser of charge, FUL, state MAC or AWP-12%, plus $4.94 dispensing fee, $5.54 dispensing fee if unit dose | ||
| Illinois | Yes | CN & MN | $3/brand Rx | 3 brand Rxs/month | AWP-12%, plus $3.40 dispensing fee for brand Rx, AWP-25%, plus $4.60 dispensing fee for generic Rx | |
| Indiana | Yes | CN | $3/Rx | Specified drugs | AWP-16% for brand Rx, AWP-20% for generic Rx, plus $4.90 dispensing fee for each | |
| Iowa | Yes | CN & MN | $1/generic and preferred brand Rx, $2-$3/non-preferred brand Rx depending on payment | Specified drugs | AWP-17% for specialty drugs and AWP-12% for other drugs, plus $4.34 dispensing fee | |
| Kansas | Yes | CN & MN | $3/Rx | 5 single-source Rxs/month, adult vitamins limited to pregnancy supplements | Specified drugs | AWP-13% for brand Rx, AWP-27% for generic Rx, plus $3.40 dispensing fee for each |
| Kentucky | Yes | A, B & C - See state-specific FN | $1/generic Rx; $2/preferred brand Rx; 5% of payment up to $20 for non-preferred brand Rx; annual out-of-pocket expense capped at $225 | A, C & D - 4 Rxs/month including up to 3 brand Rxs | Specified drugs, including amphetamines and OTCs | AWP-15% for brand Rx plus $4.50 dispensing fee; AWP-14% for generic Rx plus $5.00 dispensing fee |
| Louisiana | Yes | CN & MN | $.50-$3/Rx depending on drug cost | 5 Rxs/month, overrides possible, limit not applicable to residents in institutions | Specified drugs | AWP-13.5% for independent pharmacies, AWP-15% for chain stores, plus $5.77 dispensing fee for each |
| Maine | Yes | CN & MN | $3/Rx, up to $30/month, no copayment required for mail order Rxs | 4 brand Rxs/month for residents in supervised settings, drug coverage limited by PDL | Specified products | AWP-15% for brand Rx , AWP-13% for generic Rx, AWP-17% for direct supply drugs, plus $3.35 dispensing fee for each in urban areas and 55-65 cents higher in rural areas; AWP-60% for generic Rx and AWP-20% for brand Rx through mail order pharmacy, plus $1.00 dispensing fee for each |
| Maryland | Yes | CN & MN | $1/Rx for generic, preferred brand or HIV/AIDS drug, $3/Rx for non-preferred brand | Specified quantity limits and clinical criteria for selected drugs | Specified drugs and drug therapies | Lower of FUL, IDC (See state-specific FN) or EAC (AWP-12%, WAC+8% or Direct+8%), plus $3.69 dispensing fee for generic or preferred brand Rx by traditional pharmacies or $2.69 dispensing fee for non-preferred Rx, non-traditional pharmacies paid $1.00 more/Rx but only one dispensing fee/month |
| Massachusetts | Yes | CN & MN | $1/selected generic Rx or selected OTCs, $3/other generic Rx, $3/brand Rx or other specified OTCs | Specified drugs and drug classes | Specified drugs and drug classes | Lesser of charge, FUL, state MAC or WAC+5% plus $3.00 dispensing fee |
| Michigan | Yes | CN & MN | $1/generic Rx, $3/brand Rx | AWP-13.5% for pharmacies with up to 4 stores, AWP-15.1% for pharmacies with 5 or more stores, plus $2.75 dispensing fee for each, non-traditional pharmacies paid $3.00 dispensing fee | ||
| Minnesota | Yes | A & B - See state-specific FN | A - $1/generic Rx, $3/brand Rx, up to $7/month, antipsychotic Rxs not subject to copayments; B - $3/Rx with no cap and no exceptions - See state-specific FN | Non-preferred and brand Rx when generic available | AWP-12%, plus $3.65 dispensing fee; specialty drug products paid less - See state-specific FN | |
| Mississippi | Yes | CN | $3/Rx | Generic products required if available, 5 Rxs/month including 2 brand Rxs, 5 brand Rxs/month for HIV/AIDS, limit not applicable to nursing facility residents | Specified drugs | AWP-12% or WAC+9% for brand Rx plus $3.91 dispensing fee; AWP-25% for generic Rx plus $5.50 dispensing fee; non-traditional pharmacies paid $3.91 dispensing fee |
| Missouri | Yes | CN | $.50-$2/Rx depending on ingredient cost | Lower of FUL, state MAC, AWP-10.43% or WAC+10%, plus base dispensing fee of $4.84 and enhanced dispensing fee of $4.82; generic product preferred incentive fee is $4.00 | ||
| Montana | Yes | A & B - See state-specific FN | $1-$5/Rx depending on drug cost, up to $25 max per month | Specified drugs | Lesser of FUL, state MAC, EAC (AWP-15%) plus dispensing fee between $2 and $5.04 in-state or $3.50 out of state | |
| Nebraska | Yes | CN & MN | $2/Rx | Specified drugs | AWP-11%, plus pharmacy specific dispensing fee of $3.27-$5.00 | |
| Nevada | Yes | CN | Specified drugs | AWP-15%, plus $4.76 dispensing fee | ||
| New Hampshire | Yes | CN & MN | $1/generic Rx, $2/brand or compound Rx | 30-day supply for maintenance medications unless specified medical condition | Specified drugs | AWP-16%, plus $1.75 dispensing fee |
| New Jersey | Yes | CN & MN - See state-specific FN | OTC products covered in limited medically necessary circumstances | Specified drugs including nutritional supplements and methadone | AWP-17.5%, plus pharmacy specific dispensing fee of $3.73-$3.99 depending on services provided, non-traditional pharmacies receive a capitated dispensing fee | |
| New Mexico | Yes | CN | A - $3/Rx, B - $5/Rx - see state-specific FN | Rx must be generic unless DAW, mail order dispensing permitted, A - OTCs not covered except for certain allergy medications | AWP-14%, plus $2.50 dispensing fee; if a generic product is dispensed in place of a prescribed brand the fee is $3.65 | |
| New York | Yes | CN & MN | $1/generic Rx or for preferred or less costly brand Rx , $3/brand Rx, $.50/OTC product | Beneficiary Specific Utilization Thresholds apply - see state-specific FN | Specified drugs | AWP-16.25% for brand Rx, AWP-25% for generic Rx, plus $3.50 dispensing fee for brand Rx or $4.50 dispensing fee for generic Rx, specialized HIV pharmacies paid AWP-12% |
| North Carolina | Yes | CN & MN | $3/Rx | 8 Rxs/month, pharmacist may override for 3 additional if necessary | Specified high cost drugs | FUL, state MAC, AWP-10% or WAC+7%, plus $5.60 dispensing fee for generic Rx or OTC products and $4.00 dispensing fee for brand Rx; AWP-17% or WAC+2.1% for specified specialty medications |
| North Dakota | Yes | CN & MN | $3/brand Rx | Adult vitamins limited to pregnancy supplements or for specified medical conditions, smoking cessation products limited | AWP-10% or WAC+8%, plus $4.60 dispensing fee for brand Rx and $5.60 for generic Rx | |
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | 30 day supply | Non-preferred drugs | ||
| Ohio | Yes | CN | $2/selected brand Rx, $3/Rx if prior approval required | Specified drugs | WAC+7% (or AWP-14.4% if WAC unknown), plus $1.80 dispensing fee for non-compounded Rx | |
| Oklahoma | Yes | CN | $.65-$3.50/Rx, depending on allowable drug cost with no copayment required for preferred generic drugs | 6 Rxs/month, 2 brand Rxs and 7 additional generic Rxs/month for HCBS waiver participants | AWP-12%, plus $4.15 dispensing fee | |
| Oregon | Yes | A & B - See state-specific FN | A - $1/non-preferred PDL generic or generic in non-PDL class costing more than $10; $3/brand Rx | Specified drugs including nutritional supplements, growth hormones and anti-ulcer drugs | Average Acquisition Cost plus $3.50 dispensing fee for traditional pharmacies, AWP-11%, plus $3.91 dispensing fee for non-traditional pharmacies | |
| Pennsylvania | Yes | CN & MN | $1/generic Rx, $3/brand Rx | MN - limited to birth control drugs but nursing facility residents have no limitations | Lower of AWP-14% or WAC+7% for brand Rx, lower of AWP-26% or WAC+66% for generic, plus $4.00 dispensing fee ($5.00 for compound Rx) | |
