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Chartbook: Medicaid Pharmacy Benefit Use and Reimbursement in 2009

December 21, 2012

Ann D. Bagchi James Verdier Dominick Esposito

Contract Number: HHSM-500-2005-00025I Task Order: HHSM-500-T0002

Mathematica Reference Number: 06759.310

Submitted to: Centers for Medicare & Medicaid Services 7111 Security Blvd Room B2-27-00 Mail Stop B2-29-40 Baltimore, MD 21244-1850 Project Officer: Cara Petroski Submitted by: Mathematica Policy Research 1100 First Street NE 12th Floor Washington, DC 20002 Telephone: (202) 484-9220 Facsimile: (202) 863-1763 Project Director: Julie Sykes

Chartbook: Medicaid Pharmacy Benefit Use and Reimbursement in 2009

December 21, 2012

Ann D. Bagchi James Verdier Dominick Esposito

CHARTBOOK: MEDICAID PHARMACY BENEFIT USE AND REIMBURSEMENT IN 2009

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 2009. The Compendium was prepared for 42 states and the District of Columbia. Fee-for-service (FFS) pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009. The 57 exhibits in the chartbook are summarized below.

Because coverage of most prescription drugs for dual eligible beneficiaries shifted from Medicaid to Medicare in 2006, Medicaid-only prescription drug use and reimbursement for dual eligibles shown in this chartbook for 2006 through 2009 is substantially lower than in prior years.

Beneficiary Characteristics and Illustrative Use and Reimbursement Measures

Exhibit 1: Distribution of Medicaid Study Population Beneficiary Characteristics, 2009 Exhibit 2: Illustrative Measures of Medicaid Study Population Pharmacy Benefit Use and

Reimbursement, 2009

Study Population Characteristics

Exhibit 3: Distribution of Medicaid Study Population by Age Group, Nondual and Dual Eligible Beneficiaries, 2009

Exhibit 4: Distribution of Medicaid Study Population by Disability Status, Nondual and Dual Eligible Beneficiaries, 2009

Exhibit 5: Distribution of Medicaid Study Population by Race, Nondual and Dual Eligible Beneficiaries, 2009

Medicaid Pharmacy Use and Reimbursement, by Type of Beneficiary

Exhibit 6: Average Monthly Medicaid Pharmacy Reimbursement, by Age Group, 2009 Exhibit 7: Distribution of Medicaid Age Groups and Total Pharmacy Reimbursement, 2009 Exhibit 8: Distribution of Medicaid Dual Eligibility Status and Total Pharmacy Reimbursement, 2009 Exhibit 9: Average Monthly Medicaid Pharmacy Reimbursement, by Basis of Eligibility and Dual

Status, 2009 Exhibit 10: Percentage of Medicaid Beneficiaries with at Least One Prescription Drug Claim, by Dual

Eligibility Status, 2009 Exhibit 11: Average Annual Number of Medicaid Prescription Drug Claims per Beneficiary, by Dual

Eligibility Status, 2009 Exhibit 12: Average Annual Medicaid Prescription Drug Reimbursement per Beneficiary, by Dual

Eligibility Status, 2009 Exhibit 13: Number of Medicaid Prescriptions per Benefit Month, by Basis of Eligibility and Dual

Eligibility Status, 2009

Medicaid Pharmacy Use and Reimbursement, Nondual Beneficiaries

Exhibit 14: Distribution of Medicaid Beneficiaries and Total Pharmacy Reimbursement among Nondual Beneficiaries, by Basis of Eligibility, 2009

4

Exhibit 15: Total Annual Medicaid Reimbursement for Top 10 Drug Groups among Nondual Beneficiaries, 2009

Exhibit 16: Percentage of Medicaid Pharmacy Use and Reimbursement for Top 10 Drug Groups among Nondual Beneficiaries, 2009

Exhibit 17: Percentage of Medicaid Pharmacy Use and Reimbursement for Top 7 Therapeutic Categories among Nondual Beneficiaries, 2009

Exhibit 18: Average Monthly Medicaid Pharmacy Reimbursement among Nondual Beneficiaries, by State, 2009

Exhibit 19: Generic Prescriptions as Percentage of All Medicaid Prescriptions among Nondual Beneficiaries, by State, 2009

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, 2009

Exhibit 21: Total Annual Medicaid Reimbursement for Top 10 Drug Groups among Dual Eligibles, 2009

Exhibit 22: Percentage of Medicaid Pharmacy Use and Reimbursement for Top 10 Drug Groups Among Dual Eligibles, 2009

Exhibit 23: Percentage of Medicaid Pharmacy Use and Reimbursement for Top 7 Therapeutic Categories among Dual Eligibles, 2009

Exhibit 24: Distribution of Annual Medicaid Pharmacy Reimbursement for Dual Eligibles, Under-Age-65 Disabled vs. Age 65 and Older, 2009

Exhibit 25: Average Monthly Medicaid Pharmacy Reimbursement among Dual Eligibles, by Beneficiary Nursing Facility Residence, 2009

Exhibit 26: Average Monthly Medicaid Pharmacy Reimbursement among Dual Eligibles, by State, 2009

Exhibit 27: Generic Prescriptions as a Percentage of All Medicaid Prescriptions among Dual Eligibles, by State, 2009

Exhibit 28: Average Annual Medicaid Pharmacy Reimbursement Amount per Beneficiary for Aged Dual Eligibles, by State, 2009

Exhibit 29: Average Annual Medicaid Pharmacy Reimbursement Amount per Beneficiary for Under-Age-65 Disabled Dual Eligible Beneficiaries, by State, 2009

Exhibit 30: Average Annual Medicaid Pharmacy Reimbursement Amount per Beneficiary for Dual Eligible All-Year Nursing Facility Residents, by State, 2009

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, 2009

Exhibit 32: Annual Medicaid Pharmacy Reimbursement per Beneficiary for Drugs Excluded from Medicare Part D, Nondual and Dual Eligible Beneficiaries, 2009

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, 2009

Medicaid Pharmacy Use and Reimbursement, 1999 and 2001-2009

Overview Exhibit 34: Total Medicaid Pharmacy Reimbursement, 1999 and 2001-2009 Exhibit 35: Medicaid Pharmacy Reimbursement as a Percentage of Costs on All Services, 1999 and

2001-2009

5

Exhibit 36: Average Annual Medicaid Prescription Drug Reimbursement per Medicaid Beneficiary, Nondual Beneficiaries and Dual Eligibles, 1999 and 2001-2009

Exhibit 37: Average Monthly Medicaid Pharmacy Reimbursement per Beneficiary, Nondual Beneficiaries and Dual Eligibles, 1999 and 2001-2009

Exhibit 38: Percentage of Medicaid Beneficiaries with at Least One Prescription Filled, Nondual Beneficiaries and Dual Eligibles, 1999 and 2001-2009

