PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY
ANNUAL REPORT TO THE PENNSYLVANIA GENERAL ASSEMBLY
JANUARY 1 - DECEMBER 31, 2013
For the Pennsylvania Department of Aging Director Thomas M. Snedden Outreach and Enrollment Manager Rose M. Paulus Administrative Officer Kyle Kessler Administrative Officer Janis L. Rhodes Operations Manager Rebecca D. Lorah, MPA Administrative Assistant Carol Bebawi Administrative Assistant Megan McDaniel Research and Evaluation Chief Theresa V. Brown, MPA Program Analyst Ellaheh Otarod Program Analyst Antonino G. Vetrano, MPA
Pennsylvania Department of Aging
The PACE Program Forum Place Building
555 Walnut Street 5th Floor
Harrisburg, PA 17101-1919 717-787-7313 [email protected]
For Magellan Medicaid Administration, Inc. Officer in Charge Donald C. Moore Director, PACE Operations Bradley I. Kohler Assistant Director, PACE Operations Jean B. Sanders Cardholder Services Manager Janet N. Casterella Health Outcomes Scientist Jian Ding, PhD Clinical Pharmacist Judith Dooley, RPh Provider Services Manager Richard J. Flage Clinical Pharmacist Margaret R. Glessner, PharmD Senior Health Outcomes Scientist Debra A. Heller, PhD, MPH Medicare Part D Manager Lisa M. Irwin Clinical Pharmacist Colleen M. Moyer, RPh Business Services Manager Donald G. Smith LAN/WAN Manager W. Todd Spacht Quality Assurance Manager Lisa Spiegel Systems Manager John K. Wheeler
Magellan Medicaid Administration 4000 Crums Mill Road, Suite 301
Harrisburg, PA 17112 717-651-3600
Any questions or comments pertaining to information within this report may be addressed to the Pennsylvania Department of Aging at the address given above.
Revised January 2015
TABLE OF CONTENTS
Frequently Requested Program Statistics ......................................................................................... 1
History ............................................................................................................................................... 3
Administration ................................................................................................................................... 5
Section 1 – Program Research Highlights .............................................................................. 7-14
Section 2 – Financial Data by Date of Service ...................................................................... 15-30
Table 2.1A Historical Claim and Expenditure Data for PACE Enrolled ........................... 17-18 and Participating Cardholders by Semi-Annual Period Based On Date of Service January 1991 - December 2013 Table 2.1B Historical Claim and Expenditure Data for PACENET Enrolled .................... 19-20 and Participating Cardholders by Semi-Annual Period Based On Date of Service July 1996 - December 2013 Figure 2.1 PACE and PACENET Claim Distribution by Amount Paid per Claim ................ 21 January - December 2013 Figure 2.2 Distribution of PACE Annual Benefit .................................................................. 22 January - December 2013 Figure 2.3 Distribution of PACENET Annual Benefit .......................................................... 23 January - December 2013 Table 2.2 Total Prescription Cost, Expenditures, Offsets and Recoveries ........................ 24 January - December 2013 Figure 2.4 PACE and PACENET Enrollment, Claims, and ................................................. 25 Claims Expenditures by Calendar Year 1988-2013 Figure 2.5A PACE Total Enrolled and Participating Cardholders ......................................... 26 By Month January 2003 – January 2014 Figure 2.5B PACENET Total Enrolled and Participating Cardholders .................................. 27 By Month January 2003 – January 2014 Figure 2.6A PACE Average Wholesale Price (AWP) and .................................................... 28 Average Manufacturer’s Price (AMP), Brand Products Only, by Quarter January 2000 – December 2013
Figure 2.6B PACE Average Wholesale Price (AWP) and .................................................... 29 Average Manufacturer’s Price (AMP), Generic Products Only, by Quarter
January 2000 – December 2013
Section 3 – Program Data by Date of Payment ..................................................................... 31-44
Table 3.1 PACE and PACENET Claims and Expenditures Paid by Fiscal Year .......... 33-35 July 1984 - December 2013 Table 3.2A PACE High Expenditure and High Volume Claims ....................................... 36-38 January - December 2013 Table 3.2B PACENET High Expenditure and High Volume Claims ................................ 39-41 January - December 2013 Table 3.3 PACE and PACENET Number and Percent of ............................................ 42-43 Expenditures and Claims by Manufacturer January - December 2013 Table 3.4 Manufacturers' Rebate Cash Receipts by Quarter/Year .................................... 44 Billed and by Fiscal Year Received January 1991 - December 2013
Section 4 – Cardholder Utilization Data ................................................................................. 45-60
Table 4.1 PACE and PACENET Cardholder Enrollments by Quarter .......................... 47-49 July 1984 – December 2013 Table 4.2A PACE Cardholder Enrollment, Participation, Utilization, ............................... 50-51 and Expenditures by Demographic Characteristics January - December 2013 Table 4.2B PACENET Cardholder Enrollment, Participation, Utilization, ....................... 52-53 and Expenditures by Demographic Characteristics January - December 2013 Figure 4.1A Percent of Enrolled PACE Cardholders by Income and Marital Status ............. 54 January - December 2013 Figure 4.1B Percent of Enrolled PACENET Cardholders by Income and Marital Status ...... 55 January - December 2013 Table 4.3 Other Prescription Insurance Coverage of PACE and ....................................... 56 PACENET Enrolled Cardholders January - December 2013 Table 4.4 Part D Cardholder Enrollment, Participation, and Expenditures ................... 57-58 January - December 2013 Table 4.5 Annual Drug Expenditures for PACE/PACENET Enrolled ................................. 59 By Total Drug Spend, Part D Status, and LIS Status January - December 2013 Figure 4.2 PACE Generic Utilization Rates by Quarter ...................................................... 60 December 1988 - December 2013
Section 5 – County Data .......................................................................................................... 61-68
Table 5.1 Number and Percent of PACE and PACENET Cardholders ........................ 63-65 and Number of Providers by County January - December 2013 Figure 5.1 PACE and PACENET Cardholder, Claim, and Provider .................................... 66 Information by County Type (Percent of County Population Living in Urban Area) January - December 2013 Figure 5.2 Percent of Elderly Enrolled in PACE/PACENET and ......................................... 67 Percent Urban Population by County January - December 2013
Section 6 - Provider Data ......................................................................................................... 69-78
Table 6.1 PACE Claims by Product and Provider Type .................................................... 71 January - December 2013 Table 6.2 PACE Expenditures and Average State Share by Product and ........................ 72 Provider Type January - December 2013 Table 6.3 PACENET Claims and Expenditures by Provider Type ..................................... 73 January - December 2013 Table 6.4 PACENET Claims Volume by Phase of Coverage, ........................................... 74 Product Type, and Provider Type January - December 2013 Table 6.5 PACENET Expenditures by Phase of Coverage, ......................................... 75-76 Product Type, and Provider Type January - December 2013 Table 6.6 Average Cardholder and State Share Cost per PACENET ............................... 77 Claim by Phase of Coverage, Product Type, and Provider Type January - December 2013
Section 7 - Therapeutic Class Data and Drug Utilization Review Data ............................... 79-88
Table 7.1A Number and Percent of PACE Claims, State Share Expenditures, .............. 81-82 and Cardholders with Claims by Therapeutic Class January – December 2013 Table 7.1B Number and Percent of PACENET Claims, State Share .............................. 83-84 Expenditures, and Cardholders with Claims by Therapeutic Class January – December 2013 Figure 7.1 Percent of PACE State Share Expenditures by Therapeutic Class ................... 85 January - December 2013 Figure 7.2 Number and Percent of PACE and PACENET Claims ................................. 86-87 with a Prospective Review Message by Therapeutic Class January - December 2013
Section 8 - Pennsylvania Patient Assistance Program Clearinghouse (PA PAP) .............. 89-92 Appendix A - The PACE/PACENET Medical Exception Process.................................................... 93
Appendix B - American Hospital Formulary Service (AHFS) Classifications .................................. 94
Appendix C - PACE Prospective Drug Utilization Review Criteria ........................................... 95-114
FREQUENTLY REQUESTED PROGRAM STATISTICS
The table below provides frequently requested Program information and lists references within the Annual Report for additional details.
2013 PACE AND PACENET SUMMARY PACE PACENET REFER TO: DEMOGRAPHIC DATA Total enrolled for 2013 119,491 195,788 Tables 4.2, A and B % Participating 78.9% 78.9% Tables 4.2, A and B Avg. age for enrolled 79.8 yrs. 78.5 yrs. Tables 4.2, A and B Female, avg. age 80.5 yrs. 78.9 yrs. Male, avg. age 77.2 yrs. 77.6 yrs. % Female 78.7% 67.0% Tables 4.2, A and B % Own residence 54.8% 68.6% Tables 4.2, A and B % Rent 27.8% 20.4% Tables 4.2, A and B % Married 7.9% 35.3% Tables 4.2, A and B Avg. Income $12,187 $21,296 Tables 4.2, A and B % Cardholders in urban counties 41.3% 36.8% Table 5.1 % Cardholders in rural counties 13.6% 14.2% Table 5.1 BENEFIT DATA Avg. total expenditures per enrolled cardholder $1,990 $2,131 Table 4.4 Avg. total expenditures per participant $2,522 $2,700 Table 4.4 Avg. total expenditures per claim $64.76 $72.24 Table 4.4 Avg. state share per enrolled cardholder $604 $593 Table 4.4 Avg. state share per participant $765 $752 Table 4.4 Avg. state share per claim $19.65 $20.11 Table 4.4 Avg. cardholder share per enrolled cardholder $151 $288 Table 4.4 Avg. cardholder share per participant $191 $365 Table 4.4 Avg. cardholder share per claim $4.91 $9.77 Table 4.4 Avg. TPL share per enrolled cardholder $1,235 $1,250 Table 4.4 Avg. TPL share per participant $1,565 $1,583 Table 4.4 Avg. TPL share per claim $40.20 $42.36 Table 4.4
2013 percent change in state share per claim 0.4% decrease
5.3% increase
Figure 2.1, 2012 and 2013
Avg. claims per participant 38.9 37.4 Tables 4.2, A and B Avg. number of therapeutic classes per participant 5.2 5.2 Tables 7.1, A and BUTILIZATION DATA (by date of payment) Total claims 3,678,853 5,774,601 Tables 6.1 and 6.4 Avg. claims per cardholder 30.8 29.5 Tables 6.1 and 6.4 Avg. deductible claims per cardholder - 6.0 Table 6.4 Avg. copaid claims per cardholder - 23.5 Table 6.4 Generic utilization rate 80.2% 79.7% Tables 6.1 and 6.4 PAYMENT DATA Total Program payout $67.81 M $112.89 M Table 3.1 Avg. weekly Program payout $1.30 M $2.17 M Table 3.1 Avg. annual Program payout per pharmacy $22,625 $37,666 Tables 3.1 and 5.1 % Program payout to chain pharmacies 59.3% 62.0% Tables 6.2 and 6.3
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2
PENNSYLVANIA PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY History The Pharmaceutical Assistance Contract for the Elderly (PACE) Program was enacted in November 1983, and implemented on July 1, 1984. Its purpose is to assist qualified state residents who are 65 years of age or older in paying for their prescription medications. The PACE legislation was amended in 1987 for reauthorization and, in 1992, for the manufacturers’ rebate reauthorization and additional cost containment initiatives. The legislature expanded income eligibility for PACE on four occasions: 1985, 1991, 1996, and 2003. The 1996 legislation also created the PACE Needs Enhancement Tier (PACENET). In July 2001, Act 2001-77, the Pennsylvania Master Tobacco Settlement, increased PACENET income eligibility by $1,000. Recognizing that the nominal increases in Social Security income were making enrollees ineligible for PACE, the legislature also created a limited PACE moratorium, effective January 1, 2001, until December 31, 2002, which permitted enrollees to remain in benefit even though their incomes exceeded the eligibility limits. Late in 2002, Act 2002-149 extended the moratorium for the PACE enrollment and expanded it to include the PACENET enrollment as well. While this moratorium expired on December 31, 2003, cardholders who were enrolled prior to the expiration, and had their eligibility periods extending into 2004, were permitted to remain in the Program until their eligibility end date. In November 2003, Act 2003-37 enabled an unprecedented expansion for enrollment eligibility in the Programs, modified the $500 annual PACENET deductible, and changed the PACE copay structure. The legislation raised the income limits for PACE to $14,500 for individuals and $17,700 for married couples; it boosted the income cap for PACENET to $23,500 for single persons and to $31,500 for married couples. With a $480 deductible divided into monthly $40 amounts, PACENET paid benefits after the first $40 in prescription costs each month. Beginning in 2004, PACE and PACENET had a two-tiered prescription copayment structure. The PACE copayment became $6 for generic drugs and $9 for brand name products. The PACENET copayment remained at the original amounts of $8 for generics and $15 for brand name drugs. Act 37 required both Programs to adjust the copayments to reflect increasing drug prices over time. Act 37 instituted federal upper limits (FUL) in the provider reimbursement formula and raised the dispensing fee fifty cents. The Program began to reimburse pharmacies the lesser of three prices: the Average Wholesale Price (AWP) minus 10%, plus a $4.00 dispensing fee; the Usual and Customary charge to the cash-paying public; or, the most current FUL established in the Medicaid program, plus a $4.00 dispensing fee. All payment methods include the subtraction of the cardholder’s copayment. The federal Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 created a new outpatient prescription drug benefit, Part D of Medicare. Prior to the full implementation of Medicare Part D and beginning in June 2004, low income, non-HMO, PACE enrollees (134,393 cardholders over 18 months) were auto-enrolled into the interim Medicare Drug Discount Card and Transitional Assistance Program. They received a discount card that allowed for $600 per year in drug expenses in 2004 and again in 2005. Additional cardholders, estimated at 30,000, received this assistance through cards issued by their HMO. The PACE Program covered the Medicare drug card copayments for the auto-enrolled cardholders. The Medicare Transitional Assistance Program was a source of significant drug coverage for cardholders, with known savings in Program benefit payments of $112 million for the auto-enrolled cardholders.
3
The Medicare Part D drug benefit began in January 2006. The PACE Program elected to be a qualified State Pharmacy Assistance Program which, along with the passage of state Act 111 in July 2006, allowed for the creation of PACE Plus Medicare. The successful launch of PACE Plus Medicare on September 1, 2006, saw thousands of cardholders take advantage of the features of both PACE and Medicare Part D. With the goal of providing seamless coverage, PACE Plus Medicare provides benefits when Medicare Part D does not, for example, during the deductible and the coverage gap, for drugs excluded under MMA, for drugs not in a plan’s formulary, and for copayment differentials between the Part D plan coverage and the PACE and PACENET copayments. PACE Plus pays the Medicare premiums for Part D coverage for PACE cardholders. Act 111 also eliminated the monthly deductible for PACENET cardholders. PACENET cardholders who choose to forego Part D coverage are now responsible for a monthly benchmark premium payment ($32.59 in 2006; $28.45 in 2007; $26.59 in 2008; $29.23 in 2009; $32.09 in 2010; $34.07 in 2011, $34.32 in 2012; $36.57 in 2013; $35.50 in 2014; and, $33.91 in 2015) to the Program. The benchmark premium payment remains lower than the prior $40 per month deductible for the Program. Act 111 recreated the PACE and PACENET moratoriums thereby permitting some 14,000 seniors to maintain their PACE or PACENET status despite disqualifying increases in their overall income due to Social Security cost-of-living increases. The PACE moratorium expired at the end of 2006; the PACENET moratorium continued through 2007. The Act revised provider reimbursement by adjusting the Average Wholesale Price formula from AWP minus 10% to AWP minus 12%, plus a $4.00 dispensing fee. Act 69 of 2008 recreated the PACE and PACENET moratoriums, thereby permitting 15,400 seniors to maintain their Program enrollment in 2010 despite disqualifying increases in their overall 2008 income due to Social Security cost-of-living increases. Act 21 of 2011 extended the moratorium until December 31, 2013, allowing 31,000 persons to remain enrolled. Act 12 of 2014 established the moratorium expiration date for December 31, 2015, preserving the enrollment for 28,000 older adults. This Act also instituted the exclusion of Medicare Part B premium costs from the definition of total income used for income eligibility determination. As of May 2014, 46,000 cardholders retained their enrollment in the Program due to these two provisions of Act 12. PACE covers all medications requiring a prescription in the Commonwealth, as well as insulin, insulin syringes, and insulin needles, unless a manufacturer does not participate in the Manufacturers’ Rebate Program. PACE does not cover experimental medications, medications for hair-loss or wrinkles, or any medication that can be purchased without a prescription. With appropriate documentation, PACE covers Drug Efficacy Study Implementation (DESI) medications. PACE requires generic substitution of brand multi-source products when an approved, Food and Drug Administration (FDA) A-rated generic is available. At the time of dispensing, a cardholder may encounter a prospective drug utilization review edit; PACE will not reimburse the prescription unless the pharmacist or physician documents the medical necessity for it. The Department of Aging recognizes the possibility of exceptional circumstances in connection with the application of therapeutic criteria and reimbursement edits. Appendix A contains a description of the PACE/PACENET medical exception process. With the advent of PACE Plus, cardholders enrolled in Part D plans conform to the reimbursement limits established by the plans, some of which allow up to a ninety-day supply. Otherwise, cardholders not enrolled in a Part D Plan receive a thirty-day supply or 100 units (tablets or capsules) whichever is less. The Program guarantees reimbursement to the provider (including nearly 2,900 Pennsylvania pharmacies) within 21 days, paying interest on any unpaid balance after 21 days. Six types of providers dispense PACE/PACENET-funded prescriptions
4
to cardholders. The majority of providers are either independent pharmacies or chain pharmacies. Other provider types include institutional pharmacies, nursing home pharmacies, mail order pharmacies, and dispensing physicians. All providers may offer mail order services if they are enrolled as a mail order pharmacy and if they follow specialized program requirements pertaining to record keeping and cardholder verification procedures. Manufacturers for innovator products pay the Program a rebate similar to the federal “best price” Medicaid rebate. Generic manufacturers pay an 11% rebate based on the average manufacturer price (AMP). An inflation penalty applies to innovator products if annual price increases exceed the consumer price index. The inflation penalty rebate was discontinued for generic products at the end of 2006. Effective January 2010, the federal Medicaid flat rebate rate increased from 15.1% of the AMP to 23.1% and the generic rate increased from 11% to 13%. Administration The Pennsylvania Department of Aging administers the PACE/PACENET Program. A contractor directly responsible to the Department assists in conducting many of the day-to-day operations. Four primary operational responsibilities of the Program are to process applications, reimburse providers for prescriptions, protect enrollees from adverse drug events, and obtain the most cost-efficient reimbursement possible for the Program. Administrative responsibilities include research and policy development, monitoring and evaluating operations and ensuring that the mandates of the Act and Program regulations are met. Activities in these areas include conducting audits of not only the providers, but also of the cardholders and the contracting agency. The Program routinely reviews medication utilization profiles of the cardholders and dispensing practices of the providers and physicians. The Department also evaluates the procedures used to implement the Program, identifies any trends which may be relevant for future administration, and carefully scrutinizes all expenditures. The Department of Aging receives funds through restricted revenue accounts to serve as the administrative and fiscal agent for other Commonwealth-sponsored drug reimbursement programs. Pharmaceutical claims for the Chronic Renal Disease Program, Cystic Fibrosis Program, Spina Bifida Program, Metabolic Conditions Program, including Maple Syrup Urine Disease Program and the Phenylketonuria Program (all within the Department of Health), and the two Special Pharmaceutical Benefits Programs (Department of Health for SP1 and Department of Public Welfare for SP2) are processed through the PACE/PACENET system. The program also adjudicates claims for two programs in the Department of Insurance, the Workers’ Compensation Security Fund and the Pennsylvania Automobile Catastrophic Loss Benefits Continuation Fund. The PACE Program serves as the fiscal agent for the General Assistance Program (Department of Public Welfare), the Special Pharmaceutical Assistance Program, and the Chronic Renal Disease Program for the collection of rebates from pharmaceutical manufacturers. The Program processes eligibility applications for the Chronic Renal Disease Program and for the SP1 Program. The Pennsylvania Patient Assistance Program Clearinghouse (PA PAP) is available to assist all adult Pennsylvanians with the cost of prescription drugs. PA PAP outreaches to those who are uninsured or under-insured by helping them to apply for prescription assistance through various programs. Details about the Clearinghouse are found in Section 8 of this report.
5
6
SECTION 1
PROGRAM RESEARCH HIGHLIGHTS
7
8
INTERV
ENTIONS, GEN
ERAL
PRO
GRA
M ASSESSM
ENTS, A
ND M
EDICAT
ION ADHER
ENCE
STU
DIES
CURR
ENT PA
CE/PAC
ENET
COLLAB
ORA
TIVE
RESEA
RCH AND EVA
LUAT
ION PRO
JECT
S, 2008 ‐ 2
014
INTERV
ENTIONS
TOPIC
TITLE / RE
SEAR
CH GRO
UP
DESCR
IPTION
ASSESSMEN
T FO
R DEP
RESSION,
ANXIETY, AND
SLEEP
DISORD
ERS
TELEPH
ONE‐BA
SED
BEHAV
IORA
L HEA
LTH
ASSESSMEN
T FO
R SENIORS
ON
NEW
PSYCH
OTR
OPIC
MED
ICAT
ION
Beha
vioral Health
Lab
oratory,
Med
ical Schoo
l, University
of
Penn
sylvan
ia
Results from aPACE statew
ide collaborative care program
by the Beh
avioral H
ealth Laboratory (begun in
2008) support
concerns related to psychotropic m
edication prescribing in the elderly and raise additional questions about off‐label or
inappropriate prescribing. Overall, 45.0%
of p
articipan
ts did not m
eet criteria fo
r any
men
tal health
disorde
r with
low
symptom
s ind
icated
. Just 6% m
et th
e crite
ria fo
r anxiety disorde
rs. The study found that older, community dwelling
patients received new
psychotropic m
edications in excess of what m
ight be expected based
on their relatively low sym
ptom
burden
. Many reported
that the prescription was for a psychosocial stressor (43.8%), while 15.8% were unaw
are of the
reason for the prescription. In
terven
tion aims includ
e assigning individu
als with
clin
ically significan
t sym
ptom
s to m
inim
al
mon
itorin
g or m
onito
ring with
care man
agem
ent a
nd so
cial service su
pport in orde
r to de
term
ine whe
ther th
e clinical
services are im
pacting ou
tcom
es.
The project is in
Phase II with interven
tion protocols that address persons with either high or low sym
ptom m
easures. In the
high sym
ptom group, care managem
ent advice has led to the referral of 39 persons to specialist care. With low sym
ptom
patients, the assessmen
t explores reasons for the psychotropic m
edication and consideration of discontinuation after
persisten
ce of measured low sym
ptoms.
Care m
anagem
ent cases are asked
at the
nine week follo
w up ab
out the
ir satisfaction level. The
re is a very high
level of
enrollee satisfaction with
the care m
anagem
ent service (>
95%
satisfaction).
During Ph
ase II, The
Beh
avioral H
ealth
Lab
oratory also promotes non
‐pha
rmacological interven
tions and
offers
assessmen
t and
assistance with
add
ressing psycho
social stressors prio
r to the use of m
edication therap
y. The academ
ic
detailer in the Philadelphia region m
arketed the assessmen
t services to physicians visited through
academ
ic detailing (see
next page). In 2012, letters were sent to all psychotropic prescribers inviting them
to contact the project for assistance with
men
tal health assessm
ent and m
edication therapies. A
bout 42% of Phase II participants are m
inim
ally sym
ptomatic.
A recent ana
lysis o
f patient chron
ic pain foun
d significant differen
ces in levels of d
epression, anxiety, and
qua
lity of life
betw
een those who
experience interferen
ce of p
ain versus th
ose who
do no
t.
In 2013, the PACE Program
added
a dem
entia care m
anagem
ent program
, the Ca
regiver T
eleh
ealth
Edu
catio
n Program, for
cardho
lders w
ith m
oderate to severe cognitive
impa
irmen
t/de
men
tia and
their informal caregivers; 38 caregivers
participated
. Overall for the year, the Beh
avioral H
ealth Laboratory completed 839 initial assessm
ents for cardholders and
caregivers. There were 2,551 follow‐up assessm
ents with cardholders and caregivers. A
mong them
, 115 cardholders
received
care managem
ent services and 428 cardholders received
sym
ptom and m
edication m
onitoring services. Eleven
cardholders were referred
to specialty men
tal health services.
FALLS
PREV
ENTION
FALLS‐FR
EE PA
Gradu
ate Scho
ol of P
ublic
Health
, University
of P
ittsburgh
The Cen
ters for Disease Control and Prevention provided
funds for this two year research grant. R
esearche
rs at the
Gradu
ate Scho
ol of P
ublic Health
at the
University
of P
ittsburgh
and
the PA
Dep
artm
ent o
f Aging
examined
cou
nty level
falls incide
nce an
d the effect of the
Dep
artm
ent’s
Hea
lthy Step
s for Older Adu
lts and
Hea
lthy Steps in Motion projects. A
physician ed
ucation compo
nent includ
ed su
rveying ph
ysicians who
see
older adu
lts in
their p
ractice an
d offerin
g mailed
and on
line ed
ucationa
l materials (h
ealth
yaging.pitt.edu
) with
CME/CEU credits. Findings from the evaluation of the
Healthy Step
s program
s were incorporated into well‐received
Preventing Falls Among the Elderly m
odule developed
by the
Indep
enden
t Drug Inform
ation Service (IDIS) for the PACE Program
’s academ
ic detailing effort in
2014.
9
AC
ADEM
IC
DETAILING
UPD
ATING PHY
SICIAN
S AB
OUT
CHAN
GING THE
RAPIES IN
CO
MPLICAT
ED DISEA
SE STA
TES
The Division of Pha
rmaco‐
epidem
iology and
Pha
rmaco‐
econ
omics o
f the
Brig
ham and
Wom
en’s Hospital/Harvard
Med
ical Schoo
l
Since 2005, P
ACE ha
s offered a ph
ysician ed
ucation program. Ph
ysicians at the
Harvard M
edical Schoo
ltrain clin
ical
educators to m
eet o
ne‐on‐on
e with
clin
icians caring for a
large nu
mbe
r of p
atients en
rolled in PAC
E. During the office
visits, w
hich began
in 2005, the ed
ucators provide objective, research‐based
inform
ation about the most effective drugs and
non‐m
edication therapeu
tic options for common chronic conditions. A
s of M
ay 2014, clin
ical edu
cators com
pleted
19,800
visits.
In 2008‐2010, a parallel program
delivered
three ed
ucational m
odules that focused on preventing the need for
hospitalizations and institutionalizations due to cognitive im
pairm
ent and associated
beh
avioral problems (709 visits), falls
and m
obility problems (668 visits), and incontinen
ce (823 visits).
As of May 2014, for FY 2013‐14, fou
r mod
ules accou
nted
for 9
1% of the
2,100
visits
to nearly
800
physician
s.
The diab
etes m
anagem
ent m
odule (259 visits) assesses the comparative effectiven
ess and safety of type 2 diabetes
med
ications, presents eviden
ce regarding appropriate therapy, and weighs the ben
efits, risks, and value of treatm
ent
options with the intent to im
prove the quality of prescribing and patient care.
The falls prevention mod
ule (331 visits) addresses the reduction of the risk of falls among the elderly. Clinicians receive
inform
ation on how to screen patients for increased risk of falls, how to carry out a multifactorial falls assessm
ent of patients
at higher risk, and how to tailor interven
tions to red
uce this risk.
The CO
PD m
odule (576 visits) discusses the curren
t med
ical literature about chronic obstructive pulm
onary disease and
offers practical strategies for diagnosis, m
anaging stable disease, red
ucing the risk of exacerbations, and treating
exacerbations that do occur.
The mod
ule on
obe
sity (6
92 visits) provides inform
ation for primary care providers on approaches to help obese patients
achieve weight loss through
changes in diet and exercise. It also discusses the risks and ben
efits of available weight loss
med
ications, over‐the‐counter supplemen
ts, and surgical procedures.
For each topic in the academ
ic detailing program
, the IDIS staff develops print materials, trains the detailing staff and
manages the interven
tion. The physician faculty develops the modules based
upon common drugs used by and conditions
affecting the elderly. For each m
odule, drug ed
ucators distribute several different types of documen
ts to physicians during
face‐to‐face meetings: comprehen
sive reviews of biomed
ical literature, known as eviden
ce docum
ents; distillations of key
inform
ation to be used as the basis for the discussion between practitioner and the consultant, known as summary
documen
ts; p
atient or caregiver brochures that provide key inform
ation geared to the lay public, including resources for
additional inform
ation and support; and, lam
inated
, pocket‐sized
quick reference cards on treatmen
t and drug efficacy.
These materials detail unb
iased an
d ba
lanced
inform
ation useful to
the ph
ysician, fo
r example, which patient con
ditio
ns
warrant use of e
ach drug, and
clarify whe
n more costly, b
rand
‐nam
e drug
s are more effective, and
whe
n less expen
sive
gene
ric or o
ver‐the‐coun
ter d
rugs m
ay be eq
uivalent or b
etter. M
aterials can
be foun
d at www.alosafoun
datio
n.org.
In 2014, a m
odule evaluation survey for the new
est module on fall prevention m
easured strong physician agreemen
t in
response to the questions about whether the program
had
an im
pact on clinical decisions in caring for older patients.
Satisfaction elemen
ts receiving the highest agreem
ent scores included
: “The PACE academ
ic detailer presented useful,
eviden
ce‐based
inform
ation on assessing fall risk in
my elderly patients” and “The PACE academ
ic detailer provided
me with
eviden
ce‐based
recommen
dations on effective interven
tions to red
uce fall risks.” Evaluation of tw
o mod
ules, n
on‐steroidal
anti‐infla
mmatory drugs/coxib use an
d acid su
ppressing drugs, dem
onstrated that th
e program achieved significant
redu
ctions in
the med
ications ta
rgeted
.
10
GEN
ERAL
PRO
GRA
M ASSESSM
ENTS
TOPIC
TITLE / RE
SEAR
CH GRO
UP
DESCR
IPTION
IMPR
OVE
D
HEA
LTH
STAT
US AN
D
AVOIDAN
CE
OF NURS
ING
HOME EN
TRY
AND LAT
ER
ENTR
Y INTO
WAIVE
R PR
OGRA
MS
PACE
ENRO
LLMEN
T PR
OVIDE
S AD
VANTA
GE FO
R LO
W
INCO
ME, PRE
‐MED
ICAID
SENIORS
Pe
nnsylvan
ia Dep
artm
ents of
Aging an
d Pu
blic W
elfare,
Office of Lon
g Term
Living,
Magellan Health
Services/PAC
E, M
ercer
Governm
ent H
uman
Services
Consultin
g, and
the Health
Po
licy Institu
te at G
eorgetow
n University
A 2010 analysis dem
onstrates that the PACE Program
supports many seniors prior to their Med
icaid enrollm
ent. Data
compare consumers who “had” and “did not have” PACE in a five year period prior to using long‐term
care or nursing waiver
services. Re
sults
suggest P
ACE en
rollm
ent e
nables sen
iors to
remain in th
e commun
ity longer, w
ith better h
ealth
, and
to
delay en
try into and
utilization of long
‐term care an
d waiver services. Findings include:
Average length of nursing facility stay over a 5‐year period was 40 days less for previous PACE en
rolled.
