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Medicaid Pharmacy Benefit Use and Reimbursement


 Under a research contract from CMS's Office of Research, Development and Information (ORDI), Mathematica Policy Research, Inc. (MPR) is producing a series of research products related to pharmacy benefit use and reimbursement in Medicaid.  MPR is using the Medicaid Analytic eXtract (MAX) data files for calendar year 1999 and later years for these research products. 

One set of products is the Statistical Compendium:  Medicaid Pharmacy Benefit Use and Reimbursement (hereafter "the Compendium") for calendar years 1999 and 2001-2004.  The Compendium for each year provides detailed state-by-state and national data on the use of and reimbursement for prescription drugs in Medicaid.  (A Compendium was not produced for calendar year 2000.)

Using the detailed data from the Compendium, MPR has also prepared Chartbooks for 1999 and 2001-2004.  The Chartbooks present selected highlights from the Compendium and include comparisons across states.  The 2001-2004 Chartbooks also include comparisons to earlier years.


Statistical Compendiums

The Statistical Compendiums show use and reimbursement by beneficiary demographic characteristics (age, sex, and race), basis of eligibility (children, adults, disabled, and aged), and Medicare and Medicaid dual eligible status. The compendiums are arranged as sets of national-level or state-specific tables covering use and reimbursement for all beneficiaries (available for 1999 and 2001-2004); for only "nondual" Medicaid beneficiaries who are not also eligible for Medicare (available for 2001-2004); and for "dual eligible" Medicaid beneficiaries who are eligible for both Medicare and Medicaid (available for 1999 and 2001-2004). There is also a set of national comparison tables available for each of those years.

The reason for creating separate sets of tables for dual eligibles and non-duals is that Medicare assumed responsibility for almost all prescription drug coverage for dual eligibles on January 1, 2006 under the new Part D Medicare program.  As a result, states are now interested primarily in prescription drug use and reimbursement for Medicaid beneficiaries who are not dual eligibles, while use and reimbursement for dual eligibles is now of interest primarily to those concerned with Medicare Part D.  By providing a full set of tables for each of these two main subgroups of Medicaid beneficiaries for 2001-2004, the Compendium facilitates separate analysis of the results by states and those interested in Part D.  As discussed further below, there are also tables that highlight use and reimbursement for some drugs that are excluded by statute from Part D coverage, and that most states remain responsible for to varying degrees. 



  • The data tables provide statistics for all Medicaid beneficiaries who had fee-for-service (FFS) pharmacy benefit coverage for at least one month during the calendar year, whether or not they filled a prescription in that month.
  • There are national tables and state-level tables for 50 states and the District of Columbia.
  • The Medicaid prescription drug reimbursement amounts, as reported by states in MSIS, are gross amounts prior to the receipt of rebates from prescription drug manufacturers.


  • Beneficiaries who were in capitated managed care arrangements for the entire year are excluded.
  • For beneficiaries who were in capitated managed care for part of the year and FFS for part of the year, only their FFS months are included.

The download "Exhibit 1" shows counts of the included and excluded groups for 2001.  Exhibits 4, 7, and 10 show the same information for 2002 to 2004.   In the detailed state and national tables, the beneficiaries who are included are generally referred to as the "study population."


Use and Reimbursement "Per Benefit Month" 

Most of the tables in the Compendium show service use and reimbursement for Medicaid prescription drugs "per benefit month."  This is the average amount of use and reimbursement per month for all months during the year in which beneficiaries had FFS pharmacy benefit coverage, whether or not they received a prescription in those months.  This is essentially the same approach that actuaries use to calculate "per member per month" estimates in capitated managed care settings. 


