Pharmaceutical Coverage Under Medicaid
STATE:___________________
NAME OF OFFICIAL:______________________ TITLE: ___________________ PHONE:___________ DATE:__________________
Instructions: Please answer the following questions about the fee-for-service Medicaid pharmacy benefit in your state.
PART I: General Questions
1. Are mechanisms in place to ensure or enhance the following:
1a. Formulary compliance __Yes __No
1b. Cost minimization __Yes __No
1c. Avoidance of drug interactions __Yes __No
1d. Physician compliance with treatment guidelines __Yes __No
2. Is there a formulary?
Yes (Go to 3)
No (Go to 4, on the next page)
PART II: Drug-Specific Questions
| Aztreonam
(Azactam®) |
Clozapine
|
Olanzapine
(Zyprexa®) |
Omeprazole
(Prilosec®) |
Quetiapine
(Seroquel®) |
Risperidone
(Risperdal®) | |
| 3. If there is a formulary, is this drug on the formulary? | Yes (Go to
4)
No (Go to 3a) |
Yes
(Go to 4)
No (Go to 3a) |
Yes
(Go to 4)
No (Go to 3a) |
Yes (Go
to 4)
No (Go to 3a) |
Yes (Go
to 4)
No (Go to 3a) |
Yes (Go
to 4)
No (Go to 3a) |
| 3a. If this drug is not on the formulary, please describe the paperwork and process for obtaining approval. | Describe: | Describe: | Describe: | Describe: | Describe: | Describe: |
| 3b. If this drug is not on the formulary, what's the average turnaround time to receive a decision? | _____
Av. turnaround |
_____
Av. turnaround |
_____
Av. turnaround |
_____
Av. turnaround |
_____
Av. turnaround |
_____
Av. turnaround |
| Aztreonam
(Azactam®) |
Clozapine | Olanzapine
(Zyprexa®) |
Omeprazole
(Prilosec®) |
Quetiapine
(Seroquel®) |
Risperidone
(Risperdal®) | |
| 4. Is prior approval required? | Yes
No |
Yes
No |
Yes
No |
Yes
No |
Yes
No |
Yes
No |
| 5. Is this drug a "preferred" drug? (i.e. drugs physicians are encouraged but not required to prescribe) | Yes
No |
Yes
No |
Yes
No |
Yes
No |
Yes
No |
Yes
No |
| 6. Are therapeutic substitutions required for this drug? | Yes
No |
Yes
No |
Yes
No |
Yes
No |
Yes
No |
Yes
No |
| 7. Does the Medicaid member have to fail on other
medications before obtaining this drug?
If yes, specify the number of failures. |
Yes,
__# failures No |
Yes,
__# failures No |
Yes,
__# failures No |
Yes,
__# failures No |
Yes,
__# failures No |
Yes
,
__# failures No |
| 8. Are there contracts, arrangements, or rebates with pharmaceutical companies for this drug? | Yes
No END of questions |
Yes
No Go to 9 |
Yes
No END of questions |
Yes
No END of questions |
Yes
No END of questions |
Yes
No END of questions |
| 9. For Clozapine only, is the laboratory test for monitoring blood levels of Clozapine counted as a medical management visit for the mental health benefit limit? | NA | Yes
No |
NA | NA | NA | NA |
Thanks for your assistance with this survey!