How State Medicaid Programs are Managing Prescription Drug Costs: Results from a State Medicaid Pharmacy Survey for State Fiscal Years 2019 and 2020

Kathleen Gifford, Anne Winter, Linda Wiant, Rachel Dolan, Marina Tian, and Rachel Garfield
Published: Apr 29, 2020

Appendix Table 1: Drugs/Classes Carved Out of MCO Benefit, July 1, 2019
State	Hemophilia Factor	Hepatitis C Antivirals	HIV/AIDs Antiretrovirals	Mental Health Drugs	Medication Assisted Therapy (MAT) Drugs	Oncology Drugs	Other Drugs/ Classes Carved Out
Alabama
Alaska
Arizona	X						Exondys 51, Spinraza, medications to treat Gaucher Disease
Arkansas
California	X		X	X	X
Colorado
Connecticut
Delaware
DC			X
Florida	X
Georgia
Hawaii
Idaho
Illinois
Indiana	X	X					Exondys 51, Spinraza, Kalydeco, Orkambi, Symdeko, CAR-T therapies, Luxturna, Zolgensma
Iowa							Zolgensma
Kansas
Kentucky
Louisiana
Maine
Maryland			X	X	X		Spinraza, Cinryze, and Zolgensma*
Massachusetts
Michigan	X	X	X	X	X	X
Minnesota
Mississippi	X
Missouri
Montana
Nebraska
Nevada
New Hampshire	X						Carbaglu, Ravicti
New Jersey	X
New Mexico
New York
North Carolina
North Dakota
Ohio							Zolgensma
Oklahoma
Oregon				X
Pennsylvania
Rhode Island
South Carolina		X
South Dakota
Tennessee
Texas							Medicaid wrap-around services for outpatient drugs and biological products for STAR+PLUS members
Utah	NR	NR	NR	NR	NR	NR	NR
Vermont
Virginia
Washington	X	X					Zolgensma, Yescarta, Crysvita, Brineura, Radicava, Revcovi, Gamifant, Exondys 51, Lutathera, Spinraza, Palynziq, Kymriah, Luxturna
West Virginia
Wisconsin
Wyoming
Totals	9	4	4	4	3	1
NOTES: States that cover pharmacy through managed care were asked to report drug classes that were carved out as of July 1, 2019. “NR” = Not Reporting; “DF” = dispensing fee. *MD reported planned implementation of carve-out in January 2020. SOURCE: KFF / Health Management Associates 2019 Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, April 2020.

Appendix Table 2: Pharmacy Vendor Responsibilities, July 1, 2019
State	Utilization Management	Claims Payment	DUR	Rebate Admin	PDL Management	DUR Board/P&T Committee Support	Fraud, Waste, Abuse	Network Management	Other
Alabama	X	X	X						X
Alaska		X
Arizona	X	X	X				X	X
Arkansas	X	X	X	X	X	X			X
California
Colorado	X	X		X	X	X
Connecticut	X	X	X	X	X	X		X
Delaware	X	X	X	X	X	X		X
DC	X	X		X	X	X	X	X
Florida	X		X	X	X	X
Georgia	X	X	X		X	X	X
Hawaii	X	X		X
Idaho	X	X	X	X	X	X
Illinois	X	X	X	X
Indiana	X	X	X	X	X	X	X	X	X
Iowa	X	X	X	X	X	X			X
Kansas	X	X	X	X	X	X	X	X
Kentucky	X	X	X	X	X	X	X
Louisiana	X	X	X	X	X	X		X
Maine	X	X	X		X	X
Maryland	X		X	X	X	X	X		X
Massachusetts		X		X				X
Michigan	X	X	X	X	X	X	X		X
Minnesota	X		X		X	X
Mississippi	X	X		X			X
Missouri	X	X	X		X	X
Montana	X	X	X		X	X			X
Nebraska	X	X	X		X	X	X
Nevada	X	X	X	X	X	X
New Hampshire	X	X	X	X	X	X
New Jersey	X	X	X					X
New Mexico		X		X				X
New York	X	X	X	X	X	X			X
North Carolina		X
North Dakota	X	X		X	X		X
Ohio	X	X	X	X	X	X			X
Oklahoma	X	X		X	X	X			X
Oregon	X	X	X
Pennsylvania		X		X		X
Rhode Island	X		X	X	X	X	X
South Carolina	X	X	X	X	X	X	X
South Dakota		X		X					X
Tennessee	X	X	X	X	X	X	X	X	X
Texas	X		X	X	X	X		X	X
Utah	NR	NR	NR	NR	NR	NR	NR	NR	NR
Vermont	X	X	X	X	X	X			X
Virginia	X	X	X	X	X	X
Washington		X
West Virginia	X	X	X	X	X	X		X
Wisconsin	X	X	X	X	X	X
Wyoming	X	X	X	X	X	X	X	X
Totals	42	44	36	36	35	35	15	14	14
NOTES: States that reported contracting with a vendor to administer the FFS pharmacy benefit were asked to report which services were provided by a vendor as of July 1, 2019. “NR” = Not Reporting. SOURCE: KFF / Health Management Associates 2019 Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, April 2020.

