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

Download the Survey (.pdf)

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.
Conclusion