Medicaid: States' Payments for Outpatient Prescription Drugs

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Correspondence issued by the Government Accountability Office with an abstract that begins "Spending on outpatient prescription drug coverage for Medicaid beneficiaries has accounted for a substantial and growing share of Medicaid program expenditures. All states and the District of Columbia have elected to include outpatient prescription drug coverage as a benefit of their Medicaid programs. Total Medicaid expenditures on outpatient prescription drugs grew from $4.6 billion (nearly 7 percent of Medicaid's total medical care expenditures) in fiscal year 1990 to $33.8 billion (13 percent of Medicaid's total medical care expenditures) in fiscal year 2003. This represented more than twice the ... continued below

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United States. Government Accountability Office. October 31, 2005.

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Correspondence issued by the Government Accountability Office with an abstract that begins "Spending on outpatient prescription drug coverage for Medicaid beneficiaries has accounted for a substantial and growing share of Medicaid program expenditures. All states and the District of Columbia have elected to include outpatient prescription drug coverage as a benefit of their Medicaid programs. Total Medicaid expenditures on outpatient prescription drugs grew from $4.6 billion (nearly 7 percent of Medicaid's total medical care expenditures) in fiscal year 1990 to $33.8 billion (13 percent of Medicaid's total medical care expenditures) in fiscal year 2003. This represented more than twice the rate of increase in total Medicaid spending from fiscal year 1990 through fiscal year 2003. Amid concerns about increasing Medicaid drug spending, focus has been drawn to the ways states pay for prescription drugs. State Medicaid programs pay pharmacies for covered outpatient prescription drugs dispensed to Medicaid beneficiaries. The Centers for Medicare & Medicaid Services (CMS)--the agency of the Department of Health and Human Services (HHS) that oversees states' Medicaid programs--sets maximum payment limits for certain drugs--federal upper limits (FUL)--and provides guidelines regarding drug payment, as defined by regulation. Within these parameters, states may determine their own drug payment methodologies. States are to pay pharmacies the lower of the state's estimate of the drug's acquisition cost to the pharmacy, plus a dispensing fee, or the pharmacy's usual and customary charge to the general public; for certain drugs, the FUL or the state maximum allowable cost (MAC) may apply if lower. All states estimate the acquisition cost of drugs using published prices because they do not have access to actual sales price data, which are not publicly available. Most states choose to estimate drug acquisition cost by taking a percentage discount off of Average Wholesale Price (AWP). AWP is a list price that a manufacturer suggests wholesalers charge pharmacies. Based on concerns about escalating Medicaid drug expenditures, Congress asked us to review state Medicaid payments for covered outpatient prescription drugs. We reviewed how Medicaid payments for prescription drugs compared across selected states and how these states' Medicaid payments for prescription drugs compared to three market-based prices."

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Government Accountability Office Reports

The U.S. Government Accountability Office (GAO) is an independent, nonpartisan agency that works for the U.S. Congress investigating how the federal government spends taxpayers' money. Its goal is to increase accountability and improve the performance of the federal government. The Government Accountability Office Reports Collection consists of over 13,000 documents on a variety of topics ranging from fiscal issues to international affairs.

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  • October 31, 2005

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  • June 12, 2014, 7:50 p.m.

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United States. Government Accountability Office. Medicaid: States' Payments for Outpatient Prescription Drugs, text, October 31, 2005; Washington D.C.. (digital.library.unt.edu/ark:/67531/metadc302656/: accessed December 17, 2017), University of North Texas Libraries, Digital Library, digital.library.unt.edu; crediting UNT Libraries Government Documents Department.