Exhibit 39: Average Annual Number of Prescription Claims per Medicaid Beneficiary, Nondual Beneficiaries and Dual Eligibles, 1999 and 2001-2009

Exhibit 40: Brand Name and Generic Drugs as a Percentage of All Medicaid Claims, 1999 and 2001-2009

By Basis of Eligibility Exhibit 41: Number of Medicaid Beneficiaries by Basis of Eligibility, 1999 and 2001-2009 Exhibit 42: Average Monthly Medicaid Pharmacy Reimbursement by Basis of Eligibility, 1999 and

2001-2009

Nondual Beneficiaries Exhibit 43: Number of Nondual Medicaid Beneficiaries by Basis of Eligibility, 1999 and 2001-2009 Exhibit 44: Average Annual Number of Medicaid Prescription Claims by Basis of Eligibility, Nondual

Beneficiaries, 1999 and 2001-2009 Exhibit 45: Average Annual Medicaid Prescription Reimbursement by Basis of Eligibility, Nondual

Beneficiaries, 1999 and 2001-2009 Exhibit 46: Average Monthly Medicaid Prescription Reimbursement by Basis of Eligibility, Nondual

Beneficiaries, 1999 and 2001-2009

Dual Eligible Beneficiaries Exhibit 47: Number of Dual Medicaid Beneficiaries by Basis of Eligibility, 1999 and 2001-2009 Exhibit 48: Average Annual Number of Medicaid Prescription Claims by Basis of Eligibility, Dual

Eligible Beneficiaries, 1999 and 2001-2009 Exhibit 49: Average Annual Medicaid Prescription Reimbursement by Basis of Eligibility, Dual

Eligible Beneficiaries, 1999 and 2001-2009 Exhibit 50: Average Monthly Medicaid Prescription Reimbursement by Basis of Eligibility, Dual

Eligible Beneficiaries, 1999 and 2001-2009 Exhibit 51: Average Annual Medicaid Drug Reimbursement Among Dual Eligible Beneficiaries by

Age Group and Disability Status, 1999 and 2001-2009 Exhibit 52: Percentage of Dual Eligible Beneficiaries with Annual Drug Costs in Specified Ranges,

1999 and 2001-2009 Exhibit 53: Number of Dual Eligible Full-Year Nursing Facility Residents and Under-Age-65 Disabled

Dual Eligible Beneficiaries Compared to All Duals, 1999 and 2001-2009 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 and 2001-2009

Managed Care Penetration Exhibit 55: Comprehensive Managed Care Penetration Rates for Nondual Aged/Disabled Beneficiaries,

by State, 2009 Exhibit 56: Comprehensive Managed Care Penetration Rates for Nondual Adult/Children

Beneficiaries, by State, 2009 Exhibit 57: Comprehensive Managed Care Penetration Rates for Dual Eligible Beneficiaries, by State,

2009

BENEFICIARY CHARACTERISTICS AND ILLUSTRATIVE USE AND REIMBURSEMENT MEASURES

7

EXHIBIT 1

DISTRIBUTION OF MEDICAID STUDY POPULATION BENEFICIARY CHARACTERISTICS, 2009

Beneficiary Characteristics

Percent of Beneficiaries

Among All Medicaid

Beneficiariesa Among Nondual

Beneficiariesb Among Dual

Eligiblesb

Among Full-Year Nursing Facilities

Residentsc Age

5 and younger 20 24 < 1 17e 6–14 20 23 < 1 17e 15–20 13 15 < 1 17e 21–44 26 28 15 17e 45–64 11 9 25 17e 65–74 4 < 1 25 14 75–84 3 < 1 20 27 85 and older 2 < 1 15 42

Sex Male 40 41 38 31 Female 60 59 62 69

Race African American 23 23 19 15 White 40 38 53 71 Other/Unknown 37 39 28 14

Dual Eligibility Statusb Dual Eligibles 15 0 100 90 Nondual Beneficiaries 85 100 0 10

Basis of Eligibilityd Children 48 56 < 1 < 1 Adults 27 31 2 < 1 Disabled 17 12 47 20 Aged 8 1 52 80

Number of Beneficiaries in Study Population 41,970,686 35,866,720 6,103,966 683,272

Source: Medicaid Analytic eXtract (MAX), 2009. 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”). The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

aMedicaid beneficiaries featured in this chartbook include those who had FFS Medicaid pharmacy benefit coverage for at least one month during calendar year 2009. Beneficiaries who received prescription drugs through 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 2009. 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 2009. 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, 2009a

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 millions) $21,542 $20,522 $1,021 $479

Average Annual Pharmacy Reimbursement per Beneficiaryc $513 $572 $167 $701

Average Pharmacy Reimbursement per Benefit Monthd $64 $76 $16 $69

Average Annual Number of Prescriptions per Beneficiary 6.6 6.9 4.9 13.0

Average Number of Prescriptions per Benefit Month 0.8 0.9 0.5 1.3 Source: Medicaid Analytic eXtract (MAX), 2009. 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. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

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, 8.0 months of coverage. The comparable number was 7.6 months among nondual beneficiaries and 10.5 months among dual eligible beneficiaries, and 10.2 months among beneficiaries who resided in nursing facilities throughout their Medicaid enrollment in 2009.

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

100%

75%

62% 60%

50% 40%

37%

25%

1% 0% 0%

Under 21 21 to 64 65 and Older Under 21 21 to 64 65 and Older

Nondual Beneficiaries Dual Eligibles

10

EXHIBIT 3

DISTRIBUTION OF MEDICAID STUDY POPULATION BY AGE GROUP, NONDUAL AND DUAL ELIGIBLE BENEFICIARIES, 2009a

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Tables ND.2 and D.2 of the Compendium. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. 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.

11

100% 88%

75%

53% 47% 50%

25% 12%

0% Disabled Nondisabled Disabled Nondisabled


EXHIBIT 4

DISTRIBUTION OF MEDICAID STUDY POPULATION BY DISABILITY STATUS, NONDUAL AND DUAL ELIGIBLE BENEFICIARIES, 2009a,b


aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. 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.

12

100%

75%

53%

50% 38% 39%

28% 23% 25% 19%

0% African American White Other/Unknown African American White Other/Unknown


EXHIBIT 5

DISTRIBUTION OF MEDICAID STUDY POPULATION BY RACE, NONDUAL AND DUAL ELIGIBLE BENEFICIARIES, 2009a



MEDICAID PHARMACY USE AND REIMBURSEMENT, BY TYPE OF BENEFICIARY

$200$177

$180

$160

$140

$120

$100

$80 $70$64

$54$60 $48

$40 $29 $32

$20 $12 $7

$0All 5 and 6 to 14 15 to 20 21 to 44 45 to 64 65 to 74 75 to 84 85 and Older

YoungerAge

EXHIBIT 6

AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT, BY AGE GROUP, 2009a,b

14

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Table 4 of the Compendium. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.


