chartbook: medicaid pharmacy benefit use and reimbursement
TRANSCRIPT
Contract No.: 500-00-0047 (0002, Master 061) MPR Reference No.: 8929-953
Chartbook: Medicaid Pharmacy Benefit Use and Reimbursement in 2005 June 2009 Ann Bagchi James Verdier Dominick Esposito
Submitted to: Submitted by:
U.S. Department of Health and Human Services Mathematica Policy Research, Inc. Centers for Medicare & Medicaid Services P.O. Box 2393 Office of Research, Development, and Information Princeton, NJ 08543-2393 7500 Security Boulevard Telephone: (609) 799-3535 Baltimore, MD 21244 Facsimile: (609) 799-0005
Project Officer: Project Director:
David Baugh James Verdier
CHARTBOOK: MEDICAID PHARMACY BENEFIT USE AND REIMBURSEMENT IN 2005
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 2005. 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 Medicaid 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 Medicaid Age Groups and Total Pharmacy Reimbursement Exhibit 8: Average Monthly Medicaid Pharmacy Reimbursement, by Basis of Eligibility and Dual
Status Exhibit 9: Percentage of Medicaid Beneficiaries with at Least One Prescription Drug Claim, by Dual
Eligibility Status Exhibit 10: Average Annual Number of Medicaid Prescription Drug Claims per Beneficiary, by Dual
Eligibility Status Exhibit 11: Number of Medicaid Prescriptions per Benefit Month, by Basis of Eligibility and Dual
Eligibility Status Exhibit 12: Average Annual Medicaid Prescription Drug Spending per Beneficiary, by Dual Eligibility
Status Exhibit 13: Distribution of Medicaid Dual Eligibility Status and Total Pharmacy Reimbursement
Medicaid Pharmacy Use and Reimbursement, Nondual Beneficiaries
Exhibit 14: Distribution of Medicaid 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 Medicaid Pharmacy Reimbursement and Users for Top 10 Drug Groups among Nondual Beneficiaries
Exhibit 17: Percentage of Medicaid Pharmacy Reimbursement and Users for Top 7 Therapeutic Categories among Nondual Beneficiaries
Exhibit 18: Average Monthly Medicaid Pharmacy Reimbursement among Nondual Beneficiaries, by State
Medicaid Pharmacy Use and Reimbursement, Dual Eligible Beneficiaries
Exhibit 19: Generic Prescriptions as Percentage of All Medicaid Prescriptions among Nondual Beneficiaries, by State
Exhibit 20: Distribution of Medicaid 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 Medicaid Pharmacy Reimbursement and Users for Top 10 Drug Groups
Among Dual Eligibles Exhibit 23: Percentage of Medicaid Pharmacy Reimbursement and Users for Top 7 Therapeutic
Categories among Dual Eligibles Exhibit 24: Distribution of Annual Medicaid 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 Medicaid Prescriptions among Dual Eligibles, by
State Exhibit 28: Average Annual Medicaid Pharmacy Reimbursement Amount per Beneficiary for Aged Dual
Eligibles, by State Exhibit 29: Average Annual Medicaid Pharmacy Reimbursement Amount per Beneficiary for Under-
Age-65 Disabled Dual Eligible Beneficiaries, by State Exhibit 30: Average Annual Medicaid 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 Per User 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, 2003, 2004, and 2005
Overview Exhibit 34: Total Medicaid Pharmacy Reimbursement, 1999, 2000, 2001, 2003, 2004, and 2005 Exhibit 35: Medicaid Pharmacy Reimbursement as a Percentage of Costs on All Services, 1999, 2001,
2002, 2003, 2004, and 2005 Exhibit 36: Average Annual Medicaid Prescription Drug Reimbursement per Medicaid Beneficiary,
Nondual Beneficiaries and Dual Eligibles 1999, 2001, 2002, 2003, 2004, and 2005 Exhibit 37: Average Monthly Medicaid Pharmacy Reimbursement per Beneficiary, Nondual
Beneficiaries and Dual Eligibles 1999, 2001, 2002, 2003, 2004, and 2005 Exhibit 38: Percentage of Medicaid Beneficiaries with at Least One Prescription Filled, Nondual
Beneficiaries and Dual Eligibles 1999, 2001, 2002, 2003, 2004, and 2005 Exhibit 39: Average Annual Number of Prescription Claims per Medicaid Beneficiary, Nondual
Beneficiaries and Dual Eligibles 1999, 2001, 2002, 2003, 2004, and 2005 Exhibit 40: Brand Name and Generic Drugs as a Percentage of All Medicaid Claims, 1999, 2001, 2002,
2003, 2004, and 2005
3
4
By Basis of Eligibility Exhibit 41: Number of Medicaid Beneficiaries by Basis of Eligibility, 1999, 2001, 2002, 2003, 2004, and
2005 Exhibit 42: Average Monthly Medicaid Pharmacy Reimbursement by Basis of Eligibility, 1999, 2001,
2002, 2003, 2004, and 2005 Nondual Beneficiaries Exhibit 43: Number of Nondual Medicaid Beneficiaries by Basis of Eligibility, 1999, 2001, 2002, 2003,
2004, and 2005 Exhibit 44: Average Annual Number of Medicaid Prescription Claims by Basis of Eligibility, Nondual
Beneficiaries, 1999, 2001, 2002, 2003, 2004, and 2005 Exhibit 45: Average Annual Medicaid Prescription Reimbursement by Basis of Eligibility, Nondual
Beneficiaries, 1999, 2001, 2002, 2003, 2004, and 2005 Exhibit 46: Average Monthly Medicaid Prescription Reimbursement by Basis of Eligibility, Nondual
Beneficiaries, 1999, 2001, 2002, 2003, 2004, and 2005 Dual Eligible Beneficiaries Exhibit 47: Number of Dual Medicaid Beneficiaries by Basis of Eligibility, 1999, 2001, 2002, 2003,
2004, and 2005 Exhibit 48: Average Annual Number of Medicaid Prescription Claims by Basis of Eligibility, Dual
