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 144-104-3 - Maine Rx Plus Benefit › Subsection 144-104-3.09 - COVERED DRUGS

Current through 2024-29, July 17, 2024
There is no maximum frequency, number, or cost of the
					 prescriptions filled for an individual participant. When drugs are obtained
					 through a mail order pharmacy, participants may obtain only up to a 90-day
					 supply.
A. Covered Drugs
Under the Maine Rx Plus Benefit, the Department will cover
					 and reimburse only for drugs that are both prescribed by an authorized
					 prescriber and listed as preferred in the MaineCare preferred drug list (PDL)
					 established pursuant to Chapter II, Section 80, Pharmacy Services of the
					 MaineCare Benefits Manual.
B. Drug Benefit
Initial Discount
. Until October 1, 2004 Maine
					 Rx Plus participants will pay the initial discounted price (as defined above)
					 for all covered drugs.
Secondary Discount
. After October 1, 2004 the
					 Department will further reduce the cost of some covered drugs with a secondary
					 discount. A drug will receive a secondary discount if the manufacturer or
					 labeler of that drug has entered into a Maine Rx Plus rebate agreement with the
					 Department. The amount of the Secondary Discount will be an average of all the
					 rebates the Department has negotiated for Maine Rx Plus, after deducting
					 certain administrative expenses incurred by the Department.
Maine Rx Plus participants must pay the entire initial
					 discounted price or secondary discounted price, whichever is in effect. There
					 are no exceptions. If the participant refuses to pay the entire discounted
					 price, the pharmacy will deny the service.
C. Maine Rx Plus Rebate Agreements
The Department will negotiate with manufacturers of covered
					 drugs to obtain rebates for the Maine Rx Plus Benefit. As consideration for
					 such rebates, the Department will offer manufacturers or labelers that are
					 willing to pay rebates preferred status within the Maine Rx Plus list of
					 covered drugs. The drugs of manufacturers or labelers that do not agree to pay
					 rebates will remain covered drugs in Maine Rx Plus but will not be given the
					 preferred designation in Maine Rx Plus.
The rebate agreements will require each pharmaceutical
					 manufacturer or labeler to make quarterly rebate payments to the Department for
					 the total number of dosage units of each form and strength of a prescription
					 drug that the Department reports as reimbursed to participating pharmacies.
					 Such payments shall be due thirty (30) days following the date the manufacturer
					 receives utilization data from the Department summarizing the number of dosage
					 units of drugs during the period for which payment is due.
When the pharmaceutical manufacturer or labeler receives
					 the pharmacy reimbursement data, the pharmaceutical manufacturer or labeler
					 shall calculate the quarterly payment. The Department may, at its expense, hire
					 a mutually agreed upon independent auditor to verify the calculation and
					 payment.
In the event that an independent audit discovers a
					 discrepancy between the pharmaceutical manufacturer's or labeler's calculation
					 and the independent auditor's calculation that benefits the Department, the
					 pharmaceutical manufacturer or labeler shall justify its calculation or make
					 payment to the Department for any additional amount due. The pharmaceutical
					 manufacturer or labeler may, at its expense, hire a mutually agreed upon
					 independent auditor to verify the accuracy of the utilization data provided by
					 the Department.
In the event that a discrepancy is discovered that
					 benefits the pharmaceutical manufacturer or labeler, the Department shall
					 justify its data or refund any excess payment to the pharmaceutical
					 manufacturer or labeler.