Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 104 - MAINE STATE SERVICES MANUAL › Sec2 144-104-4 - Maine Part D Wrap Benefits › Subsection 144-104-4.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
4.02-1
Authorized Representative
refers to the Department's authority pursuant to
				   22 M.R.S.A.
				  §254-D to enroll and reenroll
				  participants into a Medicare Part D plan, apply for Medicare Part D benefits
				  and subsidies on their behalf, and at the Department's discretion, file
				  exceptions and appeals on their behalf. The Department may also identify a
				  designee for this function.
4.02-2
Beneficiary
under Medicare Part D means a person who is eligible
				  for benefits and enrolled in a Medicare Part D plan.
4.02-3
Brand Name Drug
is
				  defined as a single-source drug, a cross-licensed drug, or an innovator
				  drug.
4.02-4
Covered
				  Drug
is a drug for which the Department reimburses under this benefit.
				  See Subsection 4.05 and Appendix A of this Section.
4.02-5
Generic Drugs
are drugs
				  other than those defined as brand-name drugs.
4.02-6
Mail Order Pharmacy
is a
				  pharmacy provider that dispenses prescription medications by U.S. mail or
				  private carrier. Mail order pharmacies must have a NABP (National Association
				  of Boards of Pharmacy) provider number uniquely identifying the provider as a
				  mail order pharmacy for purposes of billing. Mail order pharmacies must be
				  licensed by the Maine Board of Pharmacy, enrolled as Medicare and Maine Care
				  providers, and be operating under contract with the Department. Mail order
				  pharmacies must dispense prescription medications from within the United
				  States. Mail order pharmacies must process claims through the State's
				  electronic claims processing system to the standards required by the
				  Department.
4.02-7
Maine Care
				  Benefits Manual (MBM)
is the Maine Care policy set forth in Department
				  of Health and Human Services, 10-144, Chapter 101, Maine Care Benefits
				  Manual.
4.02-8
Maine Care
				  Member
means a person who receives benefits under the Maine Care
				  Program.
4.02-9
Medicare Part
				  D
means the prescription drug benefit program provided under the
				  Medicare Prescription Drug Improvement and Modernization Act of 2003,
				  Public Law
				  108-173.
4.02-10
Medicare Part D Excluded
				  Drugs
are those drugs not covered by Medicare
Part D pursuant to Title XIX, Section 1927 of the Social
					 Security Act [
					 42 U.S.C.
					 §1396r-8 ], for which the Department
					 will continue to reimburse if otherwise covered under this Section. The
					 Department will post a complete list of these covered drugs on its designated
					 website, and the list will include but not be limited to the following
					 categories of drugs: over the counter drugs, certain weight loss drugs, agents
					 when used for the symptomatic treatment of cough and cold, vitamins/minerals,
					 outpatient drugs for which associated tests or monitoring must be purchased
					 exclusively from manufacturers, barbiturates, and
					 benzodiazepins.
4.02-11
Medicare Savings Program Eligible
refers to a participant who is
				  also eligible for Maine Care through the Medicare Buy-In Program, as defined in
				  the Maine Care Eligibility Manual (MEM) and designated as QMB, SLMB, or
				  QI.
4.02-12
National Drug
				  Code (NDC)
is a universal drug coding system for human drugs established
				  by the Federal Food and Drug Administration, as set forth in 21 C.F.R
				  §207. The FDA assigns each drug a unique identification number specifying
				  the labeler/vendor, product, and package.
4.02-13
Non-Preferred Drugs
are
				  covered drugs that are not preferred drugs.
4.02-14
OBRA 90
is the Omnibus
				  Budget Reconciliation Act of 1990 as amended.
4.02-15
Over-The-Counter Drug
				  (OTC)
is a drug that can be purchased without a prescription.
4.02-16
Participant
is an
				  individual who is eligible for and is receiving this benefit.
4.02-17
Pharmacy Provider
is a
				  corporation, association, partnership, or individual that either provides
				  pharmacy services pursuant to a provider agreement with Maine Care or is
				  related by ownership or control to an entity that provides Maine Care or DEL
				  Benefit services, and is also a Medicare pharmacy provider.
4.02-18
Preferred Drugs
are
				  covered drugs that are clinically efficacious and which have a lower
				  therapeutic category as determined by the Department after reviewing the
				  recommendation of the Drug Utilization Review Committee.
4.02-19
Preferred Drug List
				  (PDL)
is a listing of covered drugs setting forth such information as
				  their status as preferred or non-preferred, whether prior authorization may be
				  required, step order, and any other information as determined by the Department
				  to be helpful to participants, pharmacists, prescribers and other interested
				  parties. This benefit utilizes the PDL referenced in Chapter 104, Section 2,
				  Drugs for the Elderly.
4.02-20
Prescription Drug Plan (PDP)
is a Medicare Part D plan provider
				  that is also an approved contractor under contract with the DHHS.
4.02.21
Retail Pharmacy
is a
				  pharmacy that possesses a valid outpatient pharmacy license issued by the Board
				  of Pharmacy, accepts Medicare assignment, and which serves DEL
				  participants.
4.02-22
Therapeutic Category
is a grouping of drugs by comparable
				  therapeutic effect, as determined by the Department.
4.02-23
Usual & Customary
				  Charge
is the amount a pharmacy charges to individuals for prescription
				  drugs for which those individuals do not have insurance coverage.
4.02-24
Wrap Benefits
are
				  benefits offered through this Section that may include assistance with
				  co-payments, deductibles, premiums and gaps in coverage. Wrap benefits vary for
				  some members, and details of the benefit are outlined in the table in Appendix
				  A.