Eligible Beneficiaries, 1999, 2001, 2002, 2003, 2004, and 2005 Exhibit 49: Average Annual Medicaid Prescription Reimbursement by Basis of Eligibility, Dual Eligible
Beneficiaries, 1999, 2001, 2002, 2003, 2004, and 2005 Exhibit 50: Average Monthly Medicaid Prescription Reimbursement by Basis of Eligibility, Dual
Eligible Beneficiaries, 1999, 2001, 2002, 2003, 2004, and 2005 Exhibit 51: Average Annual Medicaid Drug Reimbursement Among Dual Eligible Beneficiaries by Age
Group and Disability Status, 1999, 2001, 2002, 2003, 2004, and 2005 Exhibit 52: Percentage of Dual Eligible Beneficiaries with Annual Drug Costs in Specified Ranges, 1999,
2001, 2002, 2003, 2004, and 2005 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, 2003, 2004, and 2005 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, 2003, 2004, and 2005
BENEFICIARY CHARACTERISTICS AND ILLUSTRATIVE USE AND REIMBURSEMENT MEASURES
6
EXHIBIT 1
DISTRIBUTION OF MEDICAID STUDY POPULATION BENEFICIARY CHARACTERISTICS, 2005
Beneficiary Characteristics
Percent of Beneficiaries
Among All Medicaid
Beneficiariesa
Among Nondual
Beneficiariesb Among Dual
Eligiblesb
Among Beneficiaries Who Resided in
Nursing Facilities All Yearc
Age 5 and younger 21 25 < 1
15e
6–14 20 24 < 1 15–20 12 15 < 1 21–44 25 27 14 45–64 10 8 22 65–74 5 < 1 25 13 75–84 4 < 1 23 30 85 and older 3 < 1 15 43
Sex Male 40 40 37 29 Female 60 59 63 71
Race African American 23 24 18 14 White 45 43 58 75 Other/Unknown 32 33 23 11
Dual Eligibility Statusb Dual Eligibles 16 0 100 91 Nondual Beneficiaries 84 100 0 9
Basis of Eligibilityd Children 49 58 < 1 < 1 Adults 24 29 1 < 1 Disabled 17 12 43 18 Aged 10 1 56 82
Number of Beneficiaries in Study Population 42,599,571 35,581,286 7,018,285 865,173 Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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. 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 2005. Nondual beneficiaries include beneficiaries who were never
EXHIBIT 1 (continued) ___________________________________________________________________________________
7
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 2005. 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.
8
EXHIBIT 2
ILLUSTRATIVE MEASURES OF MEDICAID STUDY POPULATION PHARMACY BENEFIT USE AND REIMBURSEMENT, 2005a
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) $40,187 $18,333 $21,854 $3,436
Average Annual Pharmacy Reimbursement per Beneficiaryc $943 $515 $3,114 $3,971
Average Pharmacy Reimbursement per Benefit Monthd $114 $66 $295 $392
Average Annual Number of Prescriptions per Beneficiary 13.5 7.3 45.2 69.9
Average Number of Prescriptions per Benefit Month 1.6 0.9 4.3 6.9 Source: Medicaid Analytic Extract (MAX), 2005. 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, 8.3 months of coverage. The comparable number was 7.8 months among nondual beneficiaries and 10.6 months among dual eligible beneficiaries, and 10.1 months among beneficiaries who resided in nursing facilities throughout their Medicaid enrollment in 2005. 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
EXHIBIT 3
DISTRIBUTION OF MEDICAID STUDY POPULATION BY AGE GROUP,
NONDUAL AND DUAL ELIGIBLE BENEFICIARIES, 2005a
64%
35%
1% 0%
37%
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
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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.
EXHIBIT 4
DISTRIBUTION OF MEDICAID STUDY POPULATION BY DISABILITY STATUS,
NONDUAL AND DUAL ELIGIBLE BENEFICIARIES, 2005a,b
12%
88%
43%
57%
0%
25%
50%
75%
100%
Disabled Non-disabled Disabled Non-disabled
Nondual Beneficiaries Dual Eligibles
11
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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.
EXHIBIT 5
DISTRIBUTION OF MEDICAID STUDY POPULATION BY RACE,
NONDUAL AND DUAL ELIGIBLE BENEFICIARIES, 2005a
24%
43%
33%
18%
58%
23%
0%
25%
50%
75%
100%
African American White Other/Unknown African American White Other/Unknown
Nondual Beneficiaries Dual Eligibles
12
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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.
MEDICAID PHARMACY REIMBURSEMENT AND USE, BY TYPE OF BENEFICIARY
EXHIBIT 6
AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT,
BY AGE GROUP, 2005a,b
$114
$23$37 $42
$109
$314
$254 $252$233
$0
$25
$50
$75
$100
$125
$150
$175
$200
$225
$250
$275
$300
$325
All 5 and Younger
6 to 14 15 to 20 21 to 44 45 to 64 65 to 74 75 to 84 85 and Older
Age
14
Source: Medicaid Analytic Extract (MAX), 2005. 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.
15
EXHIBIT 7
DISTRIBUTION OF MEDICAID AGE GROUPS AND TOTAL PHARMACY REIMBURSEMENT, 2005a
65 and Older
45 to 64
21 to 44
20 and Younger 53%
14%
25%
22%
10%
33%
12%
30%
0%
20%
40%
60%
80%
100%
Percent of Beneficiaries Percent of Pharmacy Reimbursement
Source: Medicaid Analytic Extract (MAX), 2005. 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.
EXHIBIT 8
AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT,
BY BASIS OF ELIGIBILITY AND DUAL STATUS, 2005a,b,c,d
$114
$25$45
$295
$240
$66
$295
$0
$50
$100
$150
$200
$250
$300
$350
All Children Adults Disabled Aged Nondual Beneficiaries
Dual Eligibles
Eligibility Status Dual Status
16
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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.
