NY Elder L § 248 (2021)
2021 New York Laws ELD - Elder Article 2 - Programs for the Elderly Title 3 - Program for Elderly Pharmaceutical Insurance Coverage 248 - Cost-Sharing Responsibilities of Eligible Program Participants for Catastrophic Coverage.

§  248. Cost-sharing responsibilities of eligible program participants for catastrophic coverage. 1. Deductible. Eligible  individuals  meeting the  deductible  requirements  of  this  section may purchase prescribed covered drugs for an amount  specified  by  subdivision  three  of  this section, subject to the limits on point of sale co-payments specified by subdivision four of this section.   2.  Deductible  schedule.  Eligible  individuals  electing to meet the requirements of this subdivision  shall  incur  an  amount  of  personal covered  drug  expenditures  during any annual coverage period which are not reimbursed by any other public or private third party payment source or insurance plan, and shall be deemed  to  have  met  their  deductible requirements  for  the  remainder  of  such  annual coverage period. The amount of personal covered drug expenditures to be incurred by  eligible program  participants  for catastrophic coverage under this option shall be in accordance with the following schedule:  (a) Annual personal covered drug expenditures for unmarried individual eligible program participants: individual income of $20,001 to $21,000                $530 individual income of $21,001 to $22,000                $550 individual income of $22,001 to $23,000                $580 individual income of $23,001 to $24,000                $720 individual income of $24,001 to $25,000                $750 individual income of $25,001 to $26,000                $780 individual income of $26,001 to $27,000                $810 individual income of $27,001 to $28,000                $840 individual income of $28,001 to $29,000                $870 individual income of $29,001 to $30,000                $900 individual income of $30,001 to $31,000                $930 individual income of $31,001 to $32,000                $960 individual income of $32,001 to $33,000                $1,160 individual income of $33,001 to $34,000                $1,190 individual income of $34,001 to $35,000                $1,230 individual income of $35,001 to $36,000                $1,260 individual income of $36,001 to $37,000                $1,290 individual income of $37,001 to $38,000                $1,320 individual income of $38,001 to $39,000                $1,350 individual income of $39,001 to $40,000                $1,380 individual income of $40,001 to $41,000                $1,410 individual income of $41,001 to $42,000                $1,440 individual income of $42,001 to $43,000                $1,470 individual income of $43,001 to $44,000                $1,500 individual income of $44,001 to $45,000                $1,530 individual income of $45,001 to $46,000                $1,560 individual income of $46,001 to $47,000                $1,590 individual income of $47,001 to $48,000                $1,620 individual income of $48,001 to $49,000                $1,650 individual income of $49,001 to $50,000                $1,680 individual income of $50,001 to $51,000                $1,710 individual income of $51,001 to $52,000                $1,740 individual income of $52,001 to $53,000                $1,770 individual income of $53,001 to $54,000                $1,800 individual income of $54,001 to $55,000                $1,830 individual income of $55,001 to $56,000                $1,860 individual income of $56,001 to $57,000                $1,890 individual income of $57,001 to $58,000                $1,920 individual income of $58,001 to $59,000                $1,950 individual income of $59,001 to $60,000                $1,980 individual income of $60,001 to $61,000                $2,010  individual income of $61,001 to $62,000                $2,040 individual income of $62,001 to $63,000                $2,070 individual income of $63,001 to $64,000                $2,100 individual income of $64,001 to $65,000                $2,130 individual income of $65,001 to $66,000                $2,160 individual income of $66,001 to $67,000                $2,190 individual income of $67,001 to $68,000                $2,220 individual income of $68,001 to $69,000                $2,250 individual income of $69,001 to $70,000                $2,280 individual income of $70,001 to $71,000                $2,310 individual income of $71,001 to $72,000                $2,340 individual income of $72,001 to $73,000                $2,370 individual income of $73,001 to $74,000                $2,400 individual income of $74,001 to $75,000                $2,430  (b) Annual personal covered drug expenditures for each married individual eligible program participant: joint income of $26,001 to $27,000                     $650 joint income of $27,001 to $28,000                     $675 joint income of $28,001 to $29,000                     $700 joint income of $29,001 to $30,000                     $725 joint income of $30,001 to $31,000                     $900 joint income of $31,001 to $32,000                     $930 joint income of $32,001 to $33,000                     $960 joint income of $33,001 to $34,000                     $990 joint income of $34,001 to $35,000                     $1,020 joint income of $35,001 to $36,000                     $1,050 joint income of $36,001 to $37,000                     $1,080 joint income of $37,001 to $38,000                     $1,110 joint income of $38,001 to $39,000                     $1,140 joint income of $39,001 to $40,000                     $1,170 joint income of $40,001 to $41,000                     $1,200 joint income of $41,001 to $42,000                     $1,230 joint income of $42,001 to $43,000                     $1,260 joint income of $43,001 to $44,000                     $1,290 joint income of $44,001 to $45,000                     $1,320 joint income of $45,001 to $46,000                     $1,575 joint income of $46,001 to $47,000                     $1,610 joint income of $47,001 to $48,000                     $1,645 joint income of $48,001 to $49,000                     $1,680 joint income of $49,001 to $50,000                     $1,715 joint income of $50,001 to $51,000                     $1,745 joint income of $51,001 to $52,000                     $1,775 joint income of $52,001 to $53,000                     $1,805 joint income of $53,001 to $54,000                     $1,835 joint income of $54,001 to $55,000                     $1,865 joint income of $55,001 to $56,000                     $1,895 joint income of $56,001 to $57,000                     $1,925 joint income of $57,001 to $58,000                     $1,955 joint income of $58,001 to $59,000                     $1,985 joint income of $59,001 to $60,000                     $2,015 joint income of $60,001 to $61,000                     $2,045 joint income of $61,001 to $62,000                     $2,075 joint income of $62,001 to $63,000                     $2,105 joint income of $63,001 to $64,000                     $2,135 joint income of $64,001 to $65,000                     $2,165 joint income of $65,001 to $66,000                     $2,195 joint income of $66,001 to $67,000                     $2,225 joint income of $67,001 to $68,000                     $2,255  joint income of $68,001 to $69,000                     $2,285 joint income of $69,001 to $70,000                     $2,315 joint income of $70,001 to $71,000                     $2,345 joint income of $71,001 to $72,000                     $2,375 joint income of $72,001 to $73,000                     $2,405 joint income of $73,001 to $74,000                     $2,435 joint income of $74,001 to $75,000                     $2,465 joint income of $75,001 to $76,000                     $2,495 joint income of $76,001 to $77,000                     $2,525 joint income of $77,001 to $78,000                     $2,555 joint income of $78,001 to $79,000                     $2,585 joint income of $79,001 to $80,000                     $2,615 joint income of $80,001 to $81,000                     $2,645 joint income of $81,001 to $82,000                     $2,675 joint income of $82,001 to $83,000                     $2,705 joint income of $83,001 to $84,000                     $2,735 joint income of $84,001 to $85,000                     $2,765 joint income of $85,001 to $86,000                     $2,795 joint income of $86,001 to $87,000                     $2,825 joint income of $87,001 to $88,000                     $2,855 joint income of $88,001 to $89,000                     $2,885 joint income of $89,001 to $90,000                     $2,915 joint income of $90,001 to $91,000                     $2,945 joint income of $91,001 to $92,000                     $2,975 joint income of $92,001 to $93,000                     $3,005 joint income of $93,001 to $94,000                     $3,035 joint income of $94,001 to $95,000                     $3,065 joint income of $95,001 to $96,000                     $3,095 joint income of $96,001 to $97,000                     $3,125 joint income of $97,001 to $98,000                     $3,155 joint income of $98,001 to $99,000                     $3,185 joint income of $99,001 to $100,000                    $3,215  (c)  In the event that the state expenditures per participant electing to meet the deductible requirements of this  subdivision,  exclusive  of expenditures  for program administration, in the program year commencing October first, nineteen hundred eighty-eight, and in each  program  year thereafter,  exceed  such expenditures in the previous program year by a minimum of ten percent, the annual personal  covered  drug  expenditures set  forth in this subdivision may, unless otherwise provided by law, be increased, pro-rata, for the subsequent program year, provided that such increase shall not exceed eight  percent  of  the  prior  year  personal covered  drug  expenditures as may have been adjusted in accordance with this paragraph.  (d) In the event that the state  expenditures  per  such  participant, incurred  pursuant  to  this  subdivision, exclusive of expenditures for program administration, in the program year  commencing  October  first, nineteen  hundred eighty-eight, and in each program year thereafter, are less than such expenditures in the previous program year by a minimum of ten percent, the annual personal covered drug expenditures set forth  in this  subdivision  may,  unless otherwise provided by law, be decreased, pro-rata, for the subsequent program year, provided that  such  decrease shall  not  exceed eight percent of the prior year personal covered drug expenditures  as  may  have  been  adjusted  in  accordance  with   this paragraph.  (e)   The   determination  to  adjust  annual  personal  covered  drug expenditures set forth in this subdivision, shall  follow  a  review  of such  factors  as  the relative financial capacity of the state and such eligible program participants to support such adjustments and changes in  the consumer price index. The frequency of such  adjustments  shall  not exceed  once  in  any twelve month period and such adjustments shall not become effective for individual program participants prior to the  first day of the next annual coverage period for each participant.   3.  Point  of sale co-payment. (a) Upon satisfaction of the deductible requirements pursuant to subdivision two of this  section,  an  eligible program participant shall pay a point of sale co-payment as set forth in paragraph  (b)  of  this  subdivision  at the time of each purchase of a covered drug prescribed for such individual. Such co-payment  shall  not be waived or reduced in whole or in part, subject to the limits provided by subdivision four of this section.  (b)  The  point  of  sale  co-payment  amounts which are to be charged eligible program participants shall be in accordance with the  following schedule: For each prescription of covered drugs costing $15.00 or less                           $3.00 For each prescription of covered drugs costing $15.01 to $35.00                         $7.00 For each prescription of covered drugs costing $35.01 to $55.00                         $15.00 For each prescription of covered drugs costing $55.01 or more                           $20.00  (c)  For  the  purposes  of  the  foregoing  schedule of point of sale co-payments, "costing" shall mean  the  amount  of  reimbursement  which shall  be  paid  by  the  state  to a participating provider pharmacy in accordance with section two hundred fifty of this title plus  the  point of sale co-payment, calculated as of the date of sale.   4.  Annual  limits  on  point  of sale co-payments. During each annual coverage  period,  no  point  of  sale  co-payments  as  set  forth   in subdivision  three  of this section shall be required to be made for the remainder of such period by any eligible program participant meeting the personal covered drug expenditure requirements  of  subdivision  two  of this  section  in  excess  of  the  limits  set  forth  in the following schedule:  (a) Limits on co-payments by  unmarried  individual  eligible  program participants: individual income of $20,001 to $21,000           no more than $1,050 individual income of $21,001 to $22,000           no more than $1,100 individual income of $22,001 to $23,000           no more than $1,150 individual income of $23,001 to $24,000           no more than $1,200 individual income of $24,001 to $25,000           no more than $1,250 individual income of $25,001 to $26,000           no more than $1,300 individual income of $26,001 to $27,000           no more than $1,350 individual income of $27,001 to $28,000           no more than $1,400 individual income of $28,001 to $29,000           no more than $1,450 individual income of $29,001 to $30,000           no more than $1,500 individual income of $30,001 to $31,000           no more than $1,550 individual income of $31,001 to $32,000           no more than $1,600 individual income of $32,001 to $33,000           