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, 2009a

100% 65 and Older 3%

9%

11% 45 to 64 80% 37%

26%

60% 21 to 44

27%

40%

20 and 53% Younger

20%33%

0%Percent of Beneficiaries Percent of Pharmacy Reimbursement

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Tables 2, 3, and 6 of the Compendium. The

Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.


16

EXHIBIT 8

DISTRIBUTION OF MEDICAID DUAL ELIGIBILITY STATUS AND TOTAL PHARMACY REIMBURSEMENT, 2009a,b

100%

75%

85%

50% 95%Nondual

25%

15% Dual 4%0%

Percent of Beneficiaries Percent of Total Pharmacy Reimbursement

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Tables 2, ND.2, D.2, 6, ND.6, and D.6 of the Compendium. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.


bDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. 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.

$180 $173

$160

$140

$120

$100$76

$80 $64$60 $44$40 $31

$17 $16$20

$0All Children Adults Disabled Aged Nondual Dual Eligibles

Beneficiaries

Eligibility Status Dual Status

17

EXHIBIT 9

AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT, BY BASIS OF ELIGIBILITY AND DUAL STATUS, 2009a,b,c,d

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Tables 4, ND.4, and D.4 of the Compendium. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

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 2009. 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.

18

100%

75%

54%

50%

37%

25%

0% Nondual Beneficiaries Dual Eligibles

EXHIBIT 10

PERCENTAGE OF MEDICAID BENEFICIARIES WITH AT LEAST ONE PRESCRIPTION DRUG CLAIM, BY DUAL ELIGIBILITY STATUS, 2009a



19

10

9

8 6.9

7

6 4.9

5

4

3

2

1

0 Nondual Beneficiaries Dual Eligibles

EXHIBIT 11

AVERAGE ANNUAL NUMBER OF MEDICAID PRESCRIPTION DRUG CLAIMS PER BENEFICIARY, BY DUAL ELIGIBILITY STATUS, 2009a,b



bNondual beneficiaries, on average, had fewer months of Medicaid eligibility in 2009 than dual eligible beneficiaries: 7.6 months for nonduals and 10.5 months for duals.

20

$600 $572

$550

$500

$450

$400

$350

$300

$250

$200 $167

$150

$100

$50

$0 Nondual Beneficiaries Dual Eligibles

EXHIBIT 12

AVERAGE ANNUAL MEDICAID PRESCRIPTION DRUG REIMBURSEMENT PER BENEFICIARY, BY DUAL ELIGIBILITY STATUS, 2009a,b



bNonduals, on average, had fewer months of Medicaid eligibility in 2009 than dual eligible beneficiaries: 7.6 months for nonduals and 10.5 months for duals.

5

4

3 2.8

2.2

1.72

1.3

1 0.70.5 0.50.4

0Aged Disabled Adults Children Aged Disabled Adults Children


21

EXHIBIT 13

NUMBER OF MEDICAID PRESCRIPTIONS PER BENEFIT MONTH, BY BASIS OF ELIGIBILITY AND DUAL ELIGIBILITY STATUS, 2009a,b,c


aData are based on small numbers of cases for aged nonduals (256,053 beneficiaries), and adult and children duals (92,134 and 1,433, respectively). 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. cDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. 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.

22

MEDICAID PHARMACY USE AND REIMBURSEMENT, NONDUAL BENEFICIARIES

23

EXHIBIT 14

DISTRIBUTION OF MEDICAID BENEFICIARIES AND TOTAL PHARMACY REIMBURSEMENT AMONG NONDUAL BENEFICIARIES, BY BASIS OF ELIGIBILITY, 2009a,b,c

Aged 1% 2%100%

12%Disabled

75%31%

59%

Adults 50%

16%56%25%Children

22%


Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Tables ND.2, ND.3, and ND.6 of the Compendium. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

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. cDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. 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.

($ million) $3,500$3,250 $3,036$3,000$2,750$2,500$2,250$2,000

$1,684 $1,671$1,750$1,500$1,250 $1,140

$983$1,000 $882 $782 $775 $732 $705

$750$500$250

$0Antipsychotics Antiasthmatic Antiviral Anticonvulsant Stimulants/Anti- Ulcer Drugs Misc. Hematological Antidiabetic Analgesics - Antidepressants

obesity/Anorexiants Narcotic

24

EXHIBIT 15

TOTAL ANNUAL MEDICAID REIMBURSEMENT FOR TOP 10 DRUG GROUPS AMONG NONDUAL BENEFICIARIES, 2009a,b,c,d

The top 10 drug groups (out of over 90) accounted for 60 percent of total Medicaid FFS pharmacy reimbursement for nondual beneficiaries in 2009.

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Table ND.7 of the Compendium. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

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 2009. For information about these drug groups, see Wolters Kluwer Health, [http://www ] (December 21, 2012). .medispan.com/drug-information-products.aspxdDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. 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.

http://www.medispan.com/drug-information-products.aspx�

25

EXHIBIT 16

PERCENTAGE OF MEDICAID PHARMACY USE AND REIMBURSEMENT FOR TOP 10 DRUG GROUPS

AMONG NONDUAL BENEFICIARIES, 2009a,b,c,d

20% 17%

15% 15% 15%

10% 8% 8% 8% 7%

5% 5% 5% 5% 5% 4% 4% 4% 4% 4% 4% 4%

3% 1%

0% Antipsychotics Antiasthmatic Antiviral Anticonvulsant Stimulants/Anti- Ulcer Drugs Misc. Hematological Antidiabetic Analgesics - Narcotic Antidepressants

obesity/Anorexiants

Percentage of Nondual Beneficiary Pharmacy Reimbursement Percentage of Nondual Beneficiaries

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Tables ND.2, ND.6, and ND.7 of the Compendium. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

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 2009. 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 ] (December 21, 2012). .medispan.com/drug-information-products.aspx cThe top 10 drugs groups were determined based on total Medicaid reimbursement in the state for 2009. For information about these drug groups, see Wolters Kluwer Health, [http://www ] (December 21, 2012). .medispan.com/drug-information-products.aspx dDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. 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.



26

EXHIBIT 17

PERCENTAGE OF MEDICAID PHARMACY USE AND REIMBURSEMENT FOR TOP 7 THERAPEUTIC CATEGORIES AMONG NONDUAL BENEFICIARIES, 2009a,b,c,d

The top 7 therapeutic categories (out of 18 therapeutic categories) accounted for 72 percent of total Medicaid FFS pharmacy reimbursement for nondual beneficiaries in 2009.

