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CHARTBOOK: MEDICAID PHARMACY BENEFIT USE AND REIMBURSEMENT IN 2003
INTRODUCTION AND OVERVIEW
This chartbook, prepared for the Centers for Medicare & Medicaid Services (CMS) by Mathematica Policy Research, Inc., presents highlights and key comparisons from the Statistical Compendium on Medicaid pharmacy benefit use and reimbursement in 2003. The 54 exhibits in the chartbook are summarized below.
Beneficiary Characteristics and Illustrative Use and Reimbursement Measures
Exhibit 1: Distribution of Medicaid Study Population Beneficiary Characteristics Exhibit 2: Illustrative Measures for Study Population Pharmacy Benefit Use and Reimbursement
Study Population Characteristics
Exhibit 3: Distribution of Medicaid Study Population by Age Group, Nondual and Dual Eligible Beneficiaries
Exhibit 4: Distribution of Medicaid Study Population by Disability Status, Nondual and Dual Eligible Beneficiaries
Exhibit 5: Distribution of Medicaid Study Population by Race, Nondual and Dual Eligible Beneficiaries
Medicaid Pharmacy Reimbursement and Use, by Type of Beneficiary
Exhibit 6: Average Monthly Medicaid Pharmacy Reimbursement, by Age Group Exhibit 7: Distribution of Age Groups and Total Pharmacy Reimbursement Exhibit 8: Average Monthly Medicaid Pharmacy Reimbursement, by Basis of Eligibility and Dual
Status Exhibit 9: Percentage of Beneficiaries with at Least One Prescription Drug Claim, by Dual Eligibility
Status Exhibit 10: Average Annual Number of Prescription Drug Claims per Beneficiary, by Dual Eligibility
Status Exhibit 11: Number of Prescriptions per Benefit Month, by Basis of Eligibility and Dual Eligibility
Status Exhibit 12: Average Annual Prescription Drug Spending per Beneficiary, by Dual Eligibility Status Exhibit 13: Distribution of Dual Eligibility Status and Total Pharmacy Reimbursement
Medicaid Pharmacy Use and Reimbursement, Nondual Beneficiaries
Exhibit 14: Distribution of Beneficiaries and Total Pharmacy Reimbursement among Nondual Beneficiaries, by Basis of Eligibility
Exhibit 15: Total Annual Medicaid Reimbursement for Top 10 Drug Groups among Nondual Beneficiaries
Exhibit 16: Percentage of Pharmacy Reimbursement and Users for Top 10 Drug Groups among Nondual Beneficiaries
Exhibit 17: Percentage of Pharmacy Reimbursement and Users for Top 7 Therapeutic Categories among Nondual Beneficiaries
2
Exhibit 18: Average Monthly Medicaid Pharmacy Reimbursement among Nondual Beneficiaries, by State
Exhibit 19: Generic Prescriptions as Percentage of All Prescriptions among Nondual Beneficiaries, by State
Medicaid Pharmacy Use and Reimbursement, Dual Eligible Beneficiaries
Exhibit 20: Distribution of Beneficiaries and Total Pharmacy Reimbursement among Dual Eligibles, by Basis of Eligibility
Exhibit 21: Total Annual Medicaid Reimbursement for Top 10 Drug Groups among Dual Eligibles Exhibit 22: Percentage of Pharmacy Reimbursement and Users for Top 10 Drug Groups Among Dual
Eligibles Exhibit 23: Percentage of Pharmacy Reimbursement and Users for Top 7 Therapeutic Categories among
Dual Eligibles Exhibit 24: Distribution of Annual Pharmacy Reimbursement for Dual Eligibles, Under-Age-65
Disabled vs. Age 65 and Older Exhibit 25: Average Monthly Medicaid Pharmacy Reimbursement among Dual Eligibles, by
Beneficiary Nursing Facility Residence Exhibit 26: Average Monthly Medicaid Pharmacy Reimbursement among Dual Eligibles, by State Exhibit 27: Generic Prescriptions as a Percentage of All Prescriptions among Dual Eligibles, by State Exhibit 28: Average Annual Pharmacy Reimbursement Amount per Beneficiary for Aged Dual
Eligibles, by State Exhibit 29: Average Annual Pharmacy Reimbursement Amount per Beneficiary for Under-Age-65
Disabled Dual Eligible Beneficiaries, by State Exhibit 30: Average Annual Pharmacy Reimbursement Amount per Beneficiary for Dual Eligible All-
Year Nursing Facility Residents, by State
Medicaid Pharmacy Use and Reimbursement, Drugs Excluded by Statute from Medicare Part D
Exhibit 31: Percentage of Medicaid Beneficiaries Using at Least One Drug Excluded from Medicare Part D
Exhibit 32: Annual Medicaid Pharmacy Reimbursement for Drugs Excluded from Medicare Part D, Nondual and Dual Eligible Beneficiaries
Exhibit 33: Annual Medicaid Pharmacy Reimbursement for Drugs Excluded from Medicare Part D for Nondual and Dual Eligible Beneficiaries as a Percentage of Total Annual Medicaid Reimbursement for Nondual and Dual Eligible Beneficiaries
Medicaid Pharmacy Use and Reimbursement, 1999, 2001, 2002, and 2003
Overview Exhibit 34: Total Pharmacy Reimbursement, 1999, 2000, 2001, and 2003 Exhibit 35: Pharmacy Reimbursement as a Percentage of Costs on All Services, 1999, 2001, 2002, and
2003 Exhibit 36: Average Annual Prescription Drug Reimbursement per Medicaid Beneficiary, Nondual
Beneficiaries and Dual Eligibles 1999, 2001, 2002, and 2003 Exhibit 37: Average Monthly Pharmacy Reimbursement per Beneficiary, Nondual Beneficiaries and
Dual Eligibles 1999, 2001, 2002, and 2003 Exhibit 38: Percentage of Beneficiaries with at Least One Prescription Filled, Nondual Beneficiaries
and Dual Eligibles 1999, 2001, 2002, and 2003 Exhibit 39: Average Annual Number of Prescription Claims per Medicaid Beneficiary, Nondual
Beneficiaries and Dual Eligibles 1999, 2001, 2002, and 2003
3
Exhibit 40: Brand Name and Generic Drugs as a Percentage of All Claims, 1999, 2001, 2002, and 2003 By Basis of Eligibility Exhibit 41: Number of Medicaid Beneficiaries by Basis of Eligibility, 1999, 2001, 2002, and 2003 Exhibit 42: Average Monthly Medicaid Pharmacy Reimbursement by Basis of Eligibiltiy, 1999, 2001,
2002, and 2003 Nondual Beneficiaries Exhibit 43: Number of Nondual Medicaid Beneficiaries by Basis of Eligibility, 1999, 2001, 2002, and
2003 Exhibit 44: Average Annual Number of Prescription Claims by Basis of Eligibility, Nondual
Beneficiaries, 1999, 2001, 2002, and 2003 Exhibit 45: Average Annual Prescription Reimbursement by Basis of Eligibility, Nondual Beneficiaries,
1999, 2001, 2002, and 2003 Exhibit 46: Average Monthly Prescription Reimbursement by Basis of Eligibility, Nondual
Beneficiaries, 1999, 2001, 2002, and 2003 Dual Eligible Beneficiaries Exhibit 47: Number of Dual Medicaid Beneficiaries by Basis of Eligibility, 1999, 2001, 2002, and 2003 Exhibit 48: Average Annual Number of Prescription Claims by Basis of Eligibility, Dual Eligible
Beneficiaries, 1999, 2001, 2002, and 2003 Exhibit 49: Average Annual Prescription Reimbursement by Basis of Eligibility, Dual Eligible
Beneficiaries, 1999, 2001, 2002, and 2003 Exhibit 50: Average Monthly Prescription Reimbursement by Basis of Eligibility, Dual Eligible
Beneficiaries, 1999, 2001, 2002, and 2003 Exhibit 51: Average Annual Drug Reimbursement Among Dual Eligible Beneficiaries by Age Group
and Disability Status, 1999, 2001, 2002, and 2003 Exhibit 52: Percentage of Dual Eligible Beneficiaries with Annual Drug Costs in Specified Ranges,
1999, 2001, 2002, and 2003 Exhibit 53: Number of Dual Eligible Full-Year Nursing Facility Residents and Under-Age-65 Disabled
Dual Eligible Beneficiaries Compared to All Duals, 1999, 2001, 2002, and 2003 Exhibit 54: Average Monthly Medicaid Pharmacy Reimbursement for Dual Eligible Full-Year Nursing
Facility Residents and Under-Age-65 Disabled Dual Eligible Beneficiaries Compared to All Duals, 1999, 2001, 2002, and 2003
BENEFICIARY CHARACTERISTICS AND ILLUSTRATIVE USE AND REIMBURSEMENT MEASURES
5
EXHIBIT 1
DISTRIBUTION OF MEDICAID STUDY POPULATION BENEFICIARY CHARACTERISTICS, 2003
Percent of Beneficiaries
Beneficiary Characteristics
Among All Medicaid
Beneficiariesa
Among Nondual
Beneficiariesb Among Dual
Eligiblesb
Among Beneficiaries Who Resided in
Nursing Facilities All Yearc
Age 5 and younger 20 25 < 1 6–14 21 25 < 1 15–20 12 14 < 1 21–44 25 28 15 45–64 10 8 21 13e 65–74 5 1 25 13 75–84 4 < 1 24 31 85 and older 3 < 1 16 44
Sex Male 40 40 36 28 Female 60 59 64 72
Race African American 23 24 18 13 White 47 44 60 76 Other/Unknown 30 31 22 10
Dual Eligibility Statusb Dual Eligibles 16 0 100 92 Nondual Beneficiaries 84 100 0 8
Basis of Eligibilityd Children 48 58 < 1 < 1 Adults 25 30 1 < 1 Disabled 17 12 43 17 Aged 10 1 56 83
Number of Beneficiaries in Study Population 40,748,181 34,019,639 6,728,542 913,213 Source: Medicaid Analytic Extract (MAX), 2003. This table is based on information contained in Tables 2,
ND.2, D.2, ND.8, and D.8 in the Statistical Compendium Volume, United States (hereafter “the Compendium”).