PACE mem
bers were older at en
try into a nursing facility by 2.8 years.
The ages at waiver en
try show PACE mem
bers were older by 3.1 years.
Later age of entry into nursing facilities provided
an estim
ated
annual savings of $728.8 M
.
Deferred waiver program
produced estim
ated
annual savings of $86.5 M
.
PACE en
rollees who have subsequen
t Med
icaid enrollm
ent have lower costs as a result of earlier PACE coverage.
The Program
takes advantage of its ideal position to educate those PACE seniors, w
ho are specifically known to be
income eligible, about the comprehen
sive health care coverage available through
Med
icaid, producing a unique,
efficien
t outreach and im
proved coordination with M
edicaid.
Analysts at Mercer Governmen
t Human
Services Consulting evaluated
the study and were prepared
to certify results.
SATISFAC
TION
SURV
EYS
PACE
/PAC
ENET
SURV
EY ON
HEA
LTH AND W
ELL‐BE
ING
Magellan Health
Services/PA
CE
The Survey on Hea
lth and
Well‐B
eing
provides inform
ation ab
out the
cardh
olde
r pop
ulation. Q
uestions m
easure
cardho
lders’ self‐rep
orted he
alth status, self‐rep
orted med
ication ad
herence an
d affordab
ility, and
satisfaction with
their
PACE
/PAC
ENET
coverage. Survey da
ta are freq
uently link
ed with
other im
portan
t data sources, in
clud
ing prescriptio
n records, M
edicare services re
cords, and
vita
l statistics records, and
are used for p
rogram
evaluation an
d original re
search
stud
ies. Included
in the PACE/PACEN
ET new
enrollm
ent application, the optional survey gathers im
portant inform
ation
about a person’s health im
med
iately prior to joining PACE. The optional ren
ewal survey is m
ailed to existing cardholders
throughout the year. Most ren
ewal survey questions are the same as the new
enrollm
ent survey, but a few questions are
different. It provides im
portant inform
ation about the cardholder’s health after being in PACE. A
nnual updates allow the
study of changes in health over time. The revised response rate (after rem
oval of 3,324 deceased cardholders) was 49.9% for
the 2012 ren
ewal survey.
Results
from
5% Ran
dom Sam
ple: N
early 31% of curren
t responden
ts indicated
that they did not complete high school w
ith
11% of curren
t responden
ts indicating that they had
an 8
th grade or less education. Understanding the ed
ucational
background of the population helps to ensure that cardholder communications are at an appropriate reading level. Among
cardholders who were en
rolled in
PACE at the time that they completed the survey, 88% rep
orted
that they were either
“extremely” or “quite a bit” satisfied with PACE. A
mong PACEN
ET enrolled cardholders, 78% were “extremely” or “quite a
bit” satisfied that PACEN
ET. Another 9% of PACE en
rollees and 15% of PACEN
ET enrollees were “m
oderately” satisfied
. These data indicate high levels of satisfaction with both Program
s. Cardholders who responded
to the survey also expressed
a high degree of satisfaction with the combination of PACE/PACEN
ET and M
edicare Part D by scoring a high average
satisfaction that ranged between strongly and somew
hat agree
that the combination works well for them
(1.3 for PACE and
1.5 for PACEN
ET on a 4.0 scale).
Nearly
41%
of respo
nden
ts se
lf‐repo
rted
a fa
ll in th
e pa
st year, with
abo
ut 12%
of respo
nden
ts indicatin
g more than
one
fall an
d least o
ne injury due
to th
e fall. For global self‐rated health, 38% of responden
ts had
fair or poor health. PACEN
ET
cardholders report “not filling prescriptions due to cost” more frequently than
PACE cardholders with 12% of them
not filling
a prescription two or more tim
es in
past year compared
to 7% for PACE. PACE cardholders have lower cost sharing.
11
SELF‐RAT
ED
HEA
LTH
IMPA
CT OF VA
NTA
GE PO
INT
ON THE AS
SOCIAT
ION
BETW
EEN SELF‐RA
TED HEA
LTH
AND M
ORT
ALITY
Magellan Health
Services/PA
CE
and Th
e Med
icine, Health
, and
Ag
ing Project a
t Pen
n State
University
Numerous studies dem
onstrate that self‐rated health predicts m
ortality. The
goa
l of this s
tudy
was to
explore how
self‐
ratin
g vantage po
int a
ffects m
ortality pred
ictio
n. Subjects included
137,188 PACE en
rollees.
Three self‐rated he
alth van
tage points were used
: glob
al, age‐com
parativ
e (others o
f sam
e age) and
time compa
rativ
e (present vs. one
year a
go). M
ultivariate Cox proportional‐hazards regression was used to predict subsequen
t mortality over
two years, controlling for dem
ographics and m
edication‐based
comorbidity.
When
comparing global and age‐comparative ratings, 73% of persons reported
equal global and age‐comparative scores;
19% had
age‐comparative scores that exceeded
global scores; and, 8% indicated
age‐comparative scores worse than
global.
Age comparative scores worse than
global increased risk of mortality, while age‐comparative scores exceed
ing global scores
reduced risk. The im
pact of age‐comparative deviation from global was stronger in younger age groups. Controlling for
global self‐rated health, self‐assessed
change over the past year in
either direction increased m
ortality risk, but the effect
varied
by age (interaction p < .001), with the greatest im
pact observed
among younger elderly aged 65‐79.
These results
suggest tha
t com
parativ
e ratin
gs are particularly useful w
hen used
alongside
globa
l ratings, and
that
potential age differen
ces in van
tage
point m
eaning
may have a be
aring on
mortality pred
ictio
n.
BERE
AVEM
ENT
AND
MORT
ALITY
MORT
ALITY FO
LLOWING
WIDOWHOOD:
THE RO
LE OF PR
IOR SPOUSA
L HEA
LTH
Magellan Health
Services/PAC
E, The
Med
icine,
Health
, and
Aging
Project at
Penn
State University
, and
Em
ory University
Rollin
s Scho
ol
of Pub
lic Health
Prior research has shown that widowhood is associated
with increased m
ortality risk; h
owever,it is not clear whether the
rapidity of the predeceased spouse’s health decline affects this risk. This s
tudy
used grou
p‐ba
sed trajectory m
odeling to
describ
e pred
eceased spou
ses’ patterns of health
declin
e, and
examined
associatio
ns with
post‐widow
hood
survival.
Subjects included
9,967 PACE/PACEN
ET cardholders who were widowed
between 2000 and 2006. The predeceased and
bereaved spouses’ health trajectories in
the year before widowhood were evaluated
for three measures: the Combined
Comorbidity Score, inpatient hospitalized
days, and ambulatory visits. M
ultivariate Cox proportional hazards models were
used to evaluate whether the predeceased spouse’s pattern of health decline affected
the the subsequen
t survival of the
bereaved spouse, w
hile controlling for the bereaved spouse’s own historical health trajectory and other factors.
Multiple trajectory patterns of health decline before death emerged in
the predeceased sam
ple. Among predeceased
hospice users, stable low and late onset comorbidity patterns were both associated
with greater m
ortality in the bereaved,
relative to chronic high comorbidity (HR=1.47 and 1.62, respectively). Relative to stable m
edium levels of am
bulatory visits
among the predeceased, chronically high visit levels were associated
with a lower m
ortality rate in
the bereaved (HR=0.67),
while very low visit levels were associated
with higher post‐w
idowhood m
ortality in the bereaved (HR=1.32).
These results
dem
onstrate th
e utility of group
‐based
trajectory m
odels for describing pa
tterns of e
nd‐of‐life
declin
e, and
suggest tha
t una
nticipated
deaths m
ay be associated
with
greater post‐widow
hood
mortality risk for b
ereaved spou
ses.
OUTR
EACH
PA
CE APP
LICA
TION CEN
TER
Bene
fits D
ata Trust,
Philade
lphia
The PACE Application Cen
ter locates and submits PACE applications for eligible persons and enrolls eligible persons in the
Med
icare Part D Low Income Subsidy.
PACE
Enrollm
ent O
utreach: The Cen
ter uses Property Tax and Ren
t Reb
ate rolls, and energy, food and prescription
assistance listings to iden
tify enrollm
ent candidates. In 2013, outreach ha
d 523,000 mailin
gs abo
ut th
e Program,
successfully m
ade 47,500
con
tacts for e
ligibility, and
sub
mitted
12,750 ap
plications fo
r older Pen
nsylvanian
s.
Low In
come Subsidy (LIS) O
utreach: The PACE Program
, by wrapping around the Part D ben
efit, incurs costs that could be
offset by LIS ben
efits, which provide financial help to low income en
rollees. In 2013, th
e Ce
nter re
ache
d 24
,400
existing an
d po
tential cardh
olde
rs to
inform
them
abo
ut LIS, screene
d them
for e
ligibility, and
sub
mitted
7,188
app
lications on be
half
of older Pen
nsylvanian
s.
12
MED
ICAT
ION UTILIZA
TION STU
DIES
TOPIC
TITLE / RE
SEAR
CH GRO
UP
DESCR
IPTION
MED
ICAT
ION
ADHER
ENCE
AN
D HEA
LTH
OUTC
OMES
PROTO
N PUMP INHIBITO
R AD
HER
ENCE
AND FRA
CTURE
RISK
IN THE ELDER
LY
Magellan Health
Services/PA
CE
and Th
e Med
icine, Health
, and
Ag
ing Project a
t Pen
n State
University
Results of several recen
t studies suggest that long‐term
use of proton pump inhibitors (PPIs) may be associated
with an
increased risk of fracture. The
goa
l of this s
tudy
was to
examine the relatio
nship be
tween med
ication ad
herence and
fracture risk amon
g elde
rly PPI users. The study cohort included
1,604 community‐dwelling PPI users and 23,672 non‐users
who were en
rolled in
the PACE Program
. Proportion of Days Covered (PDC) was computed to m
easure adheren
ce based
on prescription refill patterns. Tim
e‐dep
enden
t Cox proportional hazards models were used to estim
ate adjusted
hazard ratios of PPI use/adheren
ce for fracture
risk while controlling for dem
ographics, comorbidity, body mass index, smoking and non‐PPI m
edication use. The overall
inciden
ce of any fracture per 100 person‐years was 8.7 for PPI users and 5.0 for non‐users. A gradient in fracture risk
according to PPI adheren
ce was observed
. Relative to non‐users, fracture hazard ratios associated
with the highest
adheren
ce (PDC > 0.80), interm
ediate (PDC 0.40‐0.79), and lowest (PDC < 0.40) adheren
ce levels were 1.46 (p < 0.0001), 1.30
(p = 0.02), and 0.95 (p = 0.75), respectively.
These results
provide
furthe
r evide
nce that PPI use m
ay increase risk in
the elde
rly, and
highlight th
e ne
ed fo
r clin
icians to
pe
riodically re
assess elderly patients’ individu
alized
needs fo
r ongoing
PPI th
erap
y, while weighing po
tential risks and
be
nefits. The findings were published
in Calcified Tissue
Internationa
l in April 2014.
STAT
IN USE
ASSO
CIAT
ION BETWEEN
STAT
IN USE AND FRA
CTURE
RISK
AMONG THE ELDER
LY
Magellan Health
Services/PA
CE
and Th
e Med
icine, Health
, and
Ag
ing Project a
t Pen
n State
University
The im
pact of statins (w
idely used to treat hyperlipidem
ia)on fracture risk is still under deb
ate. The
goa
l of this s
tudy
was to
exam
ine the association be
tween statin use and
fracture risk amon
g the elde
rly by follo
wing 5,524 ne
w statin
users and
27
,089
non
‐users fo
r an average of 3.5 years.
Time‐dep
enden
t Cox proportional hazards models were used to estim
ate adjusted
hazard ratios of statin use for fracture risk
while controlling for dem
ographics, comorbidity, body mass index, smoking status, alcohol use, and certain therapeu
tic
classes. The
incide
nce of any
fracture per 100
person‐years was 3.0 fo
r statin
users and
7.8 fo
r non
‐users. Re
lativ
e to non
‐users, th
e ha
zard ra
tio associated with
statin use was 0.86 (p < 0.001
). Statin
users with
highe
r and
lower average daily
dose were associated
with
18%
and
9% decreased
fracture risk, respe
ctively.
The ha
zard ra
tio fo
r atorvastatin
was 0.81 (p < 0.001
), an
d the effects w
ere no
t significan
t for sim
vastatin and
pravastatin.
The protectiv
e effect of statin
user a
ppeared to be stronger amon
g users olde
r tha
n 85
years old. These results suggested
statin use is associated
with red
uced fracture risk am
ong the elderly, and the effect m
ay be dep
enden
t on age and statin
type. The ben
eficial effect of statin on bone may be helpful in the prevention of fractures am
ong elderly.
13
14
SECTION 2
FINANCIAL DATA
BY DATE OF SERVICE
15
16
TA
BL
E 2
.1A
HIS
TO
RIC
AL
CL
AIM
AN
D E
XP
EN
DIT
UR
E D
AT
A F
OR
PA
CE
EN
RO
LL
ED
AN
D P
AR
TIC
IPA
TIN
G C
AR
DH
OL
DE
RS
BY
SE
MI-
AN
NU
AL
PE
RIO
D B
AS
ED
ON
DA
TE
OF
SE
RV
ICE
JAN
UA
RY
199
1 -
DE
CE
MB
ER
201
3
PA
GE
1
CLA
IMS
PE
RC
LAIM
S P
ER
AV
ER
AG
ES
EM
I-AN
NU
AL
EN
RO
LLE
DP
AR
TIC
IPA
TIN
GTO
TAL
EN
RO
LLE
DP
AR
TIC
IPA
TIN
GTO
TAL
STA
TE S
HA
RE
PE
RIO
DC
AR
DH
OLD
ER
SC
AR
DH
OLD
ER
SC
LAIM
SC
AR
DH
OLD
ER
CA
RD
HO
LDE
RE
XP
EN
DIT
UR
ES
PE
R C
LAIM
JAN
-JU
N 1
991
405,
358
337,
684
5,28
0,37
613
.03
15.6
4$1
16,0
74,6
18$2
86.3
5$3
43.7
4$2
1.98
JUL-
DE
C 1
991
394,
055
324,
574
4,67
7,15
911
.87
14.4
1$1
09,8
71,6
50$2
78.8
2$3
38.5
1$2
3.49
JAN
-JU
N 1
992
399,
721
326,
469
4,65
6,98
611
.65
14.2
6$1
16,0
82,5
06$2
90.4
1$3
55.5
7$2
4.93
JUL-
DE
C 1
992
385,
103
313,
430
4,60
2,26
111
.95
14.6
8$1
17,0
81,6
02$3
04.0
3$3
73.5
5$2
5.44
JAN
-JU
N 1
993
376,
916
310,
438
4,40
2,17
111
.68
14.1
8$1
13,0
68,7
54$2
99.9
8$3
64.2
2$2
5.68
JUL-
DE
C 1
993
357,
777
296,
802
4,45
6,22
312
.46
15.0
1$1
16,1
64,3
81$3
24.6
8$3
91.3
9$2
6.07
JAN
-JU
N 1
994
354,
819
293,
462
4,32
0,15
912
.18
14.7
2$1
15,4
13,5
42$3
25.2
7$3
93.2
8$2
6.72
JUL-
DE
C 1
994
340,
607
281,
465
4,40
4,25
712
.93
15.6
5$1
19,1
00,7
41$3
49.6
7$4
23.1
5$2
7.04
JAN
-JU
N 1
995
331,
965
277,
461
4,38
3,96
813
.21
15.8
0$1
21,1
47,2
11$3
64.9
4$4
36.6
3$2
7.63
JUL-
DE
C 1
995
317,
719
263,
576
4,34
7,33
513
.68
16.4
9$1
22,1
58,8
72$3
84.4
9$4
63.4
7$2
8.10
JAN
-JU
N 1
996
306,
062
253,
283
4,24
4,19
013
.87
16.7
6$1
20,8
68,6
54$3
94.9
2$4
77.2
1$2
8.48
JUL-
DE
C 1
996
292,
755
238,
963
4,20
4,46
114
.36
17.5
9$1
20,4
29,8
40$4
11.3
7$5
03.9
7$2
8.64
JAN
-JU
N 1
997
286,
126
236,
157
4,28
6,47
814
.98
18.1
5$1
16,7
32,8
47$4
07.9
8$4
94.3
0$2
7.23
JUL-
DE
C 1
997
276,
180
226,
806
4,35
8,89
215
.78
19.2
2$1
23,4
82,0
56$4
47.1
1$5
44.4
4$2
8.33
JAN
-JU
N 1
998
267,
225
222,
465
4,23
5,61
915
.85
19.0
4$1
26,8
72,5
48$4
74.7
8$5
70.3
0$2
9.95
JUL-
DE
C 1
998
257,
009
213,
694
4,33
1,39
016
.85
20.2
7$1
37,1
46,4
44$5
33.6
3$6
41.7
9$3
1.66
JAN
-JU
N 1
999
246,
467
208,
992
4,31
6,58
817
.51
20.6
5$1
42,4
12,9
78$5
77.8
2$6
81.4
3$3
2.99
JUL-
DE
C 1
999
238,
388
200,
921
4,45
0,89
318
.67
22.1
5$1
53,5
96,6
48$6
44.3
1$7
64.4
6$3
4.51
JAN
-JU
N 2
000
237,
017
202,
683
4,44
9,10
218
.77
21.9
5$1
60,6
15,3
39$6
77.6
5$7
92.4
5$3
6.10
JUL-
DE
C 2
000
230,
752
197,
777
4,53
0,82
919
.64
22.9
1$1
69,8
86,4
76$7
36.2
3$8
58.9
8$3
7.50
JAN
-JU
N 2
001
225,
325
197,
082
4,55
8,33
920
.23
23.1
3$1
78,6
50,9
79$7
92.8
6$9
06.4
8$3
9.19
JUL-
DE
C 2
001
218,
576
190,
540
4,59
0,21
621
.00
24.0
9$1
87,8
20,5
34$8
59.2
9$9
85.7
3$4
0.92
JAN
-JU
N 2
002
216,
719
190,
131
4,55
8,00
021
.03
23.9
7$1
94,7
88,8
89$8
98.8
1$1
,024
.50
$42.
74
JUL-
DE
C 2
002
209,
737
183,
318
4,60
5,90
621
.96
25.1
3$2
03,5
91,4
48$9
70.7
0$1
,110
.59
$44.
20
JAN
-JU
N 2
003
209,
761
182,
654
4,55
2,66
221
.70
24.9
3$2
08,1
03,6
30$9
92.1
0$1
,139
.33
$45.
71
JUL-
DE
C 2
003
207,
144
180,
460
4,68
3,17
322
.61
25.9
5$2
21,5
12,8
77$1
,069
.37
$1,2
27.4
9$4
7.30
JAN
-JU
N 2
004
215,
486
189,
762
4,67
5,69
921
.70
24.6
4$2
09,7
31,9
50$9
73.3
0$1
,105
.24
$44.
86
EX
PE
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JUL-
DE
C 2
004
209,
237
183,
970
4,63
9,59
422
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25.2
2$1
78,1
65,4
48$8
51.5
0$9
68.4
5$3
8.40
JAN
-JU
N 2
005
209,
512
182,
450
4,60
2,80
221
.97
25.2
3$1
66,4
96,0
79$7
94.6
9$9
12.5
6$3
6.17
JUL-
DE
C 2
005
203,
956
177,
667
4,62
8,80
922
.70
26.0
5$2
08,6
31,7
07$1
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$1,1
74.2
9$4
5.07
JAN
-JU
N 2
006
199,
426
172,
092
4,48
2,46
122
.48
26.0
5$1
96,3
69,2
22$9
84.6
7$1
,141
.07
$43.
81
JUL-
DE
C 2
006
194,
884
164,
174
4,07
1,75
520
.89
24.8
0$1
26,4
33,8
82$6
48.7
6$7
70.1
2$3
1.05
JAN
-JU
N 2
007
203,
104
167,
796
3,61
9,45
617
.82
21.5
7$8
1,20
2,59
5$3
99.8
1$4
83.9
4$2
2.44
JUL-
DE
C 2
007
183,
839
150,
273
3,48
7,88
218
.97
23.2
1$9
8,98
4,30
5$5
38.4
3$6
58.7
0$2
8.38
JAN
-JU
N 2
008
164,
728
133,
656
3,01
4,59
618
.30
22.5
5$7
0,09
6,78
1$4
25.5
3$5
24.4
6$2
3.25
JUL-
DE
C 2
008
160,
802
125,
319
2,87
8,01
717
.90
22.9
7$7
6,07
0,50
0$4
73.0
7$6
07.0
1$2
6.43
JAN
-JU
N 2
009
145,
634
119,
773
2,68
2,43
618
.42
22.4
0$5
5,42
6,88
9$3
80.5
9$4
62.7
7$2
0.66
JUL-
DE
C 2
009
141,
988
114,
169
2,54
6,78
117
.94
22.3
1$6
3,03
5,61
4$4
43.9
5$5
52.1
3$2
4.75
JAN
-JU
N 2
010
138,
520
113,
130
2,37
9,42
717
.18
21.0
3$5
6,13
1,54
0$4
05.2
2$4
96.1
7$2
3.59
JUL-
DE
C 2
010
134,
104
106,
535
2,17
5,10
616
.22
20.4
2$6
1,57
2,76
7$4
59.1
4$5
77.9
6$2
8.31
JAN
-JU
N 2
011
128,
440
103,
356
2,22
1,68
017
.30
21.5
0$4
5,30
7,89
8$3
52.7
6$4
38.3
7$2
0.39
JUL-
DE
C 2
011
125,
096
98,2
652,
061,
534
16.4
820
.98
$42,
777,
764
$341
.96
$435
.33
$20.
75
JAN
-JU
N 2
012
119,
166
95,4
072,
091,
129
17.5
521
.92
$42,
297,
874
$354
.95
$443
.34
$20.
23
JUL-
DE
C 2
012
116,
822
91,0
201,
943,
206
16.6
321
.35
$37,
252,
376
$318
.88
$409
.28
$19.
17
JAN
-JU
N 2
013
114,
935
88,4
421,
904,
685
16.5
721
.54
$36,
975,
064
$321
.70
$418
.07
$19.
41
JUL-
DE
C 2
013
109,
907
83,7
561,
767,
781
16.0
821
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$35,
191,
933
$320
.20
$420
.17
$19.
91
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JUL-
DE
C 1
996
1,52
374
02,
331
1.53
3.15
$823
$0.5
4$1
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$0.3
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JAN
-JU
N 1
997
9,06
36,
369
75,7
218.
3511
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$592
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$65.
37$9
3.02
$7.8
2
JUL-
DE
C 1
997
12,5
239,
007
149,
187
11.9
116
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$2,6
76,2
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13.7
1$2
97.1
3$1
7.94
JAN
-JU
N 1
998
18,0
5312
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175,
085
9.70
13.8
0$2
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,397
$161
.16
$229
.39
$16.
62
JUL-
DE
C 1
998
18,6
7313
,804
232,
846
12.4
716
.87
$4,7
38,1
27$2
53.7
4$3
43.2
4$2
0.35
JAN
-JU
N 1
999
22,2
7216
,649
263,
010
11.8
115
.80
$5,5
19,3
95$2
47.8
2$3
31.5
2$2
0.99
JUL-
DE
C 1
999
22,1
8716
,885
309,
280
13.9
418
.32
$7,4
16,8
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34.2
9$4
39.2
6$2
3.98
JAN
-JU
N 2
000
25,7
3919
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339,
481
13.1
917
.18
$8,3
71,6
58$3
25.2
5$4
23.6
2$2
4.66
JUL-
DE
C 2
000
25,4
4619
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381,
074
14.9
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.41
$10,
193,
859
$400
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$519
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$26.
75
JAN
-JU
N 2
001
29,5
2222
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412,
077
13.9
618
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$11,
255,
086
$381
.24
$508
.22
$27.
31
JUL-
DE
C 2
001
29,2
7823
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477,
954
16.3
220
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$13,
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683
$473
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$594
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$28.
98
JAN
-JU
N 2
002
35,5
0827
,594
540,
878
15.2
319
.60
$16,
333,
097
$459
.98
$591
.91
$30.
20
JUL-
DE
C 2
002
36,1
4628
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613,
528
16.9
721
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$20,
069,
086
$555
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$701
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$32.
71
JAN
-JU
N 2
003
39,2
6331
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644,
800
16.4
220
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$21,
627,
367
$550
.83
$697
.41
$33.
54
JUL-
DE
C 2
003
40,1
4831
,869
720,
687
17.9
522
.61
$25,
653,
456
$638
.97
$804
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$35.
60
JAN
-JU
N 2
004
93,8
6172
,605
1,30
5,26
613
.91
17.9
8$4
8,95
8,31
9$5
21.6
0$6
74.3
1$3
7.51
JUL-
DE
C 2
004
105,
018
82,6
311,
921,
310
18.3
023
.25
$71,
800,
234
$683
.69
$868
.93
$37.
37
JAN
-JU
N 2
005
123,
399
94,9
792,
176,
264
17.6
422
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$81,
372,
126
$659
.42
$856
.74
$37.
39
JUL-
DE
C 2
005
125,
108
99,2
422,
450,
953
19.5
924
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$96,
448,
835
$770
.92
$971
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$39.
35
JAN
-JU
N 2
006
134,
715
108,
462
2,70
8,71
020
.11
24.9
7$1
00,4
73,8
23$7
45.8
3$9
26.3
5$3
7.09
JUL-
DE
C 2
006
141,
099
109,
867
2,68
4,51
519
.03
24.4
3$7
7,09
3,60
0$5
46.3
8$7
01.7
0$2
8.72
JAN
-JU
N 2
007
162,
966
127,
001
2,63
0,62
916
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20.7
1$5
9,09
4,94
3$3
62.6
2$4
65.3
1$2
2.46
JUL-
DE
C 2
007
147,
627
116,
369
2,68
7,88
818
.21
23.1
0$8
5,50
6,49
9$5
79.2
1$7
34.7
9$3
1.81
JAN
-JU
N 2
008
176,
161
136,
910
2,95
0,98
816
.75
21.5
5$6
8,07
2,71
4$3
86.4
2$4
97.2
1$2
3.07
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JUL-
DE
C 2
008
182,
452
137,
834
3,07
8,47
716
.87
22.3
3$8
9,90
8,36
5$4
92.7
8$6
52.2
9$2
9.21
JAN
-JU
N 2
009
177,
553
140,
328
2,96
3,53
016
.69
21.1
2$6
6,83
3,67
1$3
76.4
2$4
76.2
7$2
2.55
JUL-
DE
C 2
009
184,
291
141,
689
3,02
3,68
616
.41
21.3
4$9
1,21
8,10
8$4
94.9
7$6
43.7
9$3
0.17
JAN
-JU
N 2
010
189,
558
148,
953
2,87
7,85
215
.18
19.3
2$7
8,56
0,90
4$4
14.4
4$5
27.4
2$2
7.30
JUL-
DE
C 2
010
192,
601
147,
462
2,84
9,51
814
.79
19.3
2$1
01,3
07,4
60$5
26.0
0$6
87.0
1$3
5.55
JAN
-JU
N 2
011
194,
040
151,
302
3,09
6,29
315
.96
20.4
6$6
5,22
3,93
9$3
36.1
4$4
31.0
8$2
1.07
JUL-
DE
C 2
011
193,
627
148,
687
3,06
4,46
315
.83
20.6
1$6
2,92
4,01
5$3
24.9
8$4
23.2
0$2
0.53
JAN
-JU
N 2
012
190,
699
149,
039
3,03
2,17
815
.90
20.3
4$6
4,05
3,62
3$3
35.8
9$4
29.7
8$2
1.12
JUL-
DE
C 2
012
189,
620
145,
552
2,98
3,62
815
.73
20.5
0$5
8,32
5,71
5$3
07.5
9$4
00.7
2$1
9.55
JAN
-JU
N 2
013
186,
979
143,
936
2,92
2,48
615
.63
20.3
0$5
8,08
2,93
7$3
10.6
4$4
03.5
3$1
9.87
JUL-
DE
C 2
013
183,
032
139,
397
2,85
3,56
515
.59
20.4
7$5
8,08
4,89
7$3
17.3
5$4
16.6
9$2
0.36
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83.9
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78.4
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PE
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T O
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FIG
UR
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ND
PA
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LA
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AM
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PA
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JA
NU
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DE
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(PA
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PA
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PA
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= $
19.6
5)
PA
CE
NE
T (A
VE
RA
GE
CO
ST
PE
R C
OP
AID
CLA
IM =
$25
.22)
5.3%
2.5%
1.9%
1.7%
1.1%
3.6%
7.3%
3.7%
3.0%
2.3%
1.2%
4.0%
0%10%
20%
30%
40%
$0-$
24.9
9$2
5-$4
9.99
$50-
$74.
99$7
5-$9
9.99
$100
-$12
4.99
$125
-$14
9.99
$150
AN
D O
VE
R
AM
OU
NT
PA
ID P
ER
CL
AIM
(D
OL
LA
RS
)
SO
UR
CE
: P
DA
/CLA
IMS
HIS
TOR
YN
OTE
: D
ATA
INC
LUD
E O
RIG
INA
L, P
AID
CLA
IMS
BY
DA
TE O
F S
ER
VIC
E, E
XCLU
DE
PA
CE
NE
T D
ED
UC
TIB
LE C
LAIM
S.
21
38.7
%
35.0
%
20%
25%
30%
35%
40%
45%
OLLED CARDHOLDERS
FIG
UR
E 2
.2D
IST
RIB
UT
ION
OF
PA
CE
AN
NU
AL
BE
NE
FIT
JA
NU
AR
Y -
DE
CE
MB
ER
20
13
N =
11
9,4
91
AV
ER
AG
E A
NN
UA
L P
AC
E B
EN
EFI
T =
$603
.95
9.1%
4.6%
3.3%
2.7%
2.2%
1.1%
0.8%
0.9%
1.0%
0.4%
0.3%
0%5%10%
15%
20%
$0
$1-$
499
$500
-$99
9$1
,000
-$1
,499
$1,5
00-
$1,9
99$2
,000
-$2
,499
$2,5
00-
$2,9
99$3
,000
-$3
,499
$3,5
00-
$3,9
99$4
,000
-$4
,999
$5,0
00-
$7,4
99$7
,500
-$9
,999
$10,
000+
PERCENT OF ENRO
AN
NU
AL
ST
AT
E S
HA
RE
(D
OL
LA
RS
)S
OU
RC
E:
PD
A/C
LAIM
S H
ISTO
RY
NO
TE:
DA
TA IN
CLU
DE
OR
IGIN
AL,
PA
ID C
LAIM
S B
Y D
ATE
OF
SE
RV
ICE
, EXC
LUD
E P
AC
EN
ET
CLA
IMS
.