| Puerto Rico | Yes | CN & MN | $.50/Rx | Specified high cost drugs and drugs not in plan formulary | Service is included in payment made to Pharmacy Benefit Manager and excluded from the capitated rate paid to managed care plans | |
| Rhode Island | Yes | See state-specific FN | Generic drugs must be dispensed rather than brand products with few exceptions | Specified drugs and injectables | Lower of WAC, FUL, State MAC or charge, plus $3.40 dispensing fee for traditional pharmacies and $2.85 dispensing fee for non-traditional pharmacies | |
| South Carolina | Yes | CN | $3/Rx | 4 Rxs/month or up to 10 Rxs/month with defined overrides | AWP-10%, plus $4.05 dispensing fee for traditional pharmacies and $3.15 dispensing fee for non-traditional pharmacies | |
| South Dakota | Yes | CN | $3/brand Rx | Adult vitamins limited to pregnancy supplements, OTCs not covered except insulin | Specified OTC products | AWP-13%, plus $4.75 dispensing fee for traditional pharmacies and $5.55 dispensing fee for non-traditional pharmacies |
| Tennessee | Yes | A - See state-specific FN | $3/brand Rx | 5 Rxs/month including up to 2 brand Rxs, specified additional drugs covered outside limit, OTCs not covered except for prenatal vitamins, barbiturates and benzodiazepines not covered | See state-specific FN | |
| Texas | Yes | CN & MN | 3 Rxs/month | Lower of AWP-15% or WAC+12% for independent pharmacies, AWP-18% for chain stores, plus $7.43 dispensing fee | ||
| Utah | Yes | A, B & C - See state-specific FN | A - $3/Rx up to $15/month, B - $3/Rx, C - $5/generic or preferred brand Rx and 25% cost for others, B & C - full payment for brand when generic available | A & B - OTCs covered, C - 4 Rxs/month and limited OTCs covered | AWP-17.4%, plus $3.90 dispensing fee for urban pharmacies or $4.40 dispensing fee for rural pharmacies | |
| Vermont | Yes | A & B - See state-specific FN | $1-$3 depending on drug cost | A & B - Rxs for chronic conditions must be at least 30-day supply, adult vitamins limited to specified conditions and products, lowest price generic equivalent product must be dispensed | Specified drugs | AWP-14.2%, plus $4.75 dispensing fee for in-state pharmacies; higher fee paid for compound prescriptions; dispensing fees limited to 1/drug/25 days for LTC residents |
| U.S. Virgin Islands | Yes | CN | Rxs must be dispensed by public health operated or contracted pharmacies | Acquisition cost plus dispensing fee | ||
| Virginia | Yes | CN & MN | $1/generic Rx, $3/brand Rx | Rx must be generic unless DAW or brand has preferred status on drug list | Specified drugs | AWP-13.1%, plus $3.75 dispensing fee to traditional pharmacies |
| Washington | Yes | CN & MN | 90 day supply required for selected maintenance drugs, only limited OTC cough and cold products covered | Specified drugs | AWP-14% to traditional pharmacies or AWP-19% to mail order contractors for drugs available from fewer than 5 labelers or manufacturers, AWP-50% to traditional pharmacies or AWP-15% to mail order contractors for multi-source drugs, plus a dispensing fee to traditional pharmacies dependent on Medicaid volume (low and unit dose: $5.25, med: $4.56, high: $4.24), $3.25 dispensing fee to mail order contractors | |
| West Virginia | Yes | A, B & C | $.50-$3/Rx depending on drug cost | A - 4 Rxs/month; A, B & C - 34-day supply, limits based on gender, age and drug quantity; specified OTCs covered | Specified drugs including vitamins, acute dosing of anti-ulcer drugs beyond 90 days and amphetamines | Lower of FUL, State MAC, charge or,AWP-30%, plus $5.30 dispensing fee for generic Rx; lower of FUL, charge or AWP-15%, plus $2.50 dispensing fee for brand Rx; 340b providers paid cost plus $8.25 dispensing fee; dispensing fee $1.00 more for compound Rxs |
| Wisconsin | Yes | CN & MN | $1/generic Rx and $3/brand Rx up to $12/month, $.50/OTC product | Most drugs limited to 34 day supply with 100 day supply for some | Specified drugs | AWP-14%, plus $3.94 dispensing fee for generic Rx and $3.44 dispensing fee for brand Rx |
| Wyoming | Yes | CN | $1/generic or preferred brand Rx, $3/non-preferred brand Rx | Non-preferred brand drugs, obesity products, OTC drugs | AWP-11%, plus $5.00 dispensing fee |
2008
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 56 No - 0 | Yes - 41 No - 15 | ||||
| Alabama | Yes | CN | $.50-$3/Rx depending on drug cost | 5 brand Rxs/month except brand antipsychotics and antiretrovirals up to 10 Rxs/month | Lower of AWP-10% or WAC+9.2%, plus $5.40 dispensing fee, hemophilia factor drugs paid ASP+6% | |
| Alaska | Yes | CN | $2/Rx | Specified drugs | AWP-5%, plus a dispensing fee dependent on Medicaid volume ($3.45 to $11.46) | |
| American Samoa | Yes | See territory-specific FN | Prospective payment/Rx based on prior year cost | |||
| Arizona | Yes | CN & MN | AWP-16%, plus $1.90 dispensing fee | |||
| Arkansas | Yes | CN & MN | $.50-$3/Rx depending on drug cost | 6 Rxs/month except for persons in nursing facilities or participating in HCBS waivers | More than 3 prescriptions per month for non-institutionalized beneficiaries | AWP-14% for brand Rx, AWP-20% for generic Rx, plus $5.51 dispensing fee for each, additional $2.00 dispensing fee for generic Rx with no FUL or state MAC |
| California | Yes | CN & MN | $1/Rx | 6 Rxs/month | AWP-17%, plus $7.25 dispensing fee, non-traditional pharmacies receive an $8.00 dispensing fee | |
| Colorado | Yes | CN | $1/generic or multi-source Rx, $3/brand or single source Rx | Over the counter drugs other than insulin and aspirin, compounded Rxs | AWP-13.5% for brand Rx, AWP-35% for generic Rx, plus $4.00 dispensing fee for each, non-traditional pharmacies receive a $1.89 dispensing fee | |
| Connecticut | Yes | CN & MN | 30 day supply for acute conditions, 30 day supply or 240 dosage units for chronic conditions | Vitamins, nutritional supplements, other specified drugs including amphetamines | AWP-14% for brand Rx, AWP-40% for generic Rx, plus $3.15 dispensing fee | |
| Delaware | Yes | CN | $.50-$3/Rx depending on drug cost, up to $15/month | Rx must be generic unless DAW | AWP-14% by retail pharmacies, AWP-16% by non-traditional pharmacies, plus $3.65 dispensing fee for each | |
| District of Columbia | Yes | CN & MN | $1/Rx | Specified drugs and injectables including Percodan and Dalmane | AWP-10%, plus $4.50 dispensing fee | |
| Florida | Yes | CN & MN | Step therapy required for some drugs not on PDL | Specified drugs | Lower of AWP-16.4% or WAC+4.75%, plus $4.23 dispensing fee for retail pharmacies or $4.73 dispensing fee for non-traditional pharmacies | |
| Georgia | Yes | CN & MN | $1-$3/Rx depending on drug cost and status | 5 Rxs or refills/month | Specified drugs | AWP-11%, plus $4.63 dispensing fee to for profit retail pharmacies, dispensing fee $.30 less to non-profit pharmacies |
| Guam | Yes | CN | Adult vitamins limited to pregnancy supplements | AWP, plus $4.40 dispensing fee | ||
| Hawaii | Yes | CN & MN | Specified drugs | AWP-10.5%, plus $4.67 dispensing fee | ||
| Idaho | Yes | CN | Specified drugs including amphetamines, high cost and therapeutic-equivalent drugs | AWP-12%, plus $4.94 dispensing fee, $5.54 dispensing fee if unit dose | ||
| Illinois | Yes | CN & MN | $3/brand Rx | 3 brand Rxs/month | AWP-12%, plus $3.40 dispensing fee for brand Rx, AWP-25%, plus $4.60 dispensing fee for generic Rx | |
| Indiana | Yes | CN | $3/Rx | Specified drugs | AWP-16% for brand Rx, AWP-20% for generic Rx, plus $4.90 dispensing fee for each | |