100%

75%

50% 34%

21% 25% 20% 20%

11% 13% 15% 11% 9% 7% 8% 7% 6% 6%

0% Central Nervous Anti-infective Agents Respiratory Agents Endocrine/ Metabolic Neuromuscular Agents Analgesics and Cardiovascular Agents System Drugs Drugs Anesthetics

Percent of Nondual Beneficiary Pharmacy Reimbursement Percent of Nondual Beneficiaries

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Table ND.6 of the Compendium. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

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 2009. 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 ] December 21, 2012) . .medispan.com/drug-information-products.aspx cTop 7 categories were determined based on total Medicaid reimbursement in 2009. For information about these therapeutic categories, see Wolters Kluwer Health, [http://www ] (December 21, 2012). .medispan.com/drug-information-products.aspx cDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. 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

NJ $319 DC $212 OH $142 KS $142

WV $138 IN $138

NY $126 GA $121 MD $121 OR $112 MN $101 DE $98 NV $98 WA $91 VA $86 TX $82 KY $81 CT $80 VT $77

USA $76 LA $74 NC $73 MT $72 TN $71 NE $70 MI $70 FL $70 RI $70

AK $69 CO $66 SC $65 AL $61 CA $57 MS $55 MA $55 ND $54 IA $54

WY $54 AR $50 IL $48

SD $44 PA $41

NM $7 AZ $3

$0 $25 $50 $75 $100 $125 $150 $175 $200 $225 $250 $275 $300 $325

EXHIBIT 18

AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT AMONG NONDUAL BENEFICIARIES, BY STATE, 2009a,b,c

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Table N.2 of the Compendium for the nation. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

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 2009. 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.

AZ 83.5 MA 76.9 NM 75.5 TN 75.1

WA 74.1 IL 73.6

NV 73.6 KY 73.1 AL 72.9 OR 72.8 MS 72.5 GA 71.8 ND 71.7 VA 71.4 CO 70.8 IN 70.8

NE 70.7 MN 70.6 WY 70.5 MT 70.4 WV 69.9 SD 69.7 FL 69.6 DE 69.5 PA 68.9

USA 67.7 OH 67.3 MI 67.2 NC 67.2 AR 67.2 SC 67.1 IA 66.7

VT 66.0 RI 65.7

KS 65.7 TX 65.5 CT 65.4 AK 65.4 DC 64.3 MD 63.0

NJ 62.3 NY 62.1 LA 61.5 CA 61.3

50 55 60 65 70 75 80 85

28

EXHIBIT 19 GENERIC PRESCRIPTIONS AS PERCENTAGE OF ALL MEDICAID PRESCRIPTIONS

AMONG NONDUAL BENEFICIARIES, BY STATE, 2009a,b


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 ] (December 21, 2012). .medispan.com/drug-information-products.aspxbDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. 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

30

EXHIBIT 20

DISTRIBUTION OF MEDICAID BENEFICIARIES AND TOTAL PHARMACY REIMBURSEMENT AMONG DUAL ELIGIBLES, BY BASIS OF ELIGIBILITY, 2009a,b,c,d

100%25%Aged

52%75%

50%

Disabled 67%

25% 47%


Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Tables D.2, D.3, and D.6 of the Compendium. The


aBecause children and adults comprise less than 2 percent each of dual eligible beneficiaries both in percentage of beneficiaries and in percentage of pharmacy reimbursement these beneficiaries are excluded from the exhibit.

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 2009. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.

($ million) $150

$117

$100

$70

$57 $55 $54 $52 $51 $48$50 $41 $40

$0Antipsychotic Anticonvulsant Ulcer Drugs Antidiabetic Antiviral Antianxiety Diagnostic Products Antiasthmatic Antihyperlipidemic Antidepressants

31

EXHIBIT 21

TOTAL ANNUAL MEDICAID REIMBURSEMENT FOR TOP 10 DRUG GROUPS AMONG DUAL ELIGIBLES, 2009a,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 dual eligibles in 2009.

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Table D.7 of the Compendium. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

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, 10.5 months of coverage. cThe top 10 drug groups were determined based on total Medicaid reimbursement in 2009. For information about these drug groups, see Wolters Kluwer Health, [http://www ] (December 21, 2012). .medispan.com/drug-information-products.aspxdDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.


32

EXHIBIT 22

PERCENTAGE OF MEDICAID PHARMACY USE AND REIMBURSEMENT FOR TOP 10 DRUG GROUPS AMONG DUAL ELIGIBLES, 2009a,b,c,d,e

20%

16%

15%

11%

10% 7% 7%

6% 5% 5% 5% 5% 5% 5%

5% 4% 4% 4% 3% 3% 3% 3%

2% 0%

0% Antipsychotic Anticonvulsant Ulcer Drugs Antidiabetic Antiviral Antianxiety Diagnostic Products Antiasthmatic Antihyperlipidemic Antidepressants

Percent of Dual Eligible Pharmacy Reimbursement Percent of Dual Eligible Beneficiaries

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Tables D.2, D.6, and D.7 of the Compendium. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

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 2009. 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 ] December 21, 2012). .medispan.com/drug-information-products.aspxcThe top 10 drugs groups were determined based on total Medicaid reimbursement in 2009. For information about these drug groups, see Wolters Kluwer Health, [http://www ] December 21, 2012). .medispan.com/drug-information-products.aspxdDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. eThe majority of drugs are not covered by the Part D program and thus coverage has moved primarily to Medicaid.



33

EXHIBIT 23

PERCENTAGE OF MEDICAID PHARMACY USE AND REIMBURSEMENT FOR TOP 7 THERAPEUTIC CATEGORIES AMONG DUAL ELIGIBLES, 2009a,b,c,d

The top 7 therapeutic categories (out of 18 therapeutic categories) accounted for 71 percent of total Medicaid FFS pharmacy reimbursement for dual beneficiaries in 2009.

100%

75%

50%

24% 21% 25% 10% 8% 8% 9% 6% 7% 7% 7% 7% 6% 4% 4%

0% Central Nervous System Cardiovascular Agents Neuromuscular Agents Respiratory Agents Anti-infective Agents Endocrine/Metabolic Hematological Agents

Drugs Drugs

Percent of Dual Eligible Pharmacy Reimbursement Percent of Dual Eligible Beneficiaries

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Table D.6 of the Compendium. The Compendium was

prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

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 2009. 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 ] December 21, 2012). .medispan.com/drug-information-products.aspxcTop 7 categories were determined based on total Medicaid reimbursement in 2009. For information about these therapeutic categories, see Wolters Kluwer Health, [http://www ] (December 21, 2012). .medispan.com/drug-information-products.aspxdDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. 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, 2009a,b,c

Disabled Dual Eligibles Dual Eligibles Age 65 and Older Under Age 65

4% 2%100% $1,000 $1,000 and more

and more per year 80% per year

72%60% 82%

96% 98%40%

$0 to $0 to $1,000 $1,000

per year per year 20%28%

18%0%

Percent of Beneficiaries Percent of Expenditures Percent of Beneficiaries Percent of Expenditures

(Total Benes = 2.4 million) (Total Exp. = $551 million) (Total Benes = 3.6 million) (Total Exp. = $389 million)

34

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Supplemental Tables 1A and 1B of the Compendium for the nation. The


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, 10.5 months of coverage in 2009. cDual eligibles include beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefit coverage during any month of Medicaid enrollment in 2009. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.