22
35.0
%
28.0
%
20%
25%
30%
35%
40%
OLLED CARDHOLDERS
FIG
UR
E 2
.3D
IST
RIB
UT
ION
OF
PA
CE
NE
T A
NN
UA
L B
EN
EF
ITJ
AN
UA
RY
-D
EC
EM
BE
R 2
01
3N
= 1
95
,78
8
AV
ER
AG
E A
NN
UA
L P
AC
EN
ET
BE
NE
FIT
= $5
93.3
3
9.9%
9.1%
5.2%
3.8%
3.8%
1.6%
0.9%
0.6%
0.7%
0.8%
0.3%
0.3%
0%5%10%
15%
$0
$1-$
249
$250
-$4
99$5
00-
$999
$1,0
00-
$1,4
99$1
,500
-$1
,999
$2,0
00-
$2,4
99$2
,500
-$2
,999
$3,0
00-
$3,4
99$3
,500
-$3
,999
$4,0
00-
$4,9
99$5
,000
-$7
,499
$7,5
00-
$9,9
99$1
0,00
0+
PERCENT OF ENRO
AN
NU
AL
ST
AT
E S
HA
RE
(D
OL
LA
RS
)S
OU
RC
E:
PD
A/C
LAIM
S H
ISTO
RY
NO
TE:
DA
TA IN
CLU
DE
PA
CE
NE
T O
RIG
INA
L, P
AID
CLA
IMS
BY
DA
TE O
F S
ER
VIC
E, E
XCLU
DE
PA
CE
CLA
IMS
.
23
JAN - JUN JUL - DEC CY 2013
TOTAL PRESCRIPTION COST (DATE OF SERVICE) 322,402,275$ 332,682,046$ 655,084,321$ MEDICARE PART D PREMIUMS 16,649,075 16,339,789 32,988,864
GROSS CLAIMS/PREMIUMS SUBTOTAL 339,051,350 349,021,835 688,073,185 96.9%
MHS CONTRACT OPERATIONS (INCLUDES POSTAGE) 5,867,985 8,692,293 14,560,278
GROSS CONTRACT SUBTOTAL 5,867,985 8,692,293 14,560,278 2.1%
PDA ADMINISTRATION PERSONNEL 442,523 477,800 920,323 OPERATIONS 70,162 34,745 104,907
GROSS PDA ADMIN. SUBTOTAL 512,685 512,545 1,025,230 0.1%
OTHER ADMINISTRATION AUDITS 380,000 342,500 722,500 MEDICAL ADVISOR 1,475 3,675 5,150 THIRD PARTY RECOVERY 525,159 364,882 890,041
GROSS OTHER ADMIN. SUBTOTAL 906,634 711,057 1,617,691 0.2%
BEHAVIORAL HEALTH INTERVENTIONS 635,242 284,508 919,750 0.1%
ENROLLMENT OUTREACH 1,164,252 1,234,107 2,398,359 0.3%
PRESCRIBER EDUCATION 750,000 750,000 1,500,000 0.2%
GROSS EXPENDITURES 348,888,148 361,206,345 710,094,493 100.0%
PRESCRIPTION COST OFFSETS PART D/OTHER PAYER OFFSETS (190,718,452) (201,578,484) (392,296,936) -55.2% CARDHOLDER COPAYMENTS (38,262,905) (36,189,649) (74,452,554) -10.5%
TOTAL OFFSETS (228,981,357) (237,768,133) (466,749,490) -65.7%
RECOVERIES MANUFACTURER REBATES (20,484,902) (21,805,922) (42,290,824) AUDIT ADJUSTMENTS IN CHECKWRITES (280,172) (363,191) (643,364) ATTORNEY GENERAL SETTLEMENTS (6,848,176) - (6,848,176) ATTORNEY GENERAL COLLECTIONS (3,230) (316) (3,546) THIRD-PARTY REIMBURSEMENTS (4,446,976) (5,234,424) (9,681,400)
COMBINED RECOVERIES (32,063,456) (27,403,853) (59,467,310) PRIOR YEARS' REBATE REFUNDS 686,238 65,328 751,566
NET RECOVERIES (31,377,218) (27,338,525) (58,715,744) -8.3%
NET PRESCRIPTION EXPENDITURES STATE SHARE BEFORE RECOVERIES 93,420,918 94,913,913 188,334,831 26.5% STATE SHARE AFTER RECOVERIES 62,323,872 67,938,579 130,262,451 18.3%
NET STATE EXPENDITURES
AFTER OFFSETS AND RECOVERIES 88,529,573$ 96,099,687$ 184,629,259$ 26.0%
NOTES
AUDIT ADJUSTMENTS ARE BY AUDIT DATE; RECOVERIES OCCURRED IN CY 2013 AND CY 2014. REBATES ($42.3 M) ARE 22.5% OF TOTAL STATE SHARE PRESCRIPTION DRUG COST ($188.3 M). TOTAL PRESCRIPTION COST DOES NOT INCLUDE CLAIMS PROCESSED ONLY BY THIRD PARTY COVERAGE.
TABLE 2.2TOTAL PRESCRIPTION COST, EXPENDITURES, OFFSETS AND RECOVERIES
JANUARY - DECEMBER 2013
EXPENDITURES, RECOVERIES, OFFSETS% OF TOTAL
GROSS EXPENDITURES
TABLE USES PHASE REPORT FOR ANNUAL DRUG EXPENDITURES (DATE OF SERVICE).
24
EN
RO
LLM
EN
TC
LAIM
SG
RO
SS
EXP
EN
DIT
UR
ES
NE
T E
XPE
ND
ITU
RE
S A
FTE
R R
EC
OV
ER
IES
DE
CE
MB
ER
19
88
E
NR
OL
LM
EN
T4
54
,42
8
19
88
CL
AIM
S1
1,6
46
,58
5
20
13
CL
AIM
S9
05
14
31
FIG
UR
E 2
.4P
AC
E A
ND
PA
CE
NE
T E
NR
OL
LM
EN
T,
CL
AIM
S,
AN
D C
LA
IMS
EX
PE
ND
ITU
RE
SB
Y C
AL
EN
DA
R Y
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98
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9
CA
LE
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AR
YE
AR
19
88
GR
OS
SE
XP
EN
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UR
E$
18
3,6
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4
19
88
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TE
XP
EN
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UR
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17
2,7
41
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1
DE
CE
MB
ER
20
13
E
NR
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LM
EN
T2
75
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6
9,0
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1
20
13
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TE
XP
EN
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UR
E$
13
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44
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8
20
13
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OS
SE
XP
EN
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UR
E$
18
0,6
92
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1
Enr
ollm
ent f
igur
es re
pres
ent t
he n
umbe
r of e
nrol
led
card
hold
ers
at th
e en
d of
eac
h re
porte
d ca
lend
ar y
ear.
Rec
over
ies
incl
ude
third
par
ty p
aym
ents
, man
ufac
ture
rs' r
ebat
e, a
nd re
stitu
tions
.
Sou
rce:
P
AC
E B
iann
ual R
epor
ts, 1
988-
1995
; PA
CE
Ann
ual R
epor
ts, 1
996-
2013
.N
otes
:
25
140,
000
165,
000
190,
000
215,
000
PERSONSF
IGU
RE
2.5
AP
AC
E T
OTA
L E
NR
OL
LE
D A
ND
PA
RT
ICIP
AT
ING
CA
RD
HO
LD
ER
S B
Y M
ON
TH
JA
NU
AR
Y 2
00
3 -
JA
NU
AR
Y 2
01
4
PAC
E En
rolle
dPA
CE
Parti
cipa
ting
7.0%
D
ECR
EASE
2.2%
IN
CR
EASE
1.0%
IN
CR
EASE
2.3%
D
ECR
EASE
1.3%
D
ECR
EASE
1.8%
D
ECR
EASE
2.0%
D
ECR
EASE
5.0%
D
ECR
EASE
12.5
%D
ECR
EASE
10.1
%D
ECR
EASE
7.2%
D
ECR
EASE
190,
430
194,
530
191,
938
188,
514
179,
105
156,
688
140,
908
156,
479
158,
106
154,
496
151,
363
135,
720
7.5%
D
ECR
EASE
40,0
00
65,0
00
90,0
00
115,
000
NUMBER OF
SO
UR
CE
: E
ND
-OF-
MO
NTH
PA
CE
EN
RO
LLE
D T
AK
EN
FR
OM
MR
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EP
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AR
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FR
OM
CLA
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HIS
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AS
ED
ON
DA
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ER
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E
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8.1%
DEC
REA
SE
8.4%
D
ECR
EASE
7.4%
D
ECR
EASE
DEC
REA
SE2.
6%
DEC
REA
SE9.
2%
DEC
REA
SE
7.7%
DEC
REA
SE11
.5%
DEC
REA
SE
2003
2004
2005
2006
2007
2008
2009
2010
2011
10.3
%
DEC
REA
SE
2012
15.5
%D
ECR
EASE
2013
11.0
%D
ECR
EASE
112,
513
109,
631
99,5
59
130,
824
86,4
15
79,3
93
73,2
8064
,841
114,
691
101,
943
94,3
70
121,
013
26
100,
000
120,
000
140,
000
160,
000
180,
000
200,
000
OF PERSONSF
IGU
RE
2.5
BP
AC
EN
ET
TO
TAL
EN
RO
LL
ED
AN
D P
AR
TIC
IPA
TIN
G C
AR
DH
OL
DE
RS
BY
MO
NT
HJ
AN
UA
RY
20
03
-J
AN
UA
RY
20
14
PAC
ENET
Enr
olle
dPA
CEN
ET P
artic
ipat
ing
3.7%
IN
CR
EASE
4.2%
IN
CR
EASE
0.
5%
DEC
REA
SE
0.5%
D
ECR
EASE
4.
9%
DEC
REA
SE
101.
38%
IN
CR
EASE
17.3
%
INC
REA
SE
1.2 %
13.4
%
INC
REA
SE
13.8
%IN
CR
EASE
8.1%
INC
REA
SE
121,
887
178,
127
177,
303
120,
445
117,
329
176,
483
167,
862
109,
634
100,
075
118,
140
133,
987
110,
043
152,
476
164,
777
113,
994
117,
499
171,
007
3.8%
IN
CR
EASE
0
20,0
00
40,0
00
60,0
00
80,0
00
NUMBER O SO
UR
CE
: E
ND
-OF-
MO
NTH
PA
CE
NE
T E
NR
OLL
ED
TA
KE
N F
RO
M M
R-0
-01A
RE
PO
RT,
PA
RTI
CIP
ATI
NG
TA
KE
N F
RO
M C
LAIM
S H
ISTO
RY
BA
SE
D O
N D
ATE
OF
SE
RV
ICE
1
INC
REA
SE3.
1%
INC
REA
SE
2.6%
D
ECR
EASE
6.
6%
DEC
REA
SE
62.8
%
INC
REA
SE
35.2
%
INC
REA
SE
137.
1%
INC
REA
SE
2003
2004
2005
2006
22.2
%
INC
REA
SE
2007
2008
2009
%D
ECR
EASE
2010
9.1%
INC
REA
SE
2011
14.7
%IN
CR
EASE
2012
3.7%
INC
REA
SE
22,4
68
30,3
68
30,7
35
50,0
30
72,0
06
87,9
86
95,9
80
2013
27
9.09
10.4
8
11.4
6
13.3
413
.53
14.1
7
18.3
4
1021
10.3
9
11.3
2
14.3
8
$10.
00
$12.
00
$14.
00
$16.
00
$18.
00
$20.
00
PRICE
Mea
n AW
P U
nit P
rice
Mea
n AM
P U
nit P
rice
TOTA
L IN
CR
EA
SE
IN M
EA
N A
WP
UN
IT
PR
ICE
OV
ER
14
YE
AR
S =
603
.1%
FIG
UR
E 2
.6A
PA
CE
AV
ER
AG
E W
HO
LE
SA
LE
PR
ICE
(A
WP
) A
ND
AV
ER
AG
E M
AN
UF
AC
TU
RE
R'S
PR
ICE
(A
MP
) *
BR
AN
D P
RO
DU
CT
S O
NL
Y, B
Y Q
UA
RT
ER
JA
NU
AR
Y 2
00
0 -
DE
CE
MB
ER
20
13
2.61
2.90
3.42
4.04
4.51
5.40
6.37
7.74
909
2.00
2.25
2.63
3.10
3.52
4.21
4.94
6.05
7.51
8.13
8.81
10.2
1
$0.0
0
$2.0
0
$4.0
0
$6.0
0
$8.0
0
12
34
12
34
12
34
12
34
12
34
12
34
12
34
12
34
12
34
12
34
12
34
12
34
12
34
12
34
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
UNIT
TOTA
L IN
CR
EA
SE
IN M
EA
N A
MP
UN
IT
PR
ICE
OV
ER
14
YE
AR
S =
617
.5%
SO
UR
CE
: P
AC
E C
LAIM
S H
ISTO
RY
AN
D M
AN
UFA
CTU
RE
RS
' RE
BA
TE H
ISTO
RY
* D
ATA
INC
LUD
E C
LAIM
S F
OR
ND
C'S
FO
R W
HIC
H R
EB
ATE
AM
P D
ATA
AR
E A
VA
ILA
BLE
FO
R A
NY
QU
AR
TER
IN 2
000-
2013
.
28
1.95
2.07
2.16
2.44
2.94
2.92
$2.0
0
$2.5
0
$3.0
0
$3.5
0
PRICE
Mea
n AW
P U
nit P
rice
Mea
n AM
P U
nit P
rice
TOTA
L IN
CR
EA
SE
IN M
EA
N A
WP
UN
IT
PR
ICE
OV
ER
14
YE
AR
S =
295
.0%
FIG
UR
E 2
.6B
PA
CE
AV
ER
AG
E W
HO
LE
SA
LE
PR
ICE
(A
WP
) A
ND
AV
ER
AG
E M
AN
UF
AC
TU
RE
R'S
PR
ICE
(A
MP
) *
GE
NE
RIC
PR
OD
UC
TS
ON
LY
, B
Y Q
UA
RT
ER
JA
NU
AR
Y 2
00
0 -
DE
CE
MB
ER
20
13
0.74
0.78
0.84
0.89
0.99
0.97
1.07
1.45
1.50
0.16
0.15
0.17
0.16
0.21
0.13
0.15
0.28
0.20
0.21
0.24
0.23
0.21
0.29
0.27
$0.0
0
$0.5
0
$1.0
0
$1.5
0
12
34
12
34
12
34
12
34
12
34
12
34
12
34
12
34
12
34
12
34
12
34
12
34
12
34
12
34
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
UNIT P
TOTA
L IN
CR
EA
SE
IN M
EA
N A
MP
UN
IT
PR
ICE
OV
ER
14
YE
AR
S =
73.
5%
SO
UR
CE
: P
AC
E C
LAIM
S H
ISTO
RY
AN
D M
AN
UFA
CTU
RE
RS
' RE
BA
TE H
ISTO
RY
* D
ATA
INC
LUD
E C
LAIM
S F
OR
ND
C'S
FO
R W
HIC
H R
EB
ATE
AM
P D
ATA
AR
E A
VA
ILA
BLE
FO
R A
NY
QU
AR
TER
IN 2
000-
2013
.
29
30
SECTION 3
PROGRAM DATA BY DATE OF
PAYMENT
31
32
PAGE 1
PACE PACENET
NUMBER OF SEMI-ANNUAL PROCESSED
PERIOD CLAIMS EXPENDITURES
JUL-DEC 1984 26 2,101,419 $20,714,685 $9.86JAN-JUN 1985 26 3,475,440 $36,579,102 $10.53
1st YEAR TOTAL 5,576,859 $57,293,787 $10.27
JUL-DEC 1985 26 4,372,468 $50,616,334 $11.58JAN-JUN 1986 26 4,966,536 $61,368,193 $12.36
2nd YEAR TOTAL 9,339,004 $111,984,527 $11.99
JUL-DEC 1986 26 5,237,141 $68,786,114 $13.13JAN-JUN 1987 26 5,257,747 $72,761,148 $13.84
3rd YEAR TOTAL 10,494,888 $141,547,262 $13.49
JUL-DEC 1987 27 5,515,827 $80,237,477 $14.55JAN-JUN 1988 25 5,440,743 $84,469,697 $15.53
4th YEAR TOTAL 10,956,570 $164,707,174 $15.03
JUL-DEC 1988 27 6,055,327 $99,192,197 $16.38JAN-JUN 1989 26 5,937,088 $103,781,619 $17.48
5th YEAR TOTAL 11,992,415 $202,973,816 $16.93
JUL-DEC 1989 26 5,709,497 $106,600,899 $18.67JAN-JUN 1990 26 5,544,295 $110,848,137 $19.99
6th YEAR TOTAL 11,253,792 $217,449,036 $19.32
EXPENDITURESPER PROCESSED
CLAIM **PROCESSED
WEEKS CLAIMS
TABLE 3.1PACE AND PACENET CLAIMS AND EXPENDITURES PAID BY FISCAL YEAR
JULY 1984 - DECEMBER 2013
NUMBER NUMBER OFSTATE SHARE STATE SHAREAVERAGE AVERAGE
PER PROCESSEDCLAIM *
OF
JUL-DEC 1990 26 5,352,797 $112,293,188 $20.98JAN-JUN 1991 26 5,453,044 $117,814,625 $21.61
7th YEAR TOTAL 10,805,841 $230,107,813 $21.29
JUL-DEC 1991 26 5,073,452 $115,304,410 $22.73JAN-JUN 1992 26 4,816,750 $115,596,910 $24.00
8th YEAR TOTAL 9,890,202 $230,901,320 $23.35
JUL-DEC 1992 26 4,724,142 $115,980,339 $24.55JAN-JUN 1993 26 4,403,096 $108,876,491 $24.73
9th YEAR TOTAL 9,127,238 $224,856,830 $24.64
JUL-DEC 1993 26 4,729,097 $118,778,523 $25.12JAN-JUN 1994 26 4,341,896 $111,401,456 $25.66
10th YEAR TOTAL 9,070,993 $230,179,979 $25.38
JUL-DEC 1994 26 4,721,702 $122,294,905 $25.90JAN-JUN 1995 27 4,228,653 $111,136,630 $26.28
11th YEAR TOTAL 8,950,355 $233,431,535 $26.08
JUL-DEC 1995 26 4,895,160 $131,701,547 $26.90JAN-JUN 1996 26 4,443,096 $121,066,818 $27.25
12th YEAR TOTAL 9,338,256 $252,768,365 $27.07
JUL-DEC 1996 26 4,334,551 $119,612,179 $27.60 540 $23 $0.04JAN-JUN 1997 26 4,523,225 $116,697,725 $25.80 74,647 $586,350 $7.85
13th YEAR TOTAL 8,857,776 $236,309,904 $26.68 75,187 $586,373 $7.80
JUL-DEC 1997 26 4,546,360 $121,880,844 $26.81 150,263 $2,680,675 $17.84JAN-JUN 1998 26 4,497,031 $126,776,785 $28.19 171,797 $2,860,833 $16.65
14th YEAR TOTAL 9,043,391 $248,657,629 $27.50 322,060 $5,541,508 $17.21
33
PAGE 2
PACE PACENET
NUMBER OF SEMI-ANNUAL PROCESSED
PERIOD CLAIMS EXPENDITURES
JUL-DEC 1998 26 4,504,394 $134,229,706 $29.80 233,277 $4,737,561 $20.31JAN-JUN 1999 26 4,220,448 $139,246,165 $32.99 256,109 $5,410,383 $21.13
15th YEAR TOTAL 8,724,842 $273,475,871 $31.34 489,386 $10,147,944 $20.74
JUL-DEC 1999 26 4,456,680 $153,781,999 $34.51 310,165 $7,421,422 $23.93JAN-JUN 2000 26 4,453,977 $160,846,800 $36.11 339,250 $8,389,295 $24.73
8,910,657 $314,628,799 $35.31 649,415 $15,810,717 $24.35
JUL-DEC 2000 26 4,538,814 $170,118,213 $37.48 382,379 $10,200,170 $26.68JAN-JUN 2001 26 4,536,651 $177,830,053 $39.20 420,529 $11,319,858 $26.92
9,075,465 $347,948,266 $38.34 802,908 $21,520,028 $26.80
JUL-DEC 2001 26 4,635,934 $189,489,307 $40.87 480,559 $13,924,106 $28.97JAN-JUN 2002 26 4,554,962 $194,745,251 $42.75 542,321 $16,348,022 $30.14
9,190,896 $384,234,558 $41.81 1,022,880 $30,272,128 $29.59
JUL-DEC 2002 26 4,615,282 $203,947,092 $44.19 615,169 $20,100,929 $32.68JAN-JUN 2003 26 4,554,809 $208,208,623 $45.71 644,320 $21,608,906 $33.54
19th YEAR TOTAL 9,170,091 $412,155,715 $44.95 1,259,489 $41,709,835 $33.12
JUL-DEC 2003 26 4,688,095 $221,734,037 $47.30 722,537 $25,698,628 $35.57JAN-JUN 2004 26 4,581,399 $205,908,844 $44.94 1,268,014 $47,385,206 $37.37
20th YEAR TOTAL 9,269,494 $427,642,881 $46.13 1,990,551 $73,083,834 $36.72
PER PROCESSED
17th YEAR TOTAL
AVERAGE AVERAGENUMBER STATE SHARE NUMBER OF
OF PROCESSEDSTATE SHARE
TABLE 3.1PACE AND PACENET CLAIMS AND EXPENDITURES PAID BY FISCAL YEAR
JULY 1984 - DECEMBER 2013
16th YEAR TOTAL
PER PROCESSEDWEEKS CLAIM * CLAIMS
18th YEAR TOTAL
EXPENDITURES CLAIM **
, , $ , , $ , , $ , , $
JUL-DEC 2004 26 4,646,945 $178,347,082 $38.38 1,922,663 $71,852,034 $37.37JAN-JUN 2005 26 4,613,122 $166,886,748 $36.18 2,178,944 $81,479,300 $37.39
21st YEAR TOTAL 9,260,067 $345,233,830 $37.28 4,101,607 $153,331,334 $37.38
JUL-DEC 2005 26 4,632,516 $208,781,508 $45.07 2,451,200 $96,468,947 $39.36JAN-JUN 2006 26 4,484,886 $196,409,910 $43.79 2,708,585 $100,489,805 $37.10
9,117,402 $405,191,418 $44.44 5,159,785 $196,958,752 $38.17
JUL-DEC 2006 26 4,074,738 $126,753,319 $31.11 2,686,230 $77,256,980 $28.76JAN-JUN 2007 26 3,642,398 $82,054,486 $22.53 2,633,012 $59,270,762 $22.51
23rd YEAR TOTAL 7,717,136 $208,807,805 $27.06 5,319,242 $136,527,742 $25.67
JUL-DEC 2007 26 3,491,014 $99,077,033 $28.38 2,688,584 $85,271,656 $31.72JAN-JUN 2008 26 3,015,416 $70,145,582 $23.26 2,947,413 $67,641,825 $22.95
24th YEAR TOTAL 6,506,430 $169,222,615 $26.01 5,635,997 $152,913,481 $27.13
JUL-DEC 2008 26 2,882,322 $76,213,073 $26.44 3,082,226 $89,890,137 $29.16JAN-JUN 2009 26 2,675,602 $55,324,827 $20.68 2,960,252 $66,702,151 $22.53
25th YEAR TOTAL 5,557,924 $131,537,900 $23.67 6,042,478 $156,592,288 $25.92
JUL-DEC 2009 26 2,560,054 $63,361,329 $24.75 3,031,954 $91,430,885 $30.16JAN-JUN 2010 26 2,380,428 $56,111,899 $23.57 2,824,223 $76,675,981 $27.15
26th YEAR TOTAL 4,940,482 $119,473,228 $24.18 5,856,177 $168,106,866 $28.71
JUL-DEC 2010 26 2,182,334 $61,837,441 $28.34 2,853,692 $101,435,537 $35.55JAN-JUN 2011 26 2,226,942 $45,437,610 $20.40 3,102,948 $65,404,599 $21.08
27th YEAR TOTAL 4,409,276 $107,275,051 $24.33 5,956,640 $166,840,136 $28.01
22nd YEAR TOTAL
34
PAGE 3
PACE PACENET
NUMBER OF SEMI-ANNUAL PROCESSED
PERIOD CLAIMS EXPENDITURES
JUL-DEC 2011 26 2,067,181 $42,933,134 $20.77 3,072,410 $63,057,042 $20.52JAN-JUN 2012 26 2,093,727 $42,352,837 $20.23 3,035,747 $64,106,702 $21.12
28th YEAR TOTAL 4,160,908 $85,285,971 $20.50 6,108,157 $127,163,744 $20.82
JUL-DEC 2012 26 1,924,040 $36,823,185 $19.14 2,963,999 $58,046,309 $19.58JAN-JUN 2013 26 1,853,713 $36,063,995 $19.46 2,897,931 $57,828,530 $19.96
29th YEAR TOTAL 3,777,753 $72,887,180 $19.29 5,861,930 $115,874,839 $19.77
JUL-DEC 2013 26 1,597,139 $31,742,735 $19.87 2,702,648 $55,057,471 $20.3730th YEAR-TO-DATE TOTAL 1,597,139 $31,742,735 $19.87 2,702,648 $55,057,471 $20.37
CUMULATIVE TOTAL 246,083,542 $6,619,912,800 $26.90 59,356,537 $1,628,039,020 $27.43
AVERAGENUMBER STATE SHARE NUMBER OF STATE SHARE
PROCESSED PER PROCESSEDOF PER PROCESSED
Reimbursement formulas for PACE:
July 1, 1984 - June 1985: The lesser of either the Average Wholesale Price (AWP) plus a $2.50 dispensing fee or the Usual and Customary
WEEKS CLAIM * CLAIMS
Charge (U&C), then subtracting a $4.00 cardholder payment.
TABLE 3.1PACE AND PACENET CLAIMS AND EXPENDITURES PAID BY FISCAL YEAR
JULY 1984 - DECEMBER 2013
AVERAGE
EXPENDITURES CLAIM **
manufacturers, recoupments from insurance carriers, or audit disallowances received from providers and enrollees. The number of claims
original, paid claim would be higher than the values shown on this table.
November 22, 1996 - December 31, 2003: The lesser of either the AWP minus 10% plus a $3.50 dispensing fee, or the U&C, then
July 1, 1991 - November 21, 1996: Same as above with copayment increased to $6.00.
July 1, 1985 - June 1991: The lesser of either the AWP plus a $2.75 dispensing fee or the U&C, then subtracting a $4.00 cardholder payment.
* The State Share is the amount paid by the PACE Program for each claim. The State Share per processed claim does not reflect rebates from
includes all original, debit, credit and void claims. Some claims, therefore, do not have a payment associated with them. The State Share per
September 2006 - Present: Program providers are required to accept the Medicare Part D Plan reimbursements for those claims in the coverage
June 2004 - Present: Average state share per claim reflects savings from Medicare Part D.
September 2006 - Present: Program providers are required to accept the Medicare Part D Plan reimbursements for those claims in the coverage
June 2004 - Present: Average state share per claim reflects savings from Medicare Part D.
SOURCE: PDA/MRW200-01 & MRM730-01
copayment can be adjusted annually.
copayment can be adjusted annually.
Reimbursement formulas for PACENET:
November 22, 1996 - December 31, 2003: The lesser of either AWP minus 10% plus a $3.50 dispensing fee, or the U&C, then subtracting
subtracting a $6.00 copayment.
June 2004 - December 2005: Average PACE state share per claim reflects additional savings from the Transitional Assistance benefit for Medicare
January 1, 2004 - July 9, 2006: The lesser of either AWP minus 10% plus a $4.00 dispensing fee, or the U&C, or the Federal Upper Limit for a generic product plus a $4.00 dispensing fee, then subtracting a copayment of $6.00 for generics and $9.00 for brand products. The
plus a $4.00 dispensing fee for claims not covered by an enrollee’s Part D Plan.
Discount Program cardholders.
phase received by cardholders who are enrolled in both Medicare Part D and the PACE/PACENET Program. These Part D Plan reimbursementsare comparable to the average commercial rate of AWP minus 17% plus a $2.00 dispensing fee. The Program reimburses at AWP minus 12% plus a $4.00 dispensing fee for claims not covered by an enrollee’s Part D Plan.
generic product plus a $4.00 dispensing fee, then subtracting a copayment of $8.00 for generics and $15.00 for brand products. The
** The State Share is the amount paid by the PACENET Program when the cost of the claim(s) exceeds the monthly deductible premium amount plus the copayment. The number of processed claims includes all original, debit, credit and void claims and claims without a State Share payment in the premium deductible phases and all other claims with a State Share payment. Therefore, the State Share per claim on this table is lower
generic product plus a $4.00 dispensing fee, then subtracting a copayment of $8.00 for generics and $15.00 for brand products. The
than the State Share for claims beyond the premium deductible phase. The State Share per processed claim does not reflect rebates frommanufacturers, recoupments from insurance carriers, or audit disallowances received from providers.
phase received by cardholders who are enrolled in both Medicare Part D and the PACE/PACENET Program. These Part D Plan reimbursementsare comparable to the average commercial rate of AWP minus 17% plus a $2.00 dispensing fee. The Program reimburses at AWP minus 12%
July 10, 2006 - Present: The lesser of either AWP minus 12% plus a $4.00 dispensing fee, or the U&C, or the Federal Upper Limit for a
a copayment of $8.00 for generics and $15 for brand products.
January 1, 2004 - July 9, 2006: The lesser of either AWP minus 10% plus a $4.00 dispensing fee, or the U&C, or the Federal Upper Limit for a
copayment can be adjusted annually.