Appendix Table 3: PBM Transparency Requirements in Place, July 1, 2019
State	Spread Pricing Arrangements Prohibited as of 7/1/2019?	PBM Transparency/Reporting Requirements in Place FY 2020?	FY 2020 Comments
Alabama	N/A	N/A
Alaska	N/A	N/A
Arizona	No	Yes	MCOs will report the amount paid by the PBM to the network pharmacy in FY 2020.
Arkansas	No	Yes	Legislation effective 7/24/19 to prevent spread pricing. Spread pricing currently reported and attested to each month.
California	No	No
Colorado	NR	NR	NR
Connecticut	N/A	N/A
Delaware	No	Yes	MCO must report actual paid amout to provider on submitted encounter claim.
DC	No	No
Florida	No	Yes	PBM financial records are inspected and audited regarding all financial terms and arrangements with the PBM. Pharmacies have encounter claim submission requirements. MCOs must submit compliance reports.
Georgia	Yes	Yes	State legislature requires aggregrate reporting of pharmacy expenditures.
Hawaii	No	No
Idaho	N/A	N/A
Illinois	No	Yes	New statutory regulatory transparency requirements on PBMs are effective 07/01/2020. No changes to MCO contracts/requirements.
Indiana	No	Yes	Annually, MCOs are required to provide the Medicaid agency with the aggregate amount paid to pharmacies.
Iowa	Yes	No
Kansas	Yes	Yes	Pass-through pricing on encounters with requirement for a basis of cost determination and a reimbursement policy give specific reimbursement direction to the MCO and PBM, which therefore limits spread pricing. The state fiscal agent also system checks all MCO encounters based on state policy.
Kentucky	No	Yes	MCOs are required to submit aggregated data via template to the department on a monthly basis.
Louisiana	Yes	Yes	MCOS are legislatively mandated to submit transparency reports.
Maine	N/A	N/A
Maryland	No	Yes	Effective 2021, MCOS must eliminate spread pricing from contracts. The state is adding the requirement to contracts effective 1/1/2020, allow one year to come into compliance.
Massachusetts	No	Yes	MCOs have a reporting requirement.
Michigan	Yes	Yes	PBM spread pricing prohibition reporting will be expanded and inclusion of PBM contract disclosure provisions was added.
Minnesota	Yes	Yes	A new PBM licensure law was passed during the 2019 legislative session.
Mississippi	Yes	Yes	MCOs have a monthly reporting requirement to Division of Medicaid.
Missouri	N/A	N/A
Montana	N/A	N/A
Nebraska	No	Yes	MCOs must submit monthly PDL load report, pharmacy claims report, and quarterly PDL compliance report.
Nevada	No	No
New Hampshire	No	Yes	MCOs must report encounter data and claims payment data to the Department.
New Jersey	Yes	No
New Mexico	No	Yes	MCOs are required to report quarterly to our State Medicaid Agency.
New York	No	Yes	MCOs (and their subcontracted PBMs) will be subject to quarterly reporting, which will require the disclosure of all sources and amounts of income, payments and financial benefits paid to the PBM for PBM services rendered on behalf of the MCO. This includes all rebates, clawbacks, credits, manufacturer fees, administrative payments, and other income streams or benefits received by the PBM.
North Carolina	N/A	N/A
North Dakota	Yes	No
Ohio	Yes	Yes	MCOs have financial reporting requirements, etc.
Oklahoma	N/A	N/A
Oregon	No	Yes	Additional MCO requirements were written into the 2020 MCO contracts.
Pennsylvania	No	Yes	The 2019 MCO Agreement requires quarterly transparency reporting as well as ongoing transparent outpatient drug encounters submission. The encounters must include the ingredient cost and dispensing fee paid to the dispensing provider.
Rhode Island	No	No
South Carolina	No	Yes	MCO contracts require MCOs to provide claim-level pharmacy reimbursement detail, reflecting the amount paid by the PBM to the pharmacy provider.
South Dakota	N/A	N/A
Tennessee	N/A	N/A
Texas	Yes	Yes	There are multiple accounting and financial reporting requirements in the Uniform Managed Care Contract. This includes financial disclosures for pharmacy services.
Utah	NR	NR	NR
Vermont	N/A	N/A
Virginia	No	Yes	MCOs must submit to the Agency, the PBM paid amount to the pharmacy for the drug and the dispensing.
Washington	No	Yes	Plans are required to report the spread kept by the PBM to the Agency.
West Virginia	N/A	N/A
Wisconsin	N/A	N/A
Wyoming	N/A	N/A
NOTES: States were asked to report if spread pricing arrangements in MCO subcontracts with PBMs were prohibited and if MCOs are subject to other PBM transparency requirements as of July 1, 2019. Spread pricing refers to the difference between the payment the PBM receives from the MCO and the reimbursement amount it pays to the pharmacy dispensing to the beneficiary. “NR” = Not Reporting. SOURCE: KFF / Health Management Associates 2019 Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, April 2020.