EXHIBIT 9
PERCENTAGE OF MEDICAID BENEFICIARIES WITH AT LEAST ONE PRESCRIPTION DRUG CLAIM,
BY DUAL ELIGIBILITY STATUS, 2005a
56%
86%
0%
25%
50%
75%
100%
Nondual Beneficiaries Dual Eligibles
17
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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.
EXHIBIT 10
AVERAGE ANNUAL NUMBER OF MEDICAID PRESCRIPTION DRUG CLAIMS PER BENEFICIARY,
BY DUAL ELIGIBILITY STATUS, 2005a,b
7.3
45.2
0
10
20
30
40
50
Nondual Beneficiaries Dual Eligibles
18
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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 2005 than dual eligible beneficiaries: 7.8 months for nonduals and 10.5 months for duals.
19
EXHIBIT 11
NUMBER OF MEDICAID PRESCRIPTIONS PER BENEFIT MONTH, BY BASIS OF ELIGIBILITY AND DUAL ELIGIBILITY STATUS, 2005a,b
2.62.8
0.80.5
4.3 4.3
3.23.0
0
1
2
3
4
5
Aged Disabled Adults Children Aged Disabled Adults Children
Nondual Beneficiaries Dual Eligibles
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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.
20
EXHIBIT 12
AVERAGE ANNUAL MEDICAID PRESCRIPTION DRUG SPENDING PER BENEFICIARY, BY DUAL ELIGIBILITY STATUS, 2005a,b
$515
$3,114
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
Nondual Beneficiaries Dual Eligibles
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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 2005 than dual eligible beneficiaries: 7.8 months for nonduals and 10.6 months for duals.
21
EXHIBIT 13
DISTRIBUTION OF MEDICAID DUAL ELIGIBILITY STATUS AND TOTAL PHARMACY REIMBURSEMENT, 2005a,b
Dual
16%
54%
84%
46%
0%
25%
50%
75%
100%
Percent of Beneficiaries Percent of Total Pharmacy Reimbursement
Nondual
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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.
MEDICAID PHARMACY USE AND REIMBURSEMENT, NONDUAL BENEFICIARIES
EXHIBIT 14
DISTRIBUTION OF MEDICAID BENEFICIARIES AND TOTAL PHARMACY REIMBURSEMENT AMONG NONDUAL BENEFICIARIES, BY BASIS OF ELIGIBILITY, 2005a,b,c
58%
22%
29%
17%
12%
59%
1% 2%
0%
25%
50%
75%
100%
Percent of Beneficiaries Percent of Pharmacy Reimbursement
Aged
Disabled
Adults
Children
23
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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.
EXHIBIT 15
TOTAL ANNUAL MEDICAID REIMBURSEMENT FOR TOP 10 DRUG GROUPS AMONG NONDUAL BENEFICIARIES, 2005a,b,c,d
The top 10 drug groups (out of over 90 drug groups) accounted for 57 percent of total Medicaid FFS pharmacy reimbursement for nondual beneficiaries in 2005.
$2,466
$1,273 $1,221$1,139
$1,020$867
$689 $667 $613 $610
$0
$500
$1,000
$1,500
$2,000
Antipsychotics Antiasthmatic Anticonvulsant Antiviral Antidepressants Ulcer Drugs Stimulants/Anti-obesity/Anorexiants
Analgesics -Narcotic
Antidiabetic Antihyperlipidemic
$2,500($ million)
24
Source: Medicaid Analytic Extract (MAX), 2005. 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, 7.8 months of coverage. cThe top 10 drug groups were determined based on total Medicaid reimbursement in 2005. For information about these drug groups, see Wolters Kluwer Health, [http://www.medispan.com/marketing/ContentPage.aspx?contentId=09e0f1ed-80a9-4a87-8bc9-ad778d7b6615] (October 26 2007). dDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2005. 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.
EXHIBIT 16
PERCENTAGE OF MEDICAID PHARMACY REIMBURSEMENT AND USERS FOR TOP 10 DRUG GROUPS AMONG NONDUAL BENEFICIARIES, 2005a,b,c,d
13%
7% 7% 6% 6% 5% 4% 4% 3% 3%5%
18%
5%
2%
10%8%
4%
18%
4% 3%
0%
5%
10%
15%
20%
Antipsychotics Antiasthmatic Anticonvulsant Antiviral Antidepressants Ulcer Drugs Stimulants/Anti-obesity/Anorexiants
Analgesics -Narcotic
Antidiabetic Antihyperlipidemic
Percent of Nondual Beneficiary Pharmacy Reimbursement Percent of Nondual Beneficiaries
25
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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/marketing/ContentPage.aspx?contentId=09e0f1ed-80a9-4a87-8bc9-ad778d7b6615] (October 26 2007). cThe top 10 drugs groups were determined based on total Medicaid reimbursement in the state for 2005. For information about these drug groups, see Wolters Kluwer Health, [http://www.medispan.com/marketing/ContentPage.aspx?contentId=09e0f1ed-80a9-4a87-8bc9-ad778d7b6615] (October 26 2007). dDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2005. 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.
EXHIBIT 17
PERCENTAGE OF PHARMACY MEDICAID REIMBURSEMENT AND USERS FOR TOP 7 THERAPEUTIC CATEGORIES AMONG NONDUAL BENEFICIARIES, 2005a,b,c,d
The top 7 therapeutic categories (out of 18 therapeutic categories) accounted for 74 percent of total Medicaid FFS pharmacy reimbursement for nondual beneficiaries in 2005
21%
13%11%
8% 8% 8% 7%
11%
36%
25%
8% 7%
15%
21%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Central Nervous System Drugs
Anti-infective Agents Respiratory Agents Cardiovascular Agents Neuromuscular Agents Endocrine/ Metabolic Drugs
Analgesics and Anesthetics
Percent of Nondual BeneficiariesPercent of Nondual Beneficiary Pharmacy Reimbursement
26
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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/marketing/ContentPage.aspx?contentId=09e0f1ed-80a9-4a87-8bc9-ad778d7b6615] (October 26 2007) . cTop 7 categories were determined based on total Medicaid reimbursement in 2005. For information about these therapeutic categories, see Wolters Kluwer Health, [http://www.medispan.com/marketing/ContentPage.aspx?contentId=09e0f1ed-80a9-4a87-8bc9-ad778d7b6615] (October 26 2007). cDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2005. 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.