35
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44
SECTION 4
CARDHOLDER UTILIZATION
DATA
45
46
PAGE 1
NEWLYQUARTER ENROLLED *
1st JUL-SEP 1984 273,001 100.0 273,001PROGRAM OCT-DEC 1984 23,561 7.9 296,562YEAR JAN-MAR 1985 20,941 6.6 317,503
APR-JUN 1985 69,436 17.9 386,939
2nd JUL-SEP 1985 38,750 10.0 389,177PROGRAM OCT-DEC 1985 20,522 5.0 409,699YEAR JAN-MAR 1986 18,770 4.4 428,469
APR-JUN 1986 17,367 3.9 445,836
3rd JUL-SEP 1986 23,595 5.6 420,776PROGRAM OCT-DEC 1986 14,982 3.4 435,758YEAR JAN-MAR 1987 18,130 4.0 453,888
APR-JUN 1987 18,853 4.0 472,741
4th JUL-SEP 1987 26,133 5.9 439,967PROGRAM OCT-DEC 1987 10,432 2.3 450,399YEAR JAN-MAR 1988 13,429 2.9 463,828
APR-JUN 1988 13,944 2.9 477,772
ENROLLMENT NEWLY AT END
QUARTER OF QUARTER**
5th JUL-SEP 1988 15,990 3.6 443,518PROGRAM OCT-DEC 1988 26,069 5.7 454,428YEAR JAN-MAR 1989 41,866 9.1 460,232
APR-JUN 1989 57,406 12.7 451,547
6th JUL-SEP 1989 9,847 2.2 438,834PROGRAM OCT-DEC 1989 17,787 4.2 426,822YEAR JAN-MAR 1990 30,278 7.1 424,120
APR-JUN 1990 40,169 9.8 408,493
7th JUL-SEP 1990 6,714 1.7 394,821PROGRAM OCT-DEC 1990 26,742 6.9 384,854YEAR JAN-MAR 1991 37,239 9.7 383,792
APR-JUN 1991 46,020 12.4 371,592
8th JUL-SEP 1991 8,657 2.3 370,654PROGRAM OCT-DEC 1991 17,529 4.7 373,365YEAR JAN-MAR 1992 31,581 8.4 375,697
APR-JUN 1992 44,986 12.2 369,919
9th JUL-SEP 1992 7,115 2.0 355,319PROGRAM OCT-DEC 1992 13,436 3.9 347,371YEAR JAN-MAR 1993 29,556 8.4 353,309
APR-JUN 1993 41,397 12.1 341,361
10th JUL-SEP 1993 6,658 2.0 334,757PROGRAM OCT-DEC 1993 11,519 3.5 331,338YEAR JAN-MAR 1994 20,162 6.2 324,160
APR-JUN 1994 33,967 10.4 325,090
11th JUL-SEP 1994 7,091 2.3 312,413PROGRAM OCT-DEC 1994 11,167 3.6 307,231YEAR JAN-MAR 1995 22,732 7.3 311,450
APR-JUN 1995 31,995 10.5 304,153
12th JUL-SEP 1995 5,382 1.8 298,732PROGRAM OCT-DEC 1995 8,278 2.9 289,919YEAR JAN-MAR 1996 16,146 5.6 290,460
APR-JUN 1996 22,518 8.1 279,397
TABLE 4.1PACE AND PACENET CARDHOLDER ENROLLMENTS BY QUARTER
PACE
JULY 1984 - JUNE 1988% OF NEWLY CUMULATIVEENROLLED ENROLLMENTS
PACE
JULY 1988 - JUNE 1996CUMULATIVE % OF
NEWLYENROLLED ENROLLED
47
PAGE 2
ENROLLMENT CUMULATIVE % OF ENROLLMENT NEWLY AT END NEWLY NEWLY AT END
QUARTER OF QUARTER** ENROLLED ENROLLED OF QUARTER
13th JUL-SEP 1996 4,127 1.5 267,049PROGRAM OCT-DEC 1996 9,332 3.6 260,678 1,523 100.0 1,523YEAR JAN-MAR 1997 23,797 8.6 275,607 5,771 100.0 5,771
APR-JUN 1997 30,602 11.6 264,414 9,088 100.0 9,088
14th JUL-SEP 1997 4,536 1.8 257,291 1,949 17.7 11,037PROGRAM OCT-DEC 1997 8,694 3.5 250,671 3,801 29.5 12,889YEAR JAN-MAR 1998 16,693 6.6 251,915 5,710 48.5 11,771
APR-JUN 1998 22,838 9.3 245,553 7,419 53.8 13,802
15th JUL-SEP 1998 4,375 1.8 237,753 879 5.8 15,213PROGRAM OCT-DEC 1998 8,042 3.5 230,722 1,504 9.4 15,964YEAR JAN-MAR 1999 14,744 6.4 231,049 3,216 19.9 16,164
APR-JUN 1999 20,672 9.1 227,041 4,722 27.2 17,372
16th JUL-SEP 1999 4,086 1.8 221,535 761 4.2 18,195PROGRAM OCT-DEC 1999 7,981 3.7 217,103 1,510 8.1 18,655YEAR JAN-MAR 2000 18,146 8.2 220,896 4,169 21.6 19,298
APR-JUN 2000 25,583 11.8 217,140 6,125 30.1 20,375
17th JUL-SEP 2000 5,061 2.4 213,041 1,032 4.9 21,223PROGRAM OCT-DEC 2000 10,283 4.9 208,227 2,034 9.3 21,781YEAR JAN-MAR 2001 19,041 9.1 208,299 4,610 20.8 22,167
APR-JUN 2001 24,932 12.0 207,193 6,603 28.9 22,875
18th JUL-SEP 2001 3,877 1.9 204,839 1,710 6.9 24,929PROGRAM OCT-DEC 2001 7,907 4.0 199,898 3,132 12.1 25,873YEAR JAN-MAR 2002 16,319 8.2 199,719 6,931 23.3 29,692
APR-JUN 2002 22,742 11.4 198,629 9,938 32.7 30,346
19th JUL-SEP 2002 3,490 1.8 191,935 1,378 4.6 29,980PROGRAM OCT-DEC 2002 6,925 3.7 188,566 2,476 8.2 30,356YEAR JAN-MAR 2003 13,384 7.0 190,697 5,516 17.5 31,464
APR-JUN 2003 21,287 10.9 194,961 9,654 29.7 32,520
20th JUL-SEP 2003 4,467 2.4 187,914 2,299 6.8 33,855PROGRAM OCT-DEC 2003 8,106 4.4 185,143 3,737 10.9 34,314YEAR JAN-MAR 2004 21,568 10.8 200,130 37,246 51.4 72,474
APR-JUN 2004 28,312 14.3 197,600 43,224 49.7 87,007
21st JUL-SEP 2004 4,222 2.2 194,488 7,598 8.1 94,002PROGRAM OCT-DEC 2004 6,717 3.5 191,669 15,186 15.3 99,572YEAR JAN-MAR 2005 13,536 7.0 193,946 25,934 28.2 92,035
APR-JUN 2005 19,467 10.2 190,273 35,063 34.2 102,622
22nd JUL-SEP 2005 3,935 2.1 187,696 6,301 5.9 107,240PROGRAM OCT-DEC 2005 9,001 4.8 188,495 15,579 13.3 116,755YEAR JAN-MAR 2006 14,476 7.6 190,654 25,774 20.8 123,687
APR-JUN 2006 23,477 12.5 187,311 42,841 33.4 128,212
23rd JUL-SEP 2006 2,084 1.1 184,106 3,182 2.5 127,978PROGRAM OCT-DEC 2006 5,269 2.9 179,240 11,330 8.5 132,764YEAR JAN-MAR 2007 8,687 4.8 182,332 19,571 14.6 134,018
APR-JUN 2007 11,621 6.5 178,746 26,974 19.7 136,805
24th JUL-SEP 2007 2,143 1.2 174,824 3,940 2.8 138,701PROGRAM OCT-DEC 2007 4,477 2.8 158,560 8,642 5.5 157,874YEAR JAN-MAR 2008 6,956 4.5 155,547 19,078 11.9 160,227
APR-JUN 2008 9,712 6.3 155,026 29,033 17.2 169,043
TABLE 4.1 PACE AND PACENET CARDHOLDER ENROLLMENTS BY QUARTER
JULY 1996 - DECEMBER 2013
PACE PACENET
CUMULATIVE % OF NEWLY
ENROLLED ENROLLED
48
PAGE 3
ENROLLMENT CUMULATIVE % OF ENROLLMENT NEWLY AT END NEWLY NEWLY AT END
QUARTER OF QUARTER** ENROLLED ENROLLED OF QUARTER
25th JUL-SEP 2008 2,321 1.5 150,074 6,087 3.6 170,931PROGRAM OCT-DEC 2008 4,873 3.4 141,712 11,833 6.8 173,460YEAR JAN-MAR 2009 6,838 6.7 101,470 17,435 10.5 165,925
APR-JUN 2009 8,521 6.3 134,590 23,075 13.8 167,488
26th JUL-SEP 2009 1,848 1.4 133,248 6,469 3.8 170,994PROGRAM OCT-DEC 2009 2,654 2.0 131,002 13,898 8.2 169,270YEAR JAN-MAR 2010 5,109 3.9 129,892 21,782 12.5 174,306
APR-JUN 2010 7,344 5.7 128,651 29,944 16.8 178,574
27th JUL-SEP 2010 1,203 1.0 126,424 4,636 2.6 178,869PROGRAM OCT-DEC 2010 2,800 2.3 121,369 9,292 5.2 177,774YEAR JAN-MAR 2011 4,553 3.8 120,244 15,376 8.6 179,606
APR-JUN 2011 6,438 5.4 118,605 20,912 11.6 181,016
28th JUL-SEP 2011 1,349 1.2 117,121 3,376 1.9 180,624PROGRAM OCT-DEC 2011 3,291 2.9 112,850 7,820 4.4 176,771YEAR JAN-MAR 2012 5,129 4.6 112,319 11,037 6.2 178,059
APR-JUN 2012 7,259 6.5 110,863 13,971 7.8 178,290
29th JUL-SEP 2012 1,382 1.3 110,133 2,571 1.4 177,702PROGRAM OCT-DEC 2012 3,200 2.9 109,395 5,196 3.0 175,524YEAR JAN-MAR 2013 4,756 4.5 106,109 8,428 4.9 173,206
APR-JUN 2013 5,971 5.7 104,853 11,836 6.8 173,220
30th JUL-SEP 2013 966 0.9 102,787 2,555 1.5 170,876PROGRAM OCT-DEC 2013 2,273 2.2 101,375 6,018 3.5 173,456YEAR
* THE NEWLY ENROLLED NUMBER IS CALCULATED AS A TOTAL FOR THE QUARTER.** ENROLLMENT AT END OF QUARTER REPRESENTS THE ENROLLMENT REPORTED ON THE LAST DAY OF THE QUARTER (I.E., 101,375 PACE CARDHOLDERS AND 173,456 PACENET CARDHOLDERS ON THE FILE ON DECEMBER 31, 2013).
SOURCE: PDA/MR-0-01A/CARDHOLDER FILE
TABLE 4.1 PACE AND PACENET CARDHOLDER ENROLLMENTS BY QUARTER
JULY 1996 - DECEMBER 2012
PACE PACENET
CUMULATIVE % OF NEWLY
ENROLLED ENROLLED
49
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DIA
N19
013
04,
262
0.1
32.8
$339
,068
$247
,885
73.1
$91,
183
26.9
$701
.41
0.1
HIS
PA
NIC
1,73
31,
244
40,2
620.
732
.4$2
,952
,813
$2,1
91,3
5174
.2$7
61,4
6225
.8$6
12.1
10.
7A
SIA
N82
455
513
,112
0.2
23.6
$1,3
44,3
10$9
20,2
7468
.5$4
24,0
3631
.5$7
64.0
30.
4O
THE
R1,
866
1,39
144
,866
0.8
32.3
$3,4
66,0
61$2
,514
,233
72.5
$951
,828
27.5
$684
.28
0.8
MIS
SIN
G14
,587
10,7
5135
9,82
96.
233
.5$2
6,15
0,51
8$1
8,87
5,45
572
.2$7
,275
,063
27.8
$676
.69
6.3
AN
D T
PL
TUR
ES
CLA
IMS
CA
RD
HO
LDE
RS
EN
RO
LLE
DTO
TAL
CA
RD
HO
LDE
RS
PA
RTI
CIP
ATI
NG
TOTA
L
CA
RD
HO
LDE
R
STA
TES
HA
RE
EX
PE
ND
I -TU
RE
SP
ATI
NG
SH
AR
E P
ER
PA
RTI
CI-
EX
PE
ND
I-
TA
BL
E 4
.2B
PA
CE
NE
T C
AR
DH
OL
DE
R E
NR
OL
LM
EN
T, P
AR
TIC
IPA
TIO
N, U
TIL
IZA
TIO
N, A
ND
EX
PE
ND
ITU
RE
S
JAN
UA
RY
- D
EC
EM
BE
R 2
013
BY
DE
MO
GR
AP
HIC
CH
AR
AC
TE
RIS
TIC
S
% O
F
PE
R
CA
RD
HO
LDE
RS
TATE
SH
AR
E (%
)
EX
PE
ND
I-TU
RE
SC
IPA
NT
OF
TOTA
LP
AR
TI-
STA
TES
HA
RE
(%)
OF
TOTA
L
52
PA
GE
2
TOTA
LS
TATE
% O
FC
AR
DH
OLD
ER
SH
AR
ETO
TAL
TOTA
LTO
TAL
AN
D T
PL
EX
PE
ND
I-C
LAIM
SC
LAIM
SE
XP
EN
DIT
UR
ES
EX
PE
ND
ITU
RE
STU
RE
S
AN
D T
PL
TUR
ES
CLA
IMS
CA
RD
HO
LDE
RS
EN
RO
LLE
DTO
TAL
CA
RD
HO
LDE
RS
PA
RTI
CIP
ATI
NG
TOTA
L
CA
RD
HO
LDE
R
STA
TES
HA
RE
EX
PE
ND
I -TU
RE
SP
ATI
NG
SH
AR
E P
ER
PA
RTI
CI-
EX
PE
ND
I-
TA
BL
E 4
.2B
PA
CE
NE
T C
AR
DH
OL
DE
R E
NR
OL
LM
EN
T, P
AR
TIC
IPA
TIO
N, U
TIL
IZA
TIO
N, A
ND
EX
PE
ND
ITU
RE
S
JAN
UA
RY
- D
EC
EM
BE
R 2
013
BY
DE
MO
GR
AP
HIC
CH
AR
AC
TE
RIS
TIC
S
% O
F
PE
R
CA
RD
HO
LDE
RS
TATE
SH
AR
E (%
)
EX
PE
ND
I-TU
RE
SC
IPA
NT
OF
TOTA
LP
AR
TI-
STA
TES
HA
RE
(%)
OF
TOTA
L
INC
OM
E -
SIN
GLE
$14,
501
- $17
,500
50,2
5040
,003
1,51
6,96
726
.337
.9$1
03,4
73,0
46$7
6,95
6,82
074
.4$2
6,51
6,22
625
.6$6
62.8
622
.8$1
7,50
1 - $
20,5
0044
,328
35,7
201,
401,
051
24.3
39.2
$99,
482,
886
$70,
862,
504
71.2
$28,
620,
383
28.8
$801
.24
24.6
$20,
501
- $23
,500
27,5
0421
,957
840,
268
14.5
38.3
$62,
119,
354
$44,
185,
926
71.1
$17,
933,
428
28.9
$816
.75
15.4
$23,
500
+4,
677
3,49
312
0,55
72.
134
.5$9
,157
,580
$6,3
62,6
2069
.5$2
,794
,960
30.5
$800
.16
2.4
INC
OM
E -
MA
RR
IED
$17,
701
- $22
,500
14,8
8211
,317
398,
850
6.9
35.2
$27,
155,
476
$21,
171,
623
78.0
$5,9
83,8
5322
.0$5
28.7
55.
2$2
2,50
1 - $
27,0
0024
,018
18,6
3567
7,37
911
.736
.3$5
0,24
9,78
2$3
4,97
5,57
069
.6$1
5,27
4,21
230
.4$8
19.6
513
.1$2
7,00
1 - $
31,5
0026
,168
20,6
0372
7,99
612
.635
.3$5
7,42
6,66
0$4
0,76
1,98
771
.0$1
6,66
4,67
329
.0$8
08.8
514
.3$3
1,50
0 +
3,96
12,
801
92,9
831.
633
.2$8
,193
,099
$5,8
12,9
9970
.9$2
,380
,100
29.1
$849
.73
2.0
SO
UR
CE
: P
DA
/CLA
IMS
HIS
TOR
Y, C
AR
DH
OLD
ER
FIL
EN
OTE
: D
ATA
INC
LUD
E O
RIG
INA
L, P
AID
PA
CE
NE
T C
LAIM
S B
Y D
ATE
OF
SE
RV
ICE
. TO
TAL
CLA
IMS
INC
LUD
E D
ED
UC
TIB
LE C
LAIM
S A
ND
CO
PA
ID C
LAIM
S.
T
HE
HIG
HE
ST
INC
OM
E C
ATE
GO
RY
INC
LUD
ES
CA
RD
HO
LDE
RS
WH
O H
AV
E R
EM
AIN
ED
IN T
HE
PR
OG
RA
M E
VE
N T
HO
UG
H T
HE
IR IN
CO
ME
S E
XC
EE
D IN
CO
ME
ELI
GIB
ILIT
Y L
IMIT
S D
UE
TO
N
OM
INA
L IN
CR
EA
SE
S IN
TH
EIR
SO
CIA
L S
EC
UR
ITY
INC
OM
E.
THIS
INC
OM
E G
RO
UP
MA
Y A
LSO
INC
LUD
E C
AR
DH
OLD
ER
S W
HO
EX
CE
ED
TH
E IN
CO
ME
LIM
ITS
AN
D L
OS
E E
LIG
IBIL
ITY
D
UR
ING
TH
E Y
EA
R.
53
FIG
UR
E 4
.1A
PE
RC
EN
T O
F E
NR
OL
LE
D P
AC
E C
AR
DH
OL
DE
RS
BY
IN
CO
ME
AN
D M
AR
ITA
L S
TA
TU
SJA
NU
AR
Y -
DE
CE
MB
ER
201
3(T
OT
AL
N =
119
,491
)
SIN
GL
EN
=11
0,06
1M
AR
RIE
DN
=9,
430
$0-$
2,99
93.
4%
$3,0
00-$
5,99
91.
3%$6
,000
-$8,
999
3.1%
$9,0
00-$
11,9
996.
3%
$12,
000-
$14,
999
16.2
%
*$17
,700
+22
.0%
$0-$
2,99
92.
1%$3
,000
-$5,
999
2.8%
$6,0
00-$
8,99
910
.4%
*$14
,500
+12
.9%
in
thei
r Soc
ial S
ecur
ity in
com
e. T
his
inco
me
grou
p m
ay a
lso
incl
ude
card
hold
ers
who
exc
eed
the
inco
me
limits
and
lose
elig
ibilit
y du
ring
the
year
.* T
he h
ighe
st in
com
e ca
tego
ry in
clud
es c
ardh
olde
rs w
ho h
ave
rem
aine
d in
the
prog
ram
eve
n th
ough
thei
r inc
omes
exc
eed
inco
me
elig
ibilit
y lim
its d
ue to
nom
inal
incr
ease
s
SO
UR
CE
: P
DA
CA
RD
HO
LDE
R F
ILE
NO
TE:
Due
to ro
undi
ng, c
ateg
ory
perc
enta
ges
may
not
add
up
to 1
00%
.
$15,
000-
$17,
700
47.8
%
$9,0
00-$
11,9
9926
.2%
$12,
000-
$14,
500
45.6
%
54
FIG
UR
E 4
.1B
PE
RC
EN
T O
F E
NR
OL
LE
D P
AC
EN
ET
CA
RD
HO
LD
ER
SB
Y I
NC
OM
E A
ND
MA
RIT
AL
ST
AT
US
JAN
UA
RY
- D
EC
EM
BE
R 2
013
(TO
TA
L N
=19
5,78
8)
SIN
GL
EN
=12
6,75
9M
AR
RIE
DN
=69
,029
$17,
701-
$22,
500
21.6
%
$27,
001-
$31,
500
37.9
%
*$31
,500
+5.
7%$1
4,50
1-$1
7,50
039
.6%
$20,
501-
$23,
500
21.7
%
*$23
,500
+3.
7%
NO
TE:
Due
to ro
undi
ng, c
ateg
ory
perc
enta
ges
may
not
add
up
to 1
00%
.
SO
UR
CE
: P
DA
CA
RD
HO
LDE
R F
ILE
* The
hig
hest
inco
me
cate
gory
incl
udes
car
dhol
ders
who
hav
e re
mai
ned
in th
e pr
ogra
m e
ven
thou
gh th
eir i
ncom
es e
xcee
d in
com
e el
igib
ility
limits
due
to n
omin
al in
crea
ses
in
thei
r Soc
ial S
ecur
ity in
com
e. T
his
inco
me
grou
p m
ay a
lso
incl
ude
card
hold
ers
who
exc
eed
the
inco
me
limits
and
lose
elig
ibilit
y du
ring
the
year
.
$22,
501-
$27,
000
34.8
%$1
7,50
1-$2
0,50
035
.0%
55
TA
BL
E 4
.3O
TH
ER
PR
ES
CR
IPT
ION
INS
UR
AN
CE
CO
VE
RA
GE
OF
PA
CE
AN
D P
AC
EN
ET
EN
RO
LL
ED
CA
RD
HO
LD
ER
SJA
NU
AR
Y -
DE
CE
MB
ER
201
3
PA
CE
PA
CE
STA
TE S
HA
RE
A.
PA
CE
EN
RO
LLE
D C
AR
DH
OLD
ER
SC
LAIM
SE
XP
EN
DIT
UR
ES
CLA
IMS
PE
RTO
TAL
STA
TEE
XP
EN
DIT
UR
ES
TOTA
LE
NR
OLL
ED
SH
AR
EP
ER
EN
RO
LLE
DN
UM
BE
R%
OF
TOTA
LC
LAIM
SC
AR
DH
OLD
ER
EX
PE
ND
ITU
RE
SC
AR
DH
OLD
ER
115,
153
96.4
3,63
1,48
131
.5$6
9,83
8,37
5$6
06.4
8
ME
DIC
AR
E P
AR
T D
CO
VE
RA
GE
104,
732
87.6
3,26
8,62
631
.2$4
7,95
5,87
3$4
57.8
9
NO
N M
ED
ICA
RE
PA
RT
D C
OV
ER
AG
E10
,421
8.7
362,
855
34.8
$21,
882,
502
$2,0
99.8
5
NO
OTH
ER
KN
OW
N P
RE
SC
RIP
TIO
N C
OV
ER
AG
E4,
338
3.6
40,9
859.
4$2
,328
,622
$536
.80
TOTA
L P
AC
E E
NR
OLL
ED
119,
491
100.
03,
672,
466
30.7
$72,
166,
997
$603
.95
PA
CE
NE
TP
AC
EN
ET
STA
TE S
HA
RE
B.
PA
CE
NE
TE
NR
OLL
ED
CA
RD
HO
LDE
RS
CLA
IMS
EX
PE
ND
ITU
RE
SC
LAIM
S P
ER
TOTA
L S
TATE
EX
PE
ND
ITU
RE
STO
TAL
EN
RO
LLE
DS
HA
RE
PE
R E
NR
OLL
ED
NU
MB
ER
% O
F TO
TAL
CLA
IMS
CA
RD
HO
LDE
RE
XP
EN
DIT
UR
ES
CA
RD
HO
LDE
R
186,
063
95.0
5,70
5,91
130
.7$1
12,7
24,6
40$6
05.8
4
ME
DIC
AR
E P
AR
T D
CO
VE
RA
GE
165,
630
84.6
5,20
6,53
331
.4$8
6,90
3,23
5$5
24.6
8
NO
N M
ED
ICA
RE
PA
RT
D C
OV
ER
AG
E20
,433
10.4
499,
378
24.4
$25,
821,
406
$1,2
63.7
1
NO
OTH
ER
KN
OW
N P
RE
SC
RIP
TIO
N C
OV
ER
AG
E9,
725
5.0
70,1
407.
2$3
,443
,193
$354
.06
TOTA
L P
AC
EN
ET
EN
RO
LLE
D19
5,78
810
0.0
5,77
6,05
129
.5$1
16,1
67,8
33$5
93.3
3
SO
UR
CE
: P
DA
/CA
RD
HO
LDE
R F
ILE
, CLA
IMS
HIS
TOR
YN
OTE
S:
DA
TA IN
CLU
DE
OR
IGIN
AL,
PA
ID C
LAIM
S B
Y D
ATE
OF
SE
RV
ICE
. S
OM
E C
AR
DH
OLD
ER
S W
ER
E E
NR
OLL
ED
IN B
OTH
PR
OG
RA
MS
FO
R S
OM
E P
OR
TIO
N O
F TH
E Y
EA
R.
NO
T A
LL C
AR
DH
OLD
ER
S W
ITH
IDE
NTI
FIE
D R
X IN
SU
RA
NC
E H
AD
AC
TIV
E T
HIR
D P
AR
TY C
OV
ER
AG
E F
OR
DR
UG
S R
EIM
BU
RS
ED
BY
PA
CE
AT
THE
TIM
E O
F D
ISP
EN
SIN
G.
OTH
ER
PR
ES
CR
IPTI
ON
CO
VE
RA
GE
IDE
NTI
FIE
D
OTH
ER
PR
ES
CR
IPTI
ON
CO
VE
RA
GE
IDE
NTI
FIE
D
56
TABLE 4.4PART D CARDHOLDER ENROLLMENT, PARTICIPATION, AND EXPENDITURES
JANUARY - DECEMBER 2013
PAGE 1
PACE PACENET TOTAL
Part D, Auto-Enrolled 45,560 53,688 98,364Part D, Not Auto-Enrolled 59,172 111,942 168,268Not Enrolled in Part D 14,759 30,158 44,300Total PACE/PACENET Enrolled 119,491 195,788 310,932
Part D, Auto-Enrolled 39,717 48,781 87,761Part D, Not Auto-Enrolled 44,640 89,174 131,988Not Enrolled in Part D 9,939 16,574 26,194Total Participating Cardholders 94,296 154,529 245,943
Part D, Auto-Enrolled 1,686,063 2,152,657 3,838,720Part D, Not Auto-Enrolled 1,582,563 3,053,876 4,636,439Not Enrolled in Part D 403,840 569,518 973,358Total Claims 3,672,466 5,776,051 9,448,517
Part D, Auto-Enrolled 37.01 40.10 39.03Part D, Not Auto-Enrolled 26.75 27.28 27.55Not Enrolled in Part D 27.36 18.88 21.97All PACE/PACENET Enrolled 30.73 29.50 30.39
Part D, Auto-Enrolled $26,076,055 $32,532,218 $58,608,273Part D, Not Auto-Enrolled $21,879,818 $54,371,017 $76,250,835Not Enrolled in Part D $24,211,124 $29,264,599 $53,475,722All PACE/PACENET Enrolled $72,166,997 $116,167,833 $188,334,830
Part D, Auto-Enrolled $15.47 $15.11 $15.27Part D, Not Auto-Enrolled $13.83 $17.80 $16.45Not Enrolled in Part D $59.95 $51.38 $54.94All PACE/PACENET Enrolled $19.65 $20.11 $19.93
Part D, Auto-Enrolled $7,453,553 $22,121,525 $29,575,078Part D, Not Auto-Enrolled $8,052,553 $26,760,909 $34,813,462Not Enrolled in Part D $2,538,481 $7,525,534 $10,064,014All PACE/PACENET Enrolled $18,044,587 $56,407,968 $74,452,554
Part D, Auto-Enrolled $4.42 $10.28 $7.70Part D, Not Auto-Enrolled $5.09 $8.76 $7.51Not Enrolled in Part D $6.29 $13.21 $10.34All PACE/PACENET Enrolled $4.91 $9.77 $7.88
Part D, Auto-Enrolled $70,606,731 $85,434,894 $156,041,624Part D, Not Auto-Enrolled $75,635,697 $155,868,830 $231,504,527Not Enrolled in Part D $1,372,427 $3,378,358 $4,750,785All PACE/PACENET Enrolled $147,614,854 $244,682,082 $392,296,936
Total Cardholder Expenditures
Cardholder Share Per Claim
TPL Share
State Share Expenditures
State Share Per Claim
Enrolled Cardholders
Participating Cardholders
Claims
Claims Per Enrollee
57
TABLE 4.4PART D CARDHOLDER ENROLLMENT, PARTICIPATION, AND EXPENDITURES
JANUARY - DECEMBER 2013
PAGE 2
PACE PACENET TOTAL
Part D, Auto-Enrolled $41.88 $39.69 $40.65Part D, Not Auto-Enrolled $47.79 $51.04 $49.93Not Enrolled in Part D $3.40 $5.93 $4.88All PACE/PACENET Enrolled $40.20 $42.36 $41.52
Part D, Auto-Enrolled $104,136,339 $140,088,637 $244,224,975Part D, Not Auto-Enrolled $105,568,068 $237,000,756 $342,568,823Not Enrolled in Part D $28,122,031 $40,168,491 $68,290,522All PACE/PACENET Enrolled $237,826,438 $417,257,883 $655,084,321
Full LIS 20,879 5,220 25,955Partial LIS 3,186 3,319 6,451No LIS 21,495 45,149 65,958Total Auto-Enrolled Cardholders 45,560 53,688 98,364
Part D LIS Status Among Other Part D EnrolledFull LIS 30,044 11,823 41,142Partial LIS 4,119 7,705 11,635No LIS 25,009 92,414 115,491Total Other Part D Enrolled Cardholders 59,172 111,942 168,268
Notes: Auto-enrolled cardholders include individuals who were auto-enrolled by PACE/PACENET into Part D plans for 2013. The expenditure totals shown are based only on claims that were recorded in the PACE/PACENET claim adjudication system. There may be additional prescription expenditures that were not submitted to PACE/PACENET.
Total Expenditures (State, Cardholder, TPL)
Part D LIS Status Among Auto-Enrolled
TPL Share Per Claim
58
TOTA
L D
RU
G S
PE
ND
CA
TEG
OR
YP
AR
T D
AN
DLI
S S
TATU
STO
TAL
EN
RO
LLE
DTO
TAL
CLA
IMS
TOTA
L D
RU
G S
PE
ND
TOTA
L S
TATE
SH
AR
E
TOTA
L C
AR
DH
OLD
ER
S
HA
RE
TOTA
L TP
L S
HA
RE
$0N
O P
AR
T D
18,1
800
$0$0
$0$0
PA
RT
D-L
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,018
0$0
$0$0
$0P
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26,7
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$0$0
$0$0
TOTA
L64
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$0$0
$0
$0.0
1-$3
25.0
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AR
T D
7,57
166
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$947
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$297
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$592
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$57,
969
PA
RT
D-L
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131,
000
$1,8
91,0
48$2
52,7
34$4
55,1
35$1
,183
,178
PA
RT
D-N
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,108
319,
055
$4,3
65,5
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16,0
93$2
,520
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$1,0
29,4
51TO
TAL
51,7
5851
6,80
0$7
,204
,350
$1,3
66,4
38$3
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$2,2
70,5
98
$325
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$2,9
70.0
0N
O P
AR
T D
11,1
0836
5,85
5$1
4,71
8,11
5$9
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$3,7
82,2
17$1
,249
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PA
RT
D-L
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1,06
7,86
0$4
2,96
4,71
3$5
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$4,0
49,8
92$3
3,51
4,61
5P
AR
T D
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LIS
76,0
082,
587,
313
$102
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$23,
833,
269
$21,
201,
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$57,
501,
694
TOTA
L11
9,09
84,
021,
028
$160
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$38,
919,
887
$29,
033,
155
$92,
265,
794
> $2
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NO
PA
RT
D7,
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548,
312
$53,
174,
316
$43,
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D-L
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1,18
6,12
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4,14
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6$5
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$88,
176,
763
PA
RT
D-N
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IS48
,527
3,17
6,25
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26,5
15,5
60$9
0,40
7,99
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0,48
3,77
4$2
05,6
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TAL
75,0
874,
910,
689
$487
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$148
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$41,
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$297
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$2,9
70.0
1-$6
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$6,9
54.5
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O P
AR
T D
5,33
932
8,73
3$2
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9,05
2,24
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$1,8
76,9
87P
AR
T D
-LIS
14,4
4084
8,81
3$6
5,32
7,78
2$7
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$3,8
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4,01
5,57
2P
AR
T D
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34,6
422,
027,
522
$156
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$47,
319,
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$19,
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074,
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TOTA
L54
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3,20
5,06
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46,6
41,8
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3,80
9,73
3$2
6,86
5,10
7$1
45,9
66,9
69
> $6
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$6,9
54.5
2*N
O P
AR
T D
2,39
121
9,57
9$2
8,83
1,05
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4,44
4,05
5$2
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82,9
98P
AR
T D
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4,39
033
7,31
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2,64
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AR
T D
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13,8
851,
148,
728
$169
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$43,
088,
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$10,
907,
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$115
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TOTA
L20
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1,70
5,62
1$2
41,0
19,3
27$7
4,23
8,77
2$1
4,98
6,98
0$1
51,7
93,5
76
TOTA
LN
O P
AR
T D
44,5
8998
0,91
2$6
8,84
0,14
9$5
3,48
0,32
2$1
0,09
2,38
8$5
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PA
RT
D-L
IS84
,909
2,38
4,98
7$1
52,8
27,0
19$1
9,79
7,15
6$1
0,15
5,30
7$1
22,8
74,5
56P
AR
T D
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LIS
181,
434
6,08
2,61
8$4
33,4
17,1
53$1
15,0
57,3
52$5
4,20
4,85
9$2
64,1
54,9
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TAL
310,
932
9,44
8,51
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55,0
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21$1
88,3
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30$7
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96,9
36
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6,95
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5055606570758085
RCENT
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ATES
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198
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12/9
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12/9
412
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12/9
612
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12/0
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12/0
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PER
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: PD
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LY�COST�CONTA
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NE
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VE
STI
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OF
FRA
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JULY
199
0--F
DA
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AN
GE
BO
OK
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CO
ME
S S
TAN
DA
RD
FO
R G
EN
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STI
TUTI
ON
IN P
A
JULY
199
1--P
AC
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AR
DH
OLD
ER
CO
PA
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STE
D T
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6.00
DEC
EMB
ER 1
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EN
DM
EN
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PA
CE
LA
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EQ
UIR
ING
GE
NE
RIC
SU
BS
TITU
TIO
N O
N O
RA
L R
XS
X
60
SECTION 5
COUNTY DATA
61
62
PA
GE
1
NU
MB
ER
OF
NU
MB
ER
OF
P
AC
EP
AC
EN
ET
TOTA
LE
NR
OLL
ED
EN
RO
LLE
DN
UM
BE
R%
OF
PA
RTI
CIP
ATI
NG
NU
MB
ER
OF
STA
TEP
AC
EP
AC
EN
ET
PA
CE
PA
CE
NE
TC
OU
NTY
CA
RD
HO
LDE
RS
CA
RD
HO
LDE
RS
EN
RO
LLE
D*
TOTA
LC
AR
DH
OLD
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SP
RO
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ER
SS
HA
RE
CLA
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CLA
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STA
TE S
HA
RE
STA
TE S
HA
RE
PE
NN
SY
LVA
NIA
119,
491
195,
788
310,
932
100.