Appendix Table 4: State Entity Responsible for Review, July 1, 2019
State	New PDL Drugs	Step Therapy Criteria	PA Criteria	Orphan/Expedited Review Drugs
Alabama	P&T Committee	Medicaid agency	Medicaid agency	Medicaid agency
Alaska	P&T Committee	DUR Board	DUR Board	Medicaid agency
Arizona	P&T Committee	P&T Committee	Other	P&T Committee
Arkansas	Other	N/A — No Step Therapy	DUR Board	DUR Board
California	Medicaid agency	Medicaid agency	Medicaid agency	Medicaid agency
Colorado	P&T Committee	DUR Board	DUR Board	DUR Board
Connecticut	P&T Committee	Other	Medicaid agency	Other
Delaware	P&T Committee	DUR Board	Medicaid agency	Medicaid agency
DC	P&T Committee	DUR Board	DUR Board	DUR Board
Florida	P&T Committee	DUR Board	Medicaid agency	Medicaid agency
Georgia	DUR Board	Medicaid agency	Medicaid agency	DUR Board
Hawaii	N/A — No PDL	N/A — No Step Therapy	NR	Medicaid agency
Idaho	P&T Committee	Medicaid agency	Medicaid agency	P&T Committee
Illinois	P&T Committee	DUR Board	Medicaid agency	P&T Committee
Indiana	Other	Other	Other	Other
Iowa	P&T Committee	P&T Committee	DUR Board	Other
Kansas	Medicaid agency	Medicaid agency	Other	Other
Kentucky	P&T Committee	P&T Committee	P&T Committee	P&T Committee
Louisiana	P&T Committee	N/A — No Step Therapy	Other	P&T Committee
Maine	P&T Committee	P&T Committee	P&T Committee	DUR Board
Maryland	P&T Committee	Medicaid agency	Medicaid agency	Other
Massachusetts	Medicaid agency	Medicaid agency	Medicaid agency	Medicaid agency
Michigan	Other	Other	Other	Other
Minnesota	P&T Committee	N/A — No Step Therapy	P&T Committee	P&T Committee
Mississippi	P&T Committee	Other	Other	Other
Missouri	Medicaid agency	Medicaid agency	Medicaid agency	Medicaid agency
Montana	Medicaid agency	DUR Board	DUR Board	DUR Board
Nebraska	P&T Committee	Other	Other	Medicaid agency
Nevada	P&T Committee	Medicaid agency	DUR Board	DUR Board
New Hampshire	Medicaid agency	Medicaid agency	Medicaid agency	Other
New Jersey	N/A — No PDL	DUR Board	DUR Board	Medicaid agency
New Mexico	N/A — No PDL	N/A — No Step Therapy	Other	Other
New York	DUR Board	DUR Board	DUR Board	Other
North Carolina	P&T Committee	Medicaid agency	Medicaid agency	P&T Committee
North Dakota	DUR Board	DUR Board	DUR Board	Medicaid agency
Ohio	P&T Committee	P&T Committee	P&T Committee	Medicaid agency
Oklahoma	DUR Board	DUR Board	DUR Board	DUR Board
Oregon	P&T Committee	P&T Committee	P&T Committee	P&T Committee
Pennsylvania	P&T Committee	P&T Committee	DUR Board	DUR Board
Rhode Island	P&T Committee	P&T Committee	P&T Committee	Other
South Carolina	P&T Committee	Medicaid agency	Medicaid agency	Medicaid agency
South Dakota	N/A — No PDL	P&T Committee	P&T Committee	P&T Committee
Tennessee	P&T Committee	P&T Committee	P&T Committee	P&T Committee
Texas	DUR Board	DUR Board	DUR Board	Medicaid agency
Utah	NR	NR	NR	NR
Vermont	DUR Board	DUR Board	DUR Board	DUR Board
Virginia	P&T Committee	P&T Committee	Other	DUR Board
Washington	Other	Medicaid agency	Medicaid agency	Medicaid agency
West Virginia	P&T Committee	DUR Board	DUR Board	DUR Board
Wisconsin	Medicaid agency	Medicaid agency	Medicaid agency	Medicaid agency
Wyoming	P&T Committee	P&T Committee	P&T Committee	Medicaid agency
NOTES: States were asked to indicate the entity reponsible for new drugs for PDL placement, step therapy criteria, PA criteria and orphan/expedited review drugs as of July 1, 2019. Pharmacy and therapeutics (P&T) committees or drug utilization review (DUR) board are committees of physicians and pharmacists that help inform the development of the PDL, review drugs, and develop coverage decisions. “NR” = Not Reporting. This table has been modified for states that say “other” and don’t have have PDL Committee, Step Therapy, and PA criteria SOURCE: KFF / Health Management Associates 2019 Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, April 2020.

Appendix Table 5: Frequency of Reviews, July 1, 2019
State	New PDL Drugs	Step Therapy Criteria	PA Criteria	Comments
Alabama	Other	As needed	As needed	Quarterly PDL meetings
Alaska	Annually	As needed	As needed
Arizona	Annually	Annually	As needed
Arkansas	Other	N/A — no step therapy	As needed	PDL or DRC meets and reviews quarterly
California	As needed	As needed	As needed
Colorado	Other	Other	Other	PDL drug classes at least annually; non-PDL varies
Connecticut	Annually	As needed	As needed
Delaware	Annually	As needed	As needed
DC	Other	As needed	As needed	Quarterly PDL meetings
Florida	Annually	As needed	As needed	Quantity and age limitation recommendations are reviewed as needed.