35

$20

$17 $16

$15 $13

$11

$10

$5

$0 All Duals Dual All-Year NF Residents Dual Part-Year NF Residents Dual With No NF Use

EXHIBIT 25

AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT AMONG DUAL ELIGIBLES, BY BENEFICIARY NURSING FACILITY RESIDENCE, 2009a,b,c

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Table D.4 of the Compendium. The Compendium was prepared for 42

states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

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 2009. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.

36

DE $65 NJ $40 CT $39 OR $33 VT $32 DC $26

WA $24 NY $22 NC $21 NV $21 LA $19 TX $19

MN $19 WV $18 KS $17 IL $17

AK $17 GA $17 IN $16

USA $16 CO $15 MD $15 WY $15 NE $14 MS $14 AL $14 KY $14 OH $13 AR $13 ND $13 IA $13

TN $12 MT $12 CA $12 FL $12 SD $11 SC $10 PA $10

MA $10 MI $10 VA $9 RI $8

NM $1 AZ $1

$0 $5 $10 $15 $20 $25 $30 $35 $40 $45 $50 $55 $60 $65

EXHIBIT 26

AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT AMONG DUAL ELIGIBLES, BY STATE, 2009a,b,c,d


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 2009. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. dThe high expenditures for duals in Tennessee are likely due to a reporting error in the state’s Medicaid Statistical Information System (MSIS) files.

http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenInfo/MSIS-Mart-Home.html�

MA 91.5 RI 91.4

VA 89.5 ND 88.6 MI 88.6 KY 88.6 AL 88.2 AR 88.0 NE 88.0 OR 87.9 SD 87.9 MT 87.8 IA 87.4 PA 87.4 OH 87.0 FL 86.2

WV 86.1 SC 86.0

MN 85.6 WY 85.0 MS 84.6

IL 84.3 IN 84.3

MD 83.2 AK 81.8 GA 81.7 CO 81.7 NC 81.4 CA 80.8 AZ 80.6 TX 80.1

USA 80.1 DE 77.0

NM 76.6 TN 76.5 LA 75.9 NJ 75.0

WA 74.2 NY 74.2 DC 73.5 NV 73.3 VT 73.1 KS 71.0 CT 68.3

55 60 65 70 75 80 85 90 95

37

EXHIBIT 27

GENERIC PRESCRIPTIONS AS A PERCENTAGE OF ALL MEDICAID PRESCRIPTIONS AMONG DUAL ELIGIBLES, BY STATE, 2009a,b


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 ] (December 21, 2012). .medispan.com/drug-information-products.aspxbDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.


38

VT $262 DE $247 CT $244

WA $203 LA $161 TX $142 NV $131 NJ $120

MD $117 KY $115 CO $87

WV $82 NC $82

USA $80 MN $80 KS $77 NY $77 WY $76 OH $71 GA $69 PA $67 CA $65 AR $65 OR $65 AK $63 DC $61 MA $59

IL $56 IN $55 FL $55 IA $51

NE $49 VA $48 MT $47 SC $45 AL $34 MS $32 RI $32

ND $31 SD $24 MI $24 TN $23

NM $9 AZ $0

$0 $25 $50 $75 $100 $125 $150 $175 $200 $225 $250 $275

EXHIBIT 28

AVERAGE ANNUAL MEDICAID PHARMACY REIMBURSEMENT AMOUNT PER BENEFICIARY FOR AGED DUAL ELIGIBLES, BY STATE, 2009a,b,c d,e

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in State Tables D.3 of the Compendium. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

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, 10.5 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 2009. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. dPharmacy reimbursement in Wisconsin was higher than in other states because the state had a Section 1115 waiver in 2009 (“Pharmacy Plus”) that permitted Medicaid funding for their Senior Care state pharmaceutical assistance program, which included dual eligibles. eThe high expenditures for duals in Tennessee are likely due to a reporting error in the state’s MSIS files.

DE $702 CT $581 OR $516 DC $449 NJ $390

NC $351 VT $345 NV $338 NY $329 WA $325

IN $293 TX $285 LA $266

WV $258 GA $257 AK $250 KS $249 CO $246

USA $241 ND $235 MS $233 WY $232 NE $232 AR $230 CA $222 IL $221

MN $211 FL $210

OH $205 MT $202 IA $189

AL $186 MD $172 SD $167 KY $160 SC $151

MA $148 MI $147 PA $137 VA $136 TN $130 RI $130

NM $10 AZ $7

$0 $50 $100 $150 $200 $250 $300 $350 $400 $450 $500 $550 $600 $650 $700 $750

EXHIBIT 29

AVERAGE ANNUAL MEDICAID PHARMACY REIMBURSEMENT AMOUNT PER BENEFICIARY FOR UNDER-AGE-65 DISABLED DUAL ELIGIBLE BENEFICIARIES, BY STATE, 2009a,b,c,d

39


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 2009. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. dThe high expenditures for duals in Tennessee are likely due to a reporting error in the state’s MSIS files.

LA $268 NV $208 TX $207

MD $181 AK $168 CT $167 GA $161 DE $159 CA $150 NJ $146 IL $135

DC $134 KY $128

USA $109 NC $105 PA $104 AL $101 VA $100 WY $99 SC $99 AR $97 OH $93 CO $92 MS $89 FL $88 IN $83

MN $76 WA $71 VT $68 OR $67 NE $66 TN $63 IA $60 KS $52 RI $52

MA $51 SD $49

WV $45 MT $42 MI $38 NY $32 ND $28 NM $16 AZ $0

$0 $25 $50 $75 $100 $125 $150 $175 $200 $225 $250 $275

EXHIBIT 30

AVERAGE ANNUAL MEDICAID PHARMACY REIMBURSEMENT AMOUNT PER BENEFICIARY FOR DUAL ELIGIBLE ALL-YEAR NURSING FACILITY RESIDENTS, BY STATE, 2009a,b,c,d

40


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, 10.2 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 2009. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. dThe high expenditures for duals in Tennessee are likely due to a reporting error in the state’s MSIS files.

