2023 Vermont Statutes › Title 33 - Human Services › Chapter 19 - Medical Assistance › § 2073. VPharm assistance program

§ 2073. VPharm assistance program
[Subsection (a) contingently effective until the later of January 1, 2022 or federal approval of VPharm coverage expansion; see also subsection (a) contingently effective on the later of January 1, 2022 or federal approval of VPharm coverage expansion set out below.]
(a) Effective January 1, 2006, the VPharm program is established as a State pharmaceutical assistance program to provide supplemental pharmaceutical coverage to Medicare beneficiaries. The supplemental coverage under subsection (c) of this section shall provide only the same pharmaceutical coverage as the Medicaid program to enrolled individuals whose income is not greater than 150 percent of the federal poverty guidelines and only coverage for maintenance drugs for enrolled individuals whose income is greater than 150 percent and no greater than 225 percent of the federal poverty guidelines.
[Subsection (a) contingently effective January 1, 2022 or federal approval of VPharm coverage expansion; see also subsection (a) contingently effective until the later of January 1, 2022 or federal approval of VPharm coverage expansion set out above.]
(a) The VPharm program is established as a State pharmaceutical assistance program to provide supplemental pharmaceutical coverage to Medicare beneficiaries. The supplemental coverage under subsection (c) of this section shall provide the same pharmaceutical coverage as the Medicaid program to enrolled individuals whose income is not greater than 225 percent of the federal poverty guidelines.
[Subsection (b) contingently effective until the later of January 1, 2022 or federal approval of VPharm coverage expansion; see also subsection (b) contingently effective on the later of January 1, 2022 or federal approval of VPharm coverage expansion set out below.]
(b) Any individual with income no greater than 225 percent of the federal poverty guidelines participating in Medicare Part D, having secured the low income subsidy if the individual is eligible and meeting the general eligibility requirements established in section 2072 of this title, shall be eligible for VPharm.
[Subsection (b) contingently effective on the later of January 1, 2022 or federal approval of VPharm coverage expansion; see also subsection (b) contingently effective until the later of January 1, 2022 or federal approval of VPharm coverage expansion set out above.]
(b) Any individual with income not greater than 225 percent of the federal poverty guidelines participating in Medicare Part D, having secured the low-income subsidy if the individual is eligible and meeting the general eligibility requirements established in section 2072 of this title, shall be eligible for VPharm.
(c) VPharm shall provide supplemental benefits by paying or subsidizing:
(1) The actual Medicare Part D premium for the standard prescription drug benefit offered by Medicare Part D prescription drug programs, except for any late enrollment penalties, provided that DVHA may pay or subsidize a higher premium for a Medicare Part D prescription drug plan offering expanded benefits if it is cost-effective to do so.
(2) Any other cost-sharing required by Medicare Part D, except for co-payments for individuals eligible for Medicaid and as provided for in subdivision (d)(1) of this section.
(3) The following pharmaceuticals if they are not covered by the individual’s Medicare Part D prescription drug plan: pharmaceuticals or classes of pharmaceuticals, or their medical uses, which may be excluded from coverage or otherwise restricted under Medicaid under Section 1927(d)(2) or (3) of the Social Security Act.
(4) Pharmaceuticals that are not covered after the individual has exhausted the Medicare Part D prescription drug plan’s appeal process or the prescription drug plan’s transition plan approved by the Centers for Medicare and Medicaid Services, and that are deemed medically necessary by the individual’s prescriber in a manner established by the Commissioner of Vermont Health Access. The coverage decision under this subdivision shall not be subject to the exceptions process established under Medicaid. An individual may appeal to the Human Services Board or pursue any other remedies provided by law.
(d)(1) An individual shall contribute a co-payment of $1.00 for prescriptions where the cost-sharing amount required by Medicare Part D is less than $30.00, and a co-payment of $2.00 for prescriptions where the cost-sharing amount required by Medicare Part D is $30.00 or more. A pharmacy may not refuse to dispense a prescription to an individual who does not provide the co-payment.
(2) An individual shall contribute the following base cost-sharing amounts that shall be indexed to the increases established under 42 C.F.R. § 423.104(d)(5)(iv) and then rounded to the nearest dollar amount:
(A) in the case of recipients whose household income is no greater than 150 percent of the federal poverty level, such premium shall be $15.00 per month;
(B) in the case of recipients whose household income is greater than 150 percent of the federal poverty level and no greater than 175 percent of the federal poverty level, the premium shall be $20.00 per month; and
(C) in the case of recipients whose household income is greater than 175 percent of the federal poverty level and no greater than 225 percent of the federal poverty level, the premium shall be $50.00 per month.
(e) In order to ensure the appropriate payment of claims, DVHA may expand the Medicare advocacy program established under chapter 67 of this title to individuals receiving benefits from the VPharm program.
(f) A manufacturer of pharmaceuticals purchased by individuals receiving assistance from VPharm established under this section shall pay to DVHA, as required by section 1901 of this title, a rebate on all pharmaceutical claims for which State-only funds are expended in an amount that is in proportion to the State share of the total cost of the claim, as calculated annually on an aggregate basis, and based on the full Medicaid rebate amount as provided for in Section 1927(a) through (c) of the federal Social Security Act, 42 U.S.C. § 1396r-8. (Added 2005, No. 71, § 314; amended 2007, No. 172 (Adj. Sess.), § 11a; 2007, No. 192 (Adj. Sess.), § 6.017; 2009, No. 1 (Sp. Sess.), §§ E.309.6, E.309.7; 2009, No. 156 (Adj. Sess.), § E.309.16, eff. June 3, 2010; 2009, No. 156 (Adj. Sess.), §§ E.309.9, I.71; 2011, No. 162 (Adj. Sess.), §§ E.307, E.307.7; 2019, No. 140 (Adj. Sess.), § 6.)