024
5,94
32,
997
78.7
$188
,334
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3,67
2,46
65,
776,
051
$72,
166,
997
$116
,167
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AD
AM
S
919
1,53
22,
406
0.8
1,96
616
46.3
$1,1
51,3
8731
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50,4
80$4
24,3
62$7
27,0
25A
LLE
GH
EN
Y
11,1
4317
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28,5
379.
222
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284
97.5
$17,
823,
303
318,
644
494,
480
$6,9
49,0
36$1
0,87
4,26
7A
RM
STR
ON
G
819
1,38
82,
173
0.7
1,73
817
32.5
$1,2
96,8
3324
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37,4
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98,1
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98,7
14B
EA
VE
R
1,79
93,
707
5,42
81.
74,
334
4074
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,373
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51,4
7710
3,98
5$1
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$2,3
13,5
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ED
FOR
D
930
1,48
22,
388
0.8
1,90
015
16.2
$1,7
94,9
7830
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47,8
90$6
62,9
15$1
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BE
RK
S
2,97
75,
926
8,77
62.
86,
938
7076
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89,7
8216
9,64
5$1
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$2,9
32,0
38B
LAIR
1,
808
3,28
05,
018
1.6
3,94
642
76.6
$3,4
33,7
3253
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97,3
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$2,2
04,8
59B
RA
DFO
RD
88
71,
334
2,19
00.
71,
690
1527
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71,7
4025
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38,6
11$3
46,3
64$6
25,3
76B
UC
KS
3,
135
5,64
18,
649
2.8
6,86
913
991
.2$7
,694
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96,7
3916
3,22
9$3
,099
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$4,5
94,4
49B
UTL
ER
1,
486
2,79
94,
227
1.4
3,35
442
58.0
$2,7
42,9
2446
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82,0
92$1
,007
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$1,7
34,9
68
CA
MB
RIA
2,
314
3,89
46,
137
2.0
4,74
938
68.0
$4,2
80,8
4374
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108,
995
$1,7
27,0
20$2
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CA
ME
RO
N
5316
721
90.
117
12
52.7
$110
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1,74
25,
392
$14,
136
$96,
553
CA
RB
ON
1,
002
1,64
22,
594
0.8
2,06
914
52.8
$1,3
33,8
2333
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48,6
36$4
91,4
44$8
42,3
80C
EN
TRE
83
41,
557
2,35
90.
81,
872
3067
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76,2
0627
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48,3
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12,8
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63,3
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STE
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2,05
93,
383
5,36
71.
74,
305
9886
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,839
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63,5
9996
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CLA
RIO
N
487
1,01
21,
473
0.5
1,17
013
23.4
$958
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15,0
7930
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$299
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$659
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CLE
AR
FIE
LD
1,15
62,
237
3,34
71.
12,
660
1746
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37,3
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$631
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$1,1
70,1
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LIN
TON
56
01,
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1,55
20.
51,
250
854
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01,5
0520
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34,4
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30,1
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MB
IA
1,06
31,
827
2,85
90.
92,
305
1559
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36,4
5955
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$441
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$993
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CR
AW
FOR
D
1,03
52,
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2,99
91.
02,
331
2136
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30,0
1553
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$548
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$1,0
33,6
87
CU
MB
ER
LAN
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1,58
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4,58
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53,
688
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47,9
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04,8
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AU
PH
IN
1,77
12,
902
4,60
41.
53,
649
5986
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,246
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52,6
5984
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$761
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$1,4
85,2
97D
ELA
WA
RE
3,
459
5,20
68,
551
2.8
6,69
314
099
.5$6
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100,
765
146,
310
$2,9
47,9
54$3
,786
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ELK
36
887
51,
226
0.4
1,03
49
44.3
$743
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11,6
3429
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$223
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$520
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ER
IE
2,39
54,
630
6,92
82.
25,
440
5980
.0$3
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71,4
4813
3,12
0$1
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$2,4
09,9
45
FAY
ETT
E
2,15
93,
477
5,55
61.
84,
405
3952
.1$4
,442
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66,0
4810
2,43
1$1
,758
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$2,6
83,8
98FO
RE
ST
8217
425
00.
118
62
0.0
$128
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2,40
74,
862
$41,
308
$86,
885
FRA
NK
LIN
1,
226
2,13
63,
318
1.1
2,63
926
59.7
$1,6
89,3
0041
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71,6
01$5
96,5
30$1
,092
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FULT
ON
18
432
049
50.
239
23
0.0
$234
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6,04
111
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$77,
838
$156
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GR
EE
NE
39
055
192
50.
374
39
33.2
$527
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13,2
9317
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$260
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$267
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PO
PU
LATI
ON
TA
BL
E 5
.1N
UM
BE
R A
ND
PE
RC
EN
T O
F P
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PA
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AR
DH
OL
DE
RS
AN
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UM
BE
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RO
VID
ER
S B
Y C
OU
NT
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NU
AR
Y -
DE
CE
MB
ER
201
3
NU
MB
ER
OF
% U
RB
AN
63
PA
GE
2
NU
MB
ER
OF
NU
MB
ER
OF
P
AC
EP
AC
EN
ET
TOTA
LE
NR
OLL
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EN
RO
LLE
DN
UM
BE
R%
OF
PA
RTI
CIP
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NU
MB
ER
OF
STA
TEP
AC
EP
AC
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ET
PA
CE
PA
CE
NE
TC
OU
NTY
CA
RD
HO
LDE
RS
CA
RD
HO
LDE
RS
EN
RO
LLE
D*
TOTA
LC
AR
DH
OLD
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SP
RO
VID
ER
SS
HA
RE
CLA
IMS
CLA
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STA
TE S
HA
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STA
TE S
HA
RE
PO
PU
LATI
ON
TA
BL
E 5
.1N
UM
BE
R A
ND
PE
RC
EN
T O
F P
AC
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ND
PA
CE
NE
T C
AR
DH
OL
DE
RS
AN
D N
UM
BE
R O
F P
RO
VID
ER
S B
Y C
OU
NT
YJA
NU
AR
Y -
DE
CE
MB
ER
201
3
NU
MB
ER
OF
% U
RB
AN
HU
NTI
NG
DO
N
653
1,15
51,
777
0.6
1,42
79
31.3
$945
,952
19,5
0435
,146
$322
,499
$623
,453
IND
IAN
A
928
1,66
92,
555
0.8
1,97
818
39.9
$1,4
48,2
9630
,372
46,8
37$6
23,6
51$8
24,6
46JE
FFE
RS
ON
69
91,
311
1,97
70.
61,
627
1038
.5$1
,438
,389
24,1
1444
,007
$504
,119
$934
,270
JUN
IATA
31
561
191
30.
376
15
17.8
$473
,021
10,8
7120
,629
$142
,258
$330
,764
LAC
KA
WA
NN
A
3,64
04,
895
8,42
42.
76,
981
7783
.7$5
,737
,999
130,
555
162,
498
$2,6
71,9
89$3
,066
,010
LAN
CA
STE
R
3,15
26,
821
9,82
13.
27,
839
104
78.7
$4,7
64,9
0310
1,63
422
1,22
9$1
,425
,705
$3,3
39,1
98LA
WR
EN
CE
1,
281
2,52
33,
753
1.2
3,03
324
59.7
$2,2
75,7
6739
,145
71,3
34$6
80,4
24$1
,595
,343
LEB
AN
ON
1,
169
2,18
03,
305
1.1
2,53
923
73.4
$1,3
38,9
8437
,255
64,1
66$4
83,9
49$8
55,0
35LE
HIG
H
2,33
44,
112
6,36
62.
05,
105
6992
.1$3
,395
,075
73,7
7912
3,55
3$1
,231
,255
$2,1
63,8
20LU
ZER
NE
6,
134
7,99
313
,935
4.5
11,4
3291
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$8,5
85,9
0823
2,95
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9,59
4$3
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$4,8
98,2
66
LYC
OM
ING
1,
420
2,50
63,
862
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3,10
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18,4
49$1
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MC
KE
AN
49
296
01,
434
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1,12
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36.5
$662
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16,8
5831
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$224
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$437
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ME
RC
ER
1,
273
2,89
54,
118
1.3
3,27
330
55.5
$2,8
45,8
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MIF
FLIN
81
71,
567
2,34
60.
82,
001
1149
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,147
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34,4
9558
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$339
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$807
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MO
NR
OE
1,
301
2,07
03,
315
1.1
2,54
137
61.7
$1,7
48,6
5133
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72$5
96,4
55$1
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MO
NTG
OM
ER
Y
4,16
16,
896
10,9
183.
58,
663
192
97.1
$8,6
41,7
1712
6,13
819
6,72
0$3
,263
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$5,3
78,1
69M
ON
TOU
R
192
341
517
0.2
412
746
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73,1
827,
002
10,6
73$7
4,09
6$1
99,0
87N
OR
THA
MP
TON
2,
674
4,99
87,
573
2.4
6,23
271
87.2
$4,2
11,6
3885
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157,
952
$1,4
52,4
87$2
,759
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2,77
44,
603
1.5
3,79
723
65.1
$2,4
22,7
2974
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36$9
88,5
59$1
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PE
RR
Y
458
806
1,23
80.
41,
011
811
.5$6
91,7
7614
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23,6
74$2
24,4
34$4
67,3
42
PH
ILA
DE
LPH
IA
15,4
5616
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31,3
3710
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430
100.
0$2
0,53
8,28
437
7,93
441
7,85
2$1
0,03
6,15
5$1
0,50
2,12
9P
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44
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11,
178
0.4
876
1129
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88,7
9310
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18,2
20$2
00,1
73$3
88,6
19P
OTT
ER
24
144
067
50.
249
44
0.0
$299
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7,09
713
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$104
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$194
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SC
HU
YLK
ILL
3,11
84,
272
7,29
22.
35,
944
3463
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,575
,255
108,
521
138,
066
$1,4
65,9
87$2
,109
,269
SN
YD
ER
40
382
41,
200
0.4
1,00
613
33.2
$603
,010
14,0
7227
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$208
,656
$394
,354
SO
ME
RS
ET
1,42
82,
374
3,72
91.
23,
017
1729
.2$2
,893
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49,7
8271
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$1,1
40,6
43$1
,752
,796
SU
LLIV
AN
11
315
125
90.
120
22
0.0
$107
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3,51
94,
006
$49,
543
$57,
974
SU
SQ
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HA
NN
A
563
783
1,32
20.
41,
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816
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94,6
5116
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05$2
55,4
64$4
39,1
87TI
OG
A
583
952
1,50
70.
51,
153
109.
9$7
70,7
2217
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25,3
84$2
88,7
24$4
81,9
98U
NIO
N
416
781
1,18
10.
41,
003
857
.2$5
75,8
5416
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25,0
68$2
06,6
70$3
69,1
83
NO
RTH
UM
BE
RLA
ND
1
,901
64
PA
GE
3
NU
MB
ER
OF
NU
MB
ER
OF
P
AC
EP
AC
EN
ET
TOTA
LE
NR
OLL
ED
EN
RO
LLE
DN
UM
BE
R%
OF
PA
RTI
CIP
ATI
NG
NU
MB
ER
OF
STA
TEP
AC
EP
AC
EN
ET
PA
CE
PA
CE
NE
TC
OU
NTY
CA
RD
HO
LDE
RS
CA
RD
HO
LDE
RS
EN
RO
LLE
D*
TOTA
LC
AR
DH
OLD
ER
SP
RO
VID
ER
SS
HA
RE
CLA
IMS
CLA
IMS
STA
TE S
HA
RE
STA
TE S
HA
RE
PO
PU
LATI
ON
TA
BL
E 5
.1N
UM
BE
R A
ND
PE
RC
EN
T O
F P
AC
E A
ND
PA
CE
NE
T C
AR
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DE
RS
AN
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UM
BE
R O
F P
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VID
ER
S B
Y C
OU
NT
YJA
NU
AR
Y -
DE
CE
MB
ER
201
3
NU
MB
ER
OF
% U
RB
AN
VE
NA
NG
O
564
1,19
21,
731
0.6
1,37
413
45.2
$1,0
63,2
9515
,631
33,2
22$3
59,5
45$7
03,7
49W
AR
RE
N
368
835
1,18
70.
489
311
45.0
$591
,805
8,79
019
,327
$191
,652
$400
,153
WA
SH
ING
TON
2,
040
3,84
75,
807
1.9
4,58
445
69.2
$3,2
94,0
2258
,895
105,
981
$1,1
16,6
54$2
,177
,368
WA
YN
E
694
1,03
61,
700
0.5
1,34
311
11.9
$953
,130
22,4
1431
,164
$435
,621
$517
,508
WE
STM
OR
ELA
ND
4,
412
7,92
712
,176
3.9
9,90
785
74.6
$7,2
12,7
7813
0,49
922
1,84
3$2
,606
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$4,6
06,4
66
WY
OM
ING
36
157
592
80.
372
010
16.5
$449
,781
11,5
1117
,708
$159
,792
$289
,989
YO
RK
3,
205
6,78
19,
833
3.2
7,79
682
75.3
$4,6
40,0
8999
,214
203,
727
$1,4
17,9
14$3
,222
,175
SO
UR
CE
: P
DA
/CA
RD
HO
LDE
R F
ILE
; CLA
IMS
HIS
TOR
YN
OTE
: D
ATA
INC
LUD
E O
RIG
INA
L, P
AID
CLA
IMS
BY
DA
TE O
F S
ER
VIC
E.
* TO
TAL
NU
MB
ER
EN
RO
LLE
D IS
AN
UN
DU
PLI
CA
TED
CO
UN
T O
F C
AR
DH
OLD
ER
S, S
OM
E O
F W
HO
M M
AY
HA
VE
BE
EN
EN
RO
LLE
D IN
BO
TH P
RO
GR
AM
S D
UR
ING
TH
E Y
EA
R.
65
PE
NN
SY
LV
AN
IA S
EN
IOR
PA
RT
ICIP
AT
ING
EN
RO
LL
ED
CIT
IZE
N P
OP
UL
AT
ION
CA
RD
HO
LD
ER
SC
AR
DH
OL
DE
RS
N =
2,0
91,3
30N
= 2
45,9
43N
= 3
10,9
32
PA
CE
AN
D P
AC
EN
ET
CA
RD
HO
LD
ER
, C
LA
IM,
AN
D P
RO
VID
ER
IN
FO
RM
AT
ION
BY
CO
UN
TY
TY
PE
(P
ER
CE
NT
OF
CO
UN
TY
PO
PU
LA
TIO
N L
IVIN
G I
N U
RB
AN
AR
EA
)J
AN
UA
RY
- D
EC
EM
BE
R 2
01
3
FIG
UR
E 5
.1
0.5%
2.9%
9.1%
22.4
%
55.9
%
9.2%
0.5%
3.7%
11.3
%
27.2
%48
.1%
9.2%
0.5%
3.7%
11.2
%
26.9
%47
.6%
10.1
%
TO
TA
L C
LA
IMS
PE
NN
SY
LV
AN
IA C
OU
NT
IES
PA
CE
PR
OV
IDE
RS
N =
9,4
48,5
17N
= 6
7N
= 2
,997
SO
UR
CE
: P
DA
/CA
RD
HO
LDE
R F
ILE
, CLA
IMS
HIS
TOR
Y, A
ND
201
3 P
OP
ULA
TIO
N E
STI
MA
TES
NO
TE:
DA
TA IN
CLU
DE
OR
IGIN
AL,
PA
ID C
LAIM
S B
Y D
ATE
OF
SE
RV
ICE
.
0.6%
3.8%
11.6
%
27.3
%48
.4%
8.4%
6.0%
11.9
% 26.9
%29
.9%
23.9
%1.
5%0.
4%2.
7%7.
9%
19.7
%
55.1
%
14.3
%
0.00
% U
rban
0.01
-25.
00%
Urb
an25
.01-
50.0
0% U
rban
50.0
1-75
.00%
Urb
an75
.01-
99.9
9% U
rban
100.
00%
Urb
an
66
FIG
UR
E 5
.2P
ER
CE
NT
OF
EL
DE
RLY
EN
RO
LL
ED
IN
PA
CE
/PA
CE
NE
T A
ND
PE
RC
EN
T U
RB
AN
PO
PU
LA
TIO
N B
Y C
OU
NT
Y(S
TAT
EW
IDE
PE
RC
EN
T E
NR
OL
LE
D =
14.
9%)
JAN
UA
RY
-DE
CE
MB
ER
201
3
0.00
% U
rban
0.01
-25.
00%
Urb
an25
.01-
50.0
0% U
rban
PE
RC
EN
T U
RB
AN
PO
PU
LATI
ON
50.0
1-75
.00%
Urb
an75
.01-
99.9
9% U
rban
100.
00%
Urb
an
CO
UN
TIES
WIT
H H
IGH
EST
PER
CEN
T E
NR
OLL
ED
: SC
HU
YLKI
LL (2
6.3%
), N
OR
THU
MB
ERLA
ND
(25.
3%),
AN
D M
IFFL
IN (2
5.1%
)C
OU
NTI
ES W
ITH
LO
WES
T P
ER
CEN
T E
NR
OLL
ED: C
HE
STER
(7.4
%),
MO
NTG
OM
ER
Y (8
.4%
), A
ND
BU
CK
S (8
.5%
)
SO
UR
CES
: C
AR
DH
OLD
ER F
ILE
, CLA
IMS
HIS
TOR
Y, A
ND
201
3 IN
TER
CEN
SAL
ES
TIM
ATE
S
67
68
SECTION 6
PROVIDER DATA
69
70
PR
OV
IDE
RTY
PE
NO
.%
NO
.%
NO
.%
NO
.%
NO
.%
IND
EP
EN
DE
NT
895
30.3
176,
397
15.8
51,8
724.
788
5,83
779
.51,
114,
106
100.
0P
HA
RM
AC
IES
DIS
PE
NS
ING
210.
785
35.6
2811
.712
652
.723
910
0.0
PH
YS
ICIA
NS
INS
TITU
TIO
NA
L26
0.9
1,09
67.
474
55.
013
,026
87.6
14,8
6710
0.0
PH
AR
MA
CIE
S
CH
AIN
1,84
162
.333
1,33
915
.110
6,11
54.
81,
758,
511
80.1
2,19
5,96
510
0.0
PH
AR
MA
CIE
S
NU
RS
ING
HO
ME
145
4.9
44,5
9613
.512
,704
3.9
271,
985
82.6
329,
285
100.
0P
HA
RM
AC
IES
MA
IL O
RD
ER
260.
93,
959
16.2
1,22
95.
019
,203
78.7
24,3
9110
0.0
PH
AR
MA
CIE
S
TOTA
L2,
954
100.
055
7,47
215
.217
2,69
34.
72,
948,
688
80.2
3,67
8,85
310
0.0
SO
UR
CE
: PD
A/P
S-0
-100
, CLA
IMS
HIS
TOR
Y N
OTE
: DA
TA IN
CLU
DE
OR
IGIN
AL,
PA
ID C
LAIM
S B
Y D
ATE
OF
PA
YM
EN
T, E
XC
LUD
E P
AC
EN
ET
CLA
IMS
.
TA
BL
E 6
.1P
AC
E C
LA
IMS
BY
PR
OD
UC
T A
ND
PR
OV
IDE
R T
YP
EJA
NU
AR
Y -
DE
CE
MB
ER
201
3
PR
OV
IDE
RS
BR
AN
D S
ING
LE-S
OU
RC
EB
RA
ND
MU
LTI-S
OU
RC
E
G
EN
ER
IC
TO
TAL
CLA
IMS
71
IND
EP
EN
DE
NT
$12,
645,
248
55.0
$71.
69$3
,192
,675
13.9
$61.
55$7
,171
,490
31.2
$8.1
0$2
3,00
9,41
310
0.0
$20.
65P
HA
RM
AC
IES
DIS
PE
NS
ING
$30,
911
73.4
$363
.66
$9,0
3621
.4$3
22.7
2$2
,183
5.2
$17.
33$4
2,13
010
0.0
$176
.28
PH
YS
ICIA
NS
INS
TITU
TIO
NA
L$7
1,61
932
.5$6
5.35
$37,
953
17.2
$50.
94$1
10,9
2450
.3$8
.52
$220
,496
100.
0$1
4.83
PH
AR
MA
CIE
S
CH
AIN
$23,
828,
021
55.7
$71.
91$6
,286
,212
14.7
$59.
24$1
2,68
9,44
329
.6$7
.22
$42,
803,
676
100.
0$1
9.49
PH
AR
MA
CIE
S
NU
RS
ING
HO
ME
$2,6
96,0
3253
.2$6
0.45
$595
,746
11.8
$46.
89$1
,778
,213
35.1
$6.5
4$5
,069
,990
100.
0$1
5.40
PH
AR
MA
CIE
S
MA
IL O
RD
ER
$859
,533
85.9
$217
.11
$73,
925
7.4
$60.
15$6
7,36
26.
7$3
.51
$1,0
00,8
2010
0.0
$41.
03P
HA
RM
AC
IES
TOTA
L$4
0,13
1,36
355
.6$7
1.99
$10,
195,
547
14.1
$59.
04$2
1,81
9,61
430
.2$7
.40
$72,
146,
525
100.
0$1
9.61
SO
UR
CE
: PD
A/P
S-0
-100
, CLA
IMS
HIS
TOR
Y N
OTE
: DA
TA IN
CLU
DE
OR
IGIN
AL,
PA
ID C
LAIM
S B
Y D
ATE
OF
PA
YM
EN
T, E
XC
LUD
E P
AC
EN
ET
CLA
IMS
.
BR
AN
D S
ING
LE-S
OU
RC
E
EX
PE
ND
ITU
RE
%
TA
BL
E 6
.2P
AC
E E
XP
EN
DIT
UR
ES
AN
D A
VE
RA
GE
ST
AT
E S
HA
RE
BY
PR
OD
UC
T A
ND
PR
OV
IDE
R T
YP
EJA
NU
AR
Y -
DE
CE
MB
ER
201
3
PR
OV
IDE
R
TYP
E
BR
AN
D M
ULT
I-SO
UR
CE
GE
NE
RIC
TOTA
L, A
LL P
RO
DU
CTS
EX
PE
ND
ITU
RE
%
AV
ER
AG
E
STA
TE
SH
AR
E
AV
ER
AG
E
STA
TE
SH
AR
E
AV
ER
AG
E
STA
TE
SH
AR
E
AV
ER
AG
E
STA
TE
SH
AR
EE
XP
EN
DIT
UR
E
%E
XP
EN
DIT
UR
E
%
72
TA
BL
E 6
.3P
AC
EN
ET
CL
AIM
S A
ND
EX
PE
ND
ITU
RE
S B
Y P
RO
VID
ER
TY
PE
JAN
UA
RY
- D
EC
EM
BE
R 2
013
CO
PA
IDTO
TAL
CA
RD
HO
LDE
RO
THE
R P
AY
ER
STA
TE S
HA
RE
TOTA
LC
LAIM
SC
LAIM
SE
XP
EN
DIT
UR
ES
EX
PE
ND
ITU
RE
SE
XP
EN
DIT
UR
ES
EX
PE
ND
ITU
RE
S
IND
EP
EN
DE
NT
PH
AR
MA
CIE
S1,
000
914
341,
426
1,27
8,40
91,
619,
835
28.1
$15,
635,
871
$63,
353,
128
$33,
434,
697
$112
,423
,696
27.1
DIS
PE
NS
ING
P
HY
SIC
IAN
S94
2929
550
579
0.0
$7,7
00$1
,107
,862
$212
,544
$1,3
28,1
060.
3
INS
TITU
TIO
NA
L P
HA
RM
AC
IES
3027
2,18
712
,320
14,5
070.
3$1
14,6
15$7
74,3
38$3
67,2
54$1
,256
,207
0.3
CH
AIN
P
HA
RM
AC
IES
1,86
31,
849
716,
336
2,83
0,12
53,
546,
461
61.4
$35,
288,
384
$149
,205
,622
$71,
720,
627
$256
,214
,633
61.8
NU
RS
ING
H
OM
E
PH
AR
MA
CIE
S15
114
510
4,01
440
5,55
050
9,56
48.
8$4
,125
,842
$16,
213,
896
$7,5
19,1
55$2
7,85
8,89
36.
7
MA
IL O
RD
ER
P
HA
RM
AC
IES
4027
4,46
279
,193
83,6
551.
4$1
,185
,772
$12,
023,
950
$2,5
10,7
51$1
5,72
0,47
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73
TABLE 6.4
PACENET CLAIMS VOLUME BY PHASE OF COVERAGE1, PRODUCT TYPE, AND PROVIDER TYPEJANUARY - DECEMBER 2013
PROVIDER TYPE NO. % NO. % NO. % NO. %
INDEPENDENT PHARMACIES 14,278 4.2 6,233 1.8 320,915 94.0 341,426 100.0
DISPENSING PHYSICIANS 2 6.9 1 3.4 26 89.7 29 100.0
INSTITUTIONAL PHARMACIES 73 3.3 90 4.1 2,024 92.5 2,187 100.0
CHAIN PHARMACIES 26,926 3.8 15,154 2.1 674,256 94.1 716,336 100.0
NURSING HOME PHARMACIES 4,632 4.5 2,050 2.0 97,332 93.6 104,014 100.0
MAIL ORDER PHARMACIES 349 7.8 91 2.0 4,022 90.1 4,462 100.0
TOTAL (ALL PROVIDERS) 46,260 4.0 23,619 2.0 1,098,575 94.0 1,168,454 100.0
PROVIDER TYPE NO. % NO. % NO. % NO. %
INDEPENDENT PHARMACIES 248,639 19.4 65,115 5.1 964,655 75.5 1,278,409 100.0
DISPENSING PHYSICIANS 304 55.3 35 6.4 211 38.4 550 100.0
INSTITUTIONAL PHARMACIES 1,429 11.6 717 5.8 10,174 82.6 12,320 100.0
CHAIN PHARMACIES 539,428 19.1 147,660 5.2 2,143,037 75.7 2,830,125 100.0
NURSING HOME PHARMACIES 66,134 16.3 17,422 4.3 321,994 79.4 405,550 100.0
MAIL ORDER PHARMACIES 11,659 14.7 3,385 4.3 64,149 81.0 79,193 100.0
TOTAL (ALL PROVIDERS) 867,593 18.8 234,334 5.1 3,504,220 76.1 4,606,147 100.0
SOURCE: PDA/CLAIMS HISTORYNOTE: DATA INCLUDE ORIGINAL, PAID CLAIMS BY DATE OF PAYMENT.
THE DEDUCTIBLE. GENERIC UTILIZATION RATES MAY THEREFORE BE HIGHER IN THE DEDUCTIBLE PHASE
FOR WHICH THE TOTAL PRICE IS LESS THAN THE $8 OR $15 COPAY ARE NOT NECESSARILY SUBMITTED DURING THE COPAYMENT PHASE, BUT MAY BE SUBMITTED DURING THE DEDUCTIBLE PHASE TO SATISFY
DUE TO THE OVER-REPRESENTATION OF LOW-PRICED GENERIC CLAIMS.