EXHIBIT 18
AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT AMONG NONDUAL BENEFICIARIES, BY STATE, 2005a,b,c
$13$40$41$42$42$43$44$44$45$45$46$47
$49$50$51
$54$54$55
$56$58$58
$62$65$66$66$67$67
$71$72$72
$75$76
$80$81
$83$86
$89$93$93
$96$96
$102$104
$108$136
$159$164$164
$195$263
$0 $50 $100 $150 $200 $250
NMARMDSDMSSCCOALOKWY
ILCAGAID
NDNHMILAUTMTTXIA
ORVT
USAWIAKKSNCTNFL
WAVADEKYMAPAOHNEIN
NVMONYMNWV
RINJ
DCHICT
27
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table N.2 of the Compendium for the nation. The Compendium was prepared for 48 states (excluding Arizona and Maine) 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 2005. 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.
EXHIBIT 19 GENERIC PRESCRIPTIONS AS PERCENTAGE OF ALL MEDICAID PRESCRIPTIONS
AMONG NONDUAL BENEFICIARIES, BY STATE, 2005a,b
46.650.4
50.752.1
52.452.9
53.253.3
54.054.1
54.655.155.155.1
55.455.4
55.855.9
56.356.4
56.856.956.957.057.1
57.658.0
58.358.458.6
58.858.858.9
59.259.4
59.660.060.0
60.560.760.8
61.662.6
63.263.6
64.064.7
65.465.565.5
65.7
40.0 45.0 50.0 55.0 60.0 65.0 70.0
NMNJ
NYSDLADCCT
MDAKNCIA
ARRI
PAKSCAOHFLTX
MNDESC
WYNE
USANDVAWVMSWITNID
VTMIGAIN
NHMOMTCOOKKYNVMAUTIL
ALWAORNM
HI
28
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table N.2 of the Compendium for the nation. The Compendium was
prepared for 48 states (excluding Arizona and Maine) 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/marketing/ContentPage.aspx?contentId=09e0f1ed-80a9-4a87-8bc9-ad778d7b6615] (October 26 2007). bDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2005. 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.
MEDICAID PHARMACY USE AND REIMBURSEMENT, DUAL ELIGIBLE BENEFICIARIES
EXHIBIT 20
DISTRIBUTION OF MEDICAID BENEFICIARIES AND TOTAL PHARMACY REIMBURSEMENT AMONG DUAL ELIGIBLES, BY BASIS OF ELIGIBILITY, 2005a,b,c,d
43%54%
56%45%
0%
25%
50%
75%
100%
Percent of Beneficiaries Percent of Total Pharmacy Reimbursement
Aged
Disabled
30
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
EXHIBIT 21
TOTAL ANNUAL MEDICAID REIMBURSEMENT FOR TOP 10 DRUG GROUPS AMONG DUAL ELIGIBLES, 2005A,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 2005.
($ million) $2,902
$1,626 $1,554
$1,255 $1,238 $1,199
$923 $917 $894 $838
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
Antipsychotic Antihyperlipidemic Ulcer Drugs Anticonvulsant Antidepressants Antidiabetic Analgesics -Narcotic
Antihypertensive Antiasthmatic Antiviral
31
Source: Medicaid Analytic Extract (MAX), 2005. 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, dual eligible Medicaid beneficiaries in the study population had, on average, 10.6 months of coverage. cThe top 10 drug groups were determined based on total Medicaid reimbursement in 2005. For information about these drug groups, see Wolters Kluwer Health, [http://www.medispan.com/marketing/ContentPage.aspx?contentId=09e0f1ed-80a9-4a87-8bc9-ad778d7b6615] (October 26 2007). dDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2005. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
EXHIBIT 22
PERCENTAGE OF MEDICAID PHARMACY REIMBURSEMENT AND USERS FOR TOP 10 DRUG GROUPS AMONG DUAL ELIGIBLES, 2005A,B,C,D
13%
7% 7% 6% 6% 5% 4% 4% 4% 4%
25%
35%
42%
23%
44%
37%
54%
48%
36%
5%
0%
10%
20%
30%
40%
50%
60%
Antipsychotic Antihyperlipidemic Ulcer Drugs Anticonvulsant Antidepressants Antidiabetic Analgesics - Narcotic Antihypertensive Antiasthmatic Antiviral
Percent of Dual Eligible Pharmacy Reimbursement Percent of Dual Eligible Beneficiaries
32
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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/marketing/ContentPage.aspx?contentId=09e0f1ed-80a9-4a87-8bc9-ad778d7b6615] (October 26 2007). cThe top 10 drugs groups were determined based on total Medicaid reimbursement in the state for 2005. For information about these drug groups, see Wolters Kluwer Health, [http://www.medispan.com/marketing/ContentPage.aspx?contentId=09e0f1ed-80a9-4a87-8bc9-ad778d7b6615] (October 26 2007). dDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2005. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
33
The top 7 therapeutic categories (out of 18 therapeutic categories) accounted for 77 percent of total Medicaid FFS pharmacy reimbursement for dual beneficiaries in 2005
EXHIBIT 23
PERCENTAGE OF MEDICAID PHARMACY REIMBURSEMENT AND USERS FOR TOP 7 THERAPEUTIC CATEGORIES AMONG DUAL ELIGIBLES, 2005A,B,C,D
21% 18%9% 8% 8% 7% 7%
49%
64%
41% 44%50%
28%
52%
0%
25%
50%
75%
100%
Central Nervous System Drugs
Cardiovascular Agents
Gastrointestinal Agents
Endocrine/ Metabolic Drugs
Analgesics and Anesthetics
Neromuscular Agents
Anti-infective Agents
Percent of Dual Eligible BeneficiariesPercent of Dual Eligible Pharmacy Reimbursement
