C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-80, subsec. 144-101-II-80.08

Current through 2024-51, December 18, 2024

Subsection 144-101-II-80.08 - CO-PAYMENT

A co-payment is to be charged by the pharmacy to each MaineCare member for each prescription filled or refilled, with the exception of prescriptions filled by the Department's mail order pharmacy providers and tobacco cessation products. Members shall not pay a co-payment for drugs obtained from the Department's mail order pharmacy providers and tobacco cessation products. Co-payment dispute resolution procedures are described in Chapter I of the MaineCare Benefits Manual. No pharmacy may discount the co-payment for promotional purposes.

80.08-1Pharmacy Benefits Provided By Retail and Specialty Pharmacy Providers

A. The amount of the co-payment shall be three dollars ($3.00) per prescription, except for tobacco cessation products (see Section 80.08-4), not to exceed thirty dollars ($30.00) per member per month, except as otherwise described below. The co-payment is the same for Medicare Part D Excluded Drugs.

B. The pharmacy shall not deny pharmacy services to a MaineCare member on account of the member's inability to pay a co-payment. Providers must rely upon the member's representation that he or she does not have the cash available to pay the co-payment. However, the individual's inability to pay does not eliminate his or her liability for the co-payment.

C. If a member is dispensed a drug in a quantity specifically intended by the prescriber or pharmacist to last less than one month for the member's health and welfare, only one co-payment for that drug that month is required.

D. Co-payment exemptions are described in Chapter I of the MaineCare Benefits Manual.

80.08-2Pharmacy Benefits Provided By Department-approved Mail Order Pharmacy Providers

Members shall have no co-payment for drugs dispensed through Department-approved mail order pharmacy providers, except as otherwise described below.

80.08-3Benefit for People Living With HIV/AIDS

Co-payment policies for members receiving the Benefit for People Living with HIV/AIDS can be found in the MaineCare Benefits Manual, Chapter X, Section 1.

80.08-4 Pharmacy Benefits Provided by Department-Approved Smoking Cessation Products With No Co-Payment Requirements

Effective August 1, 2014, no co-payments or other out-of-pocket cost sharing, including deductibles, shall be imposed on a MaineCare member eighteen (18) years of age or older or who is pregnant who has been prescribed a smoking cessation product. No annual or lifetime dollar limit or lifetime limit on attempts to quit may be imposed on the member. The member cannot be required to participate in counseling as a condition for receiving medication. Smoking cessation products must be approved by the Federal Food and Drug Administration and be listed on the Preferred Drug List. Please see the following link: www.mainecarepdl.org.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-80, subsec. 144-101-II-80.08