Georgia	Other	Other	Other	PDL reviewed quarterly; completion of entire PDL review yearly
Hawaii	N/A — no PDL	N/A — no step therapy	As needed
Idaho	Annually	Other	Other	Department creates all step edits and criteria. The P&T committee suggests changes for specific drugs during PDL review of that drug.
Illinois	As needed	As needed	As needed
Indiana	Other	As needed	As needed	Therapeutics Committee reviews PDL biannually
Iowa	Annually	Annually	Annually
Kansas	As needed	As needed	As needed
Kentucky	Annually	As needed	As needed
Louisiana	Annually	N/A — no step therapy	As needed
Maine	Other	Other	Other	Quarterly meetings and an annual meeting
Maryland	Annually	As needed	As needed	Only drugs from PDL classes reviewed by P&T Committee. Internal agency process for clinical criteria review for most drugs (95%+). The internal agency committee meets monthly and is comprised of physicians and pharmacists.
Massachusetts	As needed	As needed	As needed	Therapeutic classes reviewed when new drugs enter the class or as needed (at least bi-annually).
Michigan	Annually	Annually	Annually
Minnesota	As needed	N/A — no step therapy	As needed
Mississippi	Other	As needed	Annually	Quarterly PDL reviews
Missouri	Annually	Annually	As needed
Montana	Annually	As needed	As needed
Nebraska	Other	As needed	As needed	PDL reviewed biannually
Nevada	Other	NR	Other	The PDL and PA criteria are reviewed by each Board on a quarterly basis.
New Hampshire	Other	As needed	As needed	The PDL reviewed at each DUR Board Meeting.
New Jersey	N/A — no PDL	As needed	As needed
New Mexico	N/A — no PDL	N/A — no step therapy	As needed
New York	As needed	As needed	As needed
North Carolina	Annually	Other	Other	Step therapy and PA criteria are reviewed monthly by the P&T Committee
North Dakota	Annually	Annually	Annually
Ohio	Other	Other	Other	Quarterly reviews
Oklahoma	As needed	Annually	Annually	Every category reviewed annually for changes
Oregon	As needed	As needed	As needed
Pennsylvania	Annually	NR	As needed
Rhode Island	Annually	As needed	As needed
South Carolina	As needed	As needed	As needed
South Dakota	N/A — no PDL	Annually	Annually
Tennessee	Other	Other	Other	The P&T Committee meets once per quarter to address PDL, Step therapy, and/or PA criteria for established classes and new drugs to market.
Texas	Other	NR	Other	The DUR Board meets quarterly to develop and submit recommendations for the Texas Medicaid preferred drug list and clinical prior authorizations on outpatient prescription drugs.
Utah	NR	NR	NR
Vermont	Other	Other	Other	Class reviews occur at least every 2 years. Meetings are about every six weeks.
Virginia	Annually	Annually	Annually
Washington	Other	Other	Other	Intent to review all at least annually
West Virginia	Annually	Annually	As needed
Wisconsin	Other	As needed	As needed	The PDL is reviewed on a semi-annual basis
Wyoming	Annually	As needed	As needed
NOTES: States were asked how often PDLs, step therapy criteria and PA criteria are reviewed by DUR boards and/or P&T committees as of July 1, 2019. Pharmacy and therapeutics (P&T) committees or drug utilization review (DUR) board are committees of physicians and pharmacists that help inform the development of the PDL, review drugs, and develop coverage decisions. “NR” = Not Reporting. SOURCE: KFF / Health Management Associates 2019 Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, April 2020.

Appendix Table 6: States Limiting Number of FFS Prescriptions, July 1, 2019
State	Description of Limit	Can Limit Be Overriden?	Drug/Drug Classes or Individuals Exempted
Alabama	Limit of 5 prescriptions per month for adults.	No	Antiretrovirals, anticonvulsants, antipsychotics, maintenance drugs
Arkansas	Limit of 3 presciptions per month for adults with extension of benefits for up to 6 prescriptions maximum.	No	Medications for tobacco cessation, family planning
California	Limit of 6 prescriptions per month.	Yes	Nursing facility patients, adult and pediatric subacute care patients Family planning drugs, drugs for the treatment of Acquired Immune Deficiency Syndrome (AIDS) or AIDS-related conditions, cancer drugs Claims for newborns when the baby uses the mother’s identification number, claims that must be submitted on paper (claims with required attachments)
Florida	Limit on controlled substances of 4 fills per month for all recipients excluding recipients with a diagnosis of sickle cell or cancer.	Yes	Recipients with sickle cell or cancer recipients may receive 6 fills per month.