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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/marketing/ContentPage.aspx?contentId=09e0f1ed-80a9-4a87-8bc9-ad778d7b6615] (October 26 2007). cTop 7 categories were determined based on total Medicaid reimbursement in 2005. For information about these therapeutic categories, see Wolters Kluwer Health, [http://www.medispan.com/marketing/ContentPage.aspx?contentId=09e0f1ed-80a9-4a87-8bc9-ad778d7b6615] (October 26 2007). dDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2005. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
EXHIBIT 24
DISTRIBUTION OF ANNUAL MEDICAID PHARMACY REIMBURSEMENT FOR
DUAL ELIGIBLES, UNDER-AGE-65 DISABLED VS. AGE 65 AND OLDER, 2005a,b,c
Disabled Dual Eligibles Under Age 65
Dual Eligibles Age 65 and Older
38%
2%
38%
4%
35%
23%
45%
45%
17%
30%
14%
35%
11%
45%
3%
16%
0%
20%
40%
60%
80%
100%
Percent of Beneficiaries Percent of Expenditures Percent of Beneficiaries Percent of Expenditures
$10,000 and more
$10,000 and more $5,001 to
$10,000
$5,001 to $10,000 $1,000 to
$5,000 $1,000 to
$5,000
$0 to $1,000 $0 to
$1,000
(Total Benes = 2.5 million) (Total Exp. = $9.9 billion) (Total Benes = 4.4 million) (Total Exp. = $11.7)
34
Source: Medicaid Analytic Extract (MAX), 2005. 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, 10.6 months of coverage in 2005. cDual eligibles include beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefit coverage during any month of Medicaid enrollment in 2005. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
EXHIBIT 25
AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT AMONG DUAL ELIGIBLES, BY BENEFICIARY NURSING FACILITY RESIDENCE, 2005A,B,C
$295
$377
$342
$281
$150
$175
$200
$225
$250
$275
$300
$325
$350
$375
$400
All Duals Dual All-Year NF Residents Dual Part-Year NF Residents Dual With No NF Use
35
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
36
EXHIBIT 26
AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT AMONG DUAL ELIGIBLES, BY STATE, 2005A,B
$64$201
$211$213
$239$243$245
$250$251$251
$259$265
$271$272$272
$283$283
$288$288
$291$292
$295$300
$311$312$314
$316$323$323$324$324
$328$328$329
$333$334$335
$340$346$347
$356$359$361
$364$365
$390$396
$418$459
$479
$50 $75 $100 $125 $150 $175 $200 $225 $250 $275 $300 $325 $350 $375 $400 $425 $450 $475 $500
NMSCMS
ILDCWIALARMDTXOKMANVMIGAWAORCONDKYCA
USAHI
VTWY
FLVATNSDLANYWVMT
RIIA
DENHKSIN
MNIDPAOHUTNCMOCTNJ
AKNE
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table N.5 of the Compendium for the nation. The Compendium was
prepared for 48 states (excluding Arizona and Maine) 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 2005. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
EXHIBIT 27
GENERIC PRESCRIPTIONS AS A PERCENTAGE OF ALL MEDICAID PRESCRIPTIONS AMONG DUAL ELIGIBLES, BY STATE, 2005A,B
44.848.2
49.550.4
51.751.9
52.752.9
53.454.154.2
54.655.5
55.855.956.056.2
56.756.856.9
57.457.7
57.958.058.058.0
58.358.358.458.558.658.758.7
59.259.559.659.659.759.9
61.161.3
61.561.7
62.162.3
62.864.0
64.866.5
68.0
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 63.0 65.0 67.0 69.0
NYNJ
AKCANCTXFLCTLADCRI
MDOH
USADESDSCPAIA
ARMNVT
NMNEIDKSUTVATNMSGAHIIN
MOCONDWVWYNHWIIL
MIMTNVMAOKKYWAORAL
Percentage
37
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table N.5 of the Compendium for the nation. The Compendium was prepared for 48 states (excluding Arizona and Maine) 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/marketing/ContentPage.aspx?contentId=09e0f1ed-80a9-4a87-8bc9-ad778d7b6615] (October 26 2007). bDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2005. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
38
EXHIBIT 28
AVERAGE ANNUAL MEDICAID PHARMACY REIMBURSEMENT AMOUNT PER BENEFICIARY FOR AGED DUAL ELIGIBLES, BY STATE, 2005A,B,C
$966$1,327
$1,454$1,607
$1,725$1,970
$2,165$2,171
$2,206$2,260
$2,291$2,400
$2,438$2,443
$2,464$2,475$2,480
$2,534$2,556
$2,575$2,589$2,597
$2,622$2,624
$2,663$2,685$2,688
$2,771$2,773
$2,792$2,813$2,829
$2,876$2,889$2,890
$2,910$2,944$2,947
$3,003$3,026
$3,124$3,155
$3,189$3,297
$3,350$3,400
$3,465$3,473
$3,547$3,619
$900 $1,400 $1,900 $2,400 $2,900 $3,400 $3,900
NMMNDCIL
SCWI
MDORMANVMSMINYOKCO
WACA
USAHIFLALMTGATXNDARVT
WYUTRI
DEKYNEIA
NHTNIN
VAIDKSPASDOHMOWVCTNCAKNJLA
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in State Tables D.3 of the Compendium. The Compendium was prepared for 48 states (excluding Arizona and Maine) 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, 10.3 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 2005. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
EXHIBIT 29
AVERAGE ANNUAL MEDICAID PHARMACY REIMBURSEMENT AMOUNT PER BENEFICIARY FOR
UNDER-AGE-65 DISABLED DUAL ELIGIBLE BENEFICIARIES, BY STATE, 2005a,b,c
$469$2,418
$2,592$2,693
$2,871$3,074
$3,163$3,170$3,199
$3,248$3,352$3,354
$3,451$3,473$3,485$3,514
$3,613$3,624$3,647$3,657
$3,700$3,754
$3,813$3,826
$3,875$3,886
$3,924$3,944$3,944$3,953
$4,105$4,145$4,150$4,155
$4,260$4,282$4,295$4,298
$4,377$4,420$4,424
$4,479$4,506$4,517
$4,556$4,793
$4,856$5,334
$5,504$6,100
$100 $600 $1,100 $1,600 $2,100 $2,600 $3,100 $3,600 $4,100 $4,600 $5,100 $5,600 $6,100