Exceptions.  In Tables 3, ND.3, ND.11, D.3, and D.11 there are estimates of use and reimbursement "per beneficiary."  This includes all use and reimbursement during the year for the number of months of coverage.  Thus, some beneficiaries in these tables may have had only one month of coverage, while others were covered for 12 months.  Similarly, Supplemental Tables 1 and 1A-1D that show mean annual reimbursement for dual eligibles and annual reimbursement per-dual-eligible beneficiary in $500 increments ($0, $1 to $500, $501 to $1,000, etc.) include all dual eligible beneficiaries for the number of months of Medicaid pharmacy coverage they had in 2001 to 2004.  Since most dual eligible beneficiaries are continuously enrolled, the average number of enrolled months for dual eligibles in 2004 was 10.5 months at the national level.  As discussed in more detail below in the "Supplemental $500 Increment Tables for Dual Eligibles" subsection of the "Major Tables Features," the data in these supplemental tables can be combined with data in Table D.2 to calculate monthly or annualized 12-month per-beneficiary measures of use and reimbursement.

Drug Types

The tables show drug use and reimbursement by brand status (patented brand name, off-patent brand name, and generic), therapeutic category (cardiovascular agents, central nervous system drugs, etc.) and drug group (anti-psychotics, anti-depressants, ulcer drugs, etc.).    

Medicaid prescription drug use and reimbursement could not be reported at this level of detail prior to 1999, since that was the first year that all states were required to submit person-level data electronically under the Medicaid Statistical Information System (MSIS).  MAX is a research extract from the MSIS data.


State-by-State Managed Care Penetration Rates

In a new feature added to the Compendium for 2002 and subsequent years, Appendix Tables A.3 and A.6 in the national tables for nonduals and duals show capitated managed care penetration rates by state and by eligibility category.  Appendix Table A.3 shows penetration rates for all nonduals combined and for aged/disabled and adults/children nondual eligibility categories.  Appendix Table A.6 shows penetration rates for all dual eligible beneficiaries combined and for aged duals and duals who are in disabled, adult, or children eligibility categories. 



The download "Exhibit 2" shows the distribution of Medicaid beneficiary characteristics in 2001 for those beneficiaries included in the study population.  Exhibits 5, 8, and 11  show the same information for 2002 to 2004.

The download "Exhibit 3" shows some illustrative measures of pharmacy benefit use and reimbursement for 2001.  Exhibits 6, 9, and 12 show the same information for 2002 to 2004.



How To Find the Tables

The "Medicaid Analytic eXtract (MAX) Table Listing" at the end of this introduction describes how to access the tables.  The tables are available in either PDF or Excel formats. 

Within each set of national and state-specific tables for All Beneficiaries, Table 1 provides an overview of the beneficiary selection criteria for the study population that is featured in the tables.   The subsequent six tables cover all Medicaid beneficiaries in the study population (Tables 2-7).  Additionally, in the national set of tables only, there are eight "National Comparison Tables" (Tables N.1a and N.1b and N.2 through N.7) that show a variety of state-by-state comparisons, as well as state-by-state comparisons of managed care penetration rates for nonduals (Table A.3) and duals (Table A.6) starting in 2002. 

Within the set of national and state-specific tables for Nonduals, there are 12 tables that focus just on nondual beneficiaries (Tables ND.2-ND.13) and two appendix tables (A.1 and A.2). 

Similarly, in the national and state tables for Duals, Tables D.2-D.13 and Tables A.4 and A.5 focus just on dual eligible beneficiaries.  In addition, there are six "supplemental" tables in the set of duals tables that show annual pharmacy reimbursement in $500 increments for all dual eligibles, disabled duals under age 65, all duals age 65 and older, and duals ages 65-74, 75-84, and 85 and over.


Brand Name vs. Generic Comparisons

Comparisons of use and reimbursement for patented brand name, off-patent brand name, and generic drugs are in Tables 5 and 6 for all Medicaid beneficiaries combined, Tables ND.5, ND.6, and ND.9 for nondual beneficiaries, and Tables D.5, D.6, and D.9 for dual eligible beneficiaries.  National comparison tables (N.2 and N.5) show data for all 50 states and the District of Columbia.