Georgia	Limit of 5 narcotic prescriptions per month.	Yes	None
Illinois	Limit of 4 presciptions per month, additional prescriptions require review.	Yes	Antipsychotics, antirejection drugs, antiretrovirals, antineoplastics
Kansas	Limit of 4 single-source drugs per month.	Yes	EPSDT beneficiaries, antiretroviral drugs, preferred PDL drugs, anti-rejection drugs used for transplant patients, state specified anti-emetics and chemotherapy drugs, interferons, immune globulins, antihemophilic drugs, mental health drugs, all contraceptives
Louisiana	Limit of 4 prescriptions per month.	Yes	Beneficiaries under 21, beneficiaries in Long Term Care, pregnant women
Mississippi	Limit of 6 prescriptions per month with no more than 2 brand-name drugs.	No	Preferred brands on the PDL do not count toward the 2 brand limit. Limit does not apply to beneficiaries in a LTC facility. EPSDT beneficiaries may receive prescriptions beyond the limit with prior authorization.
Oklahoma	Limit of 6 prescriptions per month with no more than 2 brand-name drugs. For HCBS waiver recipients, limit of 3 brand-name drugs and 10 generic drugs per month.	Yes	Antiretrovirals, hemophilia medications, oncology drugs, birth control, smoking cessation products
Tennessee	Limit of 5 prescriptions per month with no more than 2 brand-name drugs for adults 21 and over who are not in an institution or HCBS waiver.	Yes	Antidepressants, antineoplastics, antiparkinsonian agents, antitubercular agents,antivirals and antiretrovirals, cardiovascular agents, clotting factor, contraceptives, insulins, oral hypoglycemics, dialysis medications, flu vaccine, hematopoietic agents, Hepatitis C drugs, immunosuppressives, iron preparations, lipotropics, long-acting antipsychotics, respiratory drugs, smoking cessation products, thyroid hormones, transplant agents, and other miscellanious agents (MAT therapy, narcan, asthma and diabetics supplies, inhaled antibiotics, and pancreatic enzymes)
Texas	Limit of 3 prescriptions per month for adults.	No	No
Wisconsin	Limit of 5 opioid prescription fills per month.	Yes	Schedule II – V opioids are included, with the exception of suboxone film and tablet, buprenorphine tablet, methadone solution, and opioid antitussive liquid
NOTES: ‘NOTES: States were asked if there is a monthly or other limit on the number of FFS prescriptions an enrollee may receive as of July 1, 2019. “NR” = not reporting; “HCBS waiver” = Section 1915(c) Home and Community based Services waiver. SOURCE: KFF / Health Management Associates 2019 Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, April 2020.

Appendix Table 7: FFS Policies/Tools to Promote Generic Utilization, July 1, 2019
State	Mandatory Generics	Lower Copays for Generics	Provider Education	PDL Placement	Higher DF for Generic Substitution	Tiered DF Based on Generic Util.	Other	No Policies or Tools
Alabama	X
Alaska	X		X
Arizona	X
Arkansas	X	X	X		X
California								X
Colorado	X
Connecticut	X		X
Delaware	X
DC	X		X
Florida				X
Georgia	X
Hawaii	X		X
Idaho							X
Illinois	X	X			X
Indiana	X
Iowa				X
Kansas	X
Kentucky	X	X
Louisiana	X		X	X
Maine	X						X
Maryland	X	X
Massachusetts	X						X
Michigan		X	X
Minnesota	X	X
Mississippi	X		X
Missouri	X				X
Montana	X	X
Nebraska	X	X
Nevada								X
New Hampshire								X
New Jersey	X
New Mexico	X		X
New York	X	X	X
North Carolina	X					X
North Dakota	X	X
Ohio	X	X
Oklahoma	X		X
Oregon	X
Pennsylvania	X	X
Rhode Island	X
South Carolina	X		X
South Dakota	X	X
Tennessee	X	X	X
Texas	X			X
Utah	NR	NR	NR	NR	NR	NR	NR	NR
Vermont				X
Virginia	X	X
Washington
West Virginia	X
Wisconsin	X	X
Wyoming	X	X
Totals	41	17	13	5	3	1	3	3
NOTES: States were asked to report policies or tools used to promote generic drug utilization as of July 1, 2019. “NR” = Not Reporting; “DF” = dispensing fee SOURCE: KFF / Health Management Associates 2019 Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, April 2020.

Appendix Table 8: Supplemental Rebate Programs, July 1, 2019
State	Supplemental Rebate Program in Place?	Supplemental Rebate Negotiator	Negotiator Competively Procured?
