2023 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.