The Medicaid by Drug dataset presents information on spending for covered outpatient drugs prescribed to beneficiaries enrolled in Medicaid by physicians and other healthcare professionals. 

 

The dataset focuses on average spending per dosage unit and change in average spending per dosage unit over time. Units refer to the drug unit in the lowest dispensable amount. It also includes spending information for manufacturer(s) of the drugs as well as consumer-friendly information of drug uses and clinical indications.

 

Drug spending metrics for Medicaid represent the total amount reimbursed by both Medicaid and non-Medicaid entities to pharmacies for the drug. Medicaid drug spending contains both the Federal and State reimbursement and is inclusive of any applicable dispensing fees. In addition, this total is not reduced or affected by Medicaid rebates paid to the states.

The Quarterly Prescription Drug Plan Formulary, Pharmacy Network, and Pricing Information files contain formulary, pharmacy network, and pricing data for Medicare Prescription Drug Plans and Medicare Advantage (MA) Prescription Drug Plans (with the exception of employer and Program of All-Inclusive Care for the Elderly plans). These non-identifiable files are available on a quarterly basis and are comprised of the following tables:

 

Plan Information - Information such as plan name, contract ID, plan ID, service area, and plan type.
Geographic Locator - MA and Prescription Drug Plans region codes and county codes.
Basic Drugs Formulary - Formulary details for each plan including National Drug Codes (NDCs), cost share tier level, and indicators for step therapy, quantity limits, and prior authorization.
Excluded Drugs Formulary - Enhanced alternative plans may elect to provide a supplemental benefit and cover excluded drugs. File includes formulary details for excluded drugs that are covered by the plan (for enhanced alternative plans only).
Beneficiary Cost - Plan level cost sharing details for preferred, non-preferred, and mail order network pharmacies.
Pharmacy Network - National Provider Identifier (NPI) numbers for each network pharmacy including preferred, retail, and mail order indicators.
Pricing - Plan level average monthly costs for formulary Part D drugs (note: this table is only available in the quarterly files).
Partial Gap Coverage - Plan-RxCUI combinations that are on tiers that offer gap coverage for some drugs on the tier.
Indication Based Coverage Formulary File - Includes drugs covered based on FDA-approved indication for each plan.
Insulin Beneficiary Cost File - Plan level cost sharing details for insulin at preferred, non-preferred and mail order network pharmacies.

 

These are large files and can take time to download. 

 

Please read the “Agreement for Use” in the Resources section below. This document contains important information regarding timeframes for obtaining data as well as data accuracy and integrity.

 

The Monthly Prescription Drug Plan Formulary and Pharmacy Network Information is also available to access for the monthly level information.

 

Please note:  The Part D benefit year information for plans become available in October of the year prior. For example, year 2024 data is available in the fourth quarter file of 2023. Year 2024 data continues to be available in the Q1-Q3 2024  files, then in the fourth quarter of 2024 year 2025 data becomes available. 

Estimated release dates for upcoming 2024 quarterly data (files reflect data for the quarter that ended the month before the file was released):

10/16/24
1/29/25
4/23/25
7/30/25

Files older than contract year 2019 can be purchased.

The Provider of Services (POS) Clinical Laboratories (CLIA) data provides information on CLIA demographics and types of testing services the facility provides. In this file you will find provider number, name, address and characteristics of the participating institution providers.

The Monthly Prescription Drug Plan Formulary and Pharmacy Network Information files contain formulary and pharmacy network data for Medicare Prescription Drug Plans and Medicare Advantage (MA) Prescription Drug Plans (with the exception of employer and Program of All-Inclusive Care for the Elderly plans). These non-identifiable files are available on a monthly basis and are comprised of the following tables:

 

Plan Information - Information such as plan name, contract ID, plan ID, service area, and plan type.
Geographic Locator - MA and Prescription Drug Plans region codes and county codes.
Basic Drugs Formulary - Formulary details for each plan including National Drug Codes (NDCs), cost share tier level, and indicators for step therapy, quantity limits, and prior authorization.
Excluded Drugs Formulary - Enhanced alternative plans may elect to provide a supplemental benefit and cover excluded drugs. File includes formulary details for excluded drugs that are covered by the plan (for enhanced alternative plans only).
Beneficiary Cost - Plan level cost sharing details for preferred, non-preferred, and mail order network pharmacies.
Pharmacy Network - National Provider Identifier (NPI) numbers for each network pharmacy including preferred, retail, and mail order indicators.
Partial Gap Coverage - Plan-RxCUI combinations that are on tiers that offer gap coverage for some drugs on the tier.
Indication Based Coverage Formulary File - Includes drugs covered based on FDA-approved indication for each plan.
Insulin Beneficiary Cost File - Plan level cost sharing details for insulin at preferred, non-preferred and mail order network pharmacies.

 

These are large files and can take time to download. 
 

Please read the “Agreement for Use” in the Resources section below. This document contains important information regarding timeframes for obtaining data as well as data accuracy and integrity.

 

The Quarterly Prescription Drug Plan Formulary, Pharmacy Network, and Pricing Information is also available to access for the quarterly level information. 

 

Please note: The Part D benefit year information for plans become available in October of the year prior. For example, year 2024 data is available in the October, November and December 2023 monthly files. Year 2024 data continues to be available in the January through September 2024 monthly files, then beginning in October of 2024 year 2025 data becomes available.

Estimated release dates for upcoming 2024 monthly data (files reflect data for the month in which the file is released):

9/25/24
10/16/24
11/20/24
12/18/24
1/29/25
2/26/25
3/26/25
4/23/25
5/21/25
6/18/25
7/30/25
8/27/25
9/24/25

Files older than contract year 2019 can be purchased.