Alabama	Yes	Medicaid Agency	No
Alaska	Yes	Other Vendor	Yes
Arizona	Yes	Multiple Entities	Yes
Arkansas	Yes	Other Vendor	Yes
California	Yes	Medicaid Agency	No
Colorado	Yes	PBM	Yes
Connecticut	Yes	Purchasing Pool	Yes
Delaware	Yes	Purchasing Pool	Yes
DC	Yes	Purchasing Pool	Yes
Florida	Yes	Other Vendor	Yes
Georgia	Yes	Multiple Entities	Yes
Hawaii	No	N/A	N/A
Idaho	Yes	Purchasing Pool	Yes
Illinois	Yes	Medicaid Agency	No
Indiana	Yes	PBM	Yes
Iowa	Yes	Purchasing Pool	Yes
Kansas	Yes	Medicaid Agency	No
Kentucky	Yes	Purchasing Pool	Yes
Louisiana	Yes	Purchasing Pool	Yes
Maine	Yes	Purchasing Pool	Yes
Maryland	Yes	Purchasing Pool	No
Massachusetts	Yes	Medicaid Agency	No
Michigan	Yes	PBM	Yes
Minnesota	Yes	Purchasing Pool	Yes
Mississippi	Yes	Purchasing Pool	Yes
Missouri	Yes	Other Vendor	Yes
Montana	Yes	Purchasing Pool	Yes
Nebraska	Yes	Purchasing Pool	Yes
Nevada	Yes	PBM	No
New Hampshire	Yes	Purchasing Pool	Yes
New Jersey	No	N/A	N/A
New Mexico	No	N/A	N/A
New York	Yes	PBM	Yes
North Carolina	Yes	Purchasing Pool	No
North Dakota	Yes	Purchasing Pool	Yes
Ohio	Yes	Purchasing Pool	No
Oklahoma	Yes	Purchasing Pool	No
Oregon	Yes	Purchasing Pool	Yes
Pennsylvania	Yes	Other Vendor	Yes
Rhode Island	Yes	Purchasing Pool	No
South Carolina	Yes	Purchasing Pool	Yes
South Dakota	No	N/A	N/A
Tennessee	Yes	Multiple Entities	Yes
Texas	Yes	Other Vendor	Yes
Utah	NR	NR	NR
Vermont	Yes	Purchasing Pool	Yes
Virginia	Yes	PBM	Yes
Washington	Yes	Multiple Entities	Yes
West Virginia	Yes	Other Vendor	Yes
Wisconsin	Yes	Purchasing Pool	Yes
Wyoming	Yes	Purchasing Pool	Yes
NOTES:States were asked if they have supplemental rebate agreements in place, what entity negotiates supplemental rebates and if the state’s negotiator is selected through competitive procurement as of July 1, 2019. “NR” = Not Reporting. SOURCE: KFF / Health Management Associates 2019 Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, April 2020.

Appendix Table 9: MCO Rebate Requirements, July 1, 2019
State	MCOs permitted to negotiate rebates?	PBM required to pass-through supplemental rebates?	MCO required to report aggregate rebates?
Alabama	N/A — no MCOs	N/A — no MCOs	N/A — no MCOs
Alaska	N/A — no MCOs	N/A — no MCOs	N/A — no MCOs
Arizona	Yes — for other PDL drugs but not uniform classes	Yes	Yes
Arkansas	No — not for any drugs	N/A	N/A
California	Yes	Yes	Yes
Colorado	NR	NR	NR
Connecticut	N/A — no MCOs	N/A — no MCOs	N/A — no MCOs
Delaware	Yes — for other PDL drugs but not uniform classes	No	No
DC	Yes	No	No
Florida	No — not for any drugs	N/A	N/A
Georgia	Yes	No	No
Hawaii	Yes	Yes	Yes
Idaho	N/A — no MCOs	N/A — no MCOs	N/A — no MCOs
Illinois	Yes	No	No
Indiana	Yes	No	No
Iowa	No — not for any drugs	N/A	N/A
Kansas	Yes — for uniform classes and other PDL drugs	Yes	Yes
Kentucky	Yes	No	Yes
Louisiana	No — not for any drugs	N/A	N/A
Maine	N/A — no MCOs	N/A — no MCOs	N/A — no MCOs
Maryland	Yes	No	Yes
Massachusetts	Yes — for other PDL drugs but not uniform classes	No	Yes
Michigan	Yes	No	No
Minnesota	Yes — for other PDL drugs but not uniform classes	Yes	Yes
Mississippi	No — not for any drugs	N/A	N/A
Missouri	N/A — full Rx Carve-out	N/A — full Rx Carve-out	N/A — full Rx Carve-out
Montana	N/A — no MCOs	N/A — no MCOs	N/A — no MCOs
Nebraska	No — not for any drugs	N/A	N/A
Nevada	Yes	Yes	Yes
New Hampshire	Yes	Yes	Yes
New Jersey	Yes	No	Yes
New Mexico	Yes	NR	NR
New York	Yes	No	Yes
North Carolina	N/A — no MCOs	N/A — no MCOs	N/A — no MCOs
North Dakota	Yes — for other PDL drugs but not uniform classes	No	No
Ohio	Yes	Yes	Yes
Oklahoma	N/A — no MCOs	N/A — no MCOs	N/A — no MCOs
Oregon	Yes	No	No
Pennsylvania	Yes	NR	NR
Rhode Island	Yes	No	NR
South Carolina	Yes — for other PDL drugs but not uniform classes	No	Yes
South Dakota	N/A — no MCOs	N/A — no MCOs	N/A — no MCOs
Tennessee	N/A — full Rx Carve-out	N/A — full Rx Carve-out	N/A — full Rx Carve-out
Texas	No — not for any drugs	N/A	N/A
Utah	NR	NR	NR
Vermont	N/A — no MCOs	N/A — no MCOs	N/A — no MCOs
Virginia	Yes — for other PDL drugs but not uniform classes	No	Yes
Washington	Yes — for other PDL drugs but not uniform classes	Yes	Yes
West Virginia	N/A — full Rx Carve-out	N/A — full Rx Carve-out	N/A — full Rx Carve-out
Wisconsin	N/A — full Rx Carve-out	N/A — full Rx Carve-out	N/A — full Rx Carve-out
Wyoming	N/A — no MCOs	N/A — no MCOs	N/A — no MCOs
NOTES:States were asked if they have supplemental rebate agreements in place, what entity negotiates supplemental rebates and if the state’s negotiator is selected through competitive procurement as of July 1, 2019. “NR” = Not Reporting. SOURCE: KFF / Health Management Associates 2019 Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, April 2020.

