TITLE 16

Health and Safety

Regulatory Provisions Concerning Public Health

CHAPTER 30B. PRESCRIPTION DRUG PAYMENT ASSISTANCE PROGRAM


This chapter shall be known and may be cited as the "Delaware Prescription Drug Payment Assistance Program''.

72 Del. Laws, 1st Sp. Sess., c. 259, § 1.;

The purpose of this chapter is to provide payment assistance for prescription drugs and certain Medicare Part D costs to Delaware's low-income senior and disabled citizens who are ineligible for, or do not have, prescription drug benefits or coverage through federal (excluding Medicare Part D coverage), state or private sources.

72 Del. Laws, 1st Sp. Sess., c. 259, § 1; 75 Del. Laws, c. 17, § 1.;

(a) "Department'' shall mean the Department of Health and Social Services.

(b) "Eligible person'' shall mean a person eligible for the Delaware Prescription Drug Payment Assistance Program pursuant to § 3004B of this title.

(c) "Prescription drugs'' shall mean drugs and supplies that have been approved as safe and effective by the Federal Food and Drug Administration or are otherwise legally marketed in the United States, including items related to diabetes management, if not covered by Medicare, that a physician has deemed medically necessary for the diagnosis and/or treatment of the patient. For the purposes of this chapter, prescription drugs may include cost effective over-the-counter pharmaceutical products if prescribed by a health care provider authorized to prescribe prescription drugs as an alternative to more costly drugs. Prescription drugs covered under this chapter shall be limited and subject to the provisions of § 3005B of this title and the rules and regulation adopted pursuant thereto.

(d) The "Program'' shall mean the Prescription Drug Payment Assistance Program.

(e) "Secretary'' shall mean the Secretary of the Department of Health and Social Services.

(f) "Medicare Part D costs'' shall mean monthly premiums, deductibles and those drug costs falling into Part D coverage gap up to the Program benefit limits and subject to program co-pay requirements as described in § 3005B(a)(4) of this title. Medicare Part D costs do not include Medicare Part D co-payments.

72 Del. Laws, 1st Sp. Sess., c. 259, § 1; 75 Del. Laws, c. 17, § 2.;

To be eligible for the Program a person must:

(1) Be a U.S. citizen or a lawfully admitted alien;

(2) Have income that is less than 200% of the Federal Poverty Level (FPL) or have prescription drug expenses that exceed 40% of his or her annual income;

(3) Be a resident of the State;

(4) Be ineligible for Medicaid prescription benefits;

(5) Be ineligible for and/or not receiving a prescription drug benefit or any third party payer prescription benefit (excluding Medicare Part D coverage);

(6) Be enrolled in Medicare Part D and Medicare Part D Low Income Subsidy if eligible or qualify for a Medicare Part D Special Enrollment Period as an eligible person under the Delaware Prescription Drug Payment Assistance Program; and

(7) Be an individual aged 65 or over or be an individual between the ages 19 and 64 who is otherwise eligible for benefits under Title II of the Social Security Act (Federal Old Age, Survivors and Disability Insurance Benefits) [42 U.S.C. § 401 et seq.].

72 Del. Laws, 1st Sp. Sess., c. 259, § 1; 75 Del. Laws, c. 17, §§ 3-7; 76 Del. Laws, c. 7, §§ 1, 2.;

(a) The Delaware Prescription Drug Payment Assistance Program shall be administered by the Department. The Department shall promulgate and adopt rules and regulations as are necessary to implement the Program in a cost-effective manner and to ensure the Program is the payer of last resort for prescription drugs. Rules and regulations shall include the following:

(1) Payment assistance shall not exceed $3,000 in a benefit year to assist each eligible person in the purchase of prescription drugs and the payment of certain Medicare Part D costs.

(2) Medicare Part D coverage will be primary to payment assistance under the program.

(3) The Department shall restrict covered prescription drugs covered under the Program to those manufactured by pharmaceutical companies that agree to provide manufacturer rebates under the drug rebate program established for non-Medicaid programs. The Department shall establish a state rebate program that it determines is in the best interests of the citizens who are being served. The rebate amount shall be calculated using the full methodology prescribed by the federal government for the Medicaid program. Notwithstanding any provisions of the Delaware Code to the contrary, the Department shall deposit any drug rebate funds received into the appropriate Social Services program account and be used to meet program costs.

(4) The Department shall develop a copayment requirement, which shall not exceed 25% of the acquisition cost but shall be no lower than $5.00. Copayment amounts may vary when a generic drug is purchased by eligible persons in the Program. These same copayment amounts shall apply to prescription drug costs not covered by Medicare Part D. The copayment may be waived in cases of severe hardship.

(5) The Secretary or the Secretary's designee shall provide a clear, written explanation defining the scope of the Program's coverage, the amount of the cost-sharing requirements and any limitations on access to covered prescription drugs. The Department shall provide notice, when 75% of the cap has been expended. The Department will also notify persons of the process to appeal a decision denying reimbursement for prescription drugs or denying a person's eligibility for the Program. Services shall begin on the first day of the month, following the month that eligibility is determined. Eligible individuals will receive an identification card for the Program.

(6) No drug prescription may exceed 100 dosing units or a 34-day supply, whichever is greater.

(7) No system of administration shall make direct cash payment to any eligible person.

(b) The Department may promulgate and adopt rules and regulations consistent with the following:

(1) Limiting application to the Program to a specific open-enrollment period, with coverage effective as of the date the application is approved.

(2) Imposing an annual enrollment fee in an amount not to exceed $20 to be paid by all eligible persons in the Program to defray administrative expenses. Payment of any such fee shall be credited to a special fund to be designated as the Prescription Assistance Fund. For each year, the maximum unencumbered balance which shall remain in the Prescription Assistance Fund at the end of any year shall be no more than the administrative cost of the program in the subsequent year.

(3) Determining income eligibility of a person by any reasonable means, including, but not limited to a review of the person's most recent federal and state income tax returns and copies of income checks. Residency and age/disability eligibility may be verified by submission of such documents as the Secretary or the Secretary's designee deems reasonable.

(4) Rules and regulations the Secretary deemed necessary to implement the Program consistent with the purposes outlined herein and appropriations provided to implement this Program.

72 Del. Laws, 1st Sp. Sess., c. 259, § 1; 75 Del. Laws, c. 17, §§ 8, 10; 75 Del. Laws, c. 363, § 1.;

The Department shall maintain data to evaluate the cost and effectiveness of the Program and shall produce an annual report summarizing participant demographics, utilization, utilization review results and such other available information as may be needed to evaluate the costs and benefits of the Program.

72 Del. Laws, 1st Sp. Sess., c. 259, § 1; 75 Del. Laws, c. 17, § 11.;

A pharmacist shall not dispense or provide a covered prescription drug to an eligible person until the eligible person makes the required copayment.

72 Del. Laws, 1st Sp. Sess., c. 259, § 1.;