Missouri Code of State Regulations
Title 22 - MISSOURI CONSOLIDATED HEALTH CARE PLAN
Division 10 - Health Care Plan
Chapter 2 - State Membership
Section 22 CSR 10-2.089 - Pharmacy Employer Group Waiver Plan for Medicare Primary Members
Universal Citation: 22 MO Code of State Regs 10-2.089
Current through Register Vol. 49, No. 6, March 15, 2024
PURPOSE: This amendment revises Medicare Part D coverage stage and copayment amounts.
(1) The pharmacy benefit for Medicare primary non-active members is provided through a Pharmacy Employer Group Waiver Plan (EGWP) as regulated by the Centers for Medicare and Medicaid Services hereinafter referred to as the Medicare Prescription Drug Plan.
(A) Non-active subscribers that have Medicare
primary coverage and their dependents that have Medicare primary coverage
enrolled in the Medicare Advantage Plan shall receive their pharmacy benefit
through the Medicare Prescription Drug Plan.
(B) The non-Medicare dependents of Medicare
primary non-active subscribers will not be in the Medicare Prescription Drug
Plan but will have pharmacy benefit coverage as defined by
22 CSR
10-2.090.
(C) Foster parent members that have Medicare
primary coverage and their dependents that have Medicare primary coverage will
not be in the Medicare Prescription Drug Plan but will have pharmacy benefit
coverage as defined by
22 CSR
10-2.090.
(D) A retiree Medicare primary member who
chooses not to be in the Medicare Prescription Drug Plan will lose MCHCP
eligibility and will not be allowed to enroll in a medical or Medicare
Prescription Drug Plan at a later date.
(E) MCHCP will pay the Medicare financial
penalty incurred by a Medicare primary member who has had a continuous gap in
prescription drug coverage of sixty-three (63) days or more after the Medicare
Initial Election Period (IEP) and was not covered by any creditable
prescription drug coverage and failed to enroll into Part D.
(F) The Medicare Prescription Drug Plan is
comprised of a Medicare Part D prescription drug plan contracted by MCHCP and
some non-Part D medications that are not normally covered by a Medicare Part D
prescription drug plan. The requirements for the Medicare Part D prescription
drug plan are as follows:
1. The Centers for
Medicare and Medicaid Services regulates the Medicare Part D prescription drug
program. The Medicare Prescription Drug Plan abides by those
regulations;
2. Initial coverage
stage. Until a member's total yearly Part D prescription drug costs reach four
thousand six hundred sixty dollars ($4,660), the member will pay the following
copayments:
A. Preferred formulary generic
drugs: thirty-one- (31-) day supply has a ten dollar ($10) copayment; sixty-
(60-) day supply has a twenty dollar ($20) copayment; ninety- (90-) day supply
at retail has a thirty dollar ($30) copayment; and a ninety-(90-) day supply
through home delivery has a twenty-five dollar ($25) copayment;
B. Preferred formulary brand drugs:
thirty-one- (31-) day supply has a forty dollar ($40) copayment; sixty- (60-)
day supply has an eighty dollar ($80) copayment; ninety- (90-) day supply at
retail has a one hundred twenty dollar ($120) copayment; and a ninety- (90-)
day supply through home delivery has a one hundred dollar ($100) copayment;
and
C. Non-preferred formulary
drugs and approved excluded drugs: thirty-one- (31-) day supply has a one
hundred dollar ($100) copayment; sixty- (60-) day supply has a two hundred
dollar ($200) copayment; ninety- (90-) day supply at retail has a three hundred
dollar ($300) copayment; and a ninety- (90-) day supply through home delivery
has a two hundred fifty dollar ($250) copayment;
3. Coverage gap stage. After a member's total
yearly Part D prescription drug costs exceed four thousand six hundred sixty
dollars ($4,660) and remain below seven thousand four hundred dollars ($7,400),
the member will continue to pay the same cost-sharing amount as in the initial
coverage stage until the yearly out-of-pocket Part D prescription drug costs
reach seven thousand four hundred dollars ($7,400);
4. Catastrophic coverage stage. After a
member's total yearly out-of-pocket Part D prescription drug costs reach seven
thousand four hundred dollars ($7,400), the member will pay the greater of-
A. Five percent (5%) coinsurance or a four
dollar and fifteen cent ($4.15) copayment for covered generic drugs (including
brand drugs treated as generics), with a maximum not to exceed the standard
copayment during the initial coverage stage; or
B. Five percent (5%) coinsurance or a ten
dollar and thirty-five cent ($10.35) copayment for all other covered drugs,
with a maximum not to exceed the standard copayment during the initial coverage
stage; and
5. Amounts
paid by the member or the plan for nonPart D prescription drugs will not count
toward total Part D prescription drug costs or total Part D prescription drug
out-of-pocket costs.
(G)
Medications covered under
22 CSR
10-2.090 will be covered under the Medicare
Prescription Drug Plan as non-Part D medications when they are not a Part D
covered drug.
(H) Medicare Part B
Prescription Drugs are excluded from the Medicare Prescription Drug
Plan.
(I) Prescription drugs and
prescribed over-the-counter drugs as recommended by the U.S. Preventive
Services Task Force (categories A and B) are covered at one hundred percent
(100%) when filled at a network pharmacy. The following are also covered at one
hundred percent (100%) when filled at a network pharmacy:
1. Vaccines and administration as recommended
by the Advisory Committee on Immunization Practices of the Centers for Disease
Control and Prevention; and
2.
Preferred formulary brand contraception and non-preferred contraception when
the provider determines a generic is not medically appropriate or a generic
version is not available.
Disclaimer: These regulations may not be the most recent version. Missouri 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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