| Iowa | Yes | CN & MN | $1/generic and preferred brand Rx, $2-$3/non-preferred brand Rx depending on payment | Specified drugs | AWP-12%, plus $4.26 dispensing fee | |
| Kansas | Yes | CN & MN | $3/Rx | 5 single-source Rxs/month, adult vitamins limited to pregnancy supplements | Specified drugs | AWP-13% for brand Rx, AWP-27% for generic Rx, plus $3.40 dispensing fee for each |
| Kentucky | Yes | A, B & C - See state-specific FN | $1/generic Rx; $2/preferred brand Rx; 5% of payment up to $20 for non-preferred brand Rx; annual out-of-pocket expense capped at $225 | 4 Rxs/month including up to 3 brand Rxs | Specified drugs, including amphetamines and over the counter products | AWP-15% for brand Rx plus $4.50 dispensing fee; AWP-14% for generic Rx plus $5.00 dispensing fee |
| Louisiana | Yes | CN & MN | $.50-$3/Rx depending on drug cost | 8 Rxs/month | Specified drugs | AWP-13.5% for independent pharmacies, AWP-15% for chain stores, plus $5.77 dispensing fee for each |
| Maine | Yes | CN & MN | $3/Rx, up to $30/month, no copayment required for mail order Rxs | 4 brand Rxs/month for residents in supervised settings | Non-preferred drugs | AWP-15% for brand Rx , AWP-13% for generic Rx, AWP-17% for direct supply drugs, plus $3.35 dispensing fee for each in urban areas and 55-65 cents higher in rural areas; AWP-60% for generic Rx and AWP-20% for brand Rx through mail order pharmacy, plus $1.00 dispensing fee for each |
| Maryland | Yes | CN & MN | $1/Rx for generic or preferred brand, $3/Rx for non-preferred brand | Specified quantity limits for selected drugs | Specified antibiotic liquids, some nutritional supplements | Lower of AWP-12% or WAC+8%, plus $3.69 dispensing fee for generic or preferred brand Rx by traditional pharmacies or $2.69 dispensing fee for non-preferred Rx, non-traditional pharmacies paid $1.00 more/Rx but only one dispensing fee/month |
| Massachusetts | Yes | CN & MN | $1/selected generic Rx or selected OTCs,, $3/other generic Rx, $3/brand Rx or other specified OTCs | Specified drugs and drug classes | Specified drugs and drug classes | WAC+5% plus $3.00 dispensing fee; 340B pharmacies paid drug cost plus $3.00 dispensing fee |
| Michigan | Yes | CN & MN | $1/generic Rx, $3/brand Rx | AWP-13.5% for independent pharmacies, AWP-15.1% for chain stores, plus $2.50 dispensing fee for each, non-traditional pharmacies paid $2.75 dispensing fee | ||
| Minnesota | Yes | A & B - See state-specific FN | A - $1/generic Rx, $3/brand Rx, up to $12/month, antipsychotic Rxs not subject to copayments; B - $3/Rx with no cap and no exceptions - See state-specific FN | Non-preferred and brand Rx when generic available | AWP-12%, plus $3.65 dispensing fee; specialty drug products paid less - See state-specific FN | |
| Mississippi | Yes | CN | $3/Rx | 5 Rxs/month including 2 brand Rxs, 5 brand Rxs/month for HIV/AIDS, limit not applicable to nursing facility residents | Specified drugs | AWP-12% or WAC+9% for brand Rx plus $3.91 dispensing fee; AWP-25% for generic Rx plus $5.50 dispensing fee; non-traditional pharmacies paid $3.91 dispensing fee |
| Missouri | Yes | CN | $.50-$2/Rx depending on drug cost | Lower of AWP-10.43% or WAC+10%, plus $4.09 dispensing fee | ||
| Montana | Yes | A & B - See state-specific FN | $1-$5/Rx depending on drug cost, up to $25 max per month | Specified drugs | AWP-15%, plus cost based dispensing fee between $2 and $4.70 | |
| Nebraska | Yes | CN & MN | $2/Rx | 90 day supply | Specified drugs | AWP-11%, plus pharmacy specific dispensing fee of $3.27-$5.00 |
| Nevada | Yes | CN | Specified drugs | AWP-15%, plus $4.76 dispensing fee | ||
| New Hampshire | Yes | CN & MN | $1/generic Rx, $2/brand or compound Rx | Specified drugs | AWP-16%, plus $1.75 dispensing fee | |
| New Jersey | Yes | CN & MN - See state-specific FN | Specified drugs including nutritional supplements and methadone | AWP-16%, plus pharmacy specific dispensing fee of $3.73-$3.99 depending on services provided, non-traditional pharmacies receive a capitated dispensing fee | ||
| New Mexico | Yes | CN | A - $3/Rx up to $12/month, B - $5/Rx - see state-specific FN | Rx must be generic unless DAW, mail order dispensing permitted | AWP-14%, plus $3.65 dispensing fee | |
| New York | Yes | CN & MN | $1/generic Rx or preferred or less costly brand Rx , $3/brand Rx, $.50/over the counter product | 40 Rxs/year | Specified drugs | AWP-16.25% for brand Rx, AWP-25% for generic Rx, plus $3.50 dispensing fee for brand Rx or $4.50 dispensing fee for generic Rx, specialized HIV pharmacies paid AWP-12% |
| North Carolina | Yes | CN & MN | $3/Rx | 8 Rxs/month, pharmacist may override for 3 additional if necessary | Specified high cost drugs | AWP-10%, plus $5.60 dispensing fee for generic Rx or OTC products; AWP-10%, plus $4.00 dispensing fee for brand Rx,, AWP-17% for specified specialty medications |
| North Dakota | Yes | CN & MN | $3/brand Rx | Adult vitamins limited to pregnancy supplements, smoking cessation products limited | AWP-10% or WAC+12.5%, plus $4.60 dispensing fee for brand Rx and $5.60 for generic Rx | |
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | 30 day supply | Non-preferred drugs | ||
| Ohio | Yes | CN | $2/selected brand Rx, $3/Rx if prior approval required | Specified drugs | WAC+7% (or AWP-14.4% if WAC unknown), plus $3.70 dispensing fee for non-compounded Rx | |
| Oklahoma | Yes | CN | $1-$2/Rx, depending on drug cost | 6 Rxs/month including 3 brand Rxs, 7 additional generic Rxs/month for HCBS waiver participants | AWP-12%, plus $4.15 dispensing fee | |
| Oregon | Yes | A & B - See state-specific FN | A - $1/non-preferred PDL generic or generic in non-PDL class costing more than $10; $3/brand Rx | Specified drugs including nutritional supplements, growth hormones and anti-ulcer drugs | AWP-15%, plus $3.50 dispensing fee for traditional pharmacies, AWP-11%, plus $3.91 dispensing fee for non-traditional pharmacies | |
| Pennsylvania | Yes | CN & MN | $1/generic Rx, $3/brand Rx | MN - limited to birth control drugs but nursing facility residents have no limitations | WAC+7% for brand Rx or WAC+66% for generic, plus $4.00 dispensing fee | |
| Puerto Rico | Yes | CN & MN | Maintenance drugs limited to 30 day supply | Specified high cost drugs and drugs not in plan formulary | AWP minus agreed upon discount and dispensing fees | |
| Rhode Island | Yes | CN & MN - see state-specific FN | Specified drugs and injectables | WAC, plus $3.40 dispensing fee for traditional pharmacies and $2.85 dispensing fee for non-traditional pharmacies | ||
| South Carolina | Yes | CN | $3/Rx | 4 Rxs/month or up to 10 Rxs/month with defined overrides | AWP-10%, plus $4.05 dispensing fee for traditional pharmacies and $3.15 dispensing fee for non-traditional pharmacies | |
| South Dakota | Yes | CN | $3/brand Rx | Adult vitamins limited to pregnancy supplements, OTCs not covered except insulin | Specified over the counter products | AWP-10.5%, plus $4.75 dispensing fee for traditional pharmacies and $5.55 dispensing fee for non-traditional pharmacies |
| Tennessee | Yes | A - See state-specific FN | $3/brand Rx | 5 Rxs/month including up to 2 brand Rx, specified additional drugs covered outside limit, OTCs not covered except for prenatal vitamins, barbiturates and benzodiazepines not covered | ||
| Texas | Yes | CN & MN | 3 Rxs/month | Lower of AWP-15% or WAC+12% for independent pharmacies, AWP-18% for chain stores, plus $5.14 dispensing fee | ||
