The passage of the Patient Protection and Affordable Care Act has the potential to dramatically increase Medicaid and commercial enrollment in Ohio, Kentucky and Indiana with expansion of Medicaid eligibility and the creation of healthcare exchanges. The continued growth of mail order pharmacy delivery appears anything but certain, even though most insurers in the Indiana-Kentucky-Ohio region have enhanced the benefit, and offered members more incentives to take advantage of it. Competing forces, like retailers offering low-cost generics, health plans re-contracting with PBMs that don't give the best pricing and a broad-based push for more generic dispensing have all worked against mail order, even though it usually offers a better deal to members and employers. Smoking is the main cause of preventable death in the U.S., and has a high prevalance in Indiana and Kentucky, and moderately so in Ohio. Yet health plans in the region have an underwhelming approach to the problem, not covering all available treatments, and not heavily incentivizing the best treatments. A couple of insurers have gotten serious about smoking cessation, however, and are setting the standard that others should follow.