Appendix Table 10: FFS Pharmacy Copayment Requirements for Non-Exempt Adults, July 1, 2019
State	Required for Non-exempt Adults?	FFS Rx Reimbursement Decreased by Copay Amount?	Copay Requirement for Non-Expansion Adults	Copay Requirement for Expansion Adults	MCO Copay Requirements Differ?
Alabama	Yes	Yes	$0-$3.90 based on drug cost	Non-expansion state	N/A ‒ No MCOs
Alaska	Yes	Yes	$0.50/$3.50 for under/over $50 drug cost	Same	N/A ‒ No MCOs
Arizona	No	N/A	N/A	N/A	N/A
Arkansas	Yes	Yes	Sliding scale based on drug cost	None	Yes ‒ No copays
California	No	N/A	N/A	N/A	N/A
Colorado	Yes	Yes	$3 generic and brand; some $0 exceptions apply	Same	No
Connecticut	No	N/A	N/A	N/A	N/A ‒ No MCOs
Delaware	Yes	Yes	$0.50-$3.00 based on drug cost; 30-day max of $15	Same	No
DC	Yes	Yes	$1 brand and generic	Same	Yes ‒ No copays
Florida	No	N/A	N/A	Non-expansion state	N/A
Georgia	Yes	Yes	$0.50 preferred; $3 non-preferred	Non-expansion state	No
Hawaii	No	N/A	N/A	N/A	N/A
Idaho	No	N/A	N/A	Non-expansion state	N/A ‒ No MCOs
Illinois	Yes	Yes	$2 generic; $3 brand	Same	Yes ‒ MCO option up to FFS amount
Indiana	Yes	Yes	$3 brand and generic	$4 preferred; $8 non-preferred	No
Iowa	Yes	Yes	$1 brand and generic	None	Yes ‒ No copays
Kansas	Yes	Yes	$3 brand and generic	Non-expansion state	Yes ‒ No copays
Kentucky	Yes	No	$1 generic and preferred brand on formulary over generic equivalent; $4 brand	Same	No
Louisiana	Yes	Yes	$0.50-$3.00 based on drug cost	Same	No
Maine	Yes	No	$3 generic and brand (except tobacco cessation), not to exceed $30 PMPM	Same	N/A ‒ No MCOs
Maryland	Yes	Yes	$1 generic and preferred brand; $3 other brand	Same	Yes ‒ MCO option
Massachusetts	Yes	Yes	$3.65 all drugs except $1 for generic, anti-hypertensives, diabetes, and hypercholesterolemia drugs	Same	No
Michigan	Yes	Yes	$1 for generic and preferred brand, $3 non-preferred brand	$4 for generic and preferred brand, $8 non-preferred brand	Yes ‒ No copays except for ACA expansion population
Minnesota	Yes	Yes	$1 generic; $3 brand	Same	No
Mississippi	Yes	Yes	$3 brand and generic	Non-expansion state	Yes ‒ No copays
Missouri	Yes	No	$0.50-$2 based on drug cost	Non-expansion state	N/A ‒ Rx Carve-out
Montana	Yes	Yes	$4 preferred brands; $8 non-preferred and non-PDL brands; no copays generics and select therapeutic classes	Same	N/A ‒ No MCOs
Nebraska	Yes	Yes	$2 generic; $3 brand	Non-expansion state	Yes ‒ MCOs may waive
Nevada	No	N/A	N/A	N/A	N/A
New Hampshire	Yes	Yes	$1 brand and generic	Same	No
New Jersey	No	N/A	N/A	N/A	N/A
New Mexico	No	N/A	N/A	N/A	N/A
New York	Yes	Yes	$1 generic, preferred brand, and brand less than generic; $3 non-preferred brand; $0.50 OTC	Same	No
North Carolina	Yes	Yes	$3 brand and generic	Non-expansion state	N/A ‒ No MCOs
North Dakota	Yes	Yes	$0 generic; $3 brand	Same	No
Ohio	Yes	No	$3 for drugs that require PA; $2 for selected brands	Same	Yes ‒ No copays
Oklahoma	Yes	Yes	$4 brand and generic	Non-expansion state	N/A ‒ No MCOs
Oregon	No	N/A	N/A	N/A	N/A
Pennsylvania	Yes	Yes	$1 generic; $3 for brands; many drug classes are copay exempt	Same	No
Rhode Island	No	N/A	N/A	N/A	N/A
South Carolina	Yes	Yes	$3.40 brand and generic	Non-expansion state	No
South Dakota	Yes	Yes	$1 generic; $3.30 brand	Non-expansion state	N/A ‒ No MCOs
Tennessee	Yes	Yes	$1.50 generics and plan-preferred brands (brand as generics); $3.00 for brands	Non-expansion state	N/A ‒ Rx Carve-out
Texas	No	N/A	N/A	Non-expansion state	N/A
Utah	NR	NR	NR	NR	NR
Vermont	Yes	Yes	$1-$3 depending on drug cost	Same	N/A ‒ No MCOs
Virginia	Yes	Yes	$1 generic; $3 for brands	Same	Yes ‒ No copays
Washington	No	N/A	N/A	N/A	N/A
West Virginia	Yes	Yes	$0-$3 depending on drug cost	Same	N/A ‒ Rx Carve-out
Wisconsin	Yes	Yes	$.050 OTCs and diabetic supplies; $1 generics and compunds; $3 brands; not to exceed $12 PMPM per provider	Non-expansion state	N/A ‒ Rx Carve-out
Wyoming	Yes	Yes	$0.65 generics; $3.65 brands	Non-expansion state	N/A ‒ No MCOs
NOTES: States were asked to report if pharmacy copayments were required for adults and any differences for adults covered by the Medicaid expansion as of July 1, 2019. States were also asked if MCO copayments differ from those in FFS as of July 1, 2019. “Non-expansion state” = state has not implemented ACA Medicaid expansion as of Juy 1, 2019; “NR” = not reporting; “OTC” = over the counter drug.SOURCE: KFF / Health Management Associates 2019 Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, April 2020.