| Utah | Yes | A, B & C - See state-specific FN | A - $3/Rx up to $15/month, B - $3/Rx, C - $5/generic or preferred brand Rx and 25% cost for others, B & C - full payment for brand when generic available | A & B - 7 Rxs/month, C - 4 Rxs/month, A & B - limited OTCs covered, C - OTCs not covered | AWP-15%, plus $3.90 dispensing fee for urban pharmacies or $4.40 dispensing fee for rural pharmacies | |
| Vermont | Yes | A & B - See state-specific FN | A - $1-$3 depending on drug cost | A & B - Rxs for chronic conditions must be at least 30 day supply, adult vitamins limited to specified conditions and products, lowest price generic equivalent product must be dispensed | Specified drugs | AWP-11.9%, plus $4.75 dispensing fee for in-state pharmacies |
| U.S. Virgin Islands | Yes | CN | Rxs must be dispensed by public health operated or contracted pharmacies | Acquisition cost plus dispensing fee | ||
| Virginia | Yes | CN & MN | $1/generic Rx, $3/brand Rx | Rx must be generic unless DAW or brand has preferred status on drug list | Specified drugs | AWP-10.25%, plus $4.00 dispensing fee to traditional pharmacies |
| Washington | Yes | CN & MN | Specified drugs | AWP-14% to traditional pharmacies or AWP-19% to mail order contractors for drugs available from fewer than 5 labelers or manufacturers, AWP-50% to traditional pharmacies or AWP-15% to mail order contractors for multi-source drugs, plus a dispensing fee to traditional pharmacies dependent on Medicaid volume (low and unit dose: $5.25, med: $4.56, high: $4.24), $3.25 dispensing fee to mail order contractors | ||
| West Virginia | Yes | A, B & C | $.50-$3/Rx depending on drug cost | A - 4 Rxs/month, specified OTCs covered | Specified drugs including vitamins, acute dosing of anti-ulcer drugs beyond 90 days and amphetamines | AWP-30%, plus $5.30 dispensing fee for generic Rx; AWP-15%, plus $2.50 dispensing fee for brand Rx; dispensing fee $1.00 more for compound Rxs |
| Wisconsin | Yes | CN & MN | $1/generic Rx and $3/brand Rx up to $12/month, $.50/over the counter drug | Most drugs limited to 34 day supply with 100 day supply for some | Specified drugs | AWP-14%, plus $3.94 dispensing fee for generic Rx and $3.44 dispensing fee for brand Rx |
| Wyoming | Yes | CN | $1/generic or preferred brand Rx, $3/non-preferred brand Rx | Non-preferred brand drugs, obesity products, over the counter drugs | AWP-11%, plus $5.00 dispensing fee |
2006
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 56 No - 0 | Yes - 41 No - 15 | ||||
| Alabama | Yes | CN | $.50-$3/Rx depending on drug cost | 4 brand Rxs/month except brand antipsychotics and antiretrovirals up to 10 Rxs/month | Lower of AWP-10% or WAC+9.2%, plus $5.40 dispensing fee | |
| Alaska | Yes | CN | $2/Rx | Specified drugs | AWP-5%, plus a dispensing fee dependent on Medicaid volume ($3.45 to $11.46) | |
| American Samoa | Yes | See territory-specific FN | Prospective payment/Rx based on prior year cost | |||
| Arizona | Yes | CN & MN | AWP-15%, plus $2.00 dispensing fee | |||
| Arkansas | Yes | CN & MN | $.50-$3/Rx depending on drug cost | 6 Rxs/month except for persons in nursing facilities or participating in HCBS waivers | More than 3 prescriptions per month for non-institutionalized beneficiaries | AWP-14% for brand Rx, AWP-20% for generic Rx, plus $5.51 dispensing fee for each, additional $2.00 dispensing fee for generic Rx with no FUL or state MAC |
| California | Yes | CN & MN | $1/Rx | 6 Rxs/month | AWP-17%, plus $7.25 dispensing fee, non-traditional pharmacies receive an $8.00 dispensing fee | |
| Colorado | Yes | CN | $1/generic or multi-source Rx, $3/brand or single source Rx | Over the counter drugs other than insulin and aspirin, compounded Rxs | AWP-13.5% for brand Rx, AWP-35% for generic Rx, plus $4.00 dispensing fee for each, non-traditional pharmacies receive a $1.89 dispensing fee | |
| Connecticut | Yes | CN & MN | 30 day supply for acute conditions, 30 day supply or 240 dosage units for chronic conditions, | Vitamins, nutritional supplements, other specified drugs including amphetamines | AWP-14% for brand Rx, AWP-40% for generic Rx, plus $3.15 dispensing fee | |
| Delaware | Yes | CN | $.50-$3/Rx depending on drug cost, up to $15/month | Rx must be generic unless DAW | AWP-14% by retail pharmacies, AWP-16% by non-traditional pharmacies, plus $3.65 dispensing fee for each | |
| District of Columbia | Yes | CN & MN | $1/Rx | Specified drugs and injectables including Percodan and Dalmane | AWP-10%, plus $4.50 dispensing fee | |
| Florida | Yes | CN & MN | Step therapy required for some drugs not on PDL | Specified drugs | Lower of AWP-15.4% or WAC+5.75%, plus $4.23 dispensing fee for retail pharmacies or $4.73 dispensing fee for non-traditional pharmacies | |
| Georgia | Yes | CN & MN | $1-$3/Rx depending on drug cost and status | 5 Rxs or refills/month | Specified drugs | AWP-11%, plus $4.63 dispensing fee to for profit retail pharmacies, dispensing fee $.30 less to non-profit pharmacies |
| Guam | Yes | CN | Adult vitamins limited to pregnancy supplements | AWP, plus $4.40 dispensing fee | ||
| Hawaii | Yes | CN & MN | Specified drugs | AWP-10.5%, plus $4.67 dispensing fee | ||
| Idaho | Yes | CN | Specified drugs including amphetamines, high cost and therapeutic-equivalent drugs | AWP-12%, plus $4.94 dispensing fee, $5.54 dispensing fee if unit dose | ||
| Illinois | Yes | CN & MN | $3/brand Rx, $1/generic Rx | 3 brand Rxs/month | AWP-12%, plus $3.40 dispensing fee for brand Rx, AWP-25%, plus $4.60 dispensing fee for generic Rx | |
| Indiana | Yes | CN | $3/Rx | Specified drugs | AWP-16% for brand Rx, AWP-20% for generic Rx, plus $4.90 dispensing fee for each | |
| Iowa | Yes | CN & MN | $1/generic and preferred brand Rx, $2-$3/non-preferred brand Rx depending on payment | Specified drugs | AWP-12%, plus $4.26 dispensing fee | |
| Kansas | Yes | CN & MN | $3/Rx | 5 single-source Rxs/month, adult vitamins limited to pregnancy supplements | Specified drugs | AWP-13% for brand Rx, AWP-27% for generic Rx, plus $3.40 dispensing fee for each |
| Kentucky | Yes | A, B & C - See state-specific FN | $1/generic Rx; $2/preferred brand Rx; 5% of payment up to $20 for non-preferred brand Rx; annual out-of-pocket expense capped at $225 | 4 Rxs/month including up to 3 brand Rxs | Specified drugs, including amphetamines and over the counter products | AWP-15% for brand Rx plus $4.50 dispensing fee; AWP-14% for generic Rx plus $5.00 dispensing fee |
| Louisiana | Yes | CN & MN | $.50-$3/Rx depending on drug cost | 8 Rxs/month | Specified drugs | AWP-13.5% for independent pharmacies, AWP-15% for chain stores, plus $5.77 dispensing fee for each |
| Maine | Yes | CN & MN | $2.50/Rx, up to $25/month, no copayment required for mail order Rxs | 5 brand Rxs/month for residents in supervised settings | Non-preferred drugs | AWP-15% for brand Rx , AWP-13% for generic Rx, AWP-17% for direct supply drugs, plus $3.35 dispensing fee for each; AWP-60% for generic Rx and AWP-20% for brand Rx through mail order pharmacy, plus $1.00 dispensing fee for each |
| Maryland | Yes | CN & MN | $1/Rx for generic or preferred brand, $3/Rx for non-preferred brand | Specified quantity limits for selected drugs | Specified antibiotic liquids, some nutritional supplements | Lower of AWP-12% or WAC+8%, plus $3.69 dispensing fee for generic or preferred brand Rx by traditional pharmacies or $2.69 dispensing fee for non-preferred Rx, non-traditional pharmacies paid $1.00 more/Rx but only one dispensing fee/month |