NMMSARALTXGASCOKKYMIORNDMDDCLAIL
MAWVNVSD
WAPAWICO
WYUSAMTVATNKSNHCAVTFLIA
DERI
MNOHNCIN
NEHIID
UTNYMONJCTAK
39
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in State Tables D.3 of the Compendium. The Compendium was prepared for 48 states (excluding Arizona and Maine) 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, 10.9 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 2005. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
EXHIBIT 30
AVERAGE ANNUAL MEDICAID PHARMACY REIMBURSEMENT AMOUNT PER BENEFICIARY FOR
DUAL ELIGIBLE ALL-YEAR NURSING FACILITY RESIDENTS, BY STATE, 2005a,b,c
$472$1,272
$2,034$2,420
$2,882$2,911
$2,960$3,005
$3,315$3,359
$3,424$3,472$3,477
$3,546$3,552$3,563
$3,618$3,669
$3,747$3,796$3,807$3,811$3,812$3,831$3,839
$3,914$3,979
$4,034$4,077$4,092$4,102$4,105$4,106
$4,196$4,233
$4,297$4,369
$4,474$4,479$4,506$4,520
$4,603$4,657
$4,811$4,822$4,850
$4,981$5,009
$5,715$6,618
$400 $800 $1,200 $1,600 $2,000 $2,400 $2,800 $3,200 $3,600 $4,000 $4,400 $4,800 $5,200 $5,600 $6,000 $6,400
DCNYSC
MNORHI
MAARNVMI
WAMTWINDVTDE
WYNM
IAIDFLCO
USAMDNHNEGACAALOKSDIL
WVKSKYINCTVAMSRI
PAUTOHTNTX
MONJ
NCLAAK
40
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in State Tables D.3 of the Compendium. The Compendium was prepared
for 48 states (excluding Arizona and Maine) 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, 10.1 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 2005. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
41
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, 2005a,b
44%
56%At Least 1 Drug
Excluded from Part D
At Least 1 Drug
Excluded from Part D
73%
27%
No Drugs Excluded from
Part D No Drugs
Excluded from Part D
Nondual Beneficiaries 35,581,286
Dual Eligibles 7,018,285
42
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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.
43
EXHIBIT 32
ANNUAL MEDICAID PHARMACY REIMBURSEMENT PER USER FOR DRUGS EXCLUDED FROM MEDICARE PART D, NONDUAL AND DUAL ELIGIBLE BENEFICIARIES, 2005a,b
$197 $183
$20 $37$60
$40 $43
$103
$223
$280
$442
$32$62
$103 $87 $74$101
$342
$0
$50
$100
$150
$200
$250
$300
$350
$400
$450
Anorexia or Weight
Loss/Gain
Fertility Drugs Drugs for Cosmetic Purposes
Cough and Cold Medications
Vitamins and Minerals
Non-prescription Drugs
Barbiturates Benzodiazepines Other Part D Excl Rx Drugs
Nondual Beneficiaries Dual Eligibles Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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.
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, 2005a,b
0.0% 0.0% 0.0%
0.8%
0.3%
1.2%
0.0%
0.7%
0.3%
0.0% 0.0% 0.0%
0.2%
0.6%
0.9%
0.0%
0.7%
0.2%
0.0%
0.3%
0.6%
0.9%
1.2%
1.5%
Anorexia or Weight Loss/Gain
Fertility Drugs Drugs for Cosmetic Purposes
Cough and Cold Medications
Vitamins and Minerals
Non-prescription Drugs
Barbiturates Benzodiazepines Other Part D Excl Rx Drugs
Nondual Beneficiaries Dual Eligibles
44
Source: Medicaid Analytic Extract (MAX), 2005. 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 2005. 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.
MEDICAID PHARMACY USE AND REIMBURSEMENT, 1999, 2001, 2002, 2003, 2004, AND 2005
EXHIBIT 34
TOTAL MEDICAID PHARMACY REIMBURSEMENT, 1999, 2001, 2002, 2003, 2004, AND 2005a,b
(million)
$15,588
$22,910
$27,064
$33,513
$38,471$40,187
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
1999 2001 2002 2003 2004 2005
46
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table 6 of the 1999, 2001, 2002, 2003, 2004, and 2005
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.
EXHIBIT 35
MEDICAID PHARMACY REIMBURSEMENT AS A PERCENTAGE OF COSTS OF ALL SERVICES,
1999, 2001, 2002, 2003, 2004, AND 2005a,b,c
12% 15% 15% 17% 19% 19%
0%
25%
50%
75%
100%
1999 2001 2002 2003 2004 2005
47
47
47
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table 4 of the 1999, 2001, 2002, 2003, 2004, and 2005
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 2004 (DE, IA, NE, NY, TX, UT, and WV) and 8 states in 2005 (DE, IA, IL, 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. In NV, managed care plans provided a pharmacy benefit only to dual eligibles and not nondual beneficiaries. As a result, pharmacy reimbursement as a percentage of the costs of all Medicaid services is higher in 2004 and 2005 than they would otherwise be.
EXHIBIT 36
AVERAGE ANNUAL PRESCRIPTION DRUG REIMBURSEMENT PER MEDICAID BENEFICIARY, NONDUAL BENEFICIARIES AND
DUAL ELIGIBLES, 1999, 2001, 2002, 2003, 2004, AND 2005a,b,c
$298 $362 $385 $459 $504 $515
$1,629
$2,203$2,387
$2,659$2,980 $3,114
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
1999 2001 2002 2003 2004 2005
Nondual Beneficiaries Dual Eligibles
48
48
48
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Tables ND3 and D3 of the 1999, 2001, 2002, 2003,
2004, and 2005 Compendiums. aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2005. 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.
