Medicaid Pharmacy Benefit Under Managed Care Arrangements:[Insert name of MCO]

STATE:___________________

NAME OF OFFICIAL:______________________ TITLE: ___________________ PHONE:___________ DATE:__________________

Introduction: We are interested in understanding the pharmacy benefit for [Insert name of MCO].

Part I: General Questions

1. Is the pharmacy benefit included in the capitation rate for the MC benefit?

___Yes (Go to 1a)

___No (Go to 2)

1a. Is the capitation rate for an integrated HMO or behavioral health carved out?

__ Integrated HMO

__ Behavioral health carve out

2. Does an outside entity manage the pharmacy benefit?

___Yes (Go to 2a)

___No (Go to 3)

2a. Is the outside entity one of the following?

Managed care organization __Yes __No

Managed behavioral health organization __Yes __No

Pharmacy benefit management company __Yes __No

Other____________________________

3. Are mechanisms in place to ensure or enhance the following:

3a. Formulary compliance __Yes __

3b. Cost minimization __Yes __No

3c. Avoidance of drug interactions __Yes __No

3d. Physician compliance with treatment algorithm __Yes __No

4. Does the state require MCOs to provide members with the option to appeal formulary decisions?

___Yes (Go to 4a)

___No (Go to 5)

4a. What information is considered during the appeal process?

Describe:

4b. What percent of appeals overturn the original decision?

___ % overturned

5. Is there a dollar amount limit on pharmaceuticals a member receives?

(If yes, specify if per year, lifetime.)

___Yes, __ per year, lifetime

___No

PART II: Drug-Specific Questions