| Massachusetts | Yes | CN & MN | $1/generic Rx or OTC product, $3/brand Rx | Specified drugs | WAC+5% plus $3.00 dispensing fee; 340B pharmacies paid drug cost plus $3.00 dispensing fee | |
| Michigan | Yes | CN & MN | $1/generic Rx, $3/brand Rx | AWP-13.5% for independent pharmacies, AWP-15.1% for chain stores, plus $2.50 dispensing fee for each, non-traditional pharmacies paid $2.75 dispensing fee | ||
| Minnesota | Yes | A & B - See state-specific FN | A - $1/generic Rx, $3/brand Rx, up to $12/month, antipsychotic Rxs not subject to copayments; B - $3/Rx with no cap and no exceptions - See state-specific FN | Non-preferred and brand Rx when generic available | AWP-12%, plus $3.65 dispensing fee; specialty drug products paid less - See state-specific FN | |
| Mississippi | Yes | CN | $3/Rx | 5 Rxs/month including 2 brand Rxs, limit not applicable to nursing facility residents | Specified drugs | AWP-12% or WAC+9% for brand Rx plus $3.91 dispensing fee; AWP-25% for generic Rx plus $4.91 dispensing fee; non-traditional pharmacies paid $3.91 dispensing fee |
| Missouri | Yes | CN | $.50-$2/Rx depending on drug cost | Lower of AWP-10.43% or WAC+10%, plus $4.09 dispensing fee | ||
| Montana | Yes | A & B - See state-specific FN | $1-$5/Rx depending on drug cost, up to $25 max per month | Specified drugs | AWP-15%, plus cost based dispensing fee between $2 and $4.70 | |
| Nebraska | Yes | CN & MN | $2/Rx | 90 day supply | Specified drugs | AWP-11%, plus pharmacy specific dispensing fee of $3.27-$5.00 |
| Nevada | Yes | CN | Specified drugs | AWP-15%, plus $4.76 dispensing fee | ||
| New Hampshire | Yes | CN & MN | $1/generic Rx, $2/brand or compound Rx | 30 day minimum supply up to 90 day maximum supply | Specified drugs | AWP-16%, plus $1.75 dispensing fee |
| New Jersey | Yes | CN & MN - See state-specific FN | Specified drugs including nutritional supplements and methadone | AWP-12.5%, plus pharmacy specific dispensing fee of $3.73-$4.07 depending on services provided, non-traditional pharmacies receive a capitated dispensing fee | ||
| New Mexico | Yes | CN | A - $3/Rx up to $12/month, B - $5/Rx - see state-specific FN | Rx must be generic unless DAW, mail order dispensing permitted | AWP-14%, plus $3.65 dispensing fee | |
| New York | Yes | CN & MN | $.50/generic Rx and over the counter product, $2/brand Rx | 40 Rxs/year | Specified drugs | AWP-13.25% for brand Rx, AWP-20% for generic Rx, plus $3.50 dispensing fee for brand Rx or $4.50 dispensing fee for generic Rx, specialized HIV pharmacies paid AWP-12% |
| North Carolina | Yes | CN & MN | $3/Rx | 8 Rxs/month, pharmacist may override for 3 additional if necessary | Specified high cost drugs | AWP-10%, plus $5.60 dispensing fee for generic Rx or OTC products; AWP-10%, plus $4.00 dispensing fee for brand Rx |
| North Dakota | Yes | CN & MN | $3/brand Rx | Adult vitamins limited to pregnancy supplements, smoking cessation products limited | AWP-10% or WAC+12.5%, plus $4.60 dispensing fee for brand Rx and $5.60 for generic Rx | |
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | 30 day supply | Non-preferred drugs | ||
| Ohio | Yes | CN | $2/selected brand Rx, $3/Rx if not on Preferred Drug List | Specified drugs | WAC+7% (or AWP-14.4% if WAC unknown), plus $3.70 dispensing fee for non-compounded Rx | |
| Oklahoma | Yes | CN | $1-$2/Rx, depending on drug cost | 6 Rxs/month including 3 brand Rxs, 7 additional generic Rxs/month for HCBS waiver participants | AWP-12%, plus $4.15 dispensing fee | |
| Oregon | Yes | A & B - See state-specific FN | A - $2/generic Rx, $3/brand Rx | 15 Rxs/month, 100 day supply | Specified drugs including nutritional supplements, growth hormones and anti-ulcer drugs | AWP-15%, plus $3.50 dispensing fee for traditional pharmacies, AWP-11%, plus $3.91 dispensing fee for non-traditional pharmacies |
| Pennsylvania | Yes | CN & MN | $1/generic Rx, $3/brand Rx | MN - limited to birth control drugs but nursing facility residents have no limitations | WAC+7% for brand Rx or WAC+66% for generic, plus $4.00 dispensing fee | |
| Puerto Rico | Yes | CN & MN | Maintenance drugs limited to 30 day supply | Specified high cost drugs and drugs not in plan formulary | AWP minus agreed upon discount and dispensing fees | |
| Rhode Island | Yes | CN & MN - see state-specific FN | Specified drugs and injectables | WAC, plus $3.40 dispensing fee for traditional pharmacies and $2.85 dispensing fee for non-traditional pharmacies | ||
| South Carolina | Yes | CN | $3/Rx | 4 Rxs/month | AWP-10%, plus $4.05 dispensing fee for traditional pharmacies and $3.15 dispensing fee for non-traditional pharmacies | |
| South Dakota | Yes | CN | $3/brand Rx | Adult vitamins limited to pregnancy supplements, OTCs not covered except insulin | Specified over the counter products | AWP-10.5%, plus $4.75 dispensing fee for traditional pharmacies and $5.55 dispensing fee for non-traditional pharmacies |
| Tennessee | Yes | A - See state-specific FN | $3/brand Rx | 5 Rxs/month including up to 2 brand Rx, specified additional drugs covered outside limit, OTCs not covered except for prenatal vitamins, barbiturates and benzodiazepines not covered | ||
| Texas | Yes | CN & MN | 3 Rxs/month | Lower of AWP-15% or WAC+12% for independent pharmacies, AWP-18% for chain stores, plus $5.14 dispensing fee | ||
| Utah | Yes | A, B & C - See state-specific FN | A - $3/Rx up to $15/month, B - $3/Rx, C - $5/generic or preferred brand Rx and 25% cost for others, B & C - full payment for brand when generic available | A & B - 7 Rxs/month, C - 4 Rxs/month, A & B - limited OTCs covered, C - OTCs not covered | AWP-15%, plus $3.90 dispensing fee for urban pharmacies or $4.40 dispensing fee for rural pharmacies | |
| Vermont | Yes | A & B - See state-specific FN | A - $1-$3 depending on drug cost | A & B - Rxs for chronic conditions must be at least 30 day supply, adult vitamins limited to pregnancy supplements, lowest price generic equivalent product must be dispensed | Specified drugs | AWP-11.9%, plus $4.75 dispensing fee for in-state pharmacies |
| U.S. Virgin Islands | Yes | CN | Rxs must be dispensed by public health operated or contracted pharmacies | Acquisition cost plus dispensing fee | ||
| Virginia | Yes | CN & MN | $1/generic Rx, $3/brand Rx | Rx must be generic unless DAW | Specified drugs | AWP-10.25%, plus $4.00 dispensing fee to traditional pharmacies or $5.00 per month dispensing fee to non-traditional pharmacies |
| Washington | Yes | CN & MN | Specified drugs | AWP-14% to traditional pharmacies or AWP-19% to mail order contractors for drugs available from fewer than 5 labelers or manufacturers, AWP-50% to traditional pharmacies or AWP-15% to mail order contractors for multi-source drugs, plus a dispensing fee to traditional pharmacies dependent on Medicaid volume (low and unit dose: $5.25, med: $4.56, high: $4.24), $3.25 dispensing fee to mail order contractors | ||
| West Virginia | Yes | CN & MN | $.50-$3/Rx depending on drug cost | 10 Rxs/month, specified OTCs covered | Specified drugs including vitamins, acute dosing of anti-ulcer drugs beyond 90 days and amphetamines | AWP-30%, plus $5.30 dispensing fee for generic Rx; AWP-15%, plus $2.50 dispensing fee for brand Rx; dispensing fee $1.00 more for compound Rxs |
| Wisconsin | Yes | CN & MN | $3/Rx up to $5/month, $.50/over the counter drug | Most drugs limited to 34 day supply with 100 day supply for some | Specified drugs, including antibiotics costing more than $100/day and nutritional supplements | AWP-16%, plus $3.88 dispensing fee |
