Pharmaceutical

The high cost of prescription drugs is another barrier to health care in the United States, creating financial hardships for many low-income women. In most cases, spending for prescription drugs accounts for one of the highest shares of individual out-of-pocket health care spending. (1) For seniors and the disabled, Medicare began providing coverage for pharmaceuticals in 2006. (2) The Report Card examines three ways states can help low-income, elderly and disabled patients afford pharmaceuticals. Although state Medicaid programs must comply with federal guidelines to receive matching funds, they have some flexibility in determining the scope of coverage, including whether to limit the number of prescriptions covered during a specific time period. States therefore can design their Medicaid program to provide an unlimited number of prescriptions. Similarly, they can limit prescription drug co-payments. Co-payment requirements also seriously limit Medicaid patients' access to prescription drugs; even a minimal out-of-pocket cost may be too expensive for low-income women and prevent them from buying the prescriptions they need. In 2005, 30% of non-elderly women did not fill a prescription because of cost. (3) Given that the Medicaid prescription drug benefit is one of the most frequently used Medicaid benefits, these actions can greatly expand access to pharmaceuticals. (4) Moreover, states can increase access for one vulnerable population by raising eligibility levels in their state AIDS Drug Assistance Programs (ADAPs). These programs provide access to HIV/AIDS drug therapies to low-income, uninsured and under-insured people living with HIV/AIDS who otherwise could not afford drugs which could improve the quality and length of their lives. (5) As discussed in Chapter IV, low-income women are being particularly hard hit by the AIDS epidemic, making affordable access to drug therapies especially important.

Data Points for this Issue:

Medicaid Prescription Number Limits
Medicaid Prescription Co-payment
AIDS Drug Assistance Program

Medicaid Prescription Number Limits

	Strength Of Policy 2007	Change From 2004
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING

Meets Policy	44
Limited Policy	0
Weak Policy	0
No/Harmful Policy	7
Better	9
Worse	4
Same	38

Does the state Medicaid drug benefit cover an unlimited number of prescriptions?

States receive a "meets policy" when they do not restrict the number of prescriptions covered. States receive a "harmful policy" when they impose restrictions on the number of prescriptions covered.

Data Source: Medicaid Prescription Number Limits, 2005/2006.

National Pharmaceutical Council, Pharmaceutical Benefits 2005/2006 (Reston: National Pharmaceutical Council, 2006); 42 U.S.C. §§ 1396a(a)(1)(A)(ii), 1396d(a)(6) to 1396d(a)(16), 1396d(a)(18); 42 C.F.R. §§ 436.300 to 436.330. This indicator refers only to the limit on the number of prescriptions in a particular time period, not limits on quantities (e.g., limiting to a 30-day supply) or refills.

Medicaid Prescription Co-payment

	Strength Of Policy 2007	Change From 2004
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI (1)
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING

Meets Policy	11
Limited Policy	7
Weak Policy	0
No/Harmful Policy	33
Better	2
Worse	14
Same	35

1. Missouri should have received a "harmful policy" in 2004. Although Missouri has standard copays ranging from $.50-$2.00, it includes a $5.00 copay "for certain 1115 waiver populations," which puts the upper limit on copays above $2.00.

Does the state Medicaid program cover prescriptions without a patient co-payment?

States receive a "meets policy" when they provide Medicaid prescription coverage without requiring co-payments. States receive a "limited policy" when they require co-payments of two dollars or less. States receive a "harmful policy" when they require co-payments of more than two dollars.

Data Source: Medicaid Prescription Co-payment ($), 2005/2006.

National Pharmaceutical Council, Pharmaceutical Benefits 2005/2006 (Reston: National Pharmaceutical Council, 2006).

AIDS Drug Assistance Program

	Strength Of Policy 2007	Change From 2004
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE (1)
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO (2)
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING

Meets Policy	17
Limited Policy	31
Weak Policy	1
No/Harmful Policy	2
Better	4
Worse	0
Same	45

1. The data source did not provide current data for Delaware. The 2007 Report Card therefore evaluates the state as having no policy. In addition, since there is no data against which to compare, there is no comparison to 2004.
2. The data source did not provide current data for New Mexico. The 2007 Report Card therefore evaluates the state as having no policy. In addition, since there is no data against which to compare, there is no comparison to 2004.

Does the state cover pharmaceuticals for individuals with incomes at or above 400 percent of the federal poverty level (FPL) under the AIDS Drug Assistance Program?

States receive a "meets policy" if they allow people at or above 400 percent of FPL to participate in ADAP. States receive a "limited policy" if they allow people with incomes from 200 percent to 399 percent of FPL to participate. States receive a "weak policy" if they allow only individuals with incomes below 200 percent of FPL to participate.

Data Source: AIDS Drug Assistance Programs, 2006.

The Henry J. Kaiser Family Foundation, "AIDS Drug Assistance Program (ADAP) Financial Eligibility Criteria (as a Percent of the Federal Poverty Level)" as of June 2006, available at http://www.statehealthfacts.org/comparemaptable.jsp?ind=543&cat=11, accessed May 15, 2007.

1. The Henry J. Kaiser Family Foundation, "Distribution of Out-of-Pocket Spending for Health Care Services," May 2006, available at http://www.kff.org/insurance/snapshot/chcm050206oth.cfm.

2. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 was signed into law on December 8, 2003. P.L. 108-173. The legislation provides some coverage for prescription drugs to older Americans, though the benefit structure is complex and some of the lowest income people may be worse off under it as compared to Medicaid.

3. Elizabeth M. Patchias and Judy Waxman, "Women and Health Coverage: The Affordability Gap," The National Women's Law Center and the Commonwealth Fund, April 2007, available at http://www.nwlc.org/pdf/NWLCCommonwealthHealthInsuranceIssueBrief2007.pdf.

4. Brian Bruen and Arunabh Ghosh, Kaiser Commission on Medicaid and the Uninsured, "Medicaid Prescription Drug Spending and Use" June 2004, available at http://www.kff.org/medicaid/upload/Medicaid-Prescription-Drug-Spending-and-Use.pdf.

5. In the wake of rising drug costs and state fiscal crises, 4 states have imposed waiting lists in the AIDS Drug Assistance Programs. The Henry J. Kaiser Family Foundation, "AIDS Drug Assistance Programs (ADAPs) with Waiting Lists, as of March 1, 2007," available at http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi?action=compare&category=HIV%2fAIDS&subcategory=AIDS+Drug+Assistance+Program+%28ADAP%29&topic=ADAP+Waiting+Lists.