EXHIBIT 37
AVERAGE MONTHLY PHARMACY REIMBURSEMENT PER MEDICAID BENEFICIARY, NONDUAL BENEFICIARIES AND DUAL
ELIGIBLES, 1999, 2001, 2002, 2003, 2004, AND 2005a,b,c
$41 $48 $52 $59 $65 $66
$157
$211$233
$252
$283$295
$0
$50
$100
$150
$200
$250
$300
1999 2001 2002 2003 2004 2005
Nondual Beneficiaries Dual Eligibles
49
49
49
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Tables ND4 and D4 of the 1999, 2001, 2002, 2003,
2004, and 2005 Compendiums. aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2005. 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.
EXHIBIT 38
PERCENTAGE OF MEDICAID BENEFICIARIES WITH AT LEAST ONE PRESCRIPTION FILLED, NONDUAL BENEFICIARIES AND
DUAL ELIGIBLES, 1999, 2001, 2002, 2003, 2004, AND 2005a
55% 52% 53%56% 56% 56%
84% 86% 85% 84% 86% 86%
0%
20%
40%
60%
80%
100%
1999 2001 2002 2003 2004 2005
Nondual Beneficiaries Dual Eligibles
50
50
50
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Tables ND3 and D3 of the 1999, 2001, 2002, 2003,
2004, and 2005 Compendiums. aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2005. 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.
EXHIBIT 39
AVERAGE ANNUAL NUMBER OF PRESCRIPTION CLAIMS PER MEDICAID BENEFICIARY, NONDUAL BENEFICIARIES AND
DUAL ELIGIBLES, 1999, 2001, 2002, 2003, 2004, AND 2005a
6.4 6.4 6.5 7.3 7.3 7.3
34.8
39.6 40.242.3
44.7 45.2
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
1999 2001 2002 2003 2004 2005
Nondual Beneficiaries Dual Eligibles
51
51
51
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Tables ND3 and D3 of the 1999, 2001, 2002, 2003,
2004, and 2005 Compendiums.
aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2005. 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.
EXHIBIT 40
BRAND NAME AND GENERIC DRUGS AS A PERCENTAGE OF ALL MEDICAID CLAIMS, 1999, 2001, 2002, 2003, 2004, AND 2005a
50% 53%47% 50% 47% 44%
50% 47%53% 50% 53% 56%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1999 2001 2002 2003 2004 2005
Brand Name Generic
52
52
52
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table 5 of the 1999, 2001, 2002, 2003, 2004, and 2005 Compendiums.
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/marketing/ContentPage.aspx?contentId=09e0f1ed-80a9-4a87-8bc9-ad778d7b6615] (October 26 2007).
EXHIBIT 41
NUMBER OF MEDICAID BENEFICIARIES BY BASIS OF ELIGIBILITY, 1999, 2001, 2002, 2003, 2004, AND 2005a
28.6
3.3
5.7 5.3
14.2
34.4
3.4
6.1
8.6
16.2
38.2
3.6
6.7
9.9
17.9
40.7
4.1
6.9
10.1
19.6
42.4
4.2
7.2
10.3
20.7
42.6
4.2
7.3
10.3
20.7
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
All Beneficiaries Aged Disabled Adults Children
45.0(million)
1999 2001 2002 2003 2004 2005
53
53
53
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table 2 of the 1999, 2001, 2002, 2003, 2004, and 2005 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.
EXHIBIT 42
AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT BY BASIS OF ELIGIBILITY,
1999, 2001, 2002, 2003, 2004, AND 2005a,b,c
$69
$129$154
$31$12
$83
$174
$208
$28$16
$91
$193
$231
$32 $19
$100
$202
$257
$42 $22
$110
$229
$284
$48 $24
$114
$240
$295
$45 $25
$0
$50
$100
$150
$200
$250
$300
$350
All Beneficiaries Aged Disabled Adults Children
1999 2001 2002 2003 2004 2005
54
54
54
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table 4 of the 1999, 2001, 2002, 2003, 2004, and 2005
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.
EXHIBIT 43
NUMBER OF NONDUAL MEDICAID BENEFICIARIES BY BASIS OF ELIGIBILITY, 1999, 2001, 2002, 2003, 2004, AND 2005a,b
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
35.5
0.3
4.2
10.3
20.7
35.6
0.3
4.3
10.2
20.7
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
All Beneficiaries Aged Disabled Adults Children
200520042003200220011999
40.0(million)
55
55
55
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table ND2 of the 1999, 2001, 2002, 2003, 2004, and 2005 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.
EXHIBIT 44
AVERAGE ANNUAL NUMBER OF MEDICAID PRESCRIPTION CLAIMS BY BASIS OF ELIGIBILITY,
NONDUAL BENEFICIARIES, 1999, 2001, 2002, 2003, 2004, AND 2005a,b
18.920.5 20.1 20.7
22.9 23.222.4
26.0 26.128.5 29.0 28.9
4.5 3.9 4.25.4 5.7 5.3
2.9 3.1 3.2 3.6 3.5 3.5
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
1999 2001 2002 2003 2004 2005
Aged Disabled Adults Children
56
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table ND3 of the 1999, 2001, 2002, 2003, 2004, and 2005 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.
EXHIBIT 45
AVERAGE ANNUAL MEDICAID PRESCRIPTION REIMBURSEMENT BY BASIS OF ELIGIBILITY,
NONDUAL BENEFICIARIES, 1999, 2001, 2002, 2003, 2004, AND 2005a,b,c,d
$805$1,020 $1,066
$1,201$1,374 $1,423
$1,312
$1,810$1,928
$2,243$2,457 $2,538
$175 $178 $201 $279 $316 $296$83 $119 $135 $169 $183 $193
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
1999 2001 2002 2003 2004 2005
ChildrenAdultsDisabledAged
57
57
57
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table ND3 of the 1999, 2001, 2002, 2003, 2004, and 2005 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.
