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.

EMERGENCY STATEMENT: This emergency amendment must be in place by January 1, 2024, in accordance with the new plan year. Therefore, this emergency amendment is necessary to serve a compelling governmental interest of protecting members (employees, retirees, officers, and their families) enrolled in the Missouri Consolidated Health Care Plan (MCHCP) from the unintended consequences of confusion regarding eligibility or availability of benefits and will allow members to take advantage of opportunities for reduced premiums for more affordable options without which they may forego coverage. Further, it clarifies member eligibility and responsibility for various types of eligible charges, beginning with the first day of coverage for the new plan year. It may also help ensure that inappropriate claims are not made against the state and help protect the MCHCP and its members from being subjected to unexpected and significant financial liability and/or litigation. It is imperative that this amendment be filed as an emergency amendment to maintain the integrity of the current health care plan. This emergency amendment fulfills the compelling governmental interest of offering access to more convenient and affordable medical services to members as one (1) method of protecting the MCHCP trust fund from more costly expenses. This emergency amendment reflects changes made to the plan by the Missouri Consolidated Health Care Plan Board of Trustees. A proposed amendment, which covers the same material, is published in this issue of the Missouri Register. This emergency amendment complies with the protections extended by the Missouri and United States Constitutions and limits its scope to the circumstances creating the emergency. The MCHCP follows procedures best calculated to assure fairness to all interested persons and parties under the circumstances. This emergency amendment was filed October 27, 2023, becomes effective January 1, 2024, and expires June 28, 2024.

(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 five thousand thirty dollars ($5,030), 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 five thousand thirty dollars ($5,030) and remain below eight thousand dollars ($8,000), 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 eight thousand dollars ($8,000);

4. Catastrophic coverage stage. After a member's total yearly out-of-pocket Part D prescription drug costs reach eight thousand dollars ($8,000), the member will pay zero dollars ($0); 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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