Nursing Facility Comparisons

There are six tables that show pharmacy benefit use and reimbursement for full-year residents of nursing facilities, since there is extensive prescription drug utilization in those settings. Tables ND.8, ND.9, and ND.10 show the data for all nondual Medicaid beneficiaries, while Tables D.8, D.9, and D.10 show the data for dual eligible beneficiaries. 


Therapeutic Categories

There are three tables that show pharmacy use and reimbursement in 18 broad therapeutic categories.  Table 6 shows the data for all Medicaid beneficiaries combined, Table ND.6 for nonduals, and Table D.6 for duals. 


Top 10 Drug Groups

Four sets of tables show use and reimbursement in the top ten drug groups, which are narrower than the therapeutic categories.  The top 10 groups differ by state, as shown in Tables N.4 and N.7 in the national comparison section, so that, for example, the top drug group in one state might rank third in another. 

  • The top 10 drug groups for all Medicaid beneficiaries combined are in Table 7.
  • The top 10 drug groups for nondual Medicaid beneficiaries are in two sets of multi-part tables:  Tables ND.7 through ND.7D for all nonduals, and Tables ND.10 through ND.10D for nondual all-year nursing facility residents.
  • The top 10 drug groups for dual eligible beneficiaries are also in two sets of multi-part tables:  Tables D.7 through D.7D for all duals, and Tables D.10 through D.10D dual eligible all-year nursing facility residents.


Drugs Excluded by Statute From Medicare Part D

The statute that established the Medicare Part D drug benefit excluded from coverage several types of drugs (benzodiazepines, barbiturates, nonprescription drugs, cough and cold medications, etc.) that Medicaid has been allowed since 1990 to exclude from coverage, but that most states have chosen to cover to varying degrees.  CMS requires state Medicaid programs to continue providing coverage of these drugs for dual eligibles after January 1, 2006 if they are covered for any other Medicaid beneficiaries.  New Medicare legislation enacted in July 2008 extends Part D coverage to benzodiazepines and barbiturates, but not until 2013.  Tables ND.11 through ND.13 provide information on the utilization and cost of these drugs for nonduals in 2001-2004, and Tables D.11 through D.13 provide the same information for dual eligible beneficiaries.


National Comparison Tables

The national comparison tables show use and reimbursement for 50 states and the District of Columbia, using measures that are designed to facilitate comparisons and highlight state-by-state differences.  Examples of these measures include:

  • Total reimbursement per benefit month, and percentage of total prescriptions that are for patented brand name, off-patent brand name, and generic drugs (Tables N.2 [nonduals] and N.5 [duals])
  • Share of benefit months, reimbursement per benefit month, and share of total Medicaid pharmacy reimbursement by aged, disabled, adult, and child eligibility categories for nonduals (Table N.3) and duals (Table N.6)
  • Top 10 drug groups in each state for nonduals (Table N.4) and duals (Table N.7)


Supplemental $500 Increment Tables for Dual Eligibles

Supplemental Tables 1 and 1A through 1E for 2001-2004 in each set of dual eligible tables may be especially useful for those interested in Medicare Part D, since drug use by dual eligibles represents a large portion of Part D drug costs.  These six tables show annual pharmacy reimbursement per dual eligible beneficiary in $500 increments, the number and percent of dual eligible beneficiaries in each increment, and the amount and percent of total Medicaid pharmacy reimbursement in each increment.  There are separate tables for all dual eligibles combined, disabled duals under age 65, all duals age 65 and over, and duals ages 65 to 74, 75 to 84, and 85 and above.  The tables also show the total number of dual eligibles in each of these age categories, the total Medicaid pharmacy reimbursement, and the mean reimbursement per beneficiary in the category. 

