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State Medicaid Drug Coverage Policies
The APA’s Office of Healthcare Systems and Financing is conducting a 50-state survey to determine how state Medicaid programs will be approaching the January 1, 2006 transition of their dual eligible beneficiaries (Medicaid beneficiaries who also receive Medicare) from receiving prescription drug coverage under Medicaid to receiving it under Medicare Part D.
While many states are waiting to find out which prescription drug plans will be serving the dual eligible population and the specifics of these plans’ formularies (information that should become available in October 2005), it is clear that the states are very aware of the problems that may arise with the change in dual eligibles coverage.
The survey consists of three questions concerning 1) refill policy for medications prior to January 1, 2006; 2) state coverage for drugs that are excluded from Part D, specifically benzodiazepines; and 3) whether there will be assistance to help dual eligibles pay for drug co-pays that are required under Medicare.
Initial survey results suggest that although CMS recommended that state Medicaid programs provide dual eligibles with refills to tide them through the transition period, most states will be continuing with their current refill policies (i.e., if the standard refill period is for 30 days, only 30-days-worth of drugs will be provided; and if the patient is not entitled to a refill until after January 1, 2006, no refill will be supplied at all). On the issue of non-covered drugs, if the Medicaid program provides drugs that are excluded from Part D to its non-dual eligible Medicaid beneficiaries, it will continue to provide these drugs to dual eligible beneficiaries as well. Since all states currently cover benzodiazepines and there is no indication that this will change, that mean dual eligibles will continue to receive their benzodiazepines through Medicaid. On the issue of co-pays, it appears that Medicaid programs will probably not be able to cover these costs and are hoping help may be available from private organizations in their states.
Dual Eligible States
Click the links below to see details on the individual state plans:
| State | Refill policy/ transition plans |
Will Medicaid continue to cover drugs excluded in Part-D? (i.e.: benzodiazepines, barbiturates) | Will Medicaid pick up Part-D co-pays and wraparound? |
| -A- | |||
| Alabama | Maintaining current policy; AL has early refill policy (75% used) | Yes; no change in current coverage | Beneficiary responsibility; no wraparound |
| Alaska | Maintaining current policy (dispense 30 day supply); AK has early refill policy (75% used; 95% for opiods) | Yes; no change in current coverage | Beneficiary responsibility, already subject to copays; no wraparound. |
| Arizona | Maintaining current policy (dispense 30 day supply); state is not routinely providing 90 day supply (acute care population) | Yes; no change in current coverage | Beneficiary responsibility; no wraparound. |
| Arkansas | Maintaining current policy (dispense 30 day supply); | Yes; no change in current coverage | Beneficiary responsibility; no wraparound. |
| -C- | |||
| California [as of 9/13/05] | Maintaining current policy (dispense 30 day supply); | Yes | Beneficiary responsibility |
| Colorado | Maintaining current policy (dispense 30 day supply for nonmaintenance, 100 day for maintenance; refill too soon edit of 75%, 3 mos rolling | Yes; possible change to a noncovered event 1/1/06, pending funding | Beneficiary responsibility, already subject to copays ($1/$3); no wraparound |
| Connecticut | Maintaining current policy (dispense 30 days/240 units whichever is larger; PA for controlled substances) | Yes; no change in current coverage. CT does not require copays for Medicaid beneficiaries, therefore there will be no dual eligible co-pay for this category | New: Beneficiary responsibility ($1/$3 or $2/$5). Question of copays will be revisited prior to December. |
| -D- | |||
| Delaware | Maintaining current policy (dispense 30/31 day supply); doesn’t permit early refills | Yes; no change in current coverage. State will monitor PDPs | Beneficiary responsibility |
| District of Columbia | Maintaining current policy (dispense 30 day supply, every 28 days; no provision for early refills unless therapeutic change) | Yes; no change in current coverage | Beneficiary responsibility, already subject to copays ($1/$3); no wraparound |
| -F- | |||
| Florida | Maintaining current policy | Yes; no change in current coverage | Beneficiary responsibility; no wraparound |
| State | Refill policy/ transition plans |
Will Medicaid continue to cover drugs excluded in Part-D? (i.e.: benzodiazepines, barbiturates) | Will Medicaid pick up Part-D co-pays and wraparound? |
| -G- | |||
| Georgia | Maintaining current coverage (dispense 30 day supply; refill too soon edit 75%) | Yes, currently cover certain excluded drugs; will be modifying current benefits. | Beneficiary responsibility, already subject to tiered copays; limited wraparound for select drugs excluded under Medicare part D |
| -I- | |||
| Idaho | Maintaining current coverage (dispense 34 day supply; refill too soon edit 75% on most medications, 100% for triptans | Yes; no change in current coverage | Beneficiary responsibility; no wraparound |
| Illinois | Maintaining current coverage (dispense 30 day supply; refill too soon edit 75%) | Beneficiary responsibility, Medicaid beneficiaries already subject to copays ($0/$3); no wraparound. | |
| -L- | |||
| Louisiana | Maintaining current coverage (dispense 30 day supply or 100 unit doses, whichever is greater; monthly limit of 8; can be overridden) |
Yes; no change in current coverage |
Beneficiary responsibility already subject to copays ($.50, $1, $2, $3); no wraparound. |
| -K- | |||
| Kansas | Maintaining current coverage (dispense 31 day supply, state regulation) | Yes; no change in current coverage | Beneficiary responsibility; no wraparound |
| -M- | |||