| Wyoming | Yes | CN | $1/generic or preferred brand Rx, $3/non-preferred brand Rx | Non-preferred brand drugs, obesity products, over the counter drugs | AWP-11%, plus $5.00 dispensing fee |
2004
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 56 No - 0 | Yes - 40 No - 16 | ||||
| Alabama | Yes | CN | $1-$3/Rx depending on drug cost and status | 4 brand Rxs/month except brand antipsychotics and antiretrovirals up to 10 Rxs/month | Lower of AWP-10% or WAC+9.2%, plus $5.40 dispensing fee | |
| Alaska | Yes | CN | $2/Rx | Specified drugs | AWP-5%, plus a dispensing fee dependent on Medicaid volume ($3.45 to $11.46) | |
| American Samoa | Yes | See territory-specific FN | Prospective payment/Rx based on prior year cost | |||
| Arizona | Yes | CN & MN | AWP-15%, plus $2.00 dispensing fee | |||
| Arkansas | Yes | CN & MN | $.50-$3/Rx depending on drug cost | 6 Rxs/month except for persons in nursing facilities or participating in HCBS waivers | More than 3 prescriptions per month for non-institutionalized beneficiaries | AWP-14% for brand Rx, AWP-20% for generic Rx, plus $5.51 dispensing fee for each, additional $2.00 dispensing fee for generic Rx with no FUL or state MAC |
| California | Yes | CN & MN | $1/Rx | 6 Rxs/month | AWP-17%, plus $7.25 dispensing fee, non-traditional pharmacies receive a $8.00 dispensing fee | |
| Colorado | Yes | CN | $1/generic or multi-source Rx, $3/brand or single source Rx | Over the counter drugs other than insulin and aspirin, compounded Rxs | AWP-13.5% for brand Rx, AWP-35% for generic Rx, plus $4.00 dispensing fee for each, non-traditional pharmacies receive a $1.89 dispensing fee | |
| Connecticut | Yes | CN & MN | 30 day supply for acute conditions, 30 day supply or 240 dosage units for chronic conditions, | Vitamins, nutritional supplements, other specified drugs including amphetamines | AWP-12% for brand Rx, AWP-40% for generic Rx, plus $3.15 dispensing fee | |
| Delaware | Yes | CN | Rx must be generic unless DAW | AWP-14% by retail pharmacies, AWP-16% by non-traditional pharmacies, plus $3.65 dispensing fee for each | ||
| District of Columbia | Yes | CN & MN | $1/Rx | Specified drugs and injectables including Percodan and Dalmane | AWP-10%, plus $4.50 dispensing fee | |
| Florida | Yes | CN & MN | 4 brand Rxs/month | Specified drugs, nutritional supplements | Lower of AWP-13.25% or WAC+7%, plus $4.23 dispensing fee for retail pharmacies or $4.73 dispensing fee for non-traditional pharmacies | |
| Georgia | Yes | CN & MN | $.50/preferred drug or generic Rx, $.50-$3/non-preferred or brand Rx depending on drug cost | 5 Rxs or refills/month | Specified drugs | AWP-11%, plus $4.63 dispensing fee to for profit retail pharmacies, dispensing fee $.30 less to non-profit pharmacies |
| Guam | Yes | CN | Adult vitamins limited to pregnancy supplements | AWP, plus $4.40 dispensing fee | ||
| Hawaii | Yes | CN & MN | Specified drugs | AWP-10.5%, plus $4.67 dispensing fee | ||
| Idaho | Yes | CN | Specified drugs including amphetamines, high cost and therapeutic-equivalent drugs | AWP-12%, plus $4.94 dispensing fee, $5.54 dispensing fee if unit dose | ||
| Illinois | Yes | CN & MN | $3/brand Rx | AWP-12%, plus $3.40 dispensing fee for brand Rx, AWP-25%, plus $4.60 dispensing fee for generic Rx | ||
| Indiana | Yes | CN | $3/Rx | Specified drugs | AWP-13.5% for brand Rx, AWP-20% for generic Rx, plus $4.90 dispensing fee for each | |
| Iowa | Yes | CN & MN | $1/generic Rx, $.50-$3/brand Rx depending on payment | Specified drugs | AWP-12%, plus $4.26 dispensing fee | |
| Kansas | Yes | CN & MN | $3/Rx | 5 single-source Rxs/month, adult vitamins limited to pregnancy supplements | Specified drugs | AWP-13% for brand Rx, AWP-27% for generic Rx, plus $3.40 dispensing fee for each |
| Kentucky | Yes | CN & MN | $1/Rx | Specified drugs, including amphetamines and over the counter products | AWP-12%, plus $4.51 dispensing fee | |
| Louisiana | Yes | CN & MN | $.50-$3/Rx depending on drug cost | 8 Rxs/month | Specified drugs | AWP-13.5% for independent pharmacies, AWP-15% for chain stores, plus $5.77 dispensing fee for each |
| Maine | Yes | CN & MN | $2.50/Rx, up to $25/month, no copayment required for mail order Rxs | 5 brand Rxs/month for residents in supervised settings | AWP-15% for brand Rx , AWP-13% for generic Rx, AWP-17% for direct supply drugs, plus $3.35 dispensing fee for each; AWP-60% for generic Rx and AWP-20% for brand Rx through mail order pharmacy, plus $1.00 dispensing fee for each | |
| Maryland | Yes | CN & MN | $1/Rx for generic or preferred brand, $2/Rx for non-preferred brand | Specified quantity limits for selected drugs | Specified antibiotic liquids, some nutritional supplements | Lower of AWP-12% or WAC+8%, plus $3.69 dispensing fee for generic or preferred brand Rx by traditional pharmacies or $2.69 dispensing fee for non-preferred Rx, non-traditional pharmacies paid $1.00 more/Rx but only one dispensing fee/month |
| Massachusetts | Yes | CN & MN | $1/generic Rx or OTC product, $3/brand Rx | Specified drugs | WAC+5%, plus $3.00 dispensing fee | |
| Michigan | Yes | CN & MN | $1/Rx | AWP-13.5% for independent pharmacies, AWP-15.1% for chain stores, plus $3.77 dispensing fee for each | ||
| Minnesota | Yes | A & B - See state-specific FN | A - $1/generic Rx, $3/brand Rx, up to $12/month, antipsychotic Rxs not subject to copayments; B - $3/Rx with no cap and no exceptions - See state-specific FN | Non-preferred and brand Rx when generic available | AWP-11.5%, plus $3.65 dispensing fee | |
| Mississippi | Yes | CN | $1/generic Rx, $2/preferred brand Rx, $3/other brand Rx | 5 brand Rxs/month | Specified drugs | AWP-12%, plus $3.91 dispensing fee |
| Missouri | Yes | CN | $.50-$2/Rx depending on drug cost | Lower of AWP-10.43% or WAC+10%, plus $4.09 dispensing fee | ||
| Montana | Yes | A & B - See state-specific FN | $1-$5/Rx depending on drug cost, up to $25 max per month | Specified drugs | AWP-15%, plus cost based dispensing fee between $2 and $4.70 | |
| Nebraska | Yes | CN & MN | $2/Rx | 90 day supply | Specified drugs | AWP-11%, plus pharmacy specific dispensing fee of $3.27-$5.00 |
| Nevada | Yes | CN | Specified drugs | AWP-15%, plus $4.76 dispensing fee | ||
| New Hampshire | Yes | CN & MN | $1/generic Rx, $2/brand or compound Rx | 30 day minimum supply up to 90 day maximum supply | Specified drugs | AWP-16%, plus $1.75 dispensing fee |
| New Jersey | Yes | CN & MN - See state-specific FN | Specified drugs including nutritional supplements and methadone | AWP-12.5%, plus pharmacy specific dispensing fee of $3.73-$4.07 depending on services provided, non-traditional pharmacies receive a capitated dispensing fee | ||
| New Mexico | Yes | CN | B - $5/Rx - see state-specific FN | Rx must be generic unless DAW, mail order dispensing permitted | AWP-12.5%, plus $3.65 dispensing fee | |
| New York | Yes | CN & MN | $.50/generic Rx and over the counter product, $2/brand Rx | 40 Rxs/year | Specified drugs | AWP-12.75% for brand Rx, AWP-16.5% for generic Rx, plus $3.50 dispensing fee for brand Rx or $4.50 dispensing fee for generic Rx |
| North Carolina | Yes | CN & MN | $1/generic Rx and covered OTC products, $3/brand Rx | 6 Rxs/month, Rx must be generic unless DAW | Specified high cost drugs | AWP-10%, plus $5.60 dispensing fee for generic Rx or OTC products; AWP-10%, plus $4.00 dispensing fee for brand Rx |