Appendix Table 11: 340B Policies in Place, July 1, 2019
State	340B Entities Carved Into Medicaid FFS?	340B Entities Carved Into Managed Care?	340B Entites Allowed to Contract with Outside Pharmacies (FFS)?	340B Entities Allowed to Contract with Outside Pharmacies (Managed Care)?
Alabama	Yes	N/A — No MCOs	No	N/A — No MCOs
Alaska	Yes	N/A — No MCOs	No	N/A — No MCOs
Arizona	Yes	Yes	No	No
Arkansas	Yes	Yes	No	No
California	Yes	Yes	Yes	Yes
Colorado	Yes	Yes	No	No
Connecticut	Yes	N/A — No MCOs	Yes	N/A — No MCOs
Delaware	Yes	Yes	Yes	Yes
DC	Yes	Yes	No	Yes
Florida	Yes	Yes	No	No
Georgia	Yes	Yes	No	No
Hawaii	Yes	Yes	Yes	Yes
Idaho	Yes	N/A — No MCOs	No	N/A — No MCOs
Illinois	Yes	Yes	No	No
Indiana	Yes	Yes	No	Yes
Iowa	Yes	Yes	No	No
Kansas	Yes	Yes	No	No
Kentucky	Yes	Yes	No	No
Louisiana	Yes	No	No	Yes
Maine	Yes	N/A — No MCOs	No	N/A — No MCOs
Maryland	Yes	Yes	Yes	Yes
Massachusetts	Yes	Yes	Yes	Yes
Michigan	Yes	Yes	Yes	Yes
Minnesota	Yes	Yes	No	No
Mississippi	Yes	Yes	No	No
Missouri	Yes	N/A — Full Rx Carve-out	No	N/A — Full Rx Carve-out
Montana	Yes	N/A — No MCOs	Yes	N/A — No MCOs
Nebraska	Yes	No	No	No
Nevada	Yes	Yes	Yes	Yes
New Hampshire	No	No	No	No
New Jersey	Yes	Yes	No	Yes
New Mexico	Yes	Yes	Yes	Yes
New York	Yes	Yes	Yes	Yes
North Carolina	Yes	N/A — No MCOs	Yes	N/A — No MCOs
North Dakota	Yes	No	No	No
Ohio	Yes	Yes	No	No
Oklahoma	Yes	N/A — No MCOs	Yes	N/A — No MCOs
Oregon	Yes	Yes	No	Yes
Pennsylvania	Yes	Yes	No	No
Rhode Island	Yes	Yes	No	Yes
South Carolina	Yes	Yes	No	Yes
South Dakota	No	N/A — No MCOs	No	N/A — No MCOs
Tennessee	Yes	N/A — Full Rx Carve-out	No	N/A — Full Rx Carve-out
Texas	Yes	Yes	Yes	Yes
Utah	NR	NR	NR	NR
Vermont	Yes	N/A — No MCOs	No	N/A — No MCOs
Virginia	Yes	Yes	No	No
Washington	Yes	No	No	No
West Virginia	Yes	N/A — Full Rx Carve-out	No	N/A — Full Rx Carve-out
Wisconsin	Yes	N/A — Full Rx Carve-out	No	N/A — Full Rx Carve-out
Wyoming	Yes	N/A — No MCOs	No	N/A — No MCOs
NOTES: States were asked about their policies related to 340B entities as of July 1, 2019; carve in to FFS or managed care means that drugs purchased under the 340B program are used for Medicaid beneficiaries. Contract pharmacies refer to pharmacy arrangements with 340B entities to provide pharmacy services to their patients. NR” = Not Reporting. SOURCE: KFF / Health Management Associates 2019 Survey of Medicaid Officials in 50 states and DC conducted by Health Management Associates, April 2020.

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How State Medicaid Programs are Managing Prescription Drug Costs: Results from a State Medicaid Pharmacy Survey for State Fiscal Years 2019 and 2020

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