no more than $1,650 individual income of $33,001 to $34,000           no more than $1,700 individual income of $34,001 to $75,000           no more than $1,750  (b)  Limits on co-payments by each married individual eligible program participant: joint income of $26,001 to $27,000                no more than $1,080 joint income of $27,001 to $28,000                no more than $1,120 joint income of $28,001 to $29,000                no more than $1,160 joint income of $29,001 to $30,000                no more than $1,200 joint income of $30,001 to $31,000                no more than $1,240  joint income of $31,001 to $32,000                no more than $1,280 joint income of $32,001 to $33,000                no more than $1,320 joint income of $33,001 to $34,000                no more than $1,360 joint income of $34,001 to $35,000                no more than $1,400 joint income of $35,001 to $36,000                no more than $1,440 joint income of $36,001 to $37,000                no more than $1,480 joint income of $37,001 to $38,000                no more than $1,520 joint income of $38,001 to $39,000                no more than $1,560 joint income of $39,001 to $40,000                no more than $1,600 joint income of $40,001 to $41,000                no more than $1,640 joint income of $41,001 to $42,000                no more than $1,680 joint income of $42,001 to $43,000                no more than $1,720 joint income of $43,001 to $44,000                no more than $1,760 joint income of $44,001 to $45,000                no more than $1,800 joint income of $45,001 to $46,000                no more than $1,840 joint income of $46,001 to $47,000                no more than $1,880 joint income of $47,001 to $48,000                no more than $1,920 joint income of $48,001 to $49,000                no more than $1,960 joint income of $49,001 to $100,000               no more than $2,000  (c) Effective October first, nineteen hundred eighty-eight, the limits on  point  of  sale  co-payments as set forth in this subdivision may be adjusted by the commissioner on the anniversary  date  of  each  program participant's  annual  coverage  period, and such adjustment shall be in effect for the duration of that annual coverage period. Any such  annual adjustment  shall  be  made  using  a percentage adjustment factor which shall not exceed one-half of the  difference  between  the  year-to-year percentage increase in the consumer price index for all urban consumers, as  published  by the United States department of labor, and, if larger, the year-to-year percentage increase in the aggregate  average  cost  of covered  drugs purchased under this title, which year-to-year percentage increase in such cost shall be determined by comparison of such cost  in the  same  month  of each of the appropriate successive years; provided, however, that for any such adjustment based wholly on experience in  the program  year  commencing  October first, nineteen hundred eighty-seven, the year-to-year percentage increase in such cost shall be determined by comparison of such cost in each of two months no less than  five  months apart   and   within  such  program  year,  which  comparison  shall  be annualized. Such percentage adjustment factor shall be the same as  that used  to  determine  any  similar  annual adjustment for the same annual coverage periods pursuant to  the  provisions  of  subdivision  four  of section  two  hundred forty-seven of this title. Such annual adjustments shall be calculated by multiplying the percentage adjustment  factor  by (1)  ten  percent  and  applying  the  resulting percentage to the upper income  limitation  of  each  income  level  for  unmarried  individuals contained in this subdivision, and by (2) seven and one-half percent and applying the resulting percentage to the upper income limitation of each income level for married individuals contained in this subdivision; each result  of  such calculations, minus any applicable deductible increases made pursuant to subdivision two of this section and plus the result  of applying  the percentage adjustment factor to the sum of any such annual adjustments applicable thereto for any  prior  annual  coverage  period, shall  be  the  amount  by  which the limit on co-payments for each such income level may be adjusted, and such amount shall be  in  addition  to any such amount or amounts applicable to prior annual coverage periods.  (d)   The  determination  to  adjust  the  limits  on  point  of  sale co-payments set forth in this subdivision shall follow a review of  such factors  as  the  relative  financial  capacity  of  the  state and such eligible program participant to support such adjustments.