aMedicaid beneficiaries featured in this chartbook include those who had fee-for-service (FFS) Medicaid pharmacy benefit coverage for at least one month during calendar year 2003. Beneficiaries who were in capitated managed care arrangements for the entire year are excluded. For more details on how we determined the study population, see Table 1 of the Compendium.
EXHIBIT 1 (continued) ___________________________________________________________________________________
6
bDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefit coverage for at least one month during their Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefit coverage. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. cThis group includes beneficiaries who resided in nursing facilities throughout their Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined all-year nursing facility residency. dMedicaid basis of eligibility is classified as: aged, disabled, adults, and children. The disabled group includes beneficiaries of any age who were determined to be eligible because of disability or blindness. The children’s group includes children receiving foster care and adoptive services. eThe percentage represents all ages below 65.
7
EXHIBIT 2
ILLUSTRATIVE MEASURES OF STUDY POPULATION PHARMACY BENEFIT USE AND REIMBURSEMENT, 2003a
Measures of Pharmacy Benefit Use and Reimbursement
Among All Medicaid
Beneficiariesb
Among Nondual
Beneficiariesb Among Dual
Eligiblesb
Among Beneficiaries Who Resided in Nursing
Facilities All Yearb
Total Medicaid Pharmacy Reimbursement (in $ million) $33,513 $15,620 $17,893 $3,048
Average Annual Pharmacy Reimbursement per Beneficiaryc $822 $459 $2,659 $3,338
Average Pharmacy Reimbursement per Benefit Monthd $100 $59 $252 $327
Average Annual Number of Prescriptions per Beneficiary 13.1 7.3 42.3 64.2
Average Number of Prescriptions per Benefit Month 1.6 0.9 4.0 6.3 Source: Medicaid Analytic Extract (MAX), 2003. This table is based on information contained in Tables 3, 4, 6,
ND.3, ND.4, ND.6, ND.8, ND.9, D.3, D.4, D.6, D.8, D.9, and N.1a in the Compendium. aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bSee footnotes to Exhibit 1 for how these groups were defined. Annual or monthly measures reflect use and reimbursement among beneficiaries in FFS settings, and may thus be higher or lower than if use and reimbursement in capitated managed care settings were included. cAnnual per-beneficiary use and reimbursement include all use and reimbursement during the year for the number of months of Medicaid FFS pharmacy benefit coverage. Thus, some beneficiaries may have had only one month of coverage, while others were covered for twelve months. Medicaid beneficiaries in the study population had, on average, 7.8 months of coverage. The comparable number was 7.3 months among nondual beneficiaries and 10.2 months among dual eligible beneficiaries, and 10.0 months among beneficiaries who resided in nursing facilities throughout their Medicaid enrollment in 2003. dMonthly use and reimbursement amounts were calculated by dividing total use and reimbursement among all beneficiaries in the study population by the total number of benefit months of those beneficiaries. Benefit months are months during which beneficiaries had FFS pharmacy benefit coverage.
STUDY POPULATION CHARACTERISTICS
9
EXHIBIT 3
DISTRIBUTION OF MEDICAID STUDY POPULATION BY AGE GROUP, NONDUAL AND DUAL ELIGIBLE BENEFICIARIES, 2003a
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables ND.2 and D.2 of the Compendium. aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
35%
1% 0%
35%
65%63%
0%
25%
50%
75%
100%
Under 21 21 to 64 65 and Older Under 21 21 to 64 65 and Older
Nondual Beneficiaries Dual Eligibles
10
EXHIBIT 4
DISTRIBUTION OF MEDICAID STUDY POPULATION BY DISABILITY STATUS, NONDUAL AND DUAL ELIGIBLE BENEFICIARIES, 2003a,b
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables ND.2 and D.2 of the Compendium. aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. bThe disabled eligibility group includes beneficiaries of any age who were determined to be eligible for Medicaid because of disability or blindness.
88%
43%
57%
12%
0%
25%
50%
75%
100%
Disabled Non-disabled Disabled Non-disabledNondual Beneficiaries Dual Eligibles
11
EXHIBIT 5
DISTRIBUTION OF MEDICAID STUDY POPULATION BY RACE, NONDUAL AND DUAL ELIGIBLE BENEFICIARIES, 2003a
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables ND.2 and D.2 of the Compendium. aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
44%
31%
18%
60%
22%24%
0%
25%
50%
75%
100%
AfricanAmerican
W hite Other/Unknown AfricanAmerican
W hite Other/Unknown
Nondual Beneficiaries Dual Eligibles
MEDICAID PHARMACY REIMBURSEMENT AND USE, BY TYPE OF BENEFICIARY
13
EXHIBIT 6
AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT, BY AGE GROUP, 2003a,b
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table 4 of the Compendium. aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bMonthly reimbursement amounts were calculated by dividing the total reimbursement among all beneficiaries in the study population by the total number of benefit months of those beneficiaries. Benefit months are months during which beneficiaries had FFS pharmacy benefit coverage.
$21$32 $35
$98
$273
$214 $212$199
$100
$0
$50
$100
$150
$200
$250
$300
All 5 andYounger
6 to 14 15 to 20 21 to 44 45 to 64 65 to 74 75 to 84 85 and Older
Age
14
EXHIBIT 7
DISTRIBUTION OF AGE GROUPS AND TOTAL PHARMACY REIMBURSEMENT, 2003a
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables 2, 3, and 6 of the Compendium. aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states.
45 to 64
21 to 44
20 and Younger
53%
14%
26%
24%
10%
32%
11%
30%
0%
20%
40%
60%
80%
100%
Percent of Beneficiaries Percent of Pharmacy Reimbursement
65 and Older
15
EXHIBIT 8
AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT, BY BASIS OF ELIGIBILITY AND DUAL STATUS, 2003a,b,c,d
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables 4, ND.4, and D.4 of the Compendium. aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bMonthly reimbursement amounts were calculated by dividing the total reimbursement among all beneficiaries in the study population by the total number of benefit months of those beneficiaries. Benefit months are months during which beneficiaries had FFS pharmacy benefit coverage. cMedicaid basis of eligibility is classified as: aged, disabled, adults, and children. The disabled group includes beneficiaries of any age who were determined to be eligible because of disability or blindness, and thus includes a large number of dual eligibles. The children’s group includes children receiving foster care and adoptive services. The total includes some beneficiaries with unknown basis of eligibility and some whose age categories are not consistent with basis of eligibility. dDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
Dual Status
$100
$22$42
$257
$202
$59
$252
$0
$50
$100
$150
$200
$250
$300
All Children Adults Disabled Aged NondualBeneficiaries
Dual Eligibles
Eligibility Status
16
EXHIBIT 9
PERCENTAGE OF BENEFICIARIES WITH AT LEAST ONE PRESCRIPTION DRUG CLAIM, BY DUAL ELIGIBILITY STATUS, 2003a
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables ND.3 and D.3 of the Compendium. aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
84%
56%
0%
25%
50%
75%
100%
Nondual Beneficiaries Dual Eligibles
17
EXHIBIT 10
AVERAGE ANNUAL NUMBER OF PRESCRIPTION DRUG CLAIMS PER BENEFICIARY, BY DUAL ELIGIBILITY STATUS, 2003a,b
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables ND.3 and D.3 of the Compendium. aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. bNondual beneficiaries, on average, had fewer months of Medicaid eligibility in 2003 than dual eligible beneficiaries: 7.3 months for nonduals and 10.2 months for duals.
