Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 104 - MAINE STATE SERVICES MANUAL
Sec2 144-104-2 - Maine Drugs for the Elderly Benefit
Subsection 144-104-2.11 - REIMBURSEMENT
Universal Citation: 10 ME Code Rules ยง 144-104-2.11
Current through 2024-38, September 18, 2024
The Department will reimburse participating pharmacies only for drugs that are covered drugs as set forth above.
The DEL Benefit is the payor of last resort. If the participant has another prescription drug coverage plan, that plan must be billed first.
A. The Department may establish the Maine Maximum Allowable Cost (MMAC) for covered drugs, considering the following factors:
1. Multiple
manufacturers;
2. Broad wholesale
price span;
3. Availability of
drugs to retailers at the selected cost;
4. High volume of utilization; and
5. Bioequivalence or
interchangability.
B. For retail pharmacies the amount of reimbursement will be the lowest of the following:
1. For Generic Drugs
a. The usual and customary charge;
or
b. The Maine Maximum Allowable
Cost plus a $2.35 professional fee; or
c. The Average Wholesale Price minus 14% plus
a $2.35 professional fee; or
d. The
State Upper Limit (250% of Average Manufacturer's Cost for multi-source generic
drugs) plus a $2.35 professional fee.
2. For Brand-Name Drugs
a. The usual and customary charge;
or
b. The Average Wholesale Price
minus 15% plus a $2.35 professional fee.
C. For mail order pharmacies, the amount of reimbursement will be the lowest of the following:
1. For Generic Drugs
a. The usual and customary charge;
or
b. The Average Wholesale Price
minus 60% plus $1.00 professional fee except as otherwise noted below,
or
c. The Maine Maximum Allowable
Cost plus $1.00 professional fee.
2. For Brand-Name Drugs
a. The usual and customary charge;
or
b. The Average Wholesale Price
minus 20% plus $1.00 professional fee.
Disclaimer: These regulations may not be the most recent version. Maine may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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