| North Dakota | Yes | CN & MN | $3/brand Rx | Adult vitamins limited to pregnancy supplements, smoking cessation products limited | AWP-10%, plus $4.60 dispensing fee for brand Rx and $5.60 for generic Rx | |
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | 30 day supply | Non-preferred drugs | ||
| Ohio | Yes | CN | $2/selected brand Rx, $3/Rx if not on Preferred Drug List | Specified drugs | WAC+9% (or AWP-12.8% if WAC unknown), plus $3.70 dispensing fee | |
| Oklahoma | Yes | CN | $1-$2/Rx, depending on drug cost | 6 Rxs/month including 3 brand Rxs, 7 additional generic Rxs/month for HCBS waiver participants | AWP-12%, plus $4.15 dispensing fee | |
| Oregon | Yes | A & B - See state-specific FN | A - $2/generic Rx, $3/brand Rx | 15 Rxs/month, 100 day supply | Specified drugs including nutritional supplements, growth hormones and anti-ulcer drugs | AWP-15%, plus $3.50 dispensing fee for traditional pharmacies, AWP-11%, plus $3.91 dispensing fee for non-traditional pharmacies |
| Pennsylvania | Yes | CN & MN | $1/Rx | MN - limited to birth control drugs but nursing facility residents have no limitations | AWP-10%, plus $4.00 dispensing fee | |
| Puerto Rico | Yes | CN & MN | Specified high cost drugs and drugs not in plan formulary | Prospective payment/Rx based on prior year cost | ||
| Rhode Island | Yes | CN & MN - see state-specific FN | Specified drugs and injectables | WAC+5%, plus $3.40 dispensing fee for traditional pharmacies and $2.85 dispensing fee for non-traditional pharmacies | ||
| South Carolina | Yes | CN | $3/Rx | 4 Rxs/month, 34 day supply | AWP-10%, plus $4.05 dispensing fee for traditional pharmacies and $3.15 dispensing fee for non-traditional pharmacies | |
| South Dakota | Yes | CN | $2/Rx | Adult vitamins limited to pregnancy supplements, OTCs not covered except insulin | Specified over the counter products | AWP-10.5%, plus $4.75 dispensing fee for traditional pharmacies and $5.55 dispensing fee for non-traditional pharmacies |
| Tennessee | Yes | A & B - See state-specific FN | B1 - $5/Rx, B2 - $10/Rx | |||
| Texas | Yes | CN & MN | 3 Rxs/month | Lower of AWP-15% or WAC+12% for independent pharmacies, AWP-18% for chain stores, plus drug-cost based dispensing fee for each up to a state-specified ceiling | ||
| Utah | Yes | A, B & C - See state-specific FN | A - $3/Rx up to $15/month, B - $2/Rx, C - $5/generic or preferred brand Rx and 25% cost for others, B & C - full payment for brand when generic available | B - 7 Rxs/month, C - 4 Rxs/month, B & C - OTCs not covered | AWP-15%, plus $3.90 dispensing fee for urban pharmacies or $4.40 dispensing fee for rural pharmacies | |
| Vermont | Yes | A & B - See state-specific FN | A - $1-$3 depending on drug cost | Rxs for chronic conditions must be at least 30 day supply, adult vitamins limited to pregnancy supplements, lowest price generic equivalent product must be dispensed | Specified drugs | AWP-11.9%, plus $4.25 dispensing fee |
| U.S. Virgin Islands | Yes | CN | Rxs must be dispensed by public health operated or contracted pharmacies | Acquisition cost plus dispensing fee | ||
| Virginia | Yes | CN & MN | $1/generic Rx, $3/brand Rx | Rx must be generic unless DAW | Specified drugs | AWP-10.25%, plus $3.75 dispensing fee to traditional pharmacies or $5.00 dispensing fee to non-traditional pharmacies |
| Washington | Yes | CN & MN | Specified drugs | AWP-14% to traditional pharmacies or AWP-19% to mail order contractors for drugs available from fewer than 5 labelers or manufacturers, AWP-50% to traditional pharmacies or AWP-15% to mail order contractors for multi-source drugs, plus a dispensing fee to traditional pharmacies dependent on Medicaid volume (low and unit dose: $5.20, med: $4.51, high: $4.20), $3.25 dispensing fee to mail order contractors | ||
| West Virginia | Yes | CN & MN | $.50-$3/Rx depending on drug cost | 10 Rxs/month, 34 day supply, only specified OTCs covered | Specified drugs including vitamins, acute dosing of anti-ulcer drugs beyond 90 days and amphetamines | AWP-12%, plus $3.90 dispensing fee, dispensing fee $1.00 more for compounded Rxs |
| Wisconsin | Yes | CN & MN | $1/generic Rx and $3/brand Rx up to $5/month, $.50/over the counter drug | Most drugs limited to 34 day supply with 100 day supply for some | Specified drugs, including antibiotics costing more than $100/day and nutritional supplements | AWP-13%, plus $4.88 dispensing fee |
| Wyoming | Yes | CN | $1/generic Rx, $2/preferred brand Rx, $3/non-preferred brand Rx | Non-preferred brand drugs, obesity products, over the counter drugs | AWP-11%, plus $5.00 dispensing fee |
2003
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 56 No - 0 | Yes - 39 No - 17 | ||||
| Alabama | Yes | CN | $.50-$3/Rx depending on drug cost | Lower of AWP-10% or WAC+9.2%, plus $5.40 dispensing fee | ||
| Alaska | Yes | CN | $2/Rx | Specified drugs | AWP-5%, plus $3.45 dispensing fee | |
| American Samoa | Yes | See territory-specific FN | Prospective payment/Rx based on prior year cost | |||
| Arizona | Yes | CN & MN | Acquisition cost plus dispensing fee set by managed care plan | |||
| Arkansas | Yes | CN & MN | $.50-$3/Rx depending on drug cost | 6 Rxs/month except for persons in nursing facilities or participating in HCBS waivers | More than 3 prescriptions per month for non-institutionalized beneficiaries | AWP-14%, plus $5.51 dispensing fee for brand Rx, AWP-20%, plus $7.51 for generic Rx |
| California | Yes | CN & MN | $1/Rx | Most drugs limited to 100 day supply | AWP-10%, plus $3.55 dispensing fee | |
| Colorado | Yes | CN | $.75/generic or multi-source Rx, $3/brand or single source Rx | Over the counter drugs other than insulin and aspirin, compounded Rxs | AWP-13.5% for brand Rx, AWP-35% for generic Rx, plus $4.00 dispensing fee for each, non-traditional pharmacies receive a $1.89 dispensing fee | |
| Connecticut | Yes | CN & MN | 30 day supply for acute conditions, 30 day supply or 240 dosage units for chronic conditions, | Vitamins, nutritional supplements, other specified drugs including amphetamines | AWP-12%, or AWP-40% for generic Rx with MAC prices, plus $3.30 dispensing fee | |
| Delaware | Yes | CN | Rx must be generic unless DAW | AWP-14% by retail pharmacies, AWP-16% by non-traditional pharmacies, plus $3.65 dispensing fee for each | ||
| District of Columbia | Yes | CN & MN | $1/Rx | Specified drugs and injectables including Percodan and Dalmane | AWP-10%, plus $3.75 dispensing fee | |
| Florida | Yes | CN & MN | 4 brand Rxs/month | Nutritional supplements | Lower of AWP-13.25% or WAC+7%,plus $4.73 dispensing fee for drugs on state's list or $3.73 for drugs not on the list | |
| Georgia | Yes | CN & MN | $.50/preferred drug or generic Rx, $.50-$3/non-preferred or brand Rx depending on drug cost | 5 Rxs or refills/month | AWP-10%, plus $4.63 dispensing fee for brand Rx or $5.13 for generic Rx by for-profit retail pharmacies, dispensing fee $.30 less by non-profit pharmacies | |
| Guam | Yes | CN | Adult vitamins limited to pregnancy supplements | AWP, plus $4.40 dispensing fee | ||
| Hawaii | Yes | CN & MN | Specified drugs | AWP-10.5%, plus $4.67 dispensing fee | ||
| Idaho | Yes | CN | Specified drugs including amphetamines, high cost and therapeutic-equivalent drugs | AWP-12%, plus $4.94 dispensing fee | ||
| Illinois | Yes | CN & MN | $1/generic Rx, $3/brand Rx | AWP-12%, plus $3.40 dispensing fee for brand Rx, AWP-25%, plus $4.60 dispensing fee for generic Rx | ||
