Mo. Code Regs. tit. 22 § 10-2.089
Current through Register Vol. 49, No. 23, December 2, 2024
Section 22 CSR 10-2.089 - [Effective 6/29/2025] Pharmacy Employer Group Waiver Plan for Medicare Primary MembersPURPOSE: 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 & 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 & 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; andC. 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); and5. Amounts paid by the member or the plan for non-Part D prescription drugs will not count toward total Part D prescription drug costs or total Part D prescription drug out-ofpocket 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; and2. 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.AUTHORITY: section 103.059, RSMo 2000. Emergency rule filed Oct. 30, 2013, effective Jan. 1, 2014, expires June 29, 2014. Original rule filed Oct. 30, 2013, effective Jun 30 2014. Emergency amendment filed Oct 29, 2014, effective Jan. 1, 2015, terminated May 30, 2015.Amended by Missouri Register April 1, 2015/Volume 40, Number 07, effective 5/31/2015Amended by Missouri Register April 1, 2016/Volume 41, Number 07, effective 5/31/2016Amended by Missouri Register April 17, 2017/Volume 42, Number 08, effective 5/31/2017Amended by Missouri Register April 2, 2018/Volume 43, Number 7, effective 5/31/2018Amended by Missouri Register April 1, 2019/Volume 44, Number 7, effective 5/31/2019Amended by Missouri Register April 1, 2020/Volume 45, Number 7, effective 5/31/2020Amended by Missouri Register December 1, 2020/Volume 45, Number 23, effective 1/1/2021Amended by Missouri Register April 15, 2021/Volume 46, Number 08, effective 5/31/2021Amended by Missouri Register December 1, 2021/Volume 46, Number 23, effective 1/1/2022Amended by Missouri Register April 1, 2022/Volume 47, Number 7, effective 5/31/2022Amended by Missouri Register December 1, 2022/Volume 47, Number 23, effective 1/1/2023Amended by Missouri Register April 3, 2023/Volume 48, Number 7, effective 5/30/2023Amended by Missouri Register December 1, 2023/Volume 48, Number 23, effective 1/1/2024, exp. 6/28/2024 (Emergency).Amended by Missouri Register April 1, 2024/Volume 49, Number 07, effective 5/31/2024.Amended by Missouri Register December 2, 2024/Volume 49, Number 23, effective 1/1/2025, exp. 6/29/2025 (Emergency).