Missouri Code of State Regulations › Title 22 - MISSOURI CONSOLIDATED HEALTH CARE PLAN › Division 10 - Health Care Plan › Chapter 2 - State Membership › Section 22 CSR 10-2.089 - Pharmacy Employer Group Waiver Plan for Medicare Primary Members

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment revises Medicare Part D
				  coverage stage and copayment amounts.
(1) The pharmacy benefit for Medicare primary
				non-active members is provided through a Pharmacy Employer Group Waiver Plan
				(EGWP) as regulated by the Centers for Medicare & Medicaid Services
				hereinafter referred to as the Medicare Prescription Drug Plan.
(A) Non-active subscribers that have Medicare
				primary coverage and their dependents that have Medicare primary coverage
				enrolled in the Medicare Advantage Plan shall receive their pharmacy benefit
				through the Medicare Prescription Drug Plan.
(B) The non-Medicare dependents of Medicare
				primary non-active subscribers will not be in the Medicare Prescription Drug
				Plan but will have pharmacy benefit coverage as defined by
				22 CSR
				10-2.090.
(C) Foster parent members that have Medicare
				primary coverage and their dependents that have Medicare primary coverage will
				not be in the Medicare Prescription Drug Plan but will have pharmacy benefit
				coverage as defined by
				22 CSR
				10-2.090.
(D) A retiree Medicare primary member who
				chooses not to be in the Medicare Prescription Drug Plan will lose MCHCP
				eligibility and will not be allowed to enroll in a medical or Medicare
				Prescription Drug Plan at a later date.
(E) MCHCP will pay the Medicare financial
				penalty incurred by a Medicare primary member who has had a continuous gap in
				prescription drug coverage of sixty-three (63) days or more after the Medicare
				Initial Election Period (IEP) and was not covered by any creditable
				prescription drug coverage and failed to enroll into Part D.
(F) The Medicare Prescription Drug Plan is
				comprised of a Medicare Part D prescription drug plan contracted by MCHCP and
				some non-Part D medications that are not normally covered by a Medicare Part D
				prescription drug plan. The requirements for the Medicare Part D prescription
				drug plan are as follows:
1. The Centers for
				Medicare & Medicaid Services regulates the Medicare Part D prescription
				drug program. The Medicare Prescription Drug Plan abides by those
				regulations;
2. Initial coverage
				stage. Until a member's total yearly Part D prescription drug costs reach five
				thousand thirty dollars ($5,030), the member will pay the following copayments:
A. Preferred formulary generic drugs:
				thirty-one- (31-) day supply has a ten dollar ($10) copayment; sixty- (60-) day
				supply has a twenty dollar ($20) copayment; ninety- (90-) day supply at retail
				has a thirty dollar ($30) copayment; and a ninety- (90-) day supply through
				home delivery has a twenty-five dollar ($25) copayment;
B. Preferred formulary brand drugs:
				thirty-one- (31-) day supply has a forty dollar ($40) copayment; sixty- (60-)
				day supply has an eighty dollar ($80) copayment; ninety- (90-) day supply at
				retail has a one hundred twenty dollar ($120) copayment; and a ninety- (90-)
				day supply through home delivery has a one hundred dollar ($100) copayment;
				and
C. Non-preferred formulary
				drugs and approved excluded drugs: thirty-one- (31-) day supply has a one
				hundred dollar ($100) copayment; sixty- (60-) day supply has a two hundred
				dollar ($200) copayment; ninety- (90-) day supply at retail has a three hundred
				dollar ($300) copayment; and a ninety- (90-) day supply through home delivery
				has a two hundred fifty dollar ($250) copayment;
3. Coverage gap stage. After a member's total
				yearly Part D prescription drug costs exceed five thousand thirty dollars
				($5,030) and remain below eight thousand dollars ($8,000), the member will
				continue to pay the same cost-sharing amount as in the initial coverage stage
				until the yearly out-of-pocket Part D prescription drug costs reach eight
				thousand dollars ($8,000);
4.
				Catastrophic coverage stage. After a member's total yearly out-of-pocket Part D
				prescription drug costs reach eight thousand dollars ($8,000), the member will
				pay zero dollars ($0); and
5.
				Amounts paid by the member or the plan for non-Part D prescription drugs will
				not count toward total Part D prescription drug costs or total Part D
				prescription drug out-ofpocket costs.
(G) Medications covered under
				22 CSR
				10-2.090 will be covered under the Medicare
				Prescription Drug Plan as non-Part D medications when they are not a Part D
				covered drug.
(H) Medicare Part B
				Prescription Drugs are excluded from the Medicare Prescription Drug
				Plan.
(I) Prescription drugs and
				prescribed over-the-counter drugs as recommended by the U.S. Preventive
				Services Task Force (categories A and B) are covered at one hundred percent
				(100%) when filled at a network pharmacy. The following are also covered at one
				hundred percent (100%) when filled at a network pharmacy:
1. Vaccines and administration as recommended
				by the Advisory Committee on Immunization Practices of the Centers for Disease
				Control and Prevention; and
2.
				Preferred formulary brand contraception and non-preferred contraception when
				the provider determines a generic is not medically appropriate or a generic
				version is not available.