1IN 2013, THE MONTHLY PACENET DEDUCTIBLE WAS CHANGED TO $36.57 TO COINCIDE WITH THE REGIONALMEDICARE PART D PREMIUM BENCHMARK. PACENET CARDHOLDERS WHO ARE NOT ENROLLED IN PART D ARE REQUIRED TO PAY THE BENCHMARK AMOUNT PRIOR TO ANY PACENET CLAIM COVERAGE. THE DEDUCT-IBLE AND COPAYMENT PHASES DIFFER IN THE TYPES OF CLAIMS SUBMITTED. LOW-PRICED PRESCRIPTIONS
TOTAL(ALL PRODUCTS)
SINGLE-SOURCE MULTI-SOURCE GENERIC (ALL PRODUCTS)BRAND BRAND TOTAL
DEDUCTIBLE PHASE CLAIMS
COPAYMENT PHASE CLAIMS
SINGLE-SOURCE MULTI-SOURCE GENERICBRAND BRAND
74
TABLE 6.5PACENET EXPENDITURES BY PHASE OF COVERAGE, PRODUCT TYPE, AND PROVIDER TYPE
JANUARY - DECEMBER 2013
PAGE 1
A. DEDUCTIBLE PHASE CLAIMS1
PROVIDER TYPE AMOUNT % AMOUNT % AMOUNT % AMOUNT %
INDEPENDENT PHARMACIESCARDHOLDER EXPENDITURES $376,935 15.5 $104,334 4.3 $1,956,883 80.3 $2,438,152 100.0OTHER PAYER EXPENDITURES $1,819,921 34.4 $345,007 6.5 $3,127,753 59.1 $5,292,682 100.0STATE SHARE EXPENDITURES $2,436 82.2 $98 3.3 $429 14.5 $2,962 100.0TOTAL EXPENDITURES $2,199,292 28.4 $449,438 5.8 $5,085,065 65.8 $7,733,795 100.0
DISPENSING PHYSICIANSCARDHOLDER EXPENDITURES $49 21.7 $11 4.9 $166 73.4 $226 100.0OTHER PAYER EXPENDITURES $930 76.3 $212 17.4 $77 6.3 $1,219 100.0STATE SHARE EXPENDITURES $0 – $0 – $0 – $0 –
TOTAL EXPENDITURES $979 67.8 $223 15.5 $243 16.8 $1,445 100.0
INSTITUTIONAL PHARMACIESCARDHOLDER EXPENDITURES $1,440 9.2 $909 5.8 $13,363 85.1 $15,713 100.0OTHER PAYER EXPENDITURES $34,986 69.7 $1,570 3.1 $13,669 27.2 $50,225 100.0STATE SHARE EXPENDITURES $4,729 99.3 $0 0.0 $35 0.7 $4,764 100.0TOTAL EXPENDITURES $41,155 58.2 $2,479 3.5 $27,067 38.3 $70,702 100.0
CHAIN PHARMACIESCARDHOLDER EXPENDITURES $747,809 14.1 $241,220 4.5 $4,322,271 81.4 $5,311,301 100.0OTHER PAYER EXPENDITURES $3,658,982 34.3 $716,921 6.7 $6,299,543 59.0 $10,675,446 100.0STATE SHARE EXPENDITURES $2,232 86.6 $6 0.2 $340 13.2 $2,577 100.0TOTAL EXPENDITURES $4,409,022 27.6 $958,147 6.0 $10,622,154 66.4 $15,989,324 100.0
NURSING HOME PHARMACIESCARDHOLDER EXPENDITURES $98,019 16.3 $25,949 4.3 $477,786 79.4 $601,755 100.0OTHER PAYER EXPENDITURES $522,043 32.0 $112,902 6.9 $994,185 61.0 $1,629,130 100.0STATE SHARE EXPENDITURES $2,073 65.3 $87 2.7 $1,017 32.0 $3,176 100.0TOTAL EXPENDITURES $622,135 27.9 $138,938 6.2 $1,472,988 65.9 $2,234,061 100.0
MAIL ORDER PHARMACIESCARDHOLDER EXPENDITURES $2,780 11.6 $1,092 4.6 $20,103 83.9 $23,974 100.0OTHER PAYER EXPENDITURES $320,211 81.7 $13,234 3.4 $58,493 14.9 $391,938 100.0STATE SHARE EXPENDITURES $164 100.0 $0 0.0 $0 0.0 $164 100.0TOTAL EXPENDITURES $323,154 77.7 $14,325 3.4 $78,596 18.9 $416,076 100.0
TOTAL (ALL PROVIDERS)CARDHOLDER EXPENDITURES $1,227,033 14.6 $373,515 4.5 $6,790,572 80.9 $8,391,120 100.0OTHER PAYER EXPENDITURES $6,357,073 35.2 $1,189,847 6.6 $10,493,719 58.2 $18,040,639 100.0STATE SHARE EXPENDITURES $11,633 85.3 $190 1.4 $1,821 13.4 $13,643 100.0TOTAL EXPENDITURES $7,595,738 28.7 $1,563,552 5.9 $17,286,113 65.4 $26,445,403 100.0
SOURCE: PDA/CLAIMS HISTORYNOTE: DATA INCLUDE ORIGINAL, PAID CLAIMS BY DATE OF PAYMENT.
1IN 2013, THE MONTHLY PACENET DEDUCTIBLE WAS CHANGED TO $36.57 TO COINCIDE WITH THE REGIONAL MEDICARE PART DBENCHMARK PREMIUM. STATE SHARE EXPENDITURES FOR DEDUCTIBLE CLAIMS ARE ONLY INCURRED FOR TRANSITION CLAIMS WHICH COMPLETE THE $36.57 MONTHLY DEDUCTIBLE ACCUMULATION. FOR THESE CLAIMS, THE CARDHOLDER PAYS
THE PRESCRIPTION.
BRAND BRANDSINGLE-SOURCE MULTI-SOURCE GENERIC ALL PRODUCTS
THE OUTSTANDING DEDUCTIBLE AMOUNT AND A COPAYMENT, WHILE PACENET COVERS THE REMAINING COST, IF ANY, OF
75
TABLE 6.5PACENET EXPENDITURES BY PHASE OF COVERAGE, PRODUCT TYPE, AND PROVIDER TYPE
JANUARY - DECEMBER 2013
PAGE 2
B. COPAYMENT PHASE CLAIMS
PROVIDER TYPE AMOUNT % AMOUNT % AMOUNT % AMOUNT %
INDEPENDENT PHARMACIESCARDHOLDER EXPENDITURES $5,173,353 39.2 $1,232,531 9.3 $6,791,836 51.5 $13,197,720 100.0OTHER PAYER EXPENDITURES $39,684,492 68.4 $6,050,218 10.4 $12,325,737 21.2 $58,060,447 100.0STATE SHARE EXPENDITURES $20,199,185 60.4 $4,296,728 12.9 $8,935,822 26.7 $33,431,735 100.0TOTAL EXPENDITURES $65,057,030 62.1 $11,579,477 11.1 $28,053,394 26.8 $104,689,901 100.0
DISPENSING PHYSICIANSCARDHOLDER EXPENDITURES $5,321 71.2 $797 10.7 $1,356 18.1 $7,474 100.0OTHER PAYER EXPENDITURES $1,046,369 94.6 $38,921 3.5 $21,352 1.9 $1,106,643 100.0STATE SHARE EXPENDITURES1 $197,019 92.7 $7,160 3.4 $8,364 3.9 $212,544 100.0TOTAL EXPENDITURES $1,248,710 94.1 $46,879 3.5 $31,072 2.3 $1,326,661 100.0
INSTITUTIONAL PHARMACIESCARDHOLDER EXPENDITURES $26,774 27.1 $10,568 10.7 $61,562 62.2 $98,903 100.0OTHER PAYER EXPENDITURES $561,670 77.6 $57,939 8.0 $104,504 14.4 $724,112 100.0STATE SHARE EXPENDITURES $215,582 59.5 $43,029 11.9 $103,878 28.7 $362,490 100.0TOTAL EXPENDITURES $804,026 67.8 $111,535 9.4 $269,944 22.8 $1,185,505 100.0
CHAIN PHARMACIESCARDHOLDER EXPENDITURES $11,689,561 39.0 $2,792,137 9.3 $15,495,386 51.7 $29,977,083 100.0OTHER PAYER EXPENDITURES $95,153,745 68.7 $14,428,742 10.4 $28,947,690 20.9 $138,530,176 100.0STATE SHARE EXPENDITURES $45,320,238 63.2 $9,205,960 12.8 $17,191,852 24.0 $71,718,050 100.0TOTAL EXPENDITURES $152,163,544 63.3 $26,426,838 11.0 $61,634,927 25.7 $240,225,309 100.0
NURSING HOME PHARMACIESCARDHOLDER EXPENDITURES $1,245,767 35.4 $293,290 8.3 $1,985,029 56.3 $3,524,087 100.0OTHER PAYER EXPENDITURES $9,041,494 62.0 $1,593,590 10.9 $3,949,682 27.1 $14,584,766 100.0STATE SHARE EXPENDITURES $4,253,077 56.6 $854,385 11.4 $2,408,517 32.1 $7,515,979 100.0TOTAL EXPENDITURES $14,540,338 56.7 $2,741,265 10.7 $8,343,228 32.6 $25,624,831 100.0
MAIL ORDER PHARMACIESCARDHOLDER EXPENDITURES $380,733 32.8 $89,736 7.7 $691,329 59.5 $1,161,798 100.0OTHER PAYER EXPENDITURES $8,668,187 74.5 $864,788 7.4 $2,099,036 18.1 $11,632,012 100.0STATE SHARE EXPENDITURES $2,104,861 83.8 $176,916 7.1 $228,810 9.1 $2,510,587 100.0TOTAL EXPENDITURES $11,153,781 72.9 $1,131,440 7.4 $3,019,175 19.7 $15,304,397 100.0
TOTAL (ALL PROVIDERS)CARDHOLDER EXPENDITURES $18,521,508 38.6 $4,419,059 9.2 $25,026,497 52.2 $47,967,064 100.0OTHER PAYER EXPENDITURES $154,155,957 68.6 $23,034,197 10.3 $47,448,002 21.1 $224,638,156 100.0STATE SHARE EXPENDITURES $72,289,963 62.5 $14,584,178 12.6 $28,877,243 25.0 $115,751,384 100.0TOTAL EXPENDITURES $244,967,428 63.1 $42,037,435 10.8 $101,351,741 26.1 $388,356,604 100.0
SOURCE: PDA/CLAIMS HISTORYNOTE: DATA INCLUDE ORIGINAL, PAID CLAIMS BY DATE OF PAYMENT.
THE OUTSTANDING DEDUCTIBLE AMOUNT AND A COPAYMENT, WHILE PACENET COVERS THE REMAINING COST, IF ANY, OFTHE PRESCRIPTION.
1IN 2013, THE MONTHLY PACENET DEDUCTIBLE WAS CHANGED TO $36.57 TO COINCIDE WITH THE REGIONAL MEDICARE PART D
BRAND BRANDSINGLE-SOURCE MULTI-SOURCE GENERIC ALL PRODUCTS
BENCHMARK PREMIUM. STATE SHARE EXPENDITURES FOR DEDUCTIBLE CLAIMS ARE ONLY INCURRED FOR TRANSITION CLAIMS WHICH COMPLETE THE $36.57 MONTHLY DEDUCTIBLE ACCUMULATION. FOR THESE CLAIMS, THE CARDHOLDER PAYS
76
TABLE 6.6AVERAGE CARDHOLDER AND STATE SHARE COST PER PACENET CLAIM
BY PHASE OF COVERAGE, PRODUCT TYPE, AND PROVIDER TYPEJANUARY - DECEMBER 2013
BRAND BRAND BRAND BRANDSINGLE- MULTI- SINGLE- MULTI-SOURCE SOURCE GENERIC TOTAL SOURCE SOURCE GENERIC TOTAL
INDEPENDENT PHARMACIESAVERAGE CARDHOLDER SHARE2 $26.40 $16.74 $6.10 $7.14 $20.81 $18.93 $7.04 $10.32AVERAGE OTHER PAYER SHARE $127.46 $55.35 $9.75 $15.50 $159.61 $92.92 $12.78 $45.42AVERAGE STATE SHARE $0.17 $0.02 $0.00 $0.01 $81.24 $65.99 $9.26 $26.15AVERAGE TOTAL RX COST $154.03 $72.11 $15.85 $22.65 $261.65 $177.83 $29.08 $81.89
DISPENSING PHYSICIANSAVERAGE CARDHOLDER SHARE2 $24.47 $11.16 $6.37 $7.78 $17.50 $22.78 $6.42 $13.59AVERAGE OTHER PAYER SHARE $464.93 $212.14 $2.96 $42.03 $3,442.00 $1,112.04 $101.20 $2,012.08AVERAGE STATE SHARE $0.00 $0.00 $0.00 $0.00 $648.09 $204.58 $39.64 $386.44AVERAGE TOTAL RX COST $489.39 $223.30 $9.33 $49.82 $4,107.60 $1,339.41 $147.26 $2,412.11
INSTITUTIONAL PHARMACIESAVERAGE CARDHOLDER SHARE2 $19.73 $10.10 $6.60 $7.18 $18.74 $14.74 $6.05 $8.03AVERAGE OTHER PAYER SHARE $479.26 $17.45 $6.75 $22.97 $393.05 $80.81 $10.27 $58.78AVERAGE STATE SHARE $64.78 $0.00 $0.02 $2.18 $150.86 $60.01 $10.21 $29.42AVERAGE TOTAL RX COST $563.77 $27.55 $13.37 $32.33 $562.65 $155.56 $26.53 $96.23
CHAIN PHARMACIESAVERAGE CARDHOLDER SHARE2 $27.77 $15.92 $6.41 $7.41 $21.67 $18.91 $7.23 $10.59AVERAGE OTHER PAYER SHARE $135.89 $47.31 $9.34 $14.90 $176.40 $97.72 $13.51 $48.95AVERAGE STATE SHARE $0.08 $0.00 $0.00 $0.00 $84.02 $62.35 $8.02 $25.34AVERAGE TOTAL RX COST $163.75 $63.23 $15.75 $22.32 $282.08 $178.97 $28.76 $84.88
NURSING HOME PHARMACIESAVERAGE CARDHOLDER SHARE2 $21.16 $12.66 $4.91 $5.79 $18.84 $16.83 $6.16 $8.69AVERAGE OTHER PAYER SHARE $112.70 $55.07 $10.21 $15.66 $136.71 $91.47 $12.27 $35.96AVERAGE STATE SHARE $0.45 $0.04 $0.01 $0.03 $64.31 $49.04 $7.48 $18.53AVERAGE TOTAL RX COST $134.31 $67.77 $15.13 $21.48 $219.86 $157.35 $25.91 $63.19
MAIL ORDER PHARMACIESAVERAGE CARDHOLDER SHARE2 $7.96 $12.00 $5.00 $5.37 $32.66 $26.51 $10.78 $14.67AVERAGE OTHER PAYER SHARE $917.51 $145.43 $14.54 $87.84 $743.48 $255.48 $32.72 $146.88AVERAGE STATE SHARE $0.47 $0.00 $0.00 $0.04 $180.54 $52.26 $3.57 $31.70AVERAGE TOTAL RX COST $925.94 $157.42 $19.54 $93.25 $956.67 $334.25 $47.07 $193.25
TOTAL (ALL PROVIDERS)AVERAGE CARDHOLDER SHARE2 $26.52 $15.81 $6.18 $7.18 $21.35 $18.86 $7.14 $10.41AVERAGE OTHER PAYER SHARE $137.42 $50.38 $9.55 $15.44 $177.68 $98.30 $13.54 $48.77AVERAGE STATE SHARE $0.25 $0.01 $0.00 $0.01 $83.32 $62.24 $8.24 $25.13AVERAGE TOTAL RX COST $164.20 $66.20 $15.74 $22.63 $282.35 $179.39 $28.92 $84.31
SOURCE: PDA/CLAIMS HISTORYNOTE: DATA INCLUDE ORIGINAL, PAID CLAIMS BY DATE OF PAYMENT.
PAYMENTS IF BRAND IS CHOSEN OVER GENERIC. THE CARDHOLDER SHARE DURING THE COPAYMENT PHASE MAYTHEREFORE EXCEED THE $8 OR $15 COPAYMENT.
DEDUCTIBLE PHASE1 COPAYMENT PHASE
PROVIDER TYPE
2THE CARDHOLDER SHARE INCLUDES THE DEDUCTIBLE PAYMENTS, COPAYMENTS, AND GENERIC DIFFERENTIAL
1IN 2013, THE MONTHLY PACENET DEDUCTIBLE WAS CHANGED TO $36.57 TO COINCIDE WITH THE REGIONAL MEDICARE PART D BENCHMARK PREMIUM. STATE SHARE EXPENDITURES FOR DEDUCTIBLE CLAIMS ARE ONLY INCURRED FOR TRANSITION CLAIMS WHICH COMPLETE THE $36.57 MONTHLY DEDUCTIBLE ACCUMULATION. FOR THESE CLAIMS, THE CARDHOLDER PAYS THE OUTSTANDING DEDUCTIBLE AMOUNT AND A COPAYMENT, WHILE PACENET COVERS THE REMAINING COST, IF ANY, OF THE PRESCRIPTION.
77
78
SECTION 7
THERAPEUTIC CLASS DATA
AND DRUG UTILIZATION
REVIEW DATA
79
80
PA
GE
1
% O
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.46
AN
TID
IAB
ETI
C A
GE
NTS
354,
598
6.1
$15,
785,
325.
5913
.636
,992
23.9
$426
.72
$80.
62TH
YR
OID
AN
D A
NTI
THY
RO
ID A
GE
NTS
211,
920
3.7
$160
,210
.09
0.1
32,5
2421
.0$4
.93
$0.8
2
SM
OO
TH M
US
CLE
RE
LAX
AN
TS
64,0
511.
1$2
,966
,008
.71
2.6
11,2
177.
3$2
64.4
2$1
5.15
THE
OP
HY
LLIN
E A
ND
RE
LATE
D D
RU
GS
4,96
60.
1$4
9,32
9.06
0.0
870
0.6
$56.
70$0
.25
DR
UG
S F
OR
OS
TEO
PO
RO
SIS
60,2
191.
0$1
,847
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1.6
10,7
577.
0$1
71.7
9$9
.44
ALL
OTH
ER
DR
UG
S50
0,32
38.
7$1
3,21
9,62
0.78
11.4
76,8
7949
.8$1
71.9
5$6
7.52
ALL
CLA
SS
ES
CO
MB
INE
D5,
776,
051
100.
0$1
16,1
67,8
33.4
310
0.0
154,
529
100.
0$7
51.7
5$5
93.3
3
1 Th
e av
erag
e an
nual
num
ber o
f uni
que
ther
apeu
tic c
lass
es u
sed
by c
ardh
olde
rs w
ith o
ne o
r mor
e cl
aim
s in
201
3 w
as 5
.2 (b
ased
on
broa
d th
erap
eutic
cat
egor
y).
2 Th
e an
nual
cos
t per
enr
olle
e is
bas
ed o
n to
tal c
ardh
olde
rs e
nrol
led
in P
AC
EN
ET
for a
ny p
ortio
n of
cal
enda
r yea
r 201
3 (N
=195
,788
).
SO
UR
CE
: P
DA
/CLA
IMS
HIS
TOR
Y A
ND
DR
UG
FIL
ES
NO
TE:
DA
TA IN
CLU
DE
OR
IGIN
AL,
PA
ID P
AC
EN
ET
CLA
IMS
BY
DA
TE O
F S
ER
VIC
E.
TOTA
L C
LAIM
S IN
CLU
DE
DE
DU
CTI
BLE
CLA
IMS
AN
D C
OP
AID
CLA
IMS.
84
2.8%
4.7%
4.7%
5.6%
5.6%
7.2%
10.3
%
10.4
%
10.7
%
11.9
%
AN
TIN
EO
PLA
STI
C A
GE
NTS
AN
ALG
ES
ICS
/AN
TIP
YRE
TIC
S
EY
E, E
AR
, NO
SE
, TH
RO
AT
PR
EP
AR
ATI
ON
S
BLO
OD
FO
RM
ATI
ON
& C
OA
GU
LATI
ON
AG
EN
TS
RE
SP
IRA
TOR
Y T
RA
CT
AG
EN
TS
AU
TON
OM
IC D
RU
GS
AN
TID
IAB
ETI
C A
GE
NTS
LIP
ID-L
OW
ER
ING
AG
EN
TS
GA
STR
OIN
TES
TIN
AL
AG
EN
TS
CA
RD
IAC
DR
UG
S
FIG
UR
E 7
.1
PE
RC
EN
T O
F P
AC
E S
TAT
E S
HA
RE
EX
PE
ND
ITU
RE
S B
Y T
HE
RA
PE
UT
IC C
LA
SS
J
AN
UA
RY
-D
EC
EM
BE
R 2
01
3(T
OTA
L E
XP
EN
DIT
UR
ES
= $
72
,16
6,9
97
)
TH
ER
AP
EU
TIC
CL
AS
S
13.7
%
0.3%0.5%
0.5%0.
7%0.9%
1.7%1.7%1.
9%1.9%
2.4%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0
%12
.0%
14.0
%16
.0%
ALL
OTH
ER
DR
UG
S
HY
PO
TEN
SIV
E A
GE
NTS
ES
TRO
GE
NS
& C
OM
BIN
ATI
ON
AG
EN
TS
RE
PLA
CE
ME
NT
PR
EP
AR
ATI
ON
S
AN
XIO
LYTI
CS
/SE
DA
TIV
ES/
HYP
NO
TIC
S
DIU
RE
TIC
S
AN
TIP
SY
CH
OTI
CS
VA
SO
DIL
ATI
NG
AG
EN
TS
AN
TI-IN
FEC
TIV
E A
GE
NTS
OS
TEO
PO
RO
SIS
TR
EA
TME
NT
AN
TID
EP
RE
SS
AN
TS
SOU
RC
E: P
DA/
CLA
IMS
HIS
TOR
Y AN
D D
RU
G F
ILES
NO
TE:
DAT
A IN
CLU
DE
OR
IGIN
AL, P
AID
CLA
IMS
BY D
ATE
OF
SER
VIC
E, E
XCLU
DE
PAC
ENET
CLA
IMS.
PE
RC
EN
T O
F E
XP
EN
DIT
UR
ES
85
103
(01%
)64
6 (0
.6%
)
182
(0.2
%)
216
(0.2
%)
259
(0.2
%)
6,32
3 (5
.8%
)
43 (<
0.1%
)30
2 (0
.3%
)1,
297
(1.2
%)
1,77
2 (1
.6%
)
12 (<
0.1%
)24
(<0.
1%)
304
(0.3
%)
343
(0.3
%)
614
(0.6
%)
1,55
7 (1
.4%
)1,
904
(1.8
%)
15,8
57 (1
4.6%
)
MA
XIM
UM
DA
ILY
DO
SE
MA
XIM
UM
INIT
IAL
DO
SE
MA
XIM
UM
INIT
IAL
QU
AN
TIT
YD
UP
LIC
AT
E T
HE
RA
PY
MA
XIM
UM
DA
ILY
DO
SE
MA
XIM
UM
INIT
IAL
DO
SE
MA
XIM
UM
DA
ILY
DO
SE
DU
PL
ICA
TE
TH
ER
AP
YM
AX
IMU
M IN
ITIA
L Q
UA
NT
ITY
MA
XIM
UM
INIT
IAL
DO
SE
QU
AN
TIT
Y L
IMIT
DU
RA
TIO
N O
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RA
PY
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IAL
DR
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RE
VIE
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RU
G C
ON
TR
AIN
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AT
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FO
R G
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DE
RM
AX
IMU
M D
AIL
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EM
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IMU
M IN
ITIA
L Q
UA
NT
ITY
DU
PL
ICA
TE
TH
ER
AP
YM
AX
IMU
M IN
ITIA
L D
OS
E
FIG
UR
E 7
.2N
UM
BE
R A
ND
PE
RC
EN
T O
F P
AC
E A
ND
PA
CE
NE
T C
LA
IMS
WIT
H A
PR
OS
PE
CT
IVE
RE
VIE
W M
ES
SA
GE
BY
TH
ER
AP
EU
TIC
CL
AS
SJ
AN
UA
RY
-D
EC
EM
BE
R 2
01
3N
= 1
08
,35
1
PA
GE
1
AN
XIO
LY
TIC
S,
SE
DA
TIV
ES
,&
HY
PN
OT
ICS
AN
TI-
SE
IZU
RE
DR
UG
S
AN
TID
EP
RE
SS
AN
TS
AN
TIP
SY
CH
OT
ICS
13 (<
0.1%
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(<0.
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73 (0
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)56
4 (0
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)
86 (0
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4 (0
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)11
8 (0
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)19
1 (0
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)43
2 (0
.4%
)
64 (0
.1%
)37
1 (0
.3%
)97
0 (0
.9%
)1,
219
(1.1
%)2,
925
(2.7
%)
10,8
87 (1
0.0%
)
406
(0.4
%)
69 (0
.1%
)10
3 (0
.1%
)
02,
000
4,00
06,
000
8,00
010
,000
12,0
0014
,000
16,0
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QU
AN
TIT
Y L
IMIT
MA
XIM
UM
DA
ILY
DO
SE
DU
RA
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N O
F T
HE
RA
PY
MA
XIM
UM
INIT
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QU
AN
TIT
Y
DU
RA
TIO
N O
F T
HE
RA
PY
MA
XIM
UM
DA
ILY
DO
SE
MA
XIM
UM
INIT
IAL
DO
SE
MA
XIM
UM
INIT
IAL
QU
AN
TIT
YD
UP
LIC
AT
E T
HE
RA
PY
DU
PL
ICA
TE
TH
ER
AP
YIN
ITIA
L D
RU
G R
EV
IEW
QU
AN
TIT
Y L
IMIT
MA
XIM
UM
DA
ILY
DO
SE
MA
XIM
UM
INIT
IAL
QU
AN
TIT
YD
UR
AT
ION
OF
TH
ER
AP
Y
MA
XIM
UM
INIT
IAL
QU
AN
TIT
Y
MA
XIM
UM
INIT
IAL
QU
AN
TIT
YM
AX
IMU
M D
AIL
Y D
OS
E
NU
MB
ER
OF
CL
AIM
SS
OU
RC
E:
PD
A/C
LAIM
S H
ISTO
RY
NO
TES
: B
AS
ED
ON
A T
OTA
L O
F 9,
448,
517
AP
PR
OV
ED
AN
D 1
57,3
92 D
EN
IED
CLA
IMS
.D
ATA
INC
LUD
E C
LAIM
S B
Y D
ATE
OF
SE
RV
ICE
WIT
H M
ULT
IPLE
SU
BM
ISS
ION
S O
F S
AM
E C
LAIM
ON
SA
ME
DA
YD
ELE
TED
.
AN
TIP
AR
KIN
SO
NIS
M D
RU
GS
MU
SC
LE
RE
LA
XA
NT
S
NS
AID
S &
CO
X-2
INH
IBIT
OR
AN
AL
GE
SIC
S
NA
RC
OT
IC A
NA
LG
ES
ICS
86
1,05
5(1
.0%
)1,
964
(1.8
%)
12 (<
0.1%
)2,04
8 (1
.9%
)2,
340
(2.2
%)
3,90
9 (3
.6%
)
550
(0.5
%)
3,40
7 (3
.1%
)5,
426
(5.0
%)
73 (0
.1%
)29
1 (0
.3%
)59
8 (0
.6%
)1,
973
(1.8
%)
97 (0
.1%
)16
5 (0
.2%
)2,
599
(2.4
%)
INIT
IAL
DR
UG
RE
VIE
WM
AX
IMU
M IN
ITIA
L Q
UA
NT
ITY
QU
AN
TIT
Y L
IMIT
MA
XIM
UM
DA
ILY
DO
SE
MA
XIM
UM
INIT
IAL
QU
AN
TIT
YD
UP
LIC
AT
E T
HE
RA
PY
MA
XIM
UM
DA
ILY
DO
SE
MA
XIM
UM
INIT
IAL
QU
AN
TIT
YD
UP
LIC
AT
E T
HE
RA
PY
MA
XIM
UM
DA
ILY
DO
SE
MA
XIM
UM
INIT
IAL
DO
SE
MA
XIM
UM
INIT
IAL
QU
AN
TIT
YD
UP
LIC
AT
E T
HE
RA
PY
MA
XIM
UM
INIT
IAL
QU
AN
TIT
YM
AX
IMU
M D
AIL
Y D
OS
EM
AX
IMU
M IN
ITIA
L D
OS
E
FIG
UR
E 7
.2 (
CO
NT
INU
ED
)N
UM
BE
R A
ND
PE
RC
EN
T O
F P
AC
E A
ND
PA
CE
NE
T C
LA
IMS
WIT
H A
PR
OS
PE
CT
IVE
RE
VIE
W M
ES
SA
GE
BY
TH
ER
AP
EU
TIC
CL
AS
SJ
AN
UA
RY
-D
EC
EM
BE
R 2
01
3N
= 1
08
,35
1
PA
GE
2
CH
OL
INE
ST
ER
AS
E IN
HIB
ITO
RS
DIA
BE
TE
ST
RE
AT
ME
NT
GA
ST
RO
INT
ES
TIN
AL
AG
EN
TS
OT
HE
R C
AR
DIO
VA
SC
UL
AR
DR
UG
S
LIP
ID-L
OW
ER
ING
DR
UG
S
1,11
2 (1
.0%
)1,
333
(1.2
%)
21,5
17 (1
9.9%
)
47 (<
0.1%
)49
(<0.
1%)
50 (<
0.1%
)20
3 (0
.2%
)50
7 (0
.5%
)65
1 (0
.6%
)3,
742
(3.5
%)
10 (<
0.1%
)39
4 (0
.4%
)
10 (<
0.1%
)61
(0.1
%)
239
(0.2
%)
3,24
4 (3
.0%
)
47 (<
0.1%
)1,
055
(1.0
%)
05,
000
10,0
0015
,000
20,0
0025
,000
DR
UG
S IN
AP
PR
OP
RIA
TE
FO
R E
LD
ER
LY
DR
UG
-TO
-DR
UG
INT
ER
AC
TIO
NP
LA
N P
RO
TO
CO
L/O
TH
ER
CA
SE
RE
VIE
W
QU
AN
TIT
Y L
IMIT
DU
PL
ICA
TE
TH
ER
AP
YM
AX
IMU
M IN
ITIA
L D
OS
EM
AX
IMU
M D
AIL
Y D
OS
ED
RU
G C
ON
TR
AIN
DIC
AT
ED
FO
R G
EN
DE
RD
UR
AT
ION
OF
TH
ER
AP
YM
AX
IMU
M IN
ITIA
L Q
UA
NT
ITY
INIT
IAL
DR
UG
RE
VIE
WM
AX
IMU
M D
AIL
Y D
OS
E
QU
AN
TIT
Y L
IMIT
DU
PL
ICA
TE
TH
ER
AP
YM
AX
IMU
M D
AIL
Y D
OS
ED
UR
AT
ION
OF
TH
ER
AP
Y
MA
XIM
UM
DA
ILY
DO
SE
NU
MB
ER
OF
CL
AIM
SS
OU
RC
E:
PD
A/C
LAIM
S H
ISTO
RY
NO
TES
: B
AS
ED
ON
A T
OTA
L O
F 9,
448,
517
AP
PR
OV
ED
AN
D 1
57,3
92 D
EN
IED
CLA
IMS
.D
ATA
INC
LUD
E C
LAIM
S B
Y D
ATE
OF
SE
RV
ICE
WIT
H M
ULT
IPLE
SU
BM
ISS
ION
S O
F S
AM
E C
LAIM
ON
SA
ME
DA
YD
ELE
TED
.
