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 144-104-2 - Maine Drugs for the Elderly Benefit › Subsection 144-104-2.02 - DEFINITIONS

Current through 2024-29, July 17, 2024
2.02-1
Authorized Representative
refers to the Department's authority pursuant to 22 M.R.S.A. § 254-D to
				  enroll and reenroll DEL 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 behalf of participants. The
				  Department may also identify a designee for this function.
2.02-2
Beneficiary under Medicare Part
				  D
means a person who is eligible for and enrolled in a Medicare Part D
				  plan.
2.02-3
Brand Name
				  Drug
is defined as a single-source drug, a cross-licensed drug, or an
				  innovator drug.
2.02-4
Coverage Gap (donut hole)
is the portion of the standard Medicare
				  Part D benefit where the Part D plan provides no coverage and the enrollee pays
				  100% of the prescription after the deductible is met.
2.02-5
Covered Drug
is a drug
				  for which the Department reimburses under the DEL Benefit. See Subsection 2.05
				  of this Section.
2.02-6
DEL
				  Rebate Agreement
is an agreement between the Department and a drug
				  manufacturer that provides that the drug manufacturer will make rebate payments
				  for both the basic and supplemental components of the Benefit.
2.02-7
Drug Utilization Review
				  (DUR)
means a process designed to ensure that prescriptions are
				  appropriate, medically necessary, cost-effective, and not likely to result in
				  adverse medical results.
2.02-8
Drug Utilization Review Committee (DUR Committee)
means an
				  advisory committee to the Department of Health and Human Services for the
				  MaineCare Benefit and DEL Benefit, comprised of physicians and pharmacists who
				  are licensed to prescribe or dispense drugs in Maine. The DUR Committee
				  conducts drug utilization review for the Department.
2.02-9
Generic Drugs
are drugs
				  other than those defined as brand-name drugs.
2.02-10
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 MaineCare
				  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.
2.02-11
MaineCare
				  Benefits Manual (MBM)
is the MaineCare policy set forth in Department of
				  Health and Human Services, 10-144, Chapter 101, MaineCare Benefits
				  Manual.
2.02-12
MaineCare
				  Member
means a person who receives benefits under the MaineCare
				  Program.
2.02-13
Maine
				  Maximum Allowable Cost (MMAC)
is the maximum reimbursement amount that
				  is established by the Maine Department of Health and Human Services for certain
				  multiple source drugs.
2.02-14
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.
2.02-15
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 ], 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 benzodiazepines.
2.02-16
Medi-Span
is a
				  nationally recognized drug database. The Department uses this database to
				  determine which drugs are defined as brand-name (single-source, cross-licensed
				  or innovator) or generic (multiple-source) drugs for the purposes of
				  calculating reimbursement.
2.02-17
Metropolitan Statistical Area (MSA)
is a federal standardized
				  designation using postal zip codes to define rural areas. The Department will
				  define rural by applying MSA/Non-MSA designation to the zip code of the
				  member's residence.
2.02-18
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.
2.02-19
Non-Preferred Drugs
are
				  covered drugs that are not preferred drugs.
2.02-20
OBRA 90
is the Omnibus
				  Budget Reconciliation Act of 1990 as amended.
2.02-21
Over-The-Counter Drug
				  (OTC)
is a drug that can be purchased without a prescription.
2.02-22
Participant
is an
				  individual who is eligible for and is receiving the DEL Benefit.
2.02-23
Pharmacy Provider
is a
				  corporation, association, partnership, or individual that either provides
				  pharmacy services pursuant to a provider agreement with MaineCare or is related
				  by ownership or control to an entity that provides MaineCare or DEL Benefit
				  services, and is also a Medicare pharmacy provider.
2.02-24
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.
2.02-25
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.
2.02-26
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.
2.02-27
Telepharmacy
is a method of delivering prescriptions dispensed by
				  a pharmacist to a remote site. Pharmacies using telepharmacy delivery of
				  prescriptions must follow all applicable State and Federal regulations and
				  Maine State Board of Pharmacy rules, including using staff qualified to deliver
				  prescriptions through telepharmacy.
2.02-28
Therapeutic Category
is
				  a grouping of drugs by comparable therapeutic effect, as determined by the
				  Department.
2.02-29
Usual
				  & Customary Charge
is the amount a pharmacy charges to individuals
				  for prescription drugs for which those individuals do not have insurance
				  coverage.