Missouri Code of State Regulations › Title 22 - MISSOURI CONSOLIDATED HEALTH CARE PLAN › Division 10 - Health Care Plan › Chapter 2 - State Membership › Section 22 CSR 10-2.090 - Pharmacy Benefit Summary

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment revises where maintenance
				  prescriptions may be filled and drugs not subject to the deductible under the
				  Health Savings Account Plan.
(1) The pharmacy benefit provides coverage
				for prescription drugs. Vitamin and nutrient coverage is limited to prenatal
				agents, therapeutic agents for specific deficiencies and conditions, and
				hematopoietic agents as prescribed by a provider to non-Medicare primary
				members.
(A) PPO 750 Plan and PPO 1250 Plan.
1. Network:
A. Preferred formulary generic drug
				copayment: Ten dol-lars ($10) for up to a thirty-one- (31-) day supply; twenty
				dollars ($20) for up to a sixty- (60-) day supply; and thirty dollars ($30) for
				up to a ninety- (90-) day supply for a generic drug on the formulary;
B. Preferred formulary brand drug copayment:
				Forty dollars ($40) for up to a thirty-one- (31-) day supply; eighty dollars
				($80) for up to a sixty- (60-) day supply; and one hundred twenty dollars
				($120) for up to a ninety- (90-) day supply for a brand drug on the
				formulary;
C. Non-preferred
				formulary drug and approved excluded drug copayment: One hundred dollars ($100)
				for up to a thirty-one- (31-) day supply; two hundred dollars ($200) for up to
				a sixty- (60-) day supply; and three hundred dollars ($300) for up to a ninety-
				(90-) day supply for a drug not on the formulary;
D. Specialty drug copayment: Seventy-five
				dollars ($75) for up to a thirty-one- (31-) day supply for a specialty drug on
				the formulary;
E. Diabetic drug (as
				designated as such by the PBM) copayment: fifty percent (50%) of the applicable
				network copayment;
F. Ninety- (90-)
				day supply of prescriptions may be filled through the pharmacy benefit
				manager's (PBM's) home delivery program or at select retail pharmacies, as
				designated by the PBM.
G. Home
				delivery programs.
(I) Maintenance
				prescriptions may be filled through the PBM's home delivery program.
(II) Specialty drugs are covered only through
				the specialty home delivery network for up to a thirty-one- (31-) day supply
				unless the PBM has determined that the specialty drug is eligible for up to a
				ninety- (90-) day supply. All specialty prescriptions must be filled through
				the PBM's specialty pharmacy, unless the prescription is identified by the PBM
				as emergent. The first fill of a specialty prescription identified to be
				emergent, may be filled through a retail pharmacy.
(a) Specialty split-fill program-The
				specialty split-fill program applies to select specialty drugs as determined by
				the PBM. For the first three (3) months, members will be shipped a
				fifteen-(15-) day supply and charged a prorated copayment. If the member is
				able to continue with the medication, the remaining supply will be shipped and
				the member will be charged the remaining portion of the copayment. Starting
				with the fourth month, an up to thirty-one-(31-) day supply will be shipped if
				the member continues on treatment.
(III) Prescriptions filled through home
				delivery programs have the following copayments:
(a) Preferred formulary generic drug
				copayments: Ten dollars ($10) for up to a thirty-one- (31-) day supply; twenty
				dollars ($20) for up to a sixty- (60-) day supply; and twenty-five dollars
				($25) for up to a ninety- (90-) day supply for a generic drug on the
				formulary;
(b) Preferred formulary
				brand drug copayments: Forty dollars ($40) for up to a thirty-one- (31-) day
				supply; eighty dollars ($80) for up to a sixty- (60-) day supply; and one
				hundred dollars ($100) for up to a ninety- (90-) day supply for a brand drug on
				the formulary;
(c) Non-preferred
				formulary drug and approved excluded drug copayments: One hundred dollars
				($100) for up to a thirty-one- (31-) day supply; two hundred dollars ($200) for
				up to a sixty-(60-) day supply; and two hundred fifty dollars ($250) for up to
				a ninety- (90-) day supply for a drug not on the formulary;
(d) Specialty drug copayment: Seventy-five
				dollars ($75) for up to a thirty-one- (31-) day supply; one hundred fifty
				($150) for up to sixty (60-) day supply; and two hundred twenty-five ($225) for
				up to ninety- (90-) day supply for a specialty drug on the formulary;
H. Diabetic drug (as
				designated as such by the PBM) copayment: fifty percent (50%) of the applicable
				network copayment;
I. Only one (1)
				copayment is charged if a combination of different manufactured dosage amounts
				must be dispensed in order to fill a prescribed single dosage amount;
J. The copayment for a