MEDICAID PHARMACY USE AND REIMBURSEMENT, DRUGS EXCLUDED BY STATUTE FROM MEDICARE PART D

42

EXHIBIT 31

PERCENTAGE OF MEDICAID BENEFICIARIES USING AT LEAST ONE DRUG EXCLUDED FROM MEDICARE PART D, 2009a,b

At Least 1 Drug At Least 1

Excluded Drug 19% Excluded from Part D

from Part D 40%60%

81%

No Drugs No Drugs Excluded from Excluded from Part D Part D

Nondual Beneficiaries Dual Eligible Beneficiaries 35,866,720 6,103,966

Source: Medicaid Analytic eXtract (MAX), 2009. These graphs are based on the information contained in Tables ND.11 and D.11 of the Compendium. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

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 2009. 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 BENEFICIARY FOR DRUGS EXCLUDED FROM MEDICARE PART D, NONDUAL AND DUAL ELIGIBLE BENEFICIARIES, 2009a,b

$175 $163

$150

$115 $125 $98 $100

$100 $79 $82

$75 $69 $75 $60 $60 $51 $50

$45 $48 $50 $36 $31

$17 $25 $17

$0 Anorexia or Fertility Drugs Drugs for Cough and Cold Vitamins and Non-prescription Barbiturates Benzodiazepines Other Part D Excl

Weight Cosmetic Medications Minerals Drugs Rx Drugs Loss/Gain Purposes


Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Tables ND.13 and D.13 of the Compendium. The



44

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, 2009a,b

9.8% 10%

8% 6.9%

6%

4%

1.3% 2% 1.3% 0.9% 0.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.3% 0.3% 0.0% 0.2% 0.1% 0.0% 0.1% 0%

Anorexia or Fertility Drugs Drugs for Cough and Cold Vitamins and Non-prescription Barbiturates Benzodiazepines Other Part D Weight Cosmetic Medications Minerals Drugs Excl Rx Drugs

Loss/Gain Purposes


Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Tables ND.13 and D.13 of the Compendium. The



MEDICAID PHARMACY USE AND REIMBURSEMENT, 1999 and 2001-2009

(million)

$45,000$40,187

$38,471$40,000

$33,513$35,000

$30,000 $27,064

$25,000 $22,910 $22,506 $21,542$20,031 $20,535

$20,000$15,588

$15,000

$10,000

$5,000

$01999 2001 2002 2003 2004 2005 2006 2007 2008 2009

46

EXHIBIT 34

TOTAL MEDICAID PHARMACY REIMBURSEMENT, 1999 and 2001-2009a

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Table 6 of the 1999 and 2001-2009 Compendiums. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.


47

47

47

47

100%

75%

50%

25% 17% 19% 19% 15% 15% 12% 10% 10% 10% 10%

0% 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009

EXHIBIT 35

MEDICAID PHARMACY REIMBURSEMENT AS A PERCENTAGE OF COSTS OF ALL SERVICES, 1999 and 2001-2009a,b

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Table 4 of the 1999 and 2001-2009 Compendiums. The


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. bIn 7 states in 2004 (DE, IA, NE, NY, TX, UT, and WV), 8 states in 2005 (DE, IA, IL, NE, NY, TX, UT, and WV), 10 states in 2006 (DE, IA, IL, NC, NE, NY, TN, TX, UT, and WV), 8 states in 2007 (DE, IA, IL, NE, NY, TN, TX, and WV), 12 states in 2008 (CT, DE, IA, IL, NE, NJ, NY, OR, TN, TX, UT, WI, and WV), and 11 states in 2009 (CT, DE, IA, IL, NE, NJ, NY, OR, TN, TX, and WV) expenditures for Medicaid services include only Rx drug expenditures for those enrolled in capitated managed care plans, and not expenditures for other services covered by the plans or for 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 2004-2009 than it would otherwise be.

48

48

48

48

EXHIBIT 36

AVERAGE ANNUAL PRESCRIPTION DRUG REIMBURSEMENT PER MEDICAID BENEFICIARY, NONDUAL BENEFICIARIES AND DUAL ELIGIBLES, 1999 and 2001-2009a,b

$3,500 $3,114

$2,980 $3,000

$2,659 $2,387 $2,500 $2,203

$2,000 $1,629

$1,500

$1,000 $520 $550 $576 $572 $459 $504 $515 $385 $500 $298 $362 $235 $190 $186 $167

$0 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009


Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Tables ND3 and D3 of the 1999 and 2001-2009

Compendiums. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. 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.

49

49

49

49

EXHIBIT 37

AVERAGE MONTHLY PHARMACY REIMBURSEMENT PER MEDICAID BENEFICIARY, NONDUAL BENEFICIARIES AND DUAL ELIGIBLES, 1999 and 2001-2009a,b,c

$295 $300 $283

$252 $250 $233

$211

$200

$157 $150

$100 $74 $76 $76

$65 $66 $69 $59

$48 $52 $41 $50

$22 $18 $18 $16

$0 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009


Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Tables ND4 and D4 of the 1999 and 2001-2009 Compendiums. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 20098. 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.

50

50

50

50

EXHIBIT 38

PERCENTAGE OF MEDICAID BENEFICIARIES WITH AT LEAST ONE PRESCRIPTION FILLED, NONDUAL BENEFICIARIES AND DUAL ELIGIBLES, 1999 and 2001-2009a

100%

86% 86% 86% 84% 85% 84%

80%

60% 55% 56% 56% 56% 55% 54% 52% 53% 53% 53%

40% 40% 36% 37% 37%

20%

0% 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009


Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Tables ND3 and D3 of the 1999 and 2001-2009 Compendiums. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.


51

51

51

51

EXHIBIT 39

AVERAGE ANNUAL NUMBER OF PRESCRIPTION CLAIMS PER MEDICAID BENEFICIARY, NONDUAL BENEFICIARIES AND DUAL ELIGIBLES, 1999 and 2001-2009a

50 44.7 45.2

45 42.3 39.6 40.2

40 34.8

35

30

25

20

15

10 7.3 7.3 7.3 6.4 6.4 6.5 6.9 6.8 6.8 6.9 5.4 4.9 4.9 4.9

5

0 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009


Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Tables ND3 and D3 of the 1999 and 2001-2009



52

52

52

52

EXHIBIT 40

BRAND NAME AND GENERIC DRUGS AS A PERCENTAGE OF ALL MEDICAID CLAIMS, 1999 and 2001-2009a

100%

90%

80% 75%

70% 63% 63% 63%

60% 56% 53% 53% 53%

50% 50% 50% 50% 47% 47% 50% 47% 44%

37% 37% 37% 40%

30% 25%

20%

10%

0% 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009

Brand Name Generic


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 ] (December 21, 2012). .medispan.com/drug-information-products.aspx


53

53

53

53

EXHIBIT 41

NUMBER OF MEDICAID BENEFICIARIES BY BASIS OF ELIGIBILITY, 1999 and 2001-2009a

(million) Total Total Total Total Total Total

Total 42.4 42.6 42.2 41.7 43.6 42.0 45 Total 40.7 38.2

Total 4034.4

35 Total 21.120.728.6 20.7 20.6 20.019.6 20.317.930

16.22514.220

11.110.1 10.3 10.3 10.4 10.2 11.215 9.98.6

5.310

6.9 7.2 7.3 7.3 7.4 7.7 7.25.7 6.1 6.75

3.6 4.1 4.2 4.2 3.9 3.8 3.83.3 3.4 3.40

1999 2001 2002 2003 2004 2005 2006 2007 2008 2009

Aged Disabled Adults Children Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Table 2 of the 1999 and 2001-2009 Compendiums. The


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.