MU
LT
IPL
EC
LA
SS
ES
OT
HE
R S
PE
CIF
IC C
LA
SS
ES
OS
TE
OP
OR
OS
IS T
RE
AT
ME
NT
IMP
OT
EN
CE
TR
EA
TM
EN
T
87
88
SECTION 8
PENNSYLVANIA PATIENT
ASSISTANCE CLEARINGHOUSE
89
90
PENNSYLVANIA PATIENT ASSISTANCE PROGRAM CLEARINGHOUSE (PA PAP) In January 2001, the PACE Program began a referral program to assist Pennsylvanians ages 60 through 64 that facilitated contact between the Area Agency on Aging offices and the patient assistance programs offered by pharmaceutical manufacturers. That Program has evolved in recent years, and, as a result, the Program now accepts applications from individual patients, physician offices, social workers and other agencies throughout the Commonwealth. In late 2004, the name of the Program changed to reflect the Program’s current objectives; it became the Pennsylvania Patient Assistance Program Clearinghouse (PA PAP). The Pharmaceutical Research and Manufacturers of America (PhRMA) represents the country’s leading research-based pharmaceutical and biotechnology companies. Some of these manufacturers offer limited prescription drug assistance to persons who are not eligible for other forms of pharmaceutical coverage and who cannot afford the cost of one or more of their medications. The PA PAP coordinator provides the expertise necessary to determine the likelihood of eligibility for persons seeking assistance from manufacturers’ medication programs, gathers the patient information required to complete the pharmacy assistance applications, offers guidance and assistance to the patient throughout the application and—if successful—reorder processes. In 2006, the Clearinghouse extended assistance to all adult Pennsylvania residents who appear to meet the selected guidelines, without regard to age. Pharmaceutical manufacturers which offer pharmacy assistance programs set their income and eligibility guidelines as individual companies; they limit the products and the length of time for assistance. Typically, the gross household income should be at or below 200% of federal poverty level guidelines, but many manufacturers will consider circumstances of hardship that fall outside their usual guidelines. Household income is one factor of many criteria used by the manufacturers to determine eligibility for medication. Manufacturers require a wide range of information on company-specific forms which further complicates the application and review process. A substantial amount of coordination needs to occur between the PA PAP coordinator, the patient, and the patient’s physician. Since the inception of Medicare Part D, some manufacturers have instituted programs to assist cardholders while they are in the Part D coverage gap. The requirements for the Medicare Part D coverage gap programs differ from the base programs offered by the manufacturers. As a result of different settlements from the Pennsylvania Attorney General’s office, the Pennsylvania Patient Assistance Program Clearinghouse has been able to offer assistance for specific medications to patients who are not eligible for the manufacturer’s assistance programs. Eligible patients can receive a 30-day supply of medication for which they are charged varying copayments based on the program they are enrolled in. At the end of 2013 the Clearinghouse successfully enrolled 362 additional patients into this program. Despite the inherent difficulties of application, the lengthy wait for approval from the manufacturer, and the strictly limited amount of medication granted with each approval, the collaborative efforts of the local and central coordinators responded to inquiries from 26,086 patients after ten years of operation. At the end of 2013, 48% (12,627 persons) were receiving medication assistance through the PA PAP Clearinghouse. The Program successfully referred persons to the PACE Program (1,116), PACENET Program (2,788), VA benefits (60), or other insurance (229). Among the remaining inactive patients, 65 were over the income limits set by the manufacturers and were not eligible for PACE or PACENET benefits. Among the 12,627 persons receiving assistance through the PA PAP Clearinghouse, a total of 41,656 medications were obtained. Current initiatives include continuing to process manufacturers’ pharmacy assistance applications for cardholders who are uninsured, cardholders with Medicare Part D, and to initiate new Programs that are the result of Attorney General lawsuit settlements.
91
92
APPENDIX A
THE PACE/PACENET MEDICAL EXCEPTION PROCESS BACKGROUND: Act 134-96, the State Lottery Law, requires publication and dissemination of the medical exception process used by the Department of Aging for the Pharmaceutical Assistance Contract for the Elderly (PACE) and for the Pharmaceutical Assistance Contract for the Elderly Needs Enhancement Tier (PACENET). Specifically, the legislation addresses the medical exception process with regard to generic substitution when an A-rated therapeutically equivalent medication is available. The law further requires that the Department of Aging distribute the medical exception process to providers and recipients in the Program. THE MEDICAL EXCEPTION PROCESS: Through the online claims processing system, the PACE/PACENET Program provides prospective therapeutic review of prescriptions before the pharmacist dispenses the medication to the cardholder. The review checks for potential drug interactions, duplicative therapies, over-utilization, under-utilization and other misutilization. The Department of Aging, of course, recognizes the possibility of exceptional circumstances in connection with the application of therapeutic criteria and reimbursement edits. A medical exception will be considered by the Program when the cardholder’s physician indicates the diagnosis, medical rationale, anticipated therapeutic outcomes, the expected length of exception therapy, and the last trial at alternative therapy. Act 134-96 requires a pharmacist to dispense the A-rated, therapeutically equivalent, generic drug to the cardholder if they have a prescription for a multi-source brand product. If a cardholder seeks an exception to this mandate, a pharmacist may request a short term medical exception at the time of dispensing by calling 1-800-835-4080. The PACE Program may grant a 30-day medical exception if requested. Immediately following approval of the exception, the Program sends a follow-up letter to the cardholder’s prescribing physician. This letter serves as notice that the Program granted a temporary medical exception to the mandatory substitution requirement. The letter seeks the therapeutic rationale for continuing the medical exception. The Program allows 30 days for the return of the written medical exception request from the prescriber. If the Program does not receive written documentation, the short term medical exception will expire. If the prescriber does respond to the letter and provides appropriate information, the Program may grant a longer medical exception period. The cardholder may continue to obtain the brand medication without paying the extra cost of a generic differential. The Program may refer a request to a physician consultant or to a therapeutics committee for special review and consideration. The cardholder will receive a short term medical exception until completion of the review process. If the Program denies a request for a medical exception to the mandatory generic requirement, the cardholder may opt to continue using the brand multi-source product and, then, pay the generic differential. If this occurs, the pharmacist must collect the copay for the brand name product plus 70 percent of the average wholesale price of the brand name product from the cardholder. Please direct questions regarding the implementation of the medical exception process to 1-800-835-4080 or in writing to: Mr. Thomas M. Snedden Director, Bureau of Pharmaceutical Assistance Pennsylvania Department of Aging 555 Walnut Street, 5th Floor Harrisburg, PA 17101-1919 Source: Pennsylvania Bulletin, Vol. 26, No. 52, December 28, 1996; address change December 8, 1997.
93
APPENDIX B AMERICAN HOSPITAL FORMULARY SERVICE (AHFS) CLASSIFICATIONS
FOR THERAPEUTIC CLASSES USED IN REPORT The American Hospital Formulary Service (AHFS) provides a universal standard of drug classification. Listed below are the AHFS classifications corresponding to the drug classes reported in the tables and figures of this report.
Name of Therapeutic Class AHFS Classification Anti-infective agents 08 Quinolones 08:12.18 Cephalosporins 08:12.06 Antineoplastic agents 10 Autonomic drugs 12 Anticholinergics 12:08 Adrenergic agents 12:12 Blood formation and coagulation agents 20 Cardiovascular drugs 24 Cardiac drugs 24:04 or any below Angiotensin receptor blockers 24:32.08 ACE inhibitors 24:32.04 Cardiac glycosides 24:04.08 Antiarrhythmic agents 24:04.04 Beta blockers 24:24 Calcium channel blockers 24:28 Lipid-lowering agents 24:06 Antihypertensive agents 24:08, 20 Vasodilating agents 24:12 Analgesics/antipyretics 28:08 NSAID's/COX-2 Inhibitors 28:08.04 Opiate agonists 28:08.08 Psychotropic drugs 28:12,16, 20, 24, 28 Anxiolytics, sedatives, hypnotics 28:24 Antidepressants 28:16.04 Antipsychotic agents 28:16.08 Replacement solutions 40:12 Diuretics 40:28, 24:32.20, 52:40.12 Loop diuretics 40:28.08 Thiazide diuretics 40:28.20, 24 Potassium-sparing diuretics 40:28.16, 24:32.20 Respiratory tract agents 48 Eye, ear, nose and throat preparations 52 Gastrointestinal agents 56 H2-receptor antagonists (H2RA's) 56:28.12 Proton pump inhibitors 56:28.36 Miscellaneous anti-ulcer agents 56:28.28, 56:28.32 Hormones and synthetic substances 68 Adrenals and comb. 68:04 Estrogens and comb. 68:16.04 and selected other products Antidiabetic agents (including insulin) 68:20 Thyroid and antithyroid agents 68:36 Drugs for osteoporosis multiple classes (68:16.12, 68:24, 92:24) Theophylline and related smooth muscle relaxants 86:16
SOURCE: AHFS Drug Information
94
APPENDIX C
PACE
PROSPECTIVE DRUG
UTILIZATION REVIEW
CRITERIA
Updated 10/8/2014
95
Angiotensin Converting Enzyme Inhibitors - Criteria Elements and Implementation Dates
Maximum Initial Dose Maximum Daily Dose
MG Per Day Date Begun MG Per Day Date Begun Class Date Begun
Angiotensin II Receptor Antagonists - Criteria Elements and Implementation Dates
Maximum Initial Dose Maximum Daily Dose Duplicate Therapy
MG Per Day Date Begun MG Per Day Date Begun Class Date Begun
Candesartan (Atacand) No Criteria --- Less than or equal to
32 mg/day 05/19/99 No Criteria ---
Irbesartan (Avapro) No Criteria --- Less than or equal to
300 mg/day 05/15/99 No Criteria ---
Eprosartan (Teveten) No Criteria --- Less than or equal to
800 mg/day 10/08/01 No Criteria ---
Telmisartan (Micardis) No Criteria --- Less than or equal to
80 mg/day 10/08/01 No Criteria ---
Olmesartan (Benicar) No Criteria --- Less than or equal to
40 mg/day 08/19/03 No Criteria ---
Ramipril (Altace)
Moexipril (Univasc)
Perindopril (Aceon)
Less than or equal to 30 mg/day
Less than or equal to 16 mg/day
Benazepril (Lotensin)
Captopril (Capoten)
Enalapril (Vasotec)
Fosinopril (Monopril)
Lisinopril (Prinivil)
Less than or equal to 40 mg/day
Less than or equal to 80 mg/day
Less than or equal to 80 mg/day
Less than or equal to 450 mg/day
---
Quinapril (Accupril)
Less than or equal to 80 mg/day
---
---
No Criteria
No Criteria
No Criteria
No Criteria
---
---
Less than or equal to 20 mg/day
Less than or equal to 40 mg/day
10/18/95
05/13/02
01/12/98
Concurrent with other ACE Inhibitors
Concurrent with other ACE Inhibitors
05/15/99
05/15/99
No Criteria
No Criteria
No Criteria
No Criteria
Drug Name Generic (Brand)
---
---
No Criteria ---
---
No Criteria
---
---
---
Valsartan (Diovan)
Losartan (Cozaar) No Criteria --- Less than or equal to
100 mg/day 04/22/98
Concurrent with other ACE Inhibitors
10/22/96
05/13/02
Concurrent with other ACE Inhibitors 01/12/98
10/18/95
10/18/95
10/18/95
10/18/95
10/22/96
10/22/96Concurrent with other ACE Inhibitors
10/22/96
10/22/96
Concurrent with other ACE Inhibitors
Duplicate Therapy
Concurrent with other ACE Inhibitors 05/15/99
Concurrent with other ACE Inhibitors 05/15/99
Concurrent with other ACE Inhibitors
No Criteria
No Criteria
Less than or equal to 320 mg/day 08/18/97
Drug Name Generic (Brand)
96
Beta Blockers - Criteria Elements and Implementation Dates
Drug NameGeneric(Brand) MG Per Day Date Begun MG Per Day Date Begun Class Date Begun
Cardiac Glycosides - Criteria Elements and Implementation Dates
Maximum Initial Dose Maximum Daily Dose Duplicate TherapyMG Per Day MG Per Day Date Begun Class Date Begun
10/18/95No Criteria
Less than or equal to 20 mg/day
Less than or equal to 100 mg/day
---
No Criteria
No Criteria
---
---
Bisoprolol (Zebeta)
Carvedilol (Coreg)
Digoxin (Lanoxin)
Propranolol (Inderal)
Propranolol LA (Inderal LA)
Metoprolol (Toprol XL)
Nadolol (Corgard)
Less than or equal to 320 mg/day
Less than or equal to 60 mg/day
Less than or equal to 120 mg/day
Propranolol extended release
(Innopran XL)
Sotalol (Betapace)
Timolol (Blocadren)
Atenolol (Tenormin)
Betaxolol (Kerlone)
Carteolol (Cartrol)
Less than or equal to 640 mg/day
Less than or equal to 640 mg/day
Less than or equal to 400 mg/day
Less than or equal to 320 mg/day
Less than or equal to 200 mg/day
Penbutolol (Levatol)
Pindolol (Visken)
No Criteria
No Criteria
No Criteria
No Criteria
No Criteria
No Criteria
No Criteria
No Criteria
No Criteria
No Criteria
No Criteria
No Criteria
Less than or equal to 20 mg/day
Less than or equal to 10 mg/day
---
---
---
---
---
---
---
---
---
10/18/95
10/18/95
08/18/97
---
---
---
---
---
Less than or equal to 80 mg/day
Less than or equal to 60 mg/day
10/18/95
10/18/95
10/18/95
03/29/04
10/18/95
10/18/95
10/18/95
10/18/95
10/18/95
Less than or equal to 2400 mg/day
Less than or equal to 450 mg/day
Labetalol (Normodyne)
Metoprolol (Lopressor)
10/18/95
Maximum Initial Dose Maximum Daily Dose Duplicate Therapy
10/18/95
10/18/95Concurrent with other Beta Blockers
No Criteria
No Criteria
Acebutolol (Sectral)
10/18/95
Concurrent with other Beta Blockers
No Criteria ---
10/18/95
10/18/95
10/18/95
10/18/95
10/18/95
Concurrent with other Beta Blockers 10/18/95
Concurrent with other Beta Blockers
Concurrent with other Beta Blockers
Concurrent with other Beta Blockers
10/18/95
10/18/95
Concurrent with other Beta Blockers
Concurrent with other Beta Blockers
Concurrent with other Beta Blockers 12/09/9505/15/99No Criteria Less than or equal to
1200 mg/day
10/18/95
Concurrent with other Beta Blockers 10/18/95
Concurrent with other Beta Blockers 10/18/95
Concurrent with other other Beta Blockers 03/29/04
Concurrent with other Beta Blockers 08/18/97
Concurrent with other Beta Blockers 10/18/95
Concurrent with other Beta Blockers 10/18/95
Concurrent with other Beta Blockers 10/18/95
Concurrent with other Beta Blockers
Drug Name Generic (Brand)
Less than or equal to .375 mg/day
97
Calcium Channel Blockers - Criteria Elements and Implementation Dates
Drug NameGeneric Maximum Initial Dose Maximum Daily Dose(Brand) MG Per Day Date Begun MG Per Day Date Begun Class Date Begun
Nisoldipine (Sular)
Amlodipine & Atorvastatin
(Caduet)
Nifedipine (Procardia)
Verapamil (Calan, Isoptin)
Felodipine (Plendil)
Isradipine (DynaCirc)
Nicardipine (Cardene)
Diltiazem (Cardizem)
Diltiazem CD (Cardizem CD) 05/15/99
Less than or equal to 10 mg/day
Less than or equal to 400 mg/day
Less than or equal to 360 mg/day
Less than or equal to 540 mg/day
10/18/95---
---
02/14/05
10/18/95
10/18/95
10/18/95
10/18/95
10/18/95
02/14/05
Concurrent with Other Calcium Channel
Blockers
08/18/97
10/18/95
Less than or equal to 480 mg/day
Less than or equal to 60 mg/day
10/18/95
10/18/95
08/18/97
Concurrent with Other Calcium Channel
Blockers
Concurrent with Other Calcium Channel
Blockers
Concurrent with Other Calcium Channel
Blockers
---
---
No Criteria
No Criteria
No Criteria
Less than or equal to 80 mg/day (based on
Atorvastatin)
No Criteria Less than or equal to 120 mg/day---
---
---
---
Less than or equal to 20 mg/day
Less than or equal to 20 mg/day
Less than or equal to 120 mg/day 10/18/95
---
Concurrent with Other Calcium Channel
Blockers
Concurrent with Other Calcium Channel
Blockers
No Criteria
No Criteria
No Criteria
No Criteria
No Criteria ---
Concurrent with Other Calcium Channel
Blockers
---
10/18/95
12/09/95
10/18/95
10/18/95
10/15/95
Bepridil (Vascor)
No Criteria
Duplicate Therapy
Concurrent with Other Calcium Channel
Blockers
Concurrent with Other Calcium Channel
Blockers
Concurrent with Other Calcium Channel
Blockers
Concurrent with Other Calcium Channel
Blockers
10/18/95
No Criteria
12/09/95Amlodipine (Norvasc)
98
Lipid Lowering Agents - Criteria Elements and Implementation Dates
MG per Date DateDay Begun MG Per Day Begun
No Criteria
Antiplatelet Agents - Criteria Elements and Implementation Dates
MG per Date Date Date Day Begun MG Per Day Begun Begun Period
Cilostazol (Pletal)
No Criteria --- Less than or equal to 200 mg/day
04/10/00 No Criteria ---
Ticlopidine (Ticlid)
No Criteria --- Less than or equal to 500 mg/day
05/15/99 No Criteria ---
Clopidogrel bisulfate (Plavix)
No Criteria --- Less than or equal to 75 mg/day
10/08/01 No Criteria ---
Aspirin/ dipyridamole (Aggrenox)
No Criteria --- Less than or equal to 50 mg/400 mg/day
10/08/01 No Criteria ---
Less than or equal to 80 mg/day
Less than or equal to 80 mg/day
Less than or equal to 80 mg/day
Less than or equal to 80 mg/day
Less than or equal to 10 mg/day
---
---
--- 04/15/97
04/15/97
04/15/97
Concurrent HMG-Co A Reductase
Inhibitors
04/15/97
Concurrent HMG-Co A Reductase
Inhibitors
Concurrent HMG-Co A Reductase
Inhibitors
02/14/05Less than or equal to 40 mg/day
Class---
No Criteria
---
---
02/14/05
---
12/04/9712/04/97
---
---
No Criteria
No Criteria
No Criteria
No Criteria
Date Begun
No Criteria
---
Duration of Therapy
--- No Criteria
Concurrent HMG-Co A Reductase
Inhibitors
Duplicate Therapy
04/15/97 ---
---
---
Concurrent HMG-Co A Reductase
Inhibitors
---
Drug Name Generic (Brand)
Fluvastatin (Lescol)
No Criteria
No CriteriaSimvastatin (Zocor)
05/15/99
04/15/97Less than or equal to 80 mg/day
Max. Initial Dose Maximum Daily Dose Duration of Therapy
ClassDate
BegunDate
Begun
No Criteria
---
Period
Max. Initial Dose Maximum Daily Dose
--- 03/29/04
Concurrent HMG-Co A Reductase
Inhibitors
---
04/15/97
No Criteria
No Criteria
Rosuvastatin (Crestor)
Ezetimibe (Zetia)
Drug Name Generic (Brand)
Duplicate Therapy
No Criteria
02/14/05
Lovastatin (Mevacor)
Pravastatin (Pravachol)
Atorvastatin (Lipitor)
No Criteria
No Criteria
No Criteria
No Criteria
Less than or equal to 5 mg
99
Oral Antihyperglycemic Agents - Criteria Elements and Implementation Dates
MG per Date Date Date Day Begun MG Per Day Begun Begun Period
Thioglitazones – Criteria Elements and Implementation Dates
Date Begun
1/6/2009
1/6/2009
Anticonvulsant – Criteria Elements and Implementation Dates
Date Begun
Drug Name Generic (Brand)
Oxcarbazepine extended release (Oxtellar XR)
Previous therapy required with immediate release oxcarbazepine (Trileptal)
Step Therapy
Step Therapy
Medical exception required
Previous therapy required with a sulfonylurea, metformin or insulin.
Drug Name Generic (Brand)
Rosiglitazone and combinations (Avandia, Avandamet, Avandaryl)
Pioglitazone (Actos)
06/02/09---
---
---
---
---
Less than or equal to 45 mg/day
ClassNew therapy denied for
reimbursement
No Criteria
No Criteria
Plan Protocol
---
01/06/09
No Criteria
---No Criteria
---
---
---
---
---Prior therapy with either metformin, a sulfonylurea or
insulin in the previous 60 days.
1/6/2009
---No Criteria --- No Criteria
Rosiglitazone (Avandia)
Drug Name Generic (Brand)
No Criteria
Max. Initial Dose
--- 04/10/00Less than or equal to 8 mg/day
Less than or equal to 16 mg/day
Less than or equal to 300 mg/day
Maximum Daily Dose
--- 04/10/00
--- 04/10/00
Metformin (Glucophage)
No Criteria --- 04/10/00Less than or equal to 2550 mg/day
No Criteria
Acarbose (Precose)
No Criteria
Repaglinide (Prandin)
No Criteria
No Criteria ------10/08/01 No Criteria No CriteriaLess than or equal to 20 mg/2000 mg/day
---
No Criteria
Less than or equal to 360 mg/day
Less than or equal to 300 mg/day
No Criteria
No Criteria
10/08/01
10/08/01
04/10/00Miglitol (Glyset)
No Criteria
Less than or equal to 30 mg/day
Nateglinide (Starlix)
No Criteria
Pioglitazone (Actos)
No Criteria
Pioglitazone/ glimepride (Duetact)
No Criteria
Glyburide/ metformin
(Glucovance)
Date Begun
Duplicate Therapy
---
---
---
---
No Criteria
No Criteria
No Criteria
No Criteria
Sagliptin (Onglyza)
No Criteria --- Less than or equal to 5 mg/day
---12/14/10 No Criteria --- No Criteria
1/6/2009 No Criteria ---Sitagliptin (Januvia)
No Criteria --- --- 04/01/11 Prior therapy with either metformin, a sulfonylurea or
insulin in the previous 60 days.
100
Maximum Daily Dose Duplicate TherapyDate Begun Period Date Begun Class Date Begun
Aspirin (Legend) 08/06/94 No Criteria --- 08/16/92(Easprin, Zorprin)
Choline Magnesium 10/28/94 No Criteria --- 10/28/94Sulfate (Trilisate)
Diclofenac (Voltaren) 03/29/95 No Criteria --- 08/16/92(Normal Release)
Diclofenac (Cataflam) 10/28/94 No Criteria --- 10/28/94(Quick Release)
Diflunisal 07/05/93 No Criteria --- 08/16/92(Dolobid)Etodolac 07/05/93 No Criteria --- 08/16/92(Lodine)
Fenoprofen 07/05/93 No Criteria --- 08/16/92(Nalfon)
Flurbiprofen 07/05/93 No Criteria --- 08/16/92(Ansaid)Ibuprofen 07/05/93 No Criteria --- 08/16/92(Motrin)
Indomethacin 07/05/93 No Criteria --- 08/16/92(Indocin)
Indomethacin SR 07/05/93 No Criteria --- 08/16/92(Indocin SR)Ketoprofen 07/05/93 No Criteria --- 08/16/92
(Orudis, Oruvail)Ketorolac (Toradol)
I.M. Therapy 7/15/1993 5 days/ 05/15/95 08/16/9230 days
Oral Therapy 07/05/93 5 days/ 05/15/95 08/16/9230 days
Meclofenamate 07/05/93 No Criteria --- 08/16/92(Meclomen)
Mefenamic Acid 07/05/93 No Criteria --- 08/16/92(Ponstel)
Nabumetone 07/05/93 No Criteria --- 08/16/92(Relafen)Naproxen 07/05/93 No Criteria --- 08/16/92
(Naprosyn)Naproxen Sodium 07/05/93 No Criteria --- 08/16/92
(Anaprox)Oxaprozin 07/05/93 No Criteria --- 08/16/92(Daypro)Piroxicam 07/05/93 No Criteria --- 08/16/92(Feldene)Salsalate 10/28/94 No Criteria --- 10/28/94(Disalcid)Sulindac 07/05/93 No Criteria --- 08/16/92(Clinoril)Tolmetin 07/05/93 No Criteria --- 08/16/92(Tolectin)
Meloxicam 05/13/02 No Criteria --- 05/13/02(Mobic)
Diclofenac Epolamine No Criteria --- 03/10/09(Flector Patch)
Diclofenac Potassium 12/14/10 No Criteria --- 12/14/10(Zipsor)
------Diclofenac (Zorvolex)
Step TherapyRequires prior trial of generic diclofenac or other
generic NSAID
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
to 2000 mg/dayLess than or equal
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Concurrent NSAIDS
Less than or equalto 100 mg/day
to 3000 mg/dayLess than or equal
to 400 mg/dayLess than or equal
to 15 mg/day
to 1800 mg/dayLess than or equal
to 40 mg/dayLess than or equal
to 1500 mg/dayLess than or equal
to 1650 mg/dayLess than or equal
to 1250 mg/dayLess than or equal
to 2000 mg/dayLess than or equal
to 40 mg/dayLess than or equal
to 400 mg/dayLess than or equal
to 300 mg/day
Less than or equalto 60 mg/day
Less than or equal
Less than or equalto 200 mg/day
Less than or equal
Less than or equal
Less than or equal
to 200 mg/dayLess than or equal
to 1500 mg/dayLess than or equal
to 200 mg/day
to 3000 mg/dayLess than or equal
to 225 mg/day
to 1200 mg/dayLess than or equal
to 3200 mg/day
to 300 mg/dayLess than or equal
to 3200 mg/day
Drug Name Generic (Brand)
Less than or equalto 6000 mg/day
Less than or equal
Less than or equal
Non-Steroidal Anti-Inflammatory Agents (NSAIDS) - Criteria Elements and Implementation Dates
MG Per DayMaximum Duration
101
COX-2 Inhibitors - Criteria Elements and Implementation Dates
Maximum Daily Dose Duplicate Therapy
Date Begun Period Date Begun Class Date Begun
Celecoxib 04/10/00 No Criteria --- 04/10/00(Celebrex)Valdecoxib 08/19/03 No Criteria --- 08/19/03
(Bextra)
Centrally Acting Analgesics - Criteria Elements and Implementation Dates
Maximum Daily Dose Duplicate Therapy
Date Begun Period Date Begun Class Date Begun12/04/97 No Criteria --- ---
Combination Analgesics - Criteria Elements and Implementation Dates
Maximum Daily Dose Duplicate Therapy
Date Begun Period Date Begun Class Date Begun
Hydrocodone and 04/22/98 10 days/ 04/22/98 ---Ibuprofen 30 days
(Vicoprofen)
Opiate Agonists - Criteria Elements and Implementation Dates
Maximum Daily Dose Duplicate Therapy
Date Begun Period Date Begun Class Date Begun
Tramadol/acetaminophen 08/20/03 5 days out 08/20/03 ---(Ultracet) of every 30
Agents to Treat Benign Prostatic Hyperplasia - Criteria Elements and Implementation Dates
Maximum Daily Dose Gender Edit
Date Begun MG Per Day Date Begun Male/ Female Date BegunTamsulosin HCI - No Criteria - 01/04/07
(Flomax)Dutasteride - No Criteria - 02/22/07(Avodart)
Finasteride - No Criteria - 02/22/07(Proscar)Alfuzosin - No Criteria - 02/22/07
(Uroxatral)
Inhaled Corticosteroids - Criteria Elements and Implementation Dates
Maximum Daily Dose Gender EditDate Begun MG Per Day Date Begun Male/ Female Date Begun
Budesonide 06/03/09 No Criteria - -(Pulmicort-Respules)
Concurrent NSAIDS
1 mg/day
Less than or equal
Concurrent NSAIDS
to 37.5 mg/day
Drug Name Generic (Brand)
No Criteria
Maximum Initial Dose
Tramadol (Ultram)
Less than or equalto 400 mg/day
MG Per Day
400 mg daily if under 75 years of age
Maximum Duration
to 10mg/day
Less than or equalMG Per Day
Drug Name Generic (Brand)
Drug Name Generic (Brand)
Maximum Duration
300 mg daily if over 75 years of age
No Criteria
Drug Name Generic (Brand)
Duration of Therapy
MG Per Day
Less than or equal
Drug Name Generic (Brand)
Maximum Duration
MG Per Day
Drug Name Generic (Brand)
Maximum Initial DoseMG Per Day
MG Per DayMale OnlyNo Criteria
No Criteria
No Criteria
No Criteria
No CriteriaLess than or equal to
Male Only
Male Only
Male Only
No Criteriato 300 mg/day
102
Other Analgesics - Criteria Elements and Implementation Dates
Date Begun Drug
Date Begun Quantity
Date Begun Period Date Begun Quantity Date Begun
Propoxyphene HCl 05/13/02 No Criteria --- No Criteria --- No Criteria --- No Criteria ---(Darvon)
Propoxyphene napsylate 05/13/02 No Criteria --- No Criteria --- No Criteria --- No Criteria ---(Darvocet)
Acetaminophen/Codeine 05/13/02 No Criteria --- No Criteria --- 180 days out 10/18/04 No Criteria ---Combinations of 210
Morphine Sulfate No Criteria 10/18/04 No Criteria No Criteria No Criteria 10/18/04 No Criteria ---(Kadian, Various)
Fentanyl buccal --- 06/03/09 No Criteria --- No Criteria --- No Criteria ---(Fentora®)
Fentanyl Citrate No Criteria No Criteria 10/18/04 6 units 10/18/04 No Criteria --- 10/18/04(Actiq)
Fentanyl Transdermal No Criteria 10/27/04 No Criteria No Criteria 10/18/04 10/18/04(Duragesic)
Oxycontin 03/29/04 No Criteria No Criteria No Criteria No Criteria 180 days out of 210
10/18/04 No Criteria No Criteria
Tapentadol (Nucynta) 12/14/10 No Criteria No Criteria No Criteria No Criteria No Criteria No Criteria No Criteria No Criteria
Fentanyl Sublingual (Subsys)
--- --- --- Less than or equal to 100
mcg/day
5/14/2014 --- --- 4 doses/day 5/14/2014
Calcium Phosphate Binder - Criteria Elements and Implementation Dates
Date Begun Drug
Date Begun Quantity
Date Begun Period Date Begun Quantity Date Begun
Sevelamer Carbonate 04/21/08 No Criteria No Criteria No Criteria No Criteria --- --- No Criteria No Criteria(Renvela)
---
10 patches in a 30 day period. Dose increase will permit an additional 10
patches.
Less than or equal to 320 mg
No Criteria
to 7200 mg/day
Maximum Duration Maximum Quantity
MG Per DayLess than or equal
Less than or equal to 600 mg
Patches greater than 50 mcg
must show prior conversion with
opiate.
Drug Name Generic (Brand)
Maximum Daily Dose Plan Protocol Initial Quantity
Maximum Quantity
48 units in a 30 day period
Maximum Daily Dose
to 600 mg/dayLess than or equal
to 390 mg/day
No Criteria
No Criteria
Drug Name Generic (Brand)
No Criteria Tablets greater than 100/mg must show
conversion from Actiq
Less than or equal
Must show prior conversion with opiate before
reimbursement of 200 mg extended
release tab.