| Indiana | Yes | CN | $.50-$3/brand or single source Rx depending on payment, $.50/generic or compound Rx, $.50/over the counter drug | Specified drugs | AWP-13.5% for brand Rx, AWP-20% for generic Rx, plus $4.90 dispensing fee for each | |
| Iowa | Yes | CN & MN | $1/Rx | Specified drugs | AWP-10%, plus $5.17 dispensing fee | |
| Kansas | Yes | CN & MN | $3/Rx | Adult vitamins limited to pregnancy supplements | Specified drugs | AWP-11%, plus $3.40 dispensing fee |
| Kentucky | Yes | CN & MN | $1/Rx | Specified drugs, including amphetamines and over the counter products | AWP-12%, plus $4.51 dispensing fee | |
| Louisiana | Yes | CN & MN | $.50-$3/Rx depending on drug cost | 30 day supply or 100 dosage units, 8 Rxs/month | Specified drugs | AWP-13.5% for independent pharmacies, AWP-15% for chain stores, plus $5.77 dispensing fee for each |
| Maine | Yes | CN & MN | $2/generic or single source brand Rx, $3/multi-source brand Rx | 30 day supply for chronic conditions | AWP-13.5%, plus $3.35 dispensing fee | |
| Maryland | Yes | CN & MN | $2/brand Rx | Rx written as generic must be dispensed in least expensive therapeutically equivalent form, sexual dysfunction drugs limited to 6/month | Specified antibiotic liquids, some nutritional supplements | Lower of AWP-10% or WAC+10% or manufacturer direct price + 10%, plus $4.69 dispensing fee for generic Rx by retail pharmacies or $5.65 dispensing fee by non-traditional pharmacies, dispensing fees $1.00 less for brand Rx |
| Massachusetts | Yes | CN & MN | $2/Rx | Specified drugs | WAC+6%, plus $3.50 dispensing fee for brand Rx or $5.00 dispensing fee for generic Rx | |
| Michigan | Yes | CN & MN | $1/Rx | AWP-13.5% for independent pharmacies, AWP-15.1% for chain stores, plus $3.77 dispensing fee for each | ||
| Minnesota | Yes | A & B - See state-specific FN | A - $1/generic Rx, $3/brand Rx, up to $12/month, antipsychotic Rxs not subject to copayments; B - $3/Rx with no cap and no exceptions - See state-specific FN | Non-preferred and brand Rx when generic available | AWP-9%, plus $3.65 dispensing fee | |
| Mississippi | Yes | CN | $1/generic Rx, $3/brand Rx | 5 Rxs/month | Specified drugs | AWP-12%, plus $3.91 dispensing fee |
| Missouri | Yes | CN | $.50-$2/Rx depending on drug cost | Lower of AWP-10.43% or WAC+10%, plus $8.04 dispensing fee | ||
| Montana | Yes | CN & MN | $1-$5/Rx depending on drug cost, up to $25 max per month | Specified drugs | AWP-15%, plus cost based dispensing fee between $2 and $4.70 | |
| Nebraska | Yes | CN & MN | $2/Rx | 90 day supply | Specified drugs | AWP-11%, plus pharmacy specific dispensing fee of $3.27-$5.00 |
| Nevada | Yes | CN | Specified drugs | AWP-15%, plus $4.76 dispensing fee | ||
| New Hampshire | Yes | CN & MN | $.50/generic or single source brand Rx, $1/multi-source brand or compound Rx | 30 day minimum supply up to 90 day maximum supply | Specified drugs | AWP-12%, plus $2.50 dispensing fee |
| New Jersey | Yes | CN & MN - See state-specific FN | Specified drugs including nutritional supplements and methadone | AWP-10%, plus pharmacy specific dispensing fee of $3.73-$4.07 | ||
| New Mexico | Yes | CN | B - $2/Rx with annual maximum across all services based on income, see state-specific FN | Rx must be generic unless DAW | AWP-12.5%, plus $3.65 dispensing fee | |
| New York | Yes | CN & MN | $.50/generic Rx and over the counter product, $2/brand Rx | 40 Rxs/year | Specified drugs | AWP-10%, plus $3.50 dispensing fee for brand Rx or $4.50 dispensing fee for generic Rx |
| North Carolina | Yes | CN & MN | $1/generic Rx and covered OTC products, $3/brand Rx | 6 Rxs/month, Rx must be generic unless DAW | Specified high cost drugs | AWP-10%, plus $5.60 dispensing fee for generic Rx or OTC products; AWP-10%, plus $4.00 dispensing fee for brand Rx |
| North Dakota | Yes | CN & MN | $3/brand Rx | Adult vitamins limited to pregnancy supplements, smoking cessation products limited | AWP-10%, plus $4.60 dispensing fee | |
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | 30 day supply | Non-preferred drugs | ||
| Ohio | Yes | CN | Specified drugs | WAC+9% (or AWP-12.8% if WAC unknown), plus $3.70 dispensing fee | ||
| Oklahoma | Yes | CN & MN | $1/generic Rx, $2/brand Rx | 3 Rxs/month | AWP-12%, plus $4.15 dispensing fee | |
| Oregon | Yes | CN & MN | $2/generic Rx, $3/brand Rx | 100 day supply | Specified drugs including nutritional supplements, growth hormones and anti-ulcer drugs | AWP-14%, plus $3.50 dispensing fee by retail pharmacies, dispensing fee $.30 more by non-traditional pharmacies |
| Pennsylvania | Yes | CN & MN | $1/Rx | MN - limited to birth control drugs but nursing facility residents have no limitations | AWP-10%, plus $4.00 dispensing fee | |
| Puerto Rico | Yes | CN & MN | Specified high cost drugs and drugs not in plan formulary | Prospective payment/Rx based on prior year cost | ||
| Rhode Island | Yes | CN & MN - see state-specific FN | Specified drugs and injectables | WAC+5%, plus $3.40 dispensing fee for traditional pharmacies and $2.85 dispensing fee for non-traditional pharmacies | ||
| South Carolina | Yes | CN | $3/Rx | 4 Rxs/month, 34 day supply | AWP-10%, plus $4.05 dispensing fee | |
| South Dakota | Yes | CN | $2/Rx | Adult vitamins limited to pregnancy supplements, OTCs not covered except insulin | Specified over the counter products | AWP-10.5%, plus $4.75 dispensing fee |
| Tennessee | Yes | A & B - See state-specific FN | B1 - $5/Rx, B2 - $10/Rx | |||
| Texas | Yes | CN & MN | Lower of AWP-15% or WAC+12% for independent pharmacies, AWP-18% for chain stores, plus drug-cost based dispensing fee for each up to a state-specified ceiling | |||
| Utah | Yes | A, B & C - See state specific FN | A - $1/Rx up to $5/month, B - $2/Rx up to $7/month, C - $5/generic or preferred brand Rx and 25% cost for others, B & C - full payment for brand when generic available | B - 7 Rxs/month, C - 4 Rxs/month, B & C - OTCs not covered | AWP-15%, plus $3.90 dispensing fee for urban pharmacies or $4.40 dispensing fee for rural pharmacies | |
| Vermont | Yes | A & B - See state-specific FN | A - $1/Rx costing up to $30 and $2/Rx costing more, B - 60% Rx cost up to $750/year individual and $1,500/family | Rxs for chronic conditions must be at least 30 day supply, adult vitamins limited to pregnancy supplements, lowest price generic equivalent product must be dispensed | Specified drugs | AWP-11.9%, plus $4.25 dispensing fee |
| U.S. Virgin Islands | Yes | CN | Rxs must be dispensed by public health operated or contracted pharmacies | Acquisition cost plus dispensing fee | ||
| Virginia | Yes | CN & MN | $1/Rx | Rx must be generic unless DAW | Specified drugs | AWP-10.25%, plus $4.25 dispensing fee |
| Washington | Yes | CN & MN | Specified drugs | AWP-11% with full AWP for specified drugs, plus a dispensing fee dependent on Medicaid volume (low:$5.12, med:$4.44, high:$4.14) | ||
| West Virginia | Yes | CN & MN | $.50-$2/Rx depending on drug cost | 10 Rxs/month, 30 day supply, only specified OTCs covered | Specified drugs including vitamins, acute dosing of anti-ulcer drugs beyond 90 days and amphetamines | AWP-12%, plus $3.90 dispensing fee |
| Wisconsin | Yes | CN & MN | $1/Rx up to $5/month and $.50/over the counter drug | Most drugs limited to 34 day supply with 100 day supply for some | Specified drugs, including antibiotics costing more than $100/day and nutritional supplements | AWP-11.25%, plus $4.38 dispensing fee |
| Wyoming | Yes | CN | $2/Rx | Obesity products, over the counter drugs | AWP-11%, plus $5.00 dispensing fee |