54

54

54

54

EXHIBIT 42

AVERAGE MONTHLY MEDICAID PHARMACY REIMBURSEMENT BY BASIS OF ELIGIBILITY, 1999 and 2001-2009a,b,c

$295 $284 $300

$257 $240 $250 $231 $229

$208 $202

$193 $200 $174 $176 $166 $173

$154 $158

$129 $150 $110 $114

$100 $91 $100 $83 $69

$59 $62 $64 $64 $48 $42 $45 $41 $41 $42 $44

$31 $50 $28 $32 $29 $30 $31 $22 $24 $25 $21 $19 $27 $18 $19 $16 $17 $12

$0 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009

All Beneficiaries Aged Disabled Adults Children


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.

55

55

55

55

EXHIBIT 43

NUMBER OF NONDUAL MEDICAID BENEFICIARIES BY BASIS OF ELIGIBILITY, 1999 and 2001-2009a,b

(million) Total

40.0 Total Total Total Total 36.9 Total Total 35.6 35.4 35.1 35.9 35.5 Total 34.0 35.0 32.0

Total 28.7

30.0Total 23.3 21.1 20.025.0 20.7 20.7 20.6 20.319.6

17.9

16.220.0

14.215.0

10.0 11.0 11.110.3 10.2 10.3 10.19.8 10.18.5

5.35.0

4.2 4.3 4.3 4.4 4.6 4.43.5 3.7 3.9 4.10.0 0.3 0.3 0.3 0.3 0.3 0.3 0.3 0.3 0.3 0.3

1999 2001 2002 2003 2004 2005 2006 2007 2008 2009 Aged Disabled Adults Children

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Table ND2 of the 1999 and 2001-2009 Compendiums. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

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.

56

EXHIBIT 44

AVERAGE ANNUAL NUMBER OF MEDICAID PRESCRIPTION CLAIMS BY BASIS OF ELIGIBILITY, NONDUAL BENEFICIARIES, 1999 and 2001-2009a,b

35

30 28.5 29.0 28.9 28.3 28.0 28.1 27.5 26.0 26.1

25 22.4 22.9 23.2

20.5 20.7 20.1 19.9 18.9 20 18.8 19.0 18.0

15

10

5.4 5.7 5.3 4.5 4.7 4.5 4.6 4.9 5 3.9 4.2

2.9 3.5 3.4 3.1 3.2 3.6 3.5 3.3 3.2 3.4

0 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009

Aged Disabled Adults Children


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.

57

EXHIBIT 45

AVERAGE ANNUAL MEDICAID PRESCRIPTION REIMBURSEMENT BY BASIS OF ELIGIBILITY,

NONDUAL BENEFICIARIES, 1999 and 2001-2009a,b,c

$805$1,020 $1,066 $1,201 $1,374 $1,423

$1,170 $1,258 $1,340 $1,262

$1,312

$1,810 $1,928

$2,243

$2,457 $2,538$2,624

$2,723$2,865

$2,773

$175

$178$201

$279

$316$296

$272$267

$284$304

$83

$119$135

$169

$183$193

$199$212

$221$227

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

$4,500

$5,000

1999 2001 2002 2003 2004 2005 2006 2007 2008 2009


(Total Reimbursements)

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Table ND3 of the 1999 and 2001-2009 Compendiums. The Compendium

was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit

complete data to CMS for 2009.

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.

58

EXHIBIT 46

AVERAGE MONTHLY MEDICAID PRESCRIPTION REIMBURSEMENT BY BASIS OF ELIGIBILITY, NONDUAL BENEFICIARIES, 1999 and 2001-2009a,b,c,d

(Total Reimbursements) $30 $31

$500 $25 $29$24 $27 $42$450 $22 $44$43 $40$45$400 $19 $40

$40$350 $16

$31$300 $27 $288$12 $241 $249 $275 $279$250 $257$219$29 $197$200 $178

$150 $131

$100$151 $157 $141 $153 $144

$50 $114 $123 $133 $130$86

$01999 2001 2002 2003 2004 2005 2006 2007 2008 2009



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.

59

EXHIBIT 47

NUMBER OF DUAL MEDICAID BENEFICIARIES BY BASIS OF ELIGIBILITY, 1999 and 2001-2009a,b

(million) Total TotalTotal Total Total6.9 7.0 Total

6.8 6.7 7.0 6.7 6.7 Total Total6.2 Total 6.1

6.0 Total 5.7 5.3

3.0 3.02.9 3.1 3.15.0 3.12.8

2.82.52.24.0

3.0

2.0 3.8 3.9 3.9 3.6 3.63.4 3.53.1 3.2 3.2

1.0

0.01999 2001 2002 2003 2004 2005 2006 2007 2008 2009

Aged Disabled

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Table D2 of the 1999 and 2001-2009 Compendiums. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

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 2009. 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 and 2001-2009a,b

50 46.7 46.7 44.9 44.5 43.6

40.3 40.1 40.9 40.6 39.3 40

35.4 34.6

30

20

10 6.1 5.5 5.5 5.7 4.6 4.2 4.2 3.9

0 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009

Aged Disabled

60

60

60

60

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Table D3 of the 1999 and 2001-2009 Compendiums.

The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

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 2009. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.

61

61

61

61

EXHIBIT 49

AVERAGE ANNUAL MEDICAID PRESCRIPTION REIMBURSEMENT BY BASIS OF ELIGIBILITY, DUAL ELIGIBLE BENEFICIARIES, 1999 and 2001-2009a,b,c

$3,886 $4,000 $3,731

$3,500 $3,362

$2,885 $3,000 $2,698

$2,534 $2,420 $2,500

$2,138 $2,030 $1,994 $2,000 $1,834

$1,500 $1,350

$1,000

$500 $324 $260 $251 $241 $142 $197 $108 $80 $0

1999 2001 2002 2003 2004 2005 2006 2007 2008 2009

Aged Disabled


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 2009. 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.

62

EXHIBIT 50

AVERAGE MONTHLY MEDICAID PRESCRIPTION REIMBURSEMENT BY BASIS OF ELIGIBILITY, DUAL ELIGIBLE BENEFICIARIES, 1999 and 2001-2009a,b,c,d

$400 $356 $343 $350 $308 $300 $275

$250 $246 $234 $250 $189 $198 $207

$200 $179

$132 $150

$100 $30 $50 $14 $24 $23 $22 $10 $11 $8

$0 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009

Aged Disabled


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 2009. 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.

63

63

63

63

EXHIBIT 51

AVERAGE ANNUAL MEDICAID DRUG REIMBURSEMENT AMONG DUAL ELIGIBLE BENEFICIARIES BY AGE GROUP AND DISABILITY STATUS, 1999 and 2001-2009a,b

$3,963 $4,000 $3,829

$3,478 $3,500

$3,007 $3,000 $2,822

$2,648 $2,527

$2,500 $2,237 $2,143 $2,062 $1,892 $2,000

$1,387 $1,500

$1,000

$500 $340 $273 $259 $233 $155 $121 $120 $107

$0 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009

Duals Aged 65 or Older Disabled Duals Younger than 65

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Supplemental Tables 1A and 1B of the 1999 and 2001-2009 Compendiums. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. 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.