42.3
7.3
0
10
20
30
40
50
Nondual Beneficiaries Dual Eligibles
18
EXHIBIT 11
NUMBER OF PRESCRIPTIONS PER BENEFIT MONTH, BY BASIS OF ELIGIBILITY AND DUAL ELIGIBILITY STATUS, 2003a,b
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables ND.4 and D.4 of the Compendium. aMedicaid basis of eligibility is classified as: aged, disabled, adults, and children. The disabled group includes beneficiaries of any age who were determined to be eligible because of disability or blindness, and thus includes a large number of dual eligibles. The children’s group includes children receiving foster care and adoptive services. The total includes some beneficiaries with unknown basis of eligibility and some whose age categories are not consistent with basis of eligibility. bDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
2.8
0.80.5
3.94.1
3.33.1
2.3
0
1
2
3
4
5
Aged Disabled Adults Children Aged Disabled Adults Children
Nondual Beneficiaries Dual Eligibles
19
EXHIBIT 12
AVERAGE ANNUAL PRESCRIPTION DRUG SPENDING PER BENEFICIARY, BY DUAL ELIGIBILITY STATUS, 2003a,b
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables ND.3 and D.3 of the Compendium. aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. bNonduals, on average, had fewer months of Medicaid eligibility in 2003 than dual eligible beneficiaries: 7.3 months for nonduals and 10.2 months for duals.
$2,659
$459
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
Nondual Beneficiaries Dual Eligibles
20
EXHIBIT 13
DISTRIBUTION OF DUAL ELIGIBILITY STATUS AND TOTAL PHARMACY REIMBURSEMENT, 2003a,b
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables 2, ND.2, D.2, 6, ND.6, and D.6 of the
Compendium. aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
17%
53%
83%
47%
0%
25%
50%
75%
100%
Percent of Beneficiaries Percent of Total Pharmacy Reimbursement
Dual
Nondual
MEDICAID PHARMACY USE AND REIMBURSEMENT, NONDUAL BENEFICIARIES
22
EXHIBIT 14
DISTRIBUTION OF BENEFICIARIES AND TOTAL PHARMACY REIMBURSEMENT AMONG NONDUAL BENEFICIARIES, BY BASIS OF ELIGIBILITY, 2003a,b,c
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables ND.2, ND.3, and ND.6 of the Compendium. aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bMedicaid basis of eligibility is classified as: aged, disabled, adults, and children. The disabled group includes beneficiaries of any age who were determined to be eligible because of disability or blindness, and thus includes a large number of dual eligibles. The children’s group includes children receiving foster care and adoptive services. The total includes some beneficiaries with unknown basis of eligibility and some whose age categories are not consistent with basis of eligibility. cDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
58%
21%
30%
18%
12%
58%
2%1%
0%
25%
50%
75%
100%
Percent of Beneficiaries Percent of Pharmacy Reimbursement
Adults
Children
Disabled
Aged
23
EXHIBIT 15
TOTAL ANNUAL MEDICAID REIMBURSEMENT FOR TOP 10 DRUG GROUPS AMONG NONDUAL BENEFICIARIES, 2003a,b,c,d
The top 10 drug groups (out of over 90 drug groups) accounted for 55 percent of total Medicaid FFS pharmacy reimbursement for nondual beneficiaries in 2003.
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table ND.7 of the Compendium. aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bAnnual per-beneficiary reimbursement includes all reimbursement during the year for the number of months of Medicaid FFS pharmacy benefit coverage. Thus, some beneficiaries may have had only one month of coverage, while others were covered for twelve months. At the national level, nondual eligible Medicaid beneficiaries in the study population had, on average, 7.5 months of coverage. cThe top 10 drug groups were determined based on total Medicaid reimbursement in 2003. For information about these drug groups, see Wolters Kluwer Health, [http://www.medispan.com/products/index.aspx?id=1] (November 8, 2006). dDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
$1,898
$1,085$986 $966 $950
$785$561 $508 $442 $441
$0
$400
$800
$1,200
$1,600
$2,000
Antipsy
choti
cs
Antide
pressa
nts
Antiast
hmati
c
Antico
nvuls
ant
Antivir
al
Ulcer D
rugs
Analge
sics -
Narc
otic
Antidia
betic
Analge
sics -
Anti
-infla
mmatory
Stimula
nts/A
nti-ob
esity/
Anorex
iants
($ million)
24
EXHIBIT 16
PERCENTAGE OF PHARMACY REIMBURSEMENT AND USERS FOR TOP 10 DRUG GROUPS AMONG NONDUAL BENEFICIARIES, 2003a,b,c,d
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table ND.7 of the Compendium. aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bA user is a beneficiary who had at least one prescription filled in a given therapeutic category during 2003. A beneficiary who used drugs from two or more categories was counted as a user for each category. Therefore, the sum of users across categories may exceed the total number of individual users. For information about these drug groups, see Wolters Kluwer Health, [http://www.medispan.com/products/index.aspx?id=1] (November 8, 2006). cThe top 10 drugs groups were determined based on total Medicaid reimbursement in the state for 2003. For information about these drug groups, see Wolters Kluwer Health, [http://www.medispan.com/products/index.aspx?id=1] (November 8, 2006). dDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
1 2 %
7 % 6 % 6 % 6 % 5 % 4 % 3 % 3 % 3 %5 %
1 0 %
1 7 %
4 %2 %
7 %
1 7 %
4 %
1 4 %
3 %
0 %
5 %
1 0 %
1 5 %
2 0 %
Antipsy
choti
cs
Antide
pressa
nts
Antiast
hmati
c
Antico
nvuls
ant
Antivir
al
Ulcer D
rugs
Analge
sics -
Narc
otic
Antidia
betic
Analge
sics -
Anti
-infla
mmatory
Stimula
nts/A
nti-ob
esity/
Anorex
iants
P ercen t o f N on d u a l B en efic ia ry P h arm acy R eim b u rsem en t P ercen t o f N on d u a l B en efic ia ries
25
EXHIBIT 17
PERCENTAGE OF PHARMACY REIMBURSEMENT AND USERS FOR TOP 7 THERAPEUTIC CATEGORIES AMONG NONDUAL BENEFICIARIES, 2003a,b,c,d
The top 7 therapeutic categories (out of 18 therapeutic categories) accounted for 76 percent of total Medicaid FFS pharmacy reimbursement for nondual beneficiaries in 2003
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table ND.6 of the Compendium. aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bA user is a beneficiary who had at least one prescription filled in a given therapeutic category during 2003. A beneficiary who used drugs from two or more categories was counted as a user for each category. Therefore, the sum of users across categories may exceed the total number of individual users. For information about these therapeutic categories, see Wolters Kluwer Health, [http://www.medispan.com/products/index.aspx?id=1] (November 8, 2006). cTop 7 categories were determined based on total Medicaid reimbursement in 2003. For information about these therapeutic categories, see Wolters Kluwer Health, [http://www.medispan.com/products/index.aspx?id=1] (November 8, 2006). cDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
21%
14%11%
8% 7% 7% 7%
21%
7%
37%
12%
26%
7%
14%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Central NervousSystem Drugs
Anti-infectiveAgents
Respiratory Agents Analgesics andAnesthetics
CardiovascularAgents
Neurom uscularAgents
Endocrine/M etabolic Drugs
Percent of N ondual Beneficiary Pharmacy Reimbursement Percent of N ondual Beneficiaries
26
EXHIBIT 18
AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT AMONG NONDUAL BENEFICIARIES, BY STATE, 2003a,b,c
Source:
Medicaid Analytic Extrac
t (MAX), 2003. This graph is based on the information contained in Table N.2 of the Compendium for the nation. The Compendium was prepared for 49 states (excluding Arizona) and the District of Columbia. FFS pharmacy reimbursement information is not available for Arizona due to a very high share of beneficiary enrollment in prepaid managed care plans.
aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bMonthly reimbursement amounts were calculated by dividing the total reimbursement among all beneficiaries in the study population by the total number of benefit months of those beneficiaries. Benefit months are months during which beneficiaries had FFS pharmacy benefit coverage. cDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
$12$33
$35$36
$38$39$40
$41$42$43$43$43$44$44$45$46
$47$48
$51$52$52$52
$55$57$57
$58$59$60
$65$66$66$66
$71$72$72
$75$77
$78$78$79
$81$84$84
$90$93$94
$123$130
$131$140
$204
$0 $30 $60 $90 $120 $150 $180 $210
NMARSCSD
MDOK
W YCAMIID
MSNDALVTCO
ILGALAMTUTAKTXNCNHORKS
USAME
INIAFL
W AW I
MATNVAOHNEKYPADE
MOW VNYMNNVNJHIRI
DCCT
27
EXHIBIT 19
GENERIC PRESCRIPTIONS AS PERCENTAGE OF ALL PRESCRIPTIONS AMONG NONDUAL BENEFICIARIES, BY STATE, 2003a,b
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table N.2 of the Compendium for the nation. The
Compendium was prepared for 49 states (excluding Arizona) and the District of Columbia. FFS pharmacy reimbursement information is not available for Arizona due to a very high share of beneficiary enrollment in prepaid managed care plans.
aBrand-name drugs, sometimes called “innovator single-source drugs,” are drugs whose patents have not yet expired. Off-patent brand-name drugs, sometimes called “innovator multiple-source drugs,” are brand-name drugs whose patents have expired. Generic drugs, sometimes called “non-innovator multiple-source drugs,” are off-patent drugs manufactured and sold by companies other than the original patent holder. For information about this classification method, see Wolters Kluwer Health, [http://www.medispan.com/products/index.aspx?id=1] (November 8, 2006). bDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
44.945.0
45.245.3
46.646.746.7
47.147.347.4
47.647.8
48.148.448.4
48.748.948.9
49.149.2
49.649.7
50.050.1
50.350.550.650.6
51.551.751.8
52.052.052.1
52.553.4
53.753.853.9
54.054.2
54.654.7
55.355.355.455.4
56.856.9
57.162.2
40.0 44.0 48.0 52.0 56.0 60.0 64.0
NJ NY M D SD KS SC DC CT LA AK TX PA GA NC VA M S M N
RI ND AR OH FL
WI USAAL WY M E NH CA NE KY M O DE IA
OK ID
TN WV M T VT IN
UT CO
IL M A M I
NV NM
HI WA OR
MEDICAID PHARMACY USE AND REIMBURSEMENT, DUAL ELIGIBLE BENEFICIARIES
29
EXHIBIT 20
DISTRIBUTION OF BENEFICIARIES AND TOTAL PHARMACY REIMBURSEMENT AMONG DUAL ELIGIBLES, BY BASIS OF ELIGIBILITY, 2003a,b,c,d
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables D.2, D.3, and D.6 of the Compendium. aChildren and adults comprise less than 1 percent each of dual eligible beneficiaries both in percentage of beneficiaries and in percentage of pharmacy reimbursement. bThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. cMedicaid basis of eligibility is classified as: aged, disabled, adults, and children. The disabled group includes beneficiaries of any age who were determined to be eligible because of disability or blindness, and thus includes a large number of dual eligibles. The children’s group includes children receiving foster care and adoptive services. The total includes some beneficiaries with unknown basis of eligibility and some whose age categories are not consistent with basis of eligibility. dDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
43%54%
56%45%
0%
20%
40%
60%
80%
100%
Percent of Beneficiaries Percent of Pharmacy Reimbursement
Disabled
Aged
30
EXHIBIT 21
TOTAL ANNUAL MEDICAID REIMBURSEMENT FOR TOP 10 DRUG GROUPS AMONG DUAL ELIGIBLES, 2003a,b,c,d
The top 10 drug groups (out of over 90 drug groups) accounted for 61 percent of total Medicaid FFS pharmacy reimbursement for dual eligibles in 2003.
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table D.7 of the Compendium. aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bAnnual per-beneficiary reimbursement includes all reimbursement during the year for the number of months of Medicaid FFS pharmacy benefit coverage. Thus, some beneficiaries may have had only one month of coverage, while others were covered for twelve months. At the national level, nondual eligible Medicaid beneficiaries in the study population had, on average, 10.2 months of coverage. cThe top 10 drug groups were determined based on total Medicaid reimbursement in 2003. For information about these drug groups, see Wolters Kluwer Health, [http://www.medispan.com/products/index.aspx?id=1] (November 8, 2006). dDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
($ million) $2,302
$1,375$1,177
$1,053 $1,000 $937$779 $761 $754
$641
$0
$400
$800
$1,200
$1,600
$2,000
$2,400
Antipsy
choti
c
Ulcer D
rugs
Antide
pressa
nts
Antihy
perlip
idemic
Antico
nvuls
ant
Antidia
betic
Antihy
perte
nsive
Analge
sics -
Anti
-infla
mmatory
Analge
sics -
Narc
otic
Antiast
hmati
c
31
EXHIBIT 22
PERCENTAGE OF PHARMACY REIMBURSEMENT AND USERS FOR TOP 10 DRUG GROUPS AMONG DUAL ELIGIBLES, 2003a,b,c,d
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table D.7 of the Compendium. aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bA user is a beneficiary who had at least one prescription filled in a given therapeutic category during 2003. A beneficiary who used drugs from two or more categories was counted as a user for each category. Therefore, the sum of users across categories may exceed the total number of individual users. For information about these drug groups, see Wolters Kluwer Health, [http://www.medispan.com/products/index.aspx?id=1] (November 8, 2006). cThe top 10 drugs groups were determined based on total Medicaid reimbursement in the state for 2003. For information about these drug groups, see Wolters Kluwer Health, [http://www.medispan.com/products/index.aspx?id=1] (November 8, 2006). dDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
13%8% 7% 6% 6% 5% 4% 4% 4% 4%
24%
40% 41%
26%33%
44%
34%
50%
33%
22%
0%5%
10%15%20%25%30%35%40%45%50%55%
Antipsy
choti
c
Ulcer D
rugs
Antide
pressa
ntsAnti
hype
rlipide
mic
Antico
nvuls
ant
Antidia
betic
Antihy
perte
nsive
Analge
sics -
Anti
-infla
mmatory
Analge
sics -
Narc
otic
Antiast
hmati
c
Percent of Dual Eligible Pharmacy Reimbursement Percent of Dual Eligible Beneficiaries
32
EXHIBIT 23
PERCENTAGE OF PHARMACY REIMBURSEMENT AND USERS FOR TOP 7 THERAPEUTIC CATEGORIES AMONG DUAL ELIGIBLES, 2003a,b,c,d
The top 7 therapeutic categories (out of 18 therapeutic categories) accounted for 79 percent of total Medicaid FFS pharmacy reimbursement for dual beneficiaries in 2003
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table D.6 of the Compendium. aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bA user is a beneficiary who had at least one prescription filled in a given therapeutic category during 2003. A beneficiary who used drugs from two or more categories was counted as a user for each category. Therefore, the sum of users across categories may exceed the total number of individual users. For information about these therapeutic categories, see Wolters Kluwer Health, [http://www.medispan.com/products/index.aspx?id=1] (November 8, 2006). cTop 7 categories were determined based on total Medicaid reimbursement in 2003. For information about these therapeutic categories, see Wolters Kluwer Health, [http://www.medispan.com/products/index.aspx?id=1] (November 8, 2006). dDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
22%17%
10% 9% 8% 7% 7%
48%
61%
40%
50%
41%
26%
51%
0%
25%
50%
75%
100%
Central NervousSystem Drugs
CardiovascularAgents
GastrointestinalAgents
Analgesics andAnesthetics
Endocrine/M etabolic Drugs
NeromuscularAgents
Anti-infectiveAgents
Percent of Dual Eligible Pharmacy Reimbursement Percent of Dual Eligible Beneficiaries
33
40%
3%
42%
5%
37%
28%
45%
53%
16%
31%
11%
32%
8%
38%
10%2%
0%
20%
40%
60%
80%
100%
Percent of Beneficiaries Percent of Expenditures Percent of Beneficiaries Percent of Expenditures
EXHIBIT 24
DISTRIBUTION OF ANNUAL PHARMACY REIMBURSEMENT FOR DUAL ELIGIBLES, UNDER-AGE-65 DISABLED VS. AGE 65 AND OLDER, 2003a,b,c
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Supplemental Tables 1A and 1B of the Compendium for the nation. aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bAnnual per-beneficiary reimbursement includes all reimbursement during the year for the number of months of Medicaid FFS pharmacy benefit coverage. Thus, some beneficiaries may have had only one month of coverage, while others were covered for twelve months. At the national level, dual eligible Medicaid beneficiaries in the study population had, on average, 10.2 months of coverage in 2003. cDual eligibles include beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefit coverage during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
$10,000 and more
Disabled Dual Eligibles Under Age 65
Dual Eligibles Age 65 and Older
$1,000 to $5,000
$0 to $1,000
$5,001 to $10,000
$0 to $1,000
$1,000 to $5,000
$5,001 to $10,000
$10,000 and more
(Total Benes = 2.3 million) (Total Exp. = $7.9 billion) (Total Benes = 4.3 million) (Total Exp. = $9.6 billion)
34
EXHIBIT 25
AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT AMONG DUAL ELIGIBLES, BY BENEFICIARY NURSING FACILITY RESIDENCE, 2003a,b,c
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table D.4 of the Compendium. aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bMonthly reimbursement amounts were calculated by dividing the total reimbursement among all beneficiaries in the study population by the total number of benefit months of those beneficiaries. Benefit months are months during which beneficiaries had FFS pharmacy benefit coverage. cDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
$252
$316
$295
$239
$150
$175
$200
$225
$250
$275
$300
$325
All Duals Dual All-Year NF Residents Dual Part-Year NF Residents Dual W ith No NF Use
35
EXHIBIT 26
AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT AMONG DUAL ELIGIBLES, BY STATE, 2003a,b
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table N.5 of the Compendium for the nation. The
Compendium was prepared for 49 states (excluding Arizona) and the District of Columbia. FFS pharmacy reimbursement information is not available for Arizona due to a very high share of beneficiary enrollment in prepaid managed care plans.
aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bMonthly use and reimbursement amounts were calculated by dividing the total use and reimbursement among all beneficiaries in the study population by the total number of benefit months of those beneficiaries. Benefit months are months during which beneficiaries had FFS pharmacy benefit coverage. cDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
$152$156
$177$196
$198$200
$206$212$212
$216$219
$227$230
$231$233
$235$239
$249$250
$252$254
$256$259
$263$266$266$267
$270$271
$278$281
$283$283$284
$286$288
$294$295$295
$306$307
$317$320$321
$324$327
$331$334
$339$359
$386
$150 $175 $200 $225 $250 $275 $300 $325 $350 $375 $400 $425
ILSCAR
NMDEOKM SHI
W ITXALVT
M DM I
GAM ACANDORUS
M EW VW ACONYLARI
SDNCKYFLIA
M TVAKS
W YNEIN
M NID
NVTNPANHDCCTNJ
OHM OAKUT
36
EXHIBIT 27
GENERIC PRESCRIPTIONS AS A PERCENTAGE OF ALL PRESCRIPTIONS AMONG DUAL ELIGIBLES, BY STATE, 2003a,b
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table N.5 of the Compendium for the nation. The Compendium was prepared for 49 states (excluding Arizona) and the District of Columbia. FFS pharmacy reimbursement information is not available for Arizona due to a very high share of beneficiary enrollment in prepaid managed care plans.
aBrand-name drugs, sometimes called “innovator single-source drugs,” are drugs whose patents have not yet expired. Off-patent brand-name drugs, sometimes called “innovator multiple-source drugs,” are brand-name drugs whose patents have expired. Generic drugs, sometimes called “non-innovator multiple-source drugs,” are off-patent drugs manufactured and sold by companies other than the original patent holder. For information about this classification method, see Wolters Kluwer Health, [http://www.medispan.com/products/index.aspx?id=1] (November 8, 2006). bDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
41.843.3
43.946.546.6
46.746.7
47.147.7
48.649.249.2
49.649.749.749.849.949.950.050.0
50.350.4
50.751.051.0
51.251.851.851.851.8
52.552.652.752.7
52.953.053.053.0
53.453.4
53.954.254.254.3
54.955.6
55.855.956.0
56.961.0
35.0 37.0 39.0 41.0 43.0 45.0 47.0 49.0 51.0 53.0 55.0 57.0 59.0 61.0
NYAKNJ
MDSCTXCADCNCCTPARIFLSDUTLAVAOH
USAMNNHMSWYKSHI
GAVTTNMEND
ILDE
MOID
NMWINEIN
ARNVCOMTIA
KYOKMAWAAL
WVMIOR
Percentage
37
EXHIBIT 28
AVERAGE ANNUAL PHARMACY REIMBURSEMENT AMOUNT PER BENEFICIARY FOR AGED DUAL ELIGIBLES, BY STATE, 2003a,b,c
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in State Tables D.3 of the Compendium. The Compendium was prepared for 49 states (excluding Arizona) and the District of Columbia. FFS pharmacy reimbursement information is not available for Arizona due to a very high share of beneficiary enrollment in prepaid managed care plans.
aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bAnnual per-beneficiary reimbursement includes all reimbursement during the year for the number of months of Medicaid FFS pharmacy benefit coverage. Thus, some beneficiaries may have had only one month of coverage, while others were covered for twelve months. At the national level, aged dual eligible Medicaid beneficiaries in the study population had, on average, 10.1 months of coverage. cDual eligibles include beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefit coverage during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
$811$1,297
$1,324$1,342
$1,576$1,648
$1,776$1,851
$1,899$1,926
$1,946$1,949$1,956
$1,987$1,990
$2,001$2,025
$2,138$2,153$2,162
$2,208$2,250
$2,266$2,271$2,272
$2,289$2,315$2,319
$2,360$2,413
$2,538$2,541
$2,580$2,584$2,588$2,598$2,600
$2,636$2,669
$2,680$2,690$2,691$2,699
$2,732$2,792$2,797$2,797
$2,848$2,894
$2,963$2,995
$750 $1,000 $1,250 $1,500 $1,750 $2,000 $2,250 $2,500 $2,750 $3,000
ILDCMNSCWI
NMHI
ORMAMDVTMINYOKNVCAARUSMSCOALFL
NDGATXRI
WAMTMEUTNEIAID
AKWY
INWVKSVATNSDDENHNCNJPAKYCT
MOLAOH
38
EXHIBIT 29
AVERAGE ANNUAL PHARMACY REIMBURSEMENT AMOUNT PER BENEFICIARY FOR UNDER-AGE-65 DISABLED DUAL ELIGIBLE BENEFICIARIES, BY STATE, 2003a,b,c
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in State Tables D.3 of the Compendium. The Compendium was prepared for 49 states (excluding Arizona) and the District of Columbia. FFS pharmacy reimbursement information is not available for Arizona due to a very high share of beneficiary enrollment in prepaid managed care plans.
aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bAnnual per-beneficiary reimbursement includes all reimbursement during the year for the number of months of Medicaid FFS pharmacy benefit coverage. Thus, some beneficiaries may have had only one month of coverage, while others were covered for twelve months. At the national level, disabled dual eligible Medicaid beneficiaries in the study population had, on average, 10.5 months of coverage. cDual eligibles include beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefit coverage during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
$1,750$2,311
$2,359$2,454
$2,502$2,504
$2,623$2,654
$2,739$2,825$2,835$2,844
$2,893$2,959
$3,016$3,045$3,054
$3,136$3,176$3,180
$3,200$3,201
$3,297$3,298$3,307$3,313
$3,358$3,362
$3,380$3,403
$3,423$3,478
$3,499$3,515$3,524
$3,649$3,652
$3,670$3,671
$3,805$3,846$3,858
$3,927$4,017
$4,043$4,093
$4,173$4,236
$4,310$4,520
$5,051
$1,100 $1,600 $2,100 $2,600 $3,100 $3,600 $4,100 $4,600 $5,100
AROKMSNMTXALSCGAMINDWVLADCOR
MAKYSDNVMD
ILHI
VTMEMTPAWINCUS
WAKSCA
WYRIIA
VANECOIN
MNUTFLID
NYOHNHTNDENJ
MOCTAK
39
EXHIBIT 30
AVERAGE ANNUAL PHARMACY REIMBURSEMENT AMOUNT PER BENEFICIARY FOR DUAL ELIGIBLE ALL-YEAR NURSING FACILITY RESIDENTS, BY STATE, 2003a,b,c
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in State Tables D.3 of the Compendium. The Compendium was prepared
for 49 states (excluding Arizona) and the District of Columbia. FFS pharmacy reimbursement information is not available for Arizona due to a very high share of beneficiary enrollment in prepaid managed care plans.
aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bAnnual per-beneficiary reimbursement includes all reimbursement during the year for the number of months of Medicaid FFS pharmacy benefit coverage. Thus, some beneficiaries may have had only one month of coverage, while others were covered for twelve months. At the national level, dual eligible Medicaid beneficiaries in the study population who resided in nursing facilities full-year had, on average, 10.0 months of coverage. cDual eligibles include beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefit coverage during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
$598$1,012
$1,269$1,983
$2,150$2,603$2,619$2,619
$2,803$2,808
$3,000$3,023$3,041$3,053
$3,078$3,106$3,111
$3,165$3,177$3,179
$3,209$3,218$3,220
$3,244$3,250
$3,316$3,317$3,319
$3,353$3,384$3,387
$3,442$3,510$3,517
$3,541$3,560
$3,686$3,723$3,741
$3,797$3,818
$3,848$3,870$3,870
$3,963$3,981
$4,018$4,076
$4,193$4,598
$5,189
$400 $800 $1,200 $1,600 $2,000 $2,400 $2,800 $3,200 $3,600 $4,000 $4,400 $4,800 $5,200
DCNYSCHI
MNORMI
MANVVTNDWADE
NMMTMECAKSCOWI
USAAR
WVIAFL
WYALNEID
GANHSDRI
MDTNCTOK
ILVAINNJ
OHMSPANCUTTX
MOKYLAAK
MEDICAID PHARMACY USE AND REIMBURSEMENT, DRUGS EXCLUDED BY STATUTE FROM MEDICARE PART D
41
EXHIBIT 31
PERCENTAGE OF MEDICAID BENEFICIARIES USING AT LEAST ONE DRUG EXCLUDED FROM MEDICARE PART D, 2003a,b
Source: Medicaid Analytic Extract (MAX), 2003. These graph are based on the information contained in Tables ND.11 and D.11 of the Compendium. aThe statute that established the Medicare Part D drug benefit excluded several types of drugs from Part D coverage. State Medicaid programs are required to continue covering these drugs for dual eligibles if they are covered for any other Medicaid beneficiaries. Drugs excluded from the Medicare Part D drug benefit include benzodiazepines; barbiturates; nonprescription (OTC) medications; prescription vitamins and minerals (not including prenatal vitamins and fluoride preparations); and drugs used for anorexia, weight loss, or weight gain. Other excluded drugs include those that promote fertility; those used for cosmetic purposes or hair growth, for symptomatic relief of coughs and colds; or drugs for which the manufacturer requires that associated tests or monitoring services be purchased exclusively from the manufacturer. bDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
27%
73% 47%
53%
Dual Eligibles 6,653,769
Nondual Beneficiaries 33,924,633
At Least 1 Drug
Excluded from Part D
No Drugs Excluded from
Part D
No Drugs Excluded from
Part D
At Least 1 Drug
Excluded from Part D
42
42
42
EXHIBIT 32
ANNUAL MEDICAID PHARMACY REIMBURSEMENT FOR DRUGS EXCLUDED FROM MEDICARE PART D,
NONDUAL AND DUAL ELIGIBLE BENEFICIARIES, 2003a,b
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables ND.13 and D.13 of the Compendium. aThe statute that established the Medicare Part D drug benefit excluded several types of drugs from Part D coverage. State Medicaid programs are required to continue covering these drugs for dual eligibles if they are covered for any other Medicaid beneficiaries. Drugs excluded from the Medicare Part D drug benefit include benzodiazepines; barbiturates; nonprescription (OTC) medications; prescription vitamins and minerals (not including prenatal vitamins and fluoride preparations); and drugs used for anorexia, weight loss, or weight gain. Other excluded drugs include those that promote fertility; those used for cosmetic purposes or hair growth, for symptomatic relief of coughs and colds; or drugs for which the manufacturer requires that associated tests or monitoring services be purchased exclusively from the manufacturer. bDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
$169$134
$43$60
$35$58
$244
$490
$22
$68$106
$70 $70
$349
$108
$15
$196
$113
$0
$50
$100
$150
$200
$250
$300
$350
$400
$450
$500
Anorexia orWeight
Loss/Gain
Fertility Drugs Drugs forCosmeticPurposes
Cough and ColdMedications
Vitamins andMinerals
Non-prescription
Drugs
Barbiturates Benzodiazepines Other Part DExcl Rx Drugs
Nondual Beneficiaries Dual Eligibles
43
43
43
EXHIBIT 33
ANNUAL MEDICAID PHARMACY REIMBURSEMENT FOR DRUGS EXCLUDED FROM MEDICARE PART D FOR NONDUAL AND DUAL ELIGIBLE BENEFICIARIES AS A PERCENTAGE OF TOTAL ANNUAL MEDICAID REIMBURSEMENT
FOR NONDUAL AND DUAL ELIGIBLE BENEFICIARIES, 2003a,b
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables ND.13 and D.13 of the Compendium. aThe statute that established the Medicare Part D drug benefit excluded several types of drugs from Part D coverage. State Medicaid programs are required to continue covering these drugs for dual eligibles if they are covered for any other Medicaid beneficiaries. Drugs excluded from the Medicare Part D drug benefit include benzodiazepines; barbiturates; nonprescription (OTC) medications; prescription vitamins and minerals (not including prenatal vitamins and fluoride preparations); and drugs used for anorexia, weight loss, or weight gain. Other excluded drugs include those that promote fertility; those used for cosmetic purposes or hair growth, for symptomatic relief of coughs and colds; or drugs for which the manufacturer requires that associated tests or monitoring services be purchased exclusively from the manufacturer. bDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
1.3%
1.1%
0.4%
0.7%
0.3%
0.0%
0.8%
0.0%0.0%0.0%
0.9%
0.7%
0.0%
0.3%0.3%
0.0%0.0%0.0%0.0%
0.3%
0.6%
0.9%
1.2%
1.5%
Anorexia orWeight
Loss/Gain
Fertility Drugs Drugs forCosmeticPurposes
Cough and ColdMedications
Vitamins andMinerals
Non-prescription
Drugs
Barbiturates Benzodiazepines Other Part DExcl Rx Drugs
Nondual Beneficiaries Dual Eligibles
MEDICAID PHARMACY USE AND REIMBURSEMENT, 1999, 2001, 2002, AND 2003
45
EXHIBIT 34
TOTAL PHARMACY REIMBURSEMENT, 1999, 2001, 2002, AND 2003a,b
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table 6 of the 1999, 2001, 2002, and 2003
Compendiums. aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bMonthly reimbursement amounts were calculated by dividing the total reimbursement among all beneficiaries in the study population by the total number of benefit months of those beneficiaries. Benefit months are months during which beneficiaries had FFS pharmacy benefit coverage.
(million)
$15,588
$22,910
$27,064
$33,513
$0
$10,000
$20,000
$30,000
$40,000
1999 2001 2002 2003
46
46
46
EXHIBIT 35
PHARMACY REIMBURSEMENT AS A PERCENTAGE OF COSTS OF ALL SERVICES, 1999, 2001, 2002, AND 2003a,b,c
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table 4 of the 1999, 2001, 2002, and 2003
Compendiums. aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bMonthly reimbursement amounts were calculated by dividing the total reimbursement among all beneficiaries in the study population by the total number of benefit months of those beneficiaries. Benefit months are months during which beneficiaries had FFS pharmacy benefit coverage. cIn seven states in 2003 (DE, IA, NE, NY, TX, UT, and WV), expenditures include only Rx drug expenditures for those enrolled in capitated managed care plans, and not expenditures for other services covered by the plans or long-term-care services not covered by the plans. As a result, pharmacy reimbursement as a percentage of the costs of all Medicaid services is higher in 2003 than it would otherwise be.
12% 15% 15% 17%
0%
25%
50%
75%
100%
1999 200 1 2002 2 003
47
47
47
EXHIBIT 36
AVERAGE ANNUAL PRESCRIPTION DRUG REIMBURSEMENT PER MEDICAID BENEFICIARY, NONDUAL BENEFICIARIES AND DUAL ELIGIBLES, 1999, 2001, 2002, AND 2003a,b,c
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables ND3 and D3 of the 1999, 2001, 2002, and 2003
Compendiums. aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. bThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. cMonthly reimbursement amounts were calculated by dividing the total reimbursement among all beneficiaries in the study population by the total number of benefit months of those beneficiaries. Benefit months are months during which beneficiaries had FFS pharmacy benefit coverage.
$ 2 9 8 $ 3 6 2 $ 3 8 5 $ 4 5 9
$ 1 , 6 2 9
$ 2 , 2 0 3$ 2 , 3 8 7
$ 2 , 6 5 9
$ 0
$ 5 0 0
$ 1 , 0 0 0
$ 1 , 5 0 0
$ 2 , 0 0 0
$ 2 , 5 0 0
$ 3 , 0 0 0
1 9 9 9 2 0 0 1 2 0 0 2 2 0 0 3
N o n d u a l B e n e f ic ia r ie s D u a l E l ig ib le s
48
48
48
EXHIBIT 37
AVERAGE MONTHLY PHARMACY REIMBURSEMENT PER BENEFICIARY, NONDUAL BENEFICIARIES AND DUAL ELIGIBLES, 1999, 2001, 2002, AND 2003a,b,c
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables ND4 and D4 of the 1999, 2001, 2002, and 2003
Compendiums. aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. bThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. cMonthly reimbursement amounts were calculated by dividing the total reimbursement among all beneficiaries in the study population by the total number of benefit months of those beneficiaries. Benefit months are months during which beneficiaries had FFS pharmacy benefit coverage.
$ 4 1 $ 4 8 $ 5 2 $ 5 9
$ 1 5 7
$ 2 1 1$ 2 3 3
$ 2 5 2
$ 0$ 2 0$ 4 0$ 6 0$ 8 0
$ 1 0 0$ 1 2 0$ 1 4 0$ 1 6 0$ 1 8 0$ 2 0 0$ 2 2 0$ 2 4 0$ 2 6 0
1 9 9 9 2 0 0 1 2 0 0 2 2 0 0 3
N o n d u a l B e n e f ic ia r ie s D u a l E l ig ib le s
49
49
49
EXHIBIT 38
PERCENTAGE OF BENEFICIARIES WITH AT LEAST ONE PRESCRIPTION FILLED, NONDUAL BENEFICIARIES AND DUAL
ELIGIBLES, 1999, 2001, 2002, AND 2003a
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables ND3 and D3 of the 1999, 2001, 2002, and 2003
Compendiums. aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
5 5 %5 2 % 5 3 %
5 6 %
8 4 % 8 6 % 8 5 % 8 4 %
0 %
2 0 %
4 0 %
6 0 %
8 0 %
1 0 0 %
1 9 9 9 2 0 0 1 2 0 0 2 2 0 0 3
N o n d u a l B e n e fic ia rie s D u a l E lig ib le s
50
50
50
EXHIBIT 39
AVERAGE ANNUAL NUMBER OF PRESCRIPTION CLAIMS PER MEDICAID BENEFICIARY, NONDUAL BENEFICIARIES AND DUAL ELIGIBLES, 1999, 2001, 2002, AND 2003a
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Tables ND3 and D3 of the 1999, 2001, 2002, and 2003
Compendiums.
aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Nondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
6 .4 6 .4 6 .5 7 .3
3 4 .8
3 9 .6 4 0 .24 2 .3
0 .0
5 .0
1 0 .0
1 5 .0
2 0 .0
2 5 .0
3 0 .0
3 5 .0
4 0 .0
4 5 .0
1 9 9 9 2 0 0 1 2 0 0 2 2 0 0 3
N o nd ua l B en e fic ia rie s D ua l E lig ib le s
51
51
51
EXHIBIT 40
BRAND NAME AND GENERIC DRUGS AS A PERCENTAGE OF ALL CLAIMS, 1999, 2001, 2002, AND 2003a
Source: Medicaid Analytic Extract (MAX), 2003. These graph are based on the information contained in Table 5 of the Compendium. aBrand-name drugs, sometimes called “innovator single-source drugs,” are drugs whose patents have not yet expired. Off-patent brand-name drugs, sometimes called “innovator multiple-source drugs,” are brand-name drugs whose patents have expired. Generic drugs, sometimes called “non-innovator multiple-source drugs,” are off-patent drugs manufactured and sold by companies other than the original patent holder. For information about this classification method, see Wolters Kluwer Health, [http://www.medispan.com/products/index.aspx?id=1] (November 8, 2006).
Brand Name
Generic
Brand Name
Generic
53%
47%
50%
50%
47%
53%
Brand Name
Generic
Brand Name
50%
50%
1999 2001 2002 2003
Generic
52
52
52
EXHIBIT 41
NUMBER OF MEDICAID BENEFICIARIES BY BASIS OF ELIGIBILITY, 1999, 2001, 2002, AND 2003a
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table 2 of the 1999, 2001, 2002, and 2003 Compendiums.
aMedicaid basis of eligibility is classified as: aged, disabled, adults, and children. The disabled group includes beneficiaries of any age who were determined to be eligible because of disability or blindness, and thus includes a large number of dual eligibles. The children’s group includes children receiving foster care and adoptive services. The total includes some beneficiaries with unknown basis of eligibility and some whose age categories are not consistent with basis of eligibility.
28.6
3.35 .7 5 .3
14.2
34.4
3.4
6.18.6
16.2
38.2
3.6
6.7
9.9
17.9
40 .7
4 .1
6 .9
10.1
19.6
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
A ll B eneficiaries A ged D isabled A dults Children
1999 2001 2002 2003
(million)
53
53
53
EXHIBIT 42
AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT BY BASIS OF ELIGIBILITY, 1999, 2001, 2002, AND 2003a,b,c
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table 4 of the 1999, 2001, 2002, and 2003 Compendiums. aThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. bMonthly reimbursement amounts were calculated by dividing the total reimbursement among all beneficiaries in the study population by the total number of benefit months of those beneficiaries. Benefit months are months during which beneficiaries had FFS pharmacy benefit coverage. cMedicaid basis of eligibility is classified as: aged, disabled, adults, and children. The disabled group includes beneficiaries of any age who were determined to be eligible because of disability or blindness, and thus includes a large number of dual eligibles. The children’s group includes children receiving foster care and adoptive services. The total includes some beneficiaries with unknown basis of eligibility and some whose age categories are not consistent with basis of eligibility.
$69
$129$154
$31$12
$83
$174
$208
$28$16
$91
$193
$231
$32$19
$100
$202
$257
$42$22
$0
$50
$100
$150
$200
$250
$300
All Beneficiaries Aged Disabled Adults Children
1999 2001 2002 2003
54
54
54
EXHIBIT 43
NUMBER OF NONDUAL MEDICAID BENEFICIARIES BY BASIS OF ELIGIBILITY, 1999, 2001, 2002, AND 2003a,b
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table ND2 of the 1999, 2001, 2002, and 2003 Compendiums.
aMedicaid basis of eligibility is classified as: aged, disabled, adults, and children. The disabled group includes beneficiaries of any age who were determined to be eligible because of disability or blindness, and thus includes a large number of dual eligibles. The children’s group includes children receiving foster care and adoptive services. The total includes some beneficiaries with unknown basis of eligibility and some whose age categories are not consistent with basis of eligibility. bNondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
23.3
0.3
3.55.3
14.2
28.7
0.3
3.7
8.5
16.2
32.0
0.3
3.9
9.8
17.9
34.0
0.3
4.1
10.1
19.6
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
All B eneficiaries Aged D isabled Adults C hildren
1999 2001 2002 2003
(million)
55
55
55
EXHIBIT 44
AVERAGE ANNUAL NUMBER OF PRESCRIPTION CLAIMS BY BASIS OF ELIGIBILITY, NONDUAL BENEFICIARIES,
1999, 2001, 2002, AND 2003a,b
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table ND3 of the 1999, 2001, 2002, and 2003 Compendiums.
aMedicaid basis of eligibility is classified as: aged, disabled, adults, and children. The disabled group includes beneficiaries of any age who were determined to be eligible because of disability or blindness, and thus includes a large number of dual eligibles. The children’s group includes children receiving foster care and adoptive services. The total includes some beneficiaries with unknown basis of eligibility and some whose age categories are not consistent with basis of eligibility. bNondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
18.920.5 20.1 20.7
22.4
26.0 26.128.5
4.5 3.9 4.25.4
2.9 3.1 3.2 3.6
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
1999 2001 2002 2003
Aged Disabled Adults Children
56
56
56
EXHIBIT 45
AVERAGE ANNUAL PRESCRIPTION REIMBURSEMENT BY BASIS OF ELIGIBILITY, NONDUAL BENEFICIARIES, 1999, 2001, 2002, AND 2003a,b,c,d
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table ND3 of the 1999, 2001, 2002, and 2003 Compendiums.
aMedicaid basis of eligibility is classified as: aged, disabled, adults, and children. The disabled group includes beneficiaries of any age who were determined to be eligible because of disability or blindness, and thus includes a large number of dual eligibles. The children’s group includes children receiving foster care and adoptive services. The total includes some beneficiaries with unknown basis of eligibility and some whose age categories are not consistent with basis of eligibility. bNondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. cThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. dMonthly reimbursement amounts were calculated by dividing the total reimbursement among all beneficiaries in the study population by the total number of benefit months of those beneficiaries. Benefit months are months during which beneficiaries had FFS pharmacy benefit coverage.
$ 8 0 5
$ 1 , 0 2 0 $ 1 , 0 6 6$ 1 , 2 0 1
$ 1 , 3 1 2
$ 1 , 8 1 0$ 1 , 9 2 8
$ 2 , 2 4 3
$ 1 7 5 $ 1 7 8 $ 2 0 1$ 2 7 9
$ 8 3 $ 1 1 9 $ 1 3 5 $ 1 6 9
$ 0
$ 5 0 0
$ 1 , 0 0 0
$ 1 , 5 0 0
$ 2 , 0 0 0
$ 2 , 5 0 0
1 9 9 9 2 0 0 1 2 0 0 2 2 0 0 3
A g e d D i s a b l e d A d u l t s C h i l d r e n
57
57
57
EXHIBIT 46
AVERAGE MONTHLY PRESCRIPTION REIMBURSEMENT BY BASIS OF ELIGIBILITY, NONDUAL BENEFICIARIES, 1999,
2001, 2002, AND 2003a,b,c,d
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table ND4 of the 1999, 2001, 2002, and 2003 Compendiums.
aMedicaid basis of eligibility is classified as: aged, disabled, adults, and children. The disabled group includes beneficiaries of any age who were determined to be eligible because of disability or blindness, and thus includes a large number of dual eligibles. The children’s group includes children receiving foster care and adoptive services. The total includes some beneficiaries with unknown basis of eligibility and some whose age categories are not consistent with basis of eligibility. bNondual beneficiaries include beneficiaries who were never dually eligible or were dually eligible but never had Medicaid FFS pharmacy benefits. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. cThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. dMonthly reimbursement amounts were calculated by dividing the total reimbursement among all beneficiaries in the study population by the total number of benefit months of those beneficiaries. Benefit months are months during which beneficiaries had FFS pharmacy benefit coverage.
$ 8 6
$ 1 1 4$ 1 2 3
$ 1 3 3$ 1 3 1
$ 1 7 8
$ 1 9 7
$ 2 1 9
$ 2 9 $ 2 7 $ 3 1$ 4 0
$ 1 2 $ 1 6 $ 1 9 $ 2 2
$ 0
$ 5 0
$ 1 0 0
$ 1 5 0
$ 2 0 0
$ 2 5 0
1 9 9 9 2 0 0 1 2 0 0 2 2 0 0 3
A g e d D i s a b l e d A d u l t s C h i l d r e n
58
58
58
EXHIBIT 47
NUMBER OF DUAL MEDICAID BENEFICIARIES BY BASIS OF ELIGIBILITY, 1999, 2001, 2002, AND 2003a,b
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table D2 of the 1999, 2001, 2002, and 2003 Compendiums.
aMedicaid basis of eligibility is classified as: aged, disabled, adults, and children. The disabled group includes beneficiaries of any age who were determined to be eligible because of disability or blindness, and thus includes a large number of dual eligibles. The children’s group includes children receiving foster care and adoptive services. The total includes some beneficiaries with unknown basis of eligibility and some whose age categories are not consistent with basis of eligibility. bDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
5.3
3.1
2.2
5.7
3.2
2.5
6.2
3.4
2.8
6.7
3.8
2.9
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
All Beneficiaries Aged Disabled
1999 2001 2002 2003
(million)
59
59
59
EXHIBIT 48
AVERAGE ANNUAL NUMBER OF PRESCRIPTION CLAIMS BY BASIS OF ELIGIBILITY, DUAL ELIGIBLE BENEFICIARIES, 1999, 2001, 2002, AND 2003a,b
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table D3 of the 1999, 2001, 2002, and 2003 Compendiums.
aMedicaid basis of eligibility is classified as: aged, disabled, adults, and children. The disabled group includes beneficiaries of any age who were determined to be eligible because of disability or blindness, and thus includes a large number of dual eligibles. The children’s group includes children receiving foster care and adoptive services. The total includes some beneficiaries with unknown basis of eligibility and some whose age categories are not consistent with basis of eligibility. bDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
3 4 .6
3 9 .3 4 0 .1 4 0 .6
3 5 .4
4 0 .3 4 0 .9
4 4 .9
0 .0
1 0 .0
2 0 .0
3 0 .0
4 0 .0
5 0 .0
1 9 9 9 2 0 0 1 2 0 0 2 2 0 0 3
A g e d D is a b le d
60
60
60
EXHIBIT 49
AVERAGE ANNUAL PRESCRIPTION REIMBURSEMENT BY BASIS OF ELIGIBILITY, DUAL ELIGIBLE BENEFICIARIES, 1999, 2001, 2002, AND 2003a,b,c,d
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table D3 of the 1999, 2001, 2002, and 2003 Compendiums.
aMedicaid basis of eligibility is classified as: aged, disabled, adults, and children. The disabled group includes beneficiaries of any age who were determined to be eligible because of disability or blindness, and thus includes a large number of dual eligibles. The children’s group includes children receiving foster care and adoptive services. The total includes some beneficiaries with unknown basis of eligibility and some whose age categories are not consistent with basis of eligibility. bDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. cThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. dMonthly reimbursement amounts were calculated by dividing the total reimbursement among all beneficiaries in the study population by the total number of benefit months of those beneficiaries. Benefit months are months during which beneficiaries had FFS pharmacy benefit coverage.
$1,350
$1,834$1,994
$2,138$2,030
$2,698$2,885
$3,362
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
1999 2001 2002 2003
Aged Disabled
61
61
61
EXHIBIT 50
AVERAGE MONTHLY PRESCRIPTION REIMBURSEMENT BY BASIS OF ELIGIBILITY, DUAL ELIGIBLE BENEFICIARIES, 1999, 2001, 2002, AND 2003a,b,c,d
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table D4 of the 1999, 2001, 2002, and 2003 Compendiums.
aMedicaid basis of eligibility is classified as: aged, disabled, adults, and children. The disabled group includes beneficiaries of any age who were determined to be eligible because of disability or blindness, and thus includes a large number of dual eligibles. The children’s group includes children receiving foster care and adoptive services. The total includes some beneficiaries with unknown basis of eligibility and some whose age categories are not consistent with basis of eligibility. bDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. cThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. dMonthly reimbursement amounts were calculated by dividing the total reimbursement among all beneficiaries in the study population by the total number of benefit months of those beneficiaries. Benefit months are months during which beneficiaries had FFS pharmacy benefit coverage.
$132
$179$198 $207
$189
$250
$275
$308
$0
$50
$100
$150
$200
$250
$300
$350
1999 2001 2002 2003
Aged Disabled
62
62
62
EXHIBIT 51
AVERAGE ANNUAL DRUG REIMBURSEMENT AMONG DUAL ELIGIBLE BENEFICIARIES BY AGE GROUP AND DISABILITY STATUS, 1999, 2001, 2002, AND 2003a,b,c
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Supplemental Tables 1A and 1B of the 1999, 2001, 2002, and 2003 Compendiums.
aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. bThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. cMonthly reimbursement amounts were calculated by dividing the total reimbursement among all beneficiaries in the study population by the total number of benefit months of those beneficiaries. Benefit months are months during which beneficiaries had FFS pharmacy benefit coverage.
$1,387
$1,892$2,062
$2,237$2,143
$2,822$3,007
$3,478
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
1999 2001 2002 2003
Duals Aged 65 or Older Disabled Duals Younger than 65
63
63
63
EXHIBIT 52
PERCENTAGE OF DUAL ELIGIBLE BENEFICIARIES WITH ANNUAL DRUG COSTS IN SPECIFIED RANGES, 1999, 2001, 2002, AND 2003a
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Supplemental Table 1 of the 1999, 2001, 2002, and 2003 Compendiums.
aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
53%
30%
16%
45%
30%25%
43%
29% 28%
42%
27%31%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
$1,000 or Less $1,001 to $3,000 $3,001 or M ore
1999 2001 2002 2003
64
64
64
EXHIBIT 53
NUMBER OF DUAL ELIGIBLE FULL-YEAR NURSING FACILITY RESIDENTS AND UNDER-AGE-65 DISABLED DUAL ELIGIBLE BENEFICIARIES
COMPARED TO ALL DUALS, 1999, 2001, 2002, AND 2003a
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table 11 of the 1999 Compendium and Table D.2 of
the 2001, 2002, and 2003 Compendiums. aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
(million)
5.3
0.8
2.2
5.7
0.9
2.5
6.2
0.9
2.8
6.7
0.8
2.9
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
All Duals Full-Year Nursing Facility Residents Under-Age-65 Disabled Duals
1999 2001 2002 2003
65
65
65
EXHIBIT 54
AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT FOR DUAL ELIGIBLE FULL-YEAR NURSING FACILITY RESIDENTS AND UNDER-AGE-65 DISABLED DUAL ELIGIBLE BENEFICIARIES
COMPARED TO ALL DUALS, 1999, 2001, 2002, AND 2003a,b,c
Source: Medicaid Analytic Extract (MAX), 2003. This graph is based on the information contained in Table 13 of the 1999 and D.4 of the 2001, 2002, and 2003 Compendiums.
aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2003. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. bThe Medicaid pharmacy reimbursement amount is the amount Medicaid reimbursed pharmacies, including dispensing fees minus beneficiary copayment. Reimbursement amounts are gross amounts prior to the receipt of rebates from drug manufacturers to states. cMonthly reimbursement amounts were calculated by dividing the total reimbursement among all beneficiaries in the study population by the total number of benefit months of those beneficiaries. Benefit months are months during which beneficiaries had FFS pharmacy benefit coverage.
$157
$181$189
$211
$249$233
$282 $275
$252
$316$308
$250
$0
$50
$100
$150
$200
$250
$300
$350
All Duals Full Year Nursing Facility Residents Under-Age-65 Disabled Duals
1999 2001 2002 2003