| Maryland | Maintaining current coverage (dispense 30 day supply; standard early refill policy) | Yes; no change in current coverage | Beneficiary responsibility, already subject to copays ($1/$3); no wraparound. |
| Massachusetts | Limit most drugs to 30 day supply; MA may be in process of revising regulation for rarely used 90 day refill to 30 day refill | Yes; no change in current coverage | Beneficiary responsibility, already subject to copays ($1/$3, $2/$5); no wraparound |
| Michigan | Maintaining current policy | Yes; no change in current coverage | Beneficiary responsibility; no wraparound |
| Missouri | Maintaining current policy; AL has early refill policy (75% used) | In all probability there will be no change in coverage; depends on PDP formulary (info as of 9/13/05) | Unknown as of 9/13/05 |
| Montana | Maintaining current coverage (dispense 30 day supply) | Yes; no change in current coverage | Beneficiary responsibility, already subject to copays ;no wraparound |
| State | Refill policy/ transition plans |
Will Medicaid continue to cover drugs excluded in Part-D? (i.e.: benzodiazepines, barbiturates) | Will Medicaid pick up Part-D co-pays and wraparound? |
| -N- | |||
| New Jersey | Maintaining current coverage (dispense 34 day supply or 100 units; refill too soon edit of 85%) | Yes; no change in current coverage | Under Medicare Part D NJ will cover copays for all full dual eligible beneficiaries for all drugs; in addition, wraparound to include payment for some non formulary drugs, provision of emergency drug supply [policy evolving; accurate as of 10/17/05] |
| New Mexico | Maintaining current coverage (dispense 34 day supply for non maintenance drugs/90 day for maintenance drugs; refill too soon edit of 75%) | Yes; no change in current coverage | Beneficiary responsibility, already subject to copays ($1/$3); will be limited wraparound |
| New York | Maintaining current coverage | Yes; no change in current coverage | Beneficiary responsibility, already subject to copays ($1/$3); will be limited wraparound |
| Nevada | Maintaining current coverage (dispense 34 day supply; refill too soon edit) | Yes; no change in current coverage | Under Medicare Part D NV will cover copays for all full dual eligible beneficiaries for all drugs |
| North Carolina | Maintaining current coverage (dispense 90 day supply) |
Yes; no change in current coverage | Beneficiary responsibility; no wraparound |
| North Dakota | Maintaining current coverage (dispense 34 day supply) | Yes; no change in current coverage | Beneficiary responsibility, already subject to co-pay ($3 for brand); no wraparound |
| -O- | |||
| Ohio | Maintaining current coverage (dispense 34 day supply for acute, 102 day supply for chronic); refill too soon edit of 75% | Yes, no change in current coverage for benzodiazepines & barbiturates; change 1/1/06 to limited OTCs New: As of 1/1/06 $2 copay on trade name drugs | Beneficiary responsibility, already subject to $3 copay on drugs requiring prior authorization. |
| Oregon | Maintain current policy; early refill if 75% used on 90-day supply | Yes; no change in current coverage (no mandatory copay for Excluded Drugs) | Beneficiary responsibility; no wraparound |
| -P- | |||
| Puerto Rico, Commonwealth of | Maintaining current policy (comprehensive formulary; 30 day supply maintenance drugs, 15 day supply for acute; refill too soon edit of 75%) | Yes, no change in current coverage. No copays for drugs included or excluded under Part-D | Duals will not be subject to copays under Part-D. Wraparound only for those who disenroll from the existing Commonwealth health plan and enroll in an MA/Medicare Platinum plan |
| -S- | |||
| South Carolina | Maintaining current coverage [dispense 34 day supply; early refill policy (80% used)] (limit to # of Rx/mo; behavioral health drugs override) | Yes; no change in current coverage | Beneficiary responsibility, already subject to $3 copay, will now be $1-$3, $2-$5 depending on income; no wraparound |
| South Dakota | Maintaining current coverage (dispense 34 day supply; early refill policy (70% used), pharmacist can override early refill) | Yes; no change in current coverage | Beneficiary responsibility, already subject to copay ($0/$3); no wraparound |
| State | Refill policy/ transition plans |
Will Medicaid continue to cover drugs excluded in Part-D? (i.e.: benzodiazepines, barbiturates) | Will Medicaid pick up Part-D co-pays and wraparound? |
| -T- | |||
| Tennessee | Maintaining current coverage (dispense 31 day supply; early refills not permitted) | NEW: Currently provide, change to non covered event 1/1/06 | Beneficiary responsibility, already subject to copay; no wraparound |
| Texas | Maintaining current policy | Yes; no change in current coverage | Beneficiary responsibility; no wraparound |
| -U- | |||
| Utah | Maintaining current policy (dispense 30 day supply) | Yes; no change in current coverage for full duals | Beneficiary responsibility (to maximum out of pocket); no wraparound |
| -V- | |||
| Vermont | Refills must not exceed 5 (plus one original); for DEA code 2, no refills allowed, new prescription required for each; no early refill policy | Yes; no change in current coverage | Beneficiary responsibility, already subject to copay ($1/$3 |
| Virginia | Maintaining current policy (dispense 34 day supply) | Yes; no change in current coverage | Beneficiary responsibility |
| -W- | |||
| Washington | Maintaining current policy (dispense 30 day supply; early refill policy (75% used) | Yes; no change in current coverage | Beneficiary responsibility ($1-$5); state refers out if they know there’s a program that will help |
| Wisconsin | Maintaining current policy (dispense 34 day supply); early refill policy | Yes; no change in current coverage | Beneficiary responsibility |
| Wyoming | Maintaining current policy (dispense 34 day supply for non maintenance drugs/90 day for maintenance drugs; refill too soon edit of 80%) | Yes; no change in current coverage | Beneficiary responsibility, already subject to tiered copay ($1/$2/$3); no wraparound |
Current as of 11-4-2005