64

64

64

64

EXHIBIT 52

PERCENTAGE OF DUAL ELIGIBLE BENEFICIARIES WITH ANNUAL DRUG COSTS IN SPECIFIED RANGES, 1999 and 2001-2009a

2% 1% 1% 1% 100% 2% 3% 2% 2%

90% 16% 25% 28% 31% 35% 35% 80%

70% 30%

60% 30% 29% 27% 27% 50% 26%

96% 96% 97% 95%

40%

30% 53%

45% 43% 20% 42% 39% 38%

10%

0% 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009

$1,000 or Less $1,001 to $3,000 $3,001 or More

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Supplemental Table 1 of the 1999 and 2001-2009


aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status.

65

65

65

65

EXHIBIT 53

NUMBER OF DUAL ELIGIBLE FULL-YEAR NURSING FACILITY RESIDENTS AND UNDER-AGE-65 DISABLED DUAL ELIGIBLE BENEFICIARIES COMPARED TO ALL DUALS, 1999 and 2001-2009a,b

(million) 6.9 7.0 6.87 6.7 6.7 6.7

6.2 6.16 5.7

5.3

5

4 3.53.0 3.0 3.1 3.1

2.8 2.9 2.83 2.52.2

2

0.9 0.90.8 0.8 0.8 0.8 0.81 0.7 0.7 0.6

0Full-Year Nursing Facility Residents Under-Age-65 Disabled Duals All Duals

1999 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Table 11 of the 1999 Compendium and Table D.2 of the 2001-2009 Compendiums. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. Refer to Table 1 in the Compendium for more information about how we determined dual eligibility status. bFull-year nursing facility residents and under-age-65 disabled duals are shown separately in this exhibit because their prescription drug use and expenditures are unusually high, compared to other dual eligibles.

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 and 2001-2009a,b,c,d

$400 $377 $356 $356

$343 $350 $316 $308

$295 $300 $282 $283 $275

$249 $250 $252 $250 $233

$211 $189 $200 $181

$157 $150

$100

$50 $30 $24 $23 $22 $22 $15 $11 $18 $18 $16 $10 $11

$0 Full Year Nursing Facility Residents Under-Age-65 Disabled Duals All Duals

1999 2001 2002 2003 2004 2005 2006 2007 2008 2009

66

66

66

66

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Table 13 of the 1999 and D.4 of the 2001-2009 Compendiums. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

aDual eligibles are beneficiaries who had Medicare as well as Medicaid FFS pharmacy benefits during any month of Medicaid enrollment in 2009. 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. dFull-year nursing facility residents and under-age-65 disabled duals are shown separately in this exhibit because their prescription drug use and expenditures are unusually high, compared to other dual eligibles.

COMPREHENSIVE MANAGED CARE PENETRATION RATES

68

DE 99.7 AZ 86.1 OR 82.3 TN 73.8 NJ 65.3

MD 61.2 MI 61.0

NM 58.2 VA 49.4 NY 49.3 PA 42.9 SC 33.6 OH 29.9

USA 28.0 CA 25.2 FL 23.8 TX 23.4 RI 20.3

MA 19.3 KY 17.7 IN 15.3

NE 13.8 DC 10.4 CO 9.1 MN 6.9 KS 2.2

WA 2.1 GA 0.9 AL 0.1

WV 0.0 VT 0.0 IL 0.0 IA 0.0

LA 0.0 WY 0.0 SD 0.0 ND 0.0 NC 0.0 NV 0.0 MT 0.0 MS 0.0 CT 0.0 AR 0.0 AK 0.0

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

EXHIBIT 55

COMPREHENSIVE MANAGED CARE PENETRATION RATES FOR NONDUAL AGED/DISABLED BENEFICIARIES, BY STATE, 2009a,b

Source: Medicaid Analytic eXtract (MAX), 2009. This graph is based on the information contained in Table A.3 of the 2009 Compendium. The Compendium was prepared for 42 states and the District of Columbia. FFS pharmacy reimbursement information for the remaining states is not included because they did not submit complete data to CMS for 2009.

aComprehensive managed care (MC) in this table means enrollment in a capitated comprehensive managed care plan that covers all, or almost all, Medicaid benefits. (Comprehensive plans in some states do not include some or all prescription drugs, but we still classify them as comprehensive plans for purposes of this table.) This table does not include enrollees in primary care case management (PCCM), less-than-comprehensive prepaid health plans (PHPs), prepaid ambulatory health plans (PAHPs), or prepaid inpatient health plans (PIHPs), unless the beneficiary is simultaneously enrolled in a comprehensive managed care plan (MC). 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. 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

69

69

69

TN 97.8 DE 94.8 AZ 82.5 NJ 79.3

DC 74.2 OR 72.0 RI 69.1

MD 62.7 IN 58.9

OH 57.3 NM 55.2 NY 54.5 WA 51.5 MI 51.0 GA 50.1 WV 45.3 VA 44.3

USA 36.2 PA 36.1

MN 35.1 CA 34.2 KS 34.1 NV 33.4 MA 28.9 SC 26.1 KY 24.0 TX 21.9 FL 21.2 NE 11.1 IL 6.1

CO 4.3 IA 0.0

MT 0.0 WY 0.0 VT 0.0 SD 0.0 ND 0.0 NC 0.0 MS 0.0 LA 0.0 CT 0.0 AR 0.0 AK 0.0 AL 0.0

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

EXHIBIT 56

COMPREHENSIVE MANAGED CARE PENETRATION RATES FOR NONDUAL ADULT/CHILDREN BENEFICIARIES, BY STATE, 2009a,b



70

70

70

70

DE 89.0 OR 85.1 AZ 82.4 TN 81.3

MN 39.0 TX 20.9 NJ 16.9

CA 16.4 KY 12.0

USA 12.0 AL 9.1 FL 5.1

NY 5.0 CO 4.3 MI 2.4 IN 1.8 KS 1.3 OH 1.2 MD 1.2 DC 1.2

WA 1.1 RI 1.1

PA 1.0 NM 0.9 VA 0.6 GA 0.4 NV 0.3 MA 0.2 NE 0.2 SC 0.2 VT 0.2

WV 0.1 LA 0.1 MT 0.1

IL 0.1 IA 0.0

WY 0.0 SD 0.0 ND 0.0 NC 0.0 MS 0.0 CT 0.0 AR 0.0 AK 0.0

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

EXHIBIT 57

COMPREHENSIVE MANAGED CARE PENETRATION RATES FOR DUAL ELIGIBLE BENEFICIARIES, BY STATE, 2009a,b



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