The tables include all dual eligibles who had Medicaid FFS pharmacy benefit coverage during some or all months of Medicaid enrollment in the calendar year. The average number of months of enrollment per beneficiary nationally for duals of all ages was 10.5 months for 2001, 10.2 months for 2002, 10.6 months for 2003, and 10.5 months for 2004.  The average may vary by beneficiary characteristics and by state.  These averages by state and by beneficiary characteristics can be calculated from the information shown in Table D.2 in the main table set for each state by dividing the number of benefit months by the number of beneficiaries.  Users can then use the average number of benefit months to calculate the amount of reimbursement per benefit month by dividing mean annual reimbursement per beneficiary by the average number of months enrolled.  Annualized 12-month estimates can then be made by multiplying the amount per benefit month by 12.   


Illustrative example.  In Table D.2 for the United States as a whole for 2004, for example, there are  6,915,521 dual eligible beneficiaries and  72,894,339 dual eligible benefit months, so the average dual eligible is enrolled for 10.5 months (72,894,339/6,915,521 = 10.54).  There are  1,738,478 dual eligibles age 65-74 in Table D.2, and   18,500,279 benefit months, so the average enrollment for this age group of duals is 10.64 months.  In Supplemental Table 1C, the mean annual pharmacy reimbursement for dual eligible beneficiaries age 65-74 is $2,646.  Dividing that number by 10.64 months produces an average monthly reimbursement of $248.68, and an annualized 12-month reimbursement of $2,984 (12 x $248.68 = $2,984).



The 2001-2004 Statistical Compendiums contain new tables that were not produced in 1999, mainly Tables ND.11-13 and D.11-13 dealing with drugs excluded by statute from Part D coverage.  In addition, the tables for 2001-2004 show data separately for all Medicaid beneficiaries who are not dual eligibles, and for all those who are.  In 1999, by contrast, the tables were divided between those covering all Medicaid beneficiaries (including dual eligibles), and those covering dual eligibles alone.  The order of the tables has also changed somewhat between 1999 and 2001-2004.  However, the basic structure of each table has remained essentially the same in order to facilitate comparisons between 1999 and 2001-2004.

The "Comparisons Between 1999 and 2001-2004 Tables" download below lists all the tables for 2001-2004 on the left and all the tables for 1999 on the right, with an indication in both cases of whether there is or is not a corresponding table in the other year or years.  Where there are corresponding tables in both 1999 and 2001-2004, they are shown in the same row, even though the numbering of the tables may be different in the two periods.  As noted above, the main reason for lack of correspondence between the two periods is that most of the tables for 2001-2004 separate dual eligible and nondual beneficiaries, while many of the tables for 1999 show all Medicaid beneficiaries combined.



      The Chartbooks for 2001 and 2002 (see the links in the "Downloads" section below) contain 37 tables, charts, and graphs that present highlights from the Statistical Compendiums, including comparisons of use and reimbursement for major eligibility groups (aged, disabled, adults, children, dual eligibles) and types of drugs, and state rankings on key measures.  The 2003 and 2004 Chartbooks contain 54 tables, charts, and graphs, since a number of additional graphs have been added to show trends from 1999 to 2004.  The 2003 and 2004 Chartbooks are on the Mathematica web site.



Comparisons Between 1999 and 2001-2004 Tables [PDF, 25 KB]


Exhibits 1, 4, 7, and 10 [ZIP, 48 KB]

Exhibits 2, 5, 8, and 11 [ZIP, 61 KB]

Exhibits 3, 6, 9, and 12 [ZIP, 52 KB]

Statistical Compendium: List of Table Sets

Medicaid Analytic eXtract (MAX) Table Listing

Chartbook: Medicaid Pharmacy Benefit Use and Reimbursement

2003 Chartbook [PDF, 338 KB]

2002 Chartbook [PDF, 194 KB]

2001 Chartbook [PDF, 177 KB]

1999 Chartbook [PDF, 154 KB]

Major Pharmacy Benefit Features, By State, 1999

Major Pharmacy Benefit Features, By State, 1999 [PDF, 123 KB]

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Page Last Modified: 12/03/2008 10:52:27 AM
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