180 days out of 210
Maximum Duration
MG Per DayLess than or equal
Plan Protocol Initial Quantity
to 4000 mg/day
103
Histamine H2 Receptor Antagonists - Criteria Elements and Implementation Dates
Date Date DateMG Per Day Begun Period Begun Class Begun
Cimetidine (Tagamet)Maintenance 08/16/92 Unlimited 10/08/04 08/16/92
TherapyFamotidine (Pepcid)
Maintenance 08/16/92 Unlimited 10/08/04 08/16/92Therapy
Nizatidine (Axid)Maintenance 08/16/92 Unlimited 10/08/04 08/16/92
TherapyRanitidine (Zantac)
Maintenance 08/16/92 Unlimited 10/08/04 08/16/92Therapy
Dexlansoprazole(Dexilant) 12/14/10 Unlimited 03/30/10 12/14/10
Miscellaneous Gastrointestinal Agents - Criteria Elements and Implementation Dates
Date Date DateMG Per Day Begun Period Begun Class Begun
Metoclopramide(Reglan)
Misoprostol(Cytotec)
Omeprazole Proton Pump Inhibitors/(Prilosec) H2 Receptor AntagonistsSucralfate(Carafate)
Lansoprazole Proton Pump Inhibitors/(Prevacid) H2 Receptor Antagonists
Pantoprazole Proton Pump Inhibitors/(Protonix) H2 Receptor Antagonists
Esomeprazole Proton Pump Inhibitors/(Nexium) H2 Receptor Antagonists
Rabeprazole Proton Pump Inhibitors/(Aciphex) H2 Receptor Antagonists
Naproxen andLansoprazole
(Prevacid NapraPAC)
Agent to Treat Irritable Bowel - Criteria Elements and Implementation Dates
Date Date DateMG Per Day Begun mg/day Begun Male/Female Begun
Alosetron(Lotronex)
Antidiarrheal - Criteria and Implementation Dates
Aminosalicylate - Criteria Elements and Implementation Dates
Date Date DateMG Per Day Begun mg/day Begun Male/Female Begun
Balsalazide Disodium(Giazo) Male 12/13/12No Criteria --- No Criteria ---
Date Begun
Crofelemer (Fulyzaq)
10/22/14
Drug Name Generic (Brand)
Maximum Daily Dose Maximum Initial Dose Gender Edit
Step Therapy
Current use of an antiretroviral
Drug Name Generic (Brand)
20 mg/day
40 mg/day10/08/01 No Criteria --- 10/08/01
Drug Name Generic (Brand)
Less than or equal to
Less than or equal to
40 mg/day
Proton Pump Inhibitors and Concurrent H2.
Proton Pump Inhibitors and Concurrent H2.
Proton Pump Inhibitors and Concurrent H2.
Proton Pump Inhibitors and Concurrent H2.
No Criteria
Less than or equal to
08/28/95
Less than or equal to40 mg/day
30 mg/day
4000 mg/dayLess than or equal to
No Criteria 10/08/01
---
No Criteria
No Criteria
Duplicate Therapy
No Criteria
No Criteria
Less than or equal to
07/05/93
08/28/95
Maximum Daily Dose
---
---
10/28/94
07/05/93800 mcg/day
Drug Name Generic (Brand)
---
Drug Name Generic (Brand)
Duration of TherapyMaximum Daily Dose
Proton Pump Inhibitors and Concurrent H2.
Less than or equal to
Less than or equal to60 mg/day
Less than or equal to 60 mg/day
Duplicate TherapyDuration of Therapy
07/05/93
10/08/01 10/08/01No Criteria
No Criteria
---
10/08/01 ---
Gender EditMaximum Daily Dose Maximum Initial Dose
Naproxen)---
No Criteria
1000 mg (based on
---
08/28/95
10/18/04
No Criteria
No Criteria No Criteria No Criteria Female only
02/14/05 No Criteria
Less than or equal to 300 mg/day
Less than or equal to 300 mg/day
Less than or equal to 40 mg/day
Less than or equal to 1600 mg/day
---
---
---
---
No Criteria
No Criteria
104
Antipsychotics - Criteria Elements and Implementation Dates
Maximum Initial DoseDate Date
MG Per Day Begun MG Per Day Begun
Chlorpromazine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Thorazine) 50 mg/day 200 mg/dayClozapine Less than or equal to 01/16/95 Less than or equal to 08/18/97 No Criteria(Clozaril) 25 mg/day 100 mg/day
Fluphenazine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Prolixin) 1 mg/day 10 mg/day
Haloperidol Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Haldol) 1 mg/day 10 mg/dayLoxapine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Loxitane) 20 mg/day 100 mg/day
Mesoridazine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Serentil) 30 mg/day 125 mg/day
Perphenazine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Trilafon) 8 mg/day 24 mg/day
Risperidone 01/16/95 01/16/95 No Criteria(Risperdal & Risperdal-M)Thioridazine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria
(Mellaril) 50 mg/day 200 mg/dayThiothixene Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Navane) 4 mg/day 20 mg/day
Trifluoperazine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Stelazine) 2 mg/day 10 mg/dayQuetiapine Less than or equal to 04/22/98 Less than or equal to 04/22/98 No Criteria(Seroquel) 50 mg/day 400 mg/dayOlanzapine Less than or equal to 08/18/97 Less than or equal to 08/18/97 No Criteria(Zyprexa) 2.5 mg/day 10 mg/day
Ziprasidone No Criteria --- 160 mg per day Oral 08/19/03 No Criteria(Geodon) 40 mg/day IM
Aripiprazole No Criteria --- Less than or equal to 08/19/03 No Criteria(Abilify) 15 mg/day
Paliperidone No Criteria --- Less than or equal to 06/02/09 No Criteria(Invega) 12 mg/day
Aripiprazole, Ext. Release Injectible (Abilify Maintena)
Requires prior use of oral Aripiprazole 6/25/2014
---
Less than or equal to 0.5 mg/day
Less than or equal to 6 mg/day
---
---
---
---
---
---
---
---
---
Drug Name Generic (Brand) Class
Maximum Daily Dose
---
---
---
---
Duplicate Therapy
Date Begun
---
---
105
Antidepressants (SSRI AND SSNRI) - Criteria Elements and Implementation Dates
Maximum Initial DoseDate Date
MG Per Day Begun MG Per Day BegunAmitriptyline Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria
(Elavil) 75 mg/day 250 mg/dayAmoxapine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Asendin) 75 mg/day 300 mg/dayBupropion Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria
(Wellbutrin) 200 mg/day 450 mg/dayCitalopram Less than or equal to 05/15/99 Less than or equal to 05/15/99 No Criteria(Celexa) 20 mg/day 40 mg/day
Clomipramine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Anafranil) 50 mg/day 250 mg/day
Desipramine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Norpramin) 75 mg/day 250 mg/day
Doxepin Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Sinequan) 75 mg/day 250 mg/dayFluoxetine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Prozac) 20 mg/day 60 mg/day
Imipramine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Tofranil) 75 mg/day 250 mg/day
Isocarboxazid Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Marplan) 30 mg/day 50 mg/day
Maprotiline Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Ludiomil) 50 mg/day 200 mg/day
Mirtazapine Less than or equal to 8/18/97 Less than or equal to 08/18/97 No Criteria(Remeron) 15 mg/day 45 mg/day
Nefazodone No Criteria --- Less than or equal to 08/28/95 No Criteria(Serzone) 600 mg/day
Nortriptyline Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Pamelor) 50 mg/day 150 mg/dayParoxetine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria
(Paxil) 20 mg/day 40 mg/dayPhenelzine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria
(Nardil) 45 mg/day 90 mg/dayProtriptyline Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria
(Vivactil) 15 mg/day 40 mg/daySertraline Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Zoloft) 50 mg/day 200 mg/day
Tranylcypromine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Parnate) 30 mg/day 60 mg/day
Trazodone Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Desyrel) 150 mg/day 400 mg/day
Trimipramine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Surmontil) 75 mg/day 250 mg/dayVenlafaxine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria
(Effexor) 75 mg/day 225 mg/dayParoxetine Less than or equal to 08/19/03 Less than or equal to 08/19/03 No Criteria(Paxil CR) 12.5 mg/day 50 mg/day
Escitalopram Less than or equal to 08/19/03 Less than or equal to 08/19/03 No Criteria(Lexapro) 10 mg/day 20 mg/dayBupropion Less than or equal to 02/06/97 Less than or equal to 02/06/97 No Criteria
(Wellbutrin XL) 300 mg/day 400 mg/dayFluoxetine
(Prozac weekly)Duloxetine No Criteria --- Less than or equal to 02/11/08 No Criteria(Cymbalta) 60 mg/day
Desvenlafaxine No Criteria No Criteria Less than or equal to 12/14/10 No Criteria(Pristiq) 50 mg/day
Bupropion Less than or equal to 12/16/10(Aplenzin) 348 mg/day
Milnacipran No Criteria --- Max dose 12/14/10 No Criteria(Savella) 200 mg/day
Vortioxetine No Criteria ---(Brintellix)
12/14/2010Step TherapyRequire pre-existing use of SSRI or SSNRI
---
---
---
---
---
---
---
---
---
Drug Name Generic (Brand)
Maximum Daily Dose Duplicate Therapy
Class Date Begun
---
Prior to Prozac weekly being approved, 90 days of therapy with Prozac daily is required
---
---
---
---
---
---
---
---
---
---
---
---
---
12/14/2010
---
Step TherapyPrevious therapy with bypropin tablets required
(not T12 or T24)
---
---
---
---
---
Desvenlafaxine Extended Release
(Khedezla)
Less than or equal to 50 mg/day No CriteriaNo Criteria ---
106
Benzodiazepines/Miscellaneous Sedative/Hypnotics - Criteria Elements and Implementation Dates
Maximum Initial Dose Maximum Daily Dose Duration of TherapyDate Date Date
MG Per Day Begun MG Per Day Begun Begun Class01/16/95 01/16/95 ---
01/16/95 01/16/95 ---
01/16/95 01/16/95 ---
03/01/94 03/01/94 03/01/94
01/31/92 01/31/92 01/31/92
01/16/95 01/16/95 ---
--- 02/19/07 ---
--- 11/01/05 ---
--- 02/19/07 ---
--- 02/19/07 No Criteria ---
Benzodiazepines - Criteria Elements and Implementation Dates
Maximum Initial Dose Maximum Daily Dose Duration of TherapyDate Date
Begun BegunAlprazolam 01/16/95 01/16/95 No Criteria Concurrent
(Xanax)Alprazolam 03/29/04 03/29/04(Xanax XR)
Chlordiazepoxide 01/16/95 01/16/95 No Criteria Concurrent (Librium)
Clonazepam 01/16/95 01/16/95 No Criteria Concurrent (Klonopin)
Clorazepate 01/16/95 01/16/95 No Criteria Concurrent (Tranxene)Diazepam 01/16/95 01/16/95 No Criteria Concurrent (Valium)
Halazepam 01/16/95 01/16/95 No Criteria Concurrent (Paxipam)Lorazepam 01/16/95 01/16/95 No Criteria Concurrent
(Ativan)Oxazepam 01/16/95 01/16/95 No Criteria Concurrent
(Serax)
Obsessive-Compulsive Disorder Agent - Criteria Elements and Implementation Dates
Maximum Initial Dose Maximum Daily Dose Duration of TherapyDate Date
MG Per Day Begun MG Per Day Begun
Fluvoxamine 08/28/95 08/28/95 No Criteria No Criteria ---(Luvox)
Duplicate Therapy
Period
Date Begun
Duplicate Therapy
Class
240 mg/6 mos
PeriodDate
Begun
No Criteria
10/25/05
Drug Name Generic (Brand) MG Per Day MG Per Day
Drug Name Generic (Brand)
Less than or equal
to 30 mg/day
to 2 mg/day
to 40 mg/day
to 5 mg/day
Less than or equal
to 50 mg/day Less than or equal
to 300 mg/day
Date Begun
---
---
03/13/00
03/13/00
4 mg/6 mos
No Criteria
---
No Criteria
Drug Name Generic (Brand)
No Criteria
No Criteria
No Criteria
Less than or equal to 1 mg/day
Less than or equal to 15 mg/day
Less than or equal to 15 mg/day
Period
Less than or equal to 2 mg/day
Less than or equal to 30 mg/day
Less than or equal to 15 mg/day
---
03/13/00
03/13/00
03/13/00
03/13/00
03/13/00
---
---
Date BegunClass
---
---
Only for Panic Disorder
Date Begun
--- 03/13/00
Ramelteon (Rozerem)
Eszopiclone (Lunesta)
Duplicate Therapy
Estazolam (Prosom)
Flurazepam (Dalmane)
Quazepam (Doral)
Temazepam (Restoril)
Less than or equal to .125 mg/day
Less than or equal to 8 mg/day
Less than or equal to 2 mg/day
Less than or equal
Less than or equalto .75 mg/day
No Criteria
No Criteria
No Criteria
Less than or equal
Less than or equalto 6 mg/day
Less than or equal
Less than or equal
to 60 mg/day
to 40 mg/day
to 40 mg/day
to 15 mg/day
to 1 mg/day
to 20 mg/day
to 0.5 mg/day
Less than or equal
Less than or equal
Less than or equal
Less than or equalto 100 mg/day
to 4 mg/day
Less than or equal
to 60 mg/day Less than or equal
Less than or equal
Less than or equal
Less than or equal
Less than or equal
to 6 mg/day
Less than or equal
to 3 mg/day
Concurrent Benzodiazepines and Misc Sed/Hypnotics
03/13/00
03/13/00
03/13/00
Concurrent Benzodiazepines and Misc Sed/Hypnotics
Concurrent Benzodiazepines and Misc Sed/Hypnotics
03/13/00
03/13/00
10/25/05
12/14/10
10/25/05
10/25/05
No Criteria
Concurrent Benzodiazepines and Misc Sed/Hypnotics
Concurrent Benzodiazepines and Misc Sed/Hypnotics
Concurrent Benzodiazepines and Misc Sed/Hypnotics
10/25/05Less than or equal to 6.25 mg/day
Zolpidem (Edluar)
Step Therapy
Documentation required as to need for sublingual dosage formLess than or equal
to 10 mg/day Concurrent
Benzodiazepines and Misc Sed/Hypnotics
No CriteriaZaleplon (Sonata)
Zolpidem (Ambien CR)
Less than or equal to 7.5 mg/day
Concurrent Benzodiazepines and Misc Sed/Hypnotics
Less than or equal to 5 mg/day
Zolpidem (Ambien)
Less than or equal to 15 mg/day
Less than or equal to .25 mg/day
Less than or equal to 10 mg/day
Concurrent Benzodiazepines and Misc Sed/Hypnotics
Concurrent Benzodiazepines and Misc Sed/Hypnotics
Triazolam (Halcion)
107
Miscellaneous Sedative/Hypnotics - Criteria Elements and Implementation Dates
Maximum Initial Dose Maximum Daily Dose Duration of Therapy Duplicate TherapyDate Date Date Date
Begun MG Per Day Begun Period Begun Class BegunAmobarbital No Criteria --- Less than or equal to 06/07/00 14 days out 06/07/00 No Criteria ---
(Amytal) 200 mg/day of every 180Butabarbital No Criteria --- Less than or equal to 11/26/97 14 days out 04/20/98 No Criteria ---
(Butisol) 90 mg/day of every 180Chloral Hydrate No Criteria --- Less than or equal to 11/26/97 14 days out 04/20/98 No Criteria ---
(Somnote) 1 gm/day of every 180Ethchlorvynol No Criteria --- Less than or equal to 11/26/97 14 days out 06/01/98 No Criteria ---
(Placidyl) 500 mg/day of every 180Secobarbital No Criteria --- Less than or equal to 11/26/97 14 days out 06/01/98 No Criteria ---
(Seconal) 100 mg/day of every 180Amobarbital/Secobarbital No Criteria --- Less than or equal to 11/26/97 14 days out 04/20/98 No Criteria ---
(Tuinal) 50 mg/day of every 180
Maximum Initial Dose Maximum Daily Dose Duration of Therapy Duplicate TherapyDate Date Date Date
Begun MG Per Day Begun Period Begun Class Begun
---
Phentermine/Topiramate (Qsymia)
Requires documentation of adherence to manufacturer recommendations for dose titration as well as weight loss related to use at each dose 08/28/13
---
1/21/2013
----
Less than or equal to 37.5 mg/day
---
No Criteria
No Criteria
---
Document at least 5%
weight loss after 12 weeks
Lorcaserin HCL (Belviq)
Phentermine HCL (Suprenza) ---1/21/2013
Orlistat (Xenical) No Criteria --- Less than or equal to
360 mg/day 07/26/99 60 days out of every 90 08/09/99
No Criteria
---
---
Diethylpropion (Tenuate) No Criteria --- Less than or equal to
100 mg/day 07/26/99 60 days out of every 120 08/09/99 ---
Phendimetrazine (Bontril) No Criteria --- Less than or equal to
105 mg/day 07/26/99 60 days out of every 120
---
60 days out of every 120 08/09/99 ---
60 days out of every 90
Sibutramine (Meridia)
Phentermine HCL (Adipex-P) No Criteria --- Less than or equal to
37.5 mg/day
08/09/99
706 CH on 10/22/2014
07/26/99
No Criteria --- Less than or equal to 30 mg/day 07/26/99 08/09/99
---
concurrent with all other anti-obesity medications
No Criteria
No Criteria
No Criteria
No Criteria
No Criteria
Drug Name Generic (Brand)
Anti-Obesity Agents - Criteria Elements and Implementation Dates
Drug Name Generic (Brand)
MG Per Day
MG Per Day
Document at least 5%
weight loss after 12 weeks
concurrent with all other anti-obesity medications
108
Maximum Initial Dose Maximum Daily Dose Duration of Therapy Duplicate TherapyDate Date Date Date
Begun MG Per Day Begun Period Begun Class BegunAlendronate No Criteria --- Less than or equal to 08/19/03 No Criteria --- No Criteria ---(Fosamax) 10 mg/day
Risedronate No Criteria --- Less than or equal to 03/29/04 No Criteria --- No Criteria ---(Actonel) 5 mg/day
Teriparatide No Criteria --- Less than or equal to 03/29/04 24 months 12/14/10 No Criteria ---(Forteo) 5 mg/day
Maximum Initial Dose Maximum Daily Dose Duration of Therapy Duplicate TherapyDate Date Date Date
Begun MG Per Day Begun Period Begun Class Begun
Maximum Initial Dose Maximum Daily Dose Duration of Therapy Duplicate TherapyDate Date Date Date
Begun MG Per Day Begun Period Begun Class Begun
No CriteriaNo Criteria --- ---Suprep Bowel Kit --- --- 1 day out of every 365
--- No Criteria ---Cabozantinib (Cometriq) No Criteria --- Less than or equal to 180 mg/day 10/14/13 No Criteria
Drug Name Generic (Brand) MG Per Day
Criteria Elements and Implementation Dates
No Criteria ---
Sodium picosulfate, magnesium oxide and anhydrous citric acid
(Prepopik)
No Criteria --- --- ---
Antineoplastic Tyrosine Kinase Inhibitors - Criteria Elements and Implementation D
1 day out of every 365
Laxatives - Criteria Elements and Implementation Dates
Drug Name Generic (Brand) MG Per Day
Drug Name Generic (Brand) MG Per Day
Bisphosphonates and Recombinant Human Parathyroid Hormone Analog -
109
DateBegun
No Criteria --- Less than or equal 06/05/00 --- 21 daysto 1400 mg/day out of 30
No Criteria --- Less than or equal 06/05/00 --- 21 daysto 3000 mg/day out of 30
No Criteria --- Less than or equal 04/19/06 --- 21 daysto 30 mg/day out of 30
No Criteria --- Less than or equal 06/05/00 --- 21 daysto 400 mg/day out of 30
No Criteria --- Less than or equal 06/05/00 --- 21 daysto 3200 mg/day out of 30
No Criteria --- Less than or equal 06/05/00 --- 21 daysto 4500 mg/day out of 30
No Criteria --- Less than or equal 06/05/00 --- 21 daysto 200 mg/day out of 30
No Criteria --- Less than or equal 06/05/00 --- 21 daysto 36 mg/day out of 30
No Criteria --- Less than or equal 06/05/00 --- 21 daysto 80 mg/day out of 30
Maximum Daily Dose Duplicate Therapy Maximum Duration
MG Per DayDate
Begun MG Per DayDate
Begun ClassDate
Begun Period Date BegunDonepezil (Aricept)
Less than or equal to 5 mg
per day
05/15/99 Less than or equal to 10 mg per day
05/15/99 No Criteria --- No Criteria ---
Tacrine (Cognex)
Less than or equal to 40 mg
per day
05/15/99 Less than or equal to 160 mg per day
05/15/99 No Criteria --- No Criteria ---
Rivastigmine (Exelon)
Less than or equal to 3 mg
per day
05/13/02 Less than or equal to 12 mg per day
05/13/02 No Criteria --- No Criteria ---
Galantamine (Reminyl)
Less than or equal to 8 mg
per day
05/13/02 Less than or equal to 24 mg per day
05/13/02 No Criteria --- No Criteria ---
Memantine (Namenda)
Less than or equal to 5 mg
02/14/05 Less than or equal to 20 mg per day
02/14/05 No Criteria --- No Criteria ---
06/12/00
Tizanidine (Zanaflex)
No Criteria 06/12/00
06/12/00
Methocarbamol (Robaxin)
No Criteria 06/12/00
Metaxalone (Skelaxin)
Baclofen (Lioresal)
No Criteria 06/12/00
Orphenadrine Citrate (Norflex)
No Criteria
06/12/00
Dantrolene (Dantrium)
No Criteria 06/12/00
Cyclobenzaprine (Flexeril)
No Criteria
06/12/00
Chlorzoxazone (Parafon Forte)
No Criteria 06/12/00
Carisoprodol (Soma)
No Criteria
No Criteria
Duration of Therapy
MG Per Day MG Per DayDate
Begun ClassDate
Begun Period Date Begun
Skeletal Muscle Relaxants - Criteria and Implementation Dates
Maximum Initial Dose
Drug Name Generic (Brand)
Maximum Initial Dose Maximum Daily Dose Duplicate Therapy
Cholinesterase Inhibitors - Criteria Elements and Implementation Dates
Drug Name Generic (Brand)
110
ClassDate
Begun MG Per DayDate
BegunMale/
FemaleDate
Begun Period Date BegunSildenafil Citrate
(Viagra)Concurrent with other erectile
dysfunction agents
05/07/04 Less than or equal to 50 mg/day
06/01/98 Male 10/18/04 8 days out of every 30 01/04/99
Vardenafil (Levitra)
Concurrent with other erectile
dysfunction agents
05/07/04 No Criteria --- Male 10/18/04 8 days out of every 30 10/31/03
Tadalafil (Cialis)
Concurrent with other erectile
dysfunction agents
04/29/08 Less than or equal to 20 mg/day
03/15/04 Male 10/18/04 8 days out of every 30 05/05/04
Alprostadil (Caverject)
Concurrent with other erectile
dysfunction agents
05/07/04 No Criteria --- Male 02/11/08 8 days out of every 30 02/11/08
MG Per DayDate
Begun MG Per DayDate
Begun ClassDate
Begun Period Date BegunDoxycycline (Periostat)
No Criteria --- Less than or equal to 40 mg/day
05/13/02 No Criteria --- 9 months out of every 12
05/13/02
Rifaximin (Xifaxan)
No Criteria --- No Criteria --- No Criteria --- 3 days out of every 180
06/03/09
Maximum Initial Dose Maximum Daily Dose Duration of Therapy Duplicate TherapyDate Date Date Date
Begun MG Per Day Begun Period Begun Class Begun
--- No Criteria ---
6/25/2014
Step Therapy
Previous therapy required with immediate release oxcarbazepine (Trileptal)
Perampanel (Fycompa) No Criteria --- Less than or equal
to 2 mg/day 10/22/2014 ---
Antiepileptic - Criteria Elements and Implementation Dates
Drug Name Generic (Brand) MG Per Day
Duplicate TherapyDrug Name Generic (Brand)
Drug Name Generic (Brand)
Maximum Daily Dose
Erectile Dysfunction Agents - Criteria Elements and Implementation Dates
Maximum DurationGender Edit
Oxcarbazepine extended release
(Oxtellar XR)
Maximum Initial Dose Maximum Daily Dose Maximum Duration
Antibiotics - Criteria Elements and Implementation Dates
Duplicate Therapy
111
Maximum Initial Dose Maximum Daily Dose Duration of Therapy Duplicate TherapyDate Date Date Date
Begun MG Per Day Begun Period Begun Class Begun
Maximum Initial Dose Maximum Daily Dose Duration of Therapy Duplicate TherapyDate Date Date Date
Begun MG Per Day Begun Period Begun Class Begun
10/22/2014
10/22/2014
Iloprost (Ventavis) No Criteria --- No Criteria --- --- --- Concurrent with other
Pulmonary Arterial 10/22/2014
Concurrent with other Pulmonary Arterial
Hypertension Agents10/22/2014
Epoprostenol (Veletri) No Criteria --- No Criteria --- --- ---
Concurrent with other Pulmonary Arterial
Hypertension Agents
---Concurrent with other
Pulmonary Arterial Hypertension Agents
10/22/2014
Tadalafil (Adcirca) No Criteria --- No Criteria --- --- ---
Macitentan (Opsumit) No Criteria --- No Criteria --- ---
10/22/2014
Sildenafil Citrate (Revatio) No Criteria --- No Criteria --- --- ---
Concurrent with other Pulmonary Arterial
Hypertension Agents10/22/2014
Concurrent with other Pulmonary Arterial
Hypertension Agents10/22/2014
Ambrisentan (Letairis) No Criteria --- No Criteria --- --- ---
Concurrent with other Pulmonary Arterial
Hypertension Agents
---Concurrent with other
Pulmonary Arterial Hypertension Agents
10/22/2014
Bosentan (Tracleer) No Criteria --- No Criteria --- --- ---
Pulmonary Arterial Hypertension - Criteria Elements and Implementation
Drug Name Generic (Brand)
MG Per Day
Riociquat (Adempas) No Criteria --- No Criteria --- ---
Naftifine hydrochloride --- --- Step Therapy
Requires a trial of a 1% naftifine product
Antifungals - Criteria Elements and Implementation Dates
Drug Name Generic (Brand)
MG Per Day
112
DateBegun
Cetirizine No Criteria --- Less than or equal 08/19/03 08/19/03 No Criteria(Zyrtec, Zyrtec-D) to 10 mg/day
Desloratadine No Criteria --- Less than or equal 08/19/03 08/19/03 No Criteria(Clarinex, Clarinex-D) to 5 mg/day
Fexofenadine No Criteria --- Less than or equal 08/19/03 08/19/03 No Criteria(Allegra, Allegra-D) to 120 mg/day
Fexofenadine No Criteria --- Less than or equal 08/19/03 08/19/03 No Criteria(Allegra, 180 mg to 180 mg/daystrength tablet)
DateBegun
Zolmitriptan No Criteria --- Less than or equal 08/19/03 08/19/03 3 days out(Zomig, ZMT) to 10 mg/day of every 30Almatriptan No Criteria --- Less than or equal 08/19/03 08/19/03 4 days out
(Axert) to 25 mg/day of every 30Methysergide No Criteria --- Less than or equal 08/19/03 08/19/03 150 days out
maleate to 8 mg/daily of every 180(Sansert)
Naratriptan(Amerge)
Frovatriptan No Criteria --- Less than or equal 08/19/03 08/19/03 4 days out(Frova) to 7.5 mg/day of every 30
Dihydroergotamine No Criteria --- Less than or equal 08/19/03 08/19/03 4 days out(Migranal) to 2 bottles daily of every 30Rizatriptan No Criteria --- Less than or equal 08/19/03 08/19/03 4 days out
(Maxalt, to 30 mg/day of every 30 Maxalt MLT)
Eletriptan No Criteria --- Less than or equal 03/29/04 03/29/04 3 days out(Relpax) to 40 mg/day of every 30
Sumitriptan and naproxen(Treximet)
DateBegun
Varenicline No Criteria --- No Criteria --- 12 weeks followed(Chantix) by another 12 weeks
if smoking cessation has been documented
Anaphylaxis Agent - Criteria and Implementation Dates
Drug Name Generic (Brand)
Step TherapyDate
Begun
Epinephrine Injection (AUVI-Q) Requires documentation as to why traditional Epi-Pen cannot be used.
Antihistamines - Criteria and Implementation Dates
Drug Name Generic (Brand)
Maximum Initial Dose Maximum Daily Dose Duplicate Therapy Duration of Therapy
MG Per Day MG Per DayDate
Begun ClassDate
BegunConcurrent with other
antihistaminesConcurrent with other
antihistaminesConcurrent with other
antihistaminesConcurrent with other
antihistamines
---
Concurrent with other anti-migraines
Concurrent with other anti-migraines
Date Begun Period
Duration of Therapy
---
---
---
08/19/03
08/19/03
MG Per Day MG Per DayDate
Begun ClassDate
Begun PeriodDate
Begun
02/19/07
Smoking Cessation Agent - Criteria and Implementation Dates
Drug Name Generic (Brand)
Maximum Initial Dose Maximum Daily Dose Duration of Therapy
MG Per Day MG Per DayDate
Begun PeriodDate
Begun
Antimigraine Agents - Criteria and Implementation Dates
Drug Name Generic (Brand)
Maximum Initial Dose Maximum Daily Dose Duplicate Therapy
Concurrent with other anti-migraines
Concurrent with other anti-migraines
Concurrent with other anti-migraines
Concurrent with other anti-migraines
03/29/04
Not indicated in the elderly
08/19/03
08/19/03
08/19/03Concurrent with other anti-migraines
Not Recommended for the Elderly
08/19/03
113
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oth
er t
han
T
AO
No
n-S
edat
ing
A
nti
his
tam
ines
Ser
zon
eE
ffex
or
Lu
vox
MA
OIn
hib
ito
rsN
itro
-g
lyce
rin
Via
gra
An
ti-
arry
thm
ics
Cla
ss 1
A, I
IIT
ricy
clic
An
ti-
dep
ress
ants
An
ti-
psy
cho
tics
Vas
cor,
H
ism
anal
, Z
agam
Cym
bal
ta
Pro
pu
lsid
co-a
dmin
co-a
dmin
co-a
dmin
co-a
dmin
co-a
dmin
co-a
dmin
co-a
dmin
co-a
dmin
Mo
nis
tat
IVco
-adm
in
Sp
ora
no
xco
-adm
inco
-adm
in
Niz
ora
lco
-adm
inco
-adm
in
TA
Oco
-adm
inco
-adm
in
Mac
rolid
es o
ther
th
an T
AO
co-a
dmin
No
n-S
edat
ing
An
tih
ista
min
esco
-adm
inco
-adm
inco
-adm
inco
-adm
inco
-adm
inco
-adm
in
Ser
zon
eco
-adm
inco
-adm
in,
14 d
ays
Eff
exo
rco
-adm
in,
14 d
ays
Lu
vox
co-a
dmin
co-a
dmin
,14
day
s
MA
OIn
hib
ito
rsco
-adm
in,
7 da
ysco
-adm
in,
7 da
ysco
-adm
in,
14 d
ays
co-a
dmin
,14
day
s
Nit
rog
lyce
rin
co-a
dmin
Via
gra
co-a
dmin
An
tiar
rhyt
hm
ics
Cla
ss 1
A, I
IIco
-adm
in
Tri
cycl
ic
An
tid
epre
ssan
tsco
-adm
in
An
tip
sych
oti
csco
-adm
in
Vas
cor,
His
man
al,
Zag
amco
-adm
in
Cym
bal
taco
-adm
in,
14 d
ays
Inco
min
g C
laim
Che
ck fo
r Dru
gs A
lread
y in
His
tory
MA
TR
IX O
F D
RU
G-D
RU
G IN
TE
RA
CT
ION
S
114