EXHIBIT 46
AVERAGE MONTHLY MEDICAID PRESCRIPTION REIMBURSEMENT BY BASIS OF ELIGIBILITY,
NONDUAL BENEFICIARIES, 1999, 2001, 2002, 2003, 2004, AND 2005a,b,c,d
$86
$114 $123$133
$151 $157
$131
$178$197
$219$241 $249
$29 $27 $31 $40 $45 $43
$12 $16 $19 $22 $24 $25
$0
$50
$100
$150
$200
$250
1999 2001 2002 2003 2004 2005
Aged Disabled Adults Children
58
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table ND4 of the 1999, 2001, 2002, 2003, 2004, and 2005 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.
EXHIBIT 47
NUMBER OF DUAL MEDICAID BENEFICIARIES BY BASIS OF ELIGIBILITY, 1999, 2001, 2002, 2003, 2004, AND 2005a,b
5.3
3.1
2.2
5.7
3.2
2.5
6.2
3.4
2.8
6.7
3.8
2.9
6.9
3.9
3.0
7.0
3.9
3.0
0.0
1.0
2.0
3.0
4.0
5.0
6.0
All Beneficiaries Aged Disabled
7.0(million)
1999 2001 2002 2003 2004 2005
59
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table D2 of the 1999, 2001, 2002, 2003, 2004, and 2005 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 2005. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
EXHIBIT 48
AVERAGE ANNUAL NUMBER OF MEDICAID PRESCRIPTION CLAIMS BY BASIS OF ELIGIBILITY,
DUAL ELIGIBLE BENEFICIARIES, 1999, 2001, 2002, 2003, 2004, AND 2005a,b
34.639.3 40.1 40.6
43.6 44.5
35.440.3 40.9
44.9 46.7 46.7
0.0
10.0
20.0
30.0
40.0
50.0
1999 2001 2002 2003 2004 2005
Aged Disabled
60
60
60
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table D3 of the 1999, 2001, 2002, 2003, 2004, and 2005 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 2005. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
EXHIBIT 49
AVERAGE ANNUAL MEDICAID PRESCRIPTION REIMBURSEMENT BY BASIS OF ELIGIBILITY,
DUAL ELIGIBLE BENEFICIARIES, 1999, 2001, 2002, 2003, 2004, AND 2005a,b,c,d
$1,350
$1,834$1,994
$2,138$2,420 $2,534
$2,030
$2,698$2,885
$3,362
$3,731$3,886
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
1999 2001 2002 2003 2004 2005
Aged Disabled
61
61
61
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table D3 of the 1999, 2001, 2002, 2003, 2004, and 2005 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 2005. 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.
62
62
62
EXHIBIT 50
AVERAGE MONTHLY MEDICAID PRESCRIPTION REIMBURSEMENT BY BASIS OF ELIGIBILITY, DUAL ELIGIBLE BENEFICIARIES, 1999, 2001, 2002, 2003, 2004, AND 2005a,b,c,d
$132$179 $198 $207
$234 $246
$189
$250$275
$308$343 $356
$0
$50$100
$150
$200
$250
$300$350
$400
1999 2001 2002 2003 2004 2005
Aged Disabled
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table D4 of the 1999, 2001, 2002, 2003, 2004, and 2005 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 2005. 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.
EXHIBIT 51
AVERAGE ANNUAL MEDICAID DRUG REIMBURSEMENT AMONG DUAL ELIGIBLE BENEFICIARIES
BY AGE GROUP AND DISABILITY STATUS, 1999, 2001, 2002, 2003, 2004, AND 2005a,b,c
$1,387
$1,892$2,062
$2,237$2,527 $2,648
$2,143
$2,822$3,007
$3,478$3,829 $3,963
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
1999 2001 2002 2003 2004 2005
Duals Aged 65 or Older Disabled Duals Younger than 65
63
63
63
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Supplemental Tables 1A and 1B of the 1999, 2001, 2002, 2003, 2004, and 2005 Compendiums.
aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2005. 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.
EXHIBIT 52
PERCENTAGE OF DUAL ELIGIBLE BENEFICIARIES WITH ANNUAL DRUG COSTS IN SPECIFIED RANGES,
1999, 2001, 2002, 2003, 2004, AND 2005a
53%
30%
16%
45%
30%25%
43%
29% 28%
42%
27%31%
39%
27%
35%38%
26%
35%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
$1,000 or Less $1,001 to $3,000 $3,001 or More
1999 2001 2002 2003 2004 2005
64
64
64
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Supplemental Table 1 of the 1999, 2001, 2002, 2003, 2004, and 2005 Compendiums.
aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2005. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
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, 2003, 2004, AND 2005a
(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
6.9
0.8
3.0
7.0
0.8
3.0
0.0
1.0
2.0
3.0
4.0
5.0
6.0
All Duals Full-Year Nursing Facility Residents Under-Age-65 Disabled Duals
7.0
1999 2001 2002 2003 2004 2005
65
65
65
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table 11 of the 1999 Compendium and Table D.2 of the 2001, 2002, 2003, 2004, and 2005 Compendiums.
aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2005. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
EXHIBIT 54
AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT FOR DUAL ELIGIBLE FULL-YEAR NURSING FACILITY RESIDENTS AND UNDER-AGE-65 DISABLED DUAL ELIGIBLE BENEFICIARIES
$157$181 $189
$211
$249 $250$233
$282 $275 $252
$316 $308 $283
$356 $343
$295
$377 $356
$0
$50
$100
$150
$200
$250
$300
$350
$400
All Duals Full Year Nursing Facility Residents Under-Age-65 Disabled Duals
1999 2001 2002 2003 2004 2005
COMPARED TO ALL DUALS, 1999, 2001, 2002, 2003, 2004, AND 2005a,b,c
66
66
66
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.
Source: Medicaid Analytic Extract (MAX), 2005. This graph is based on the information contained in Table 13 of the 1999 and D.4 of the 2001, 2002, 2003, 2004, and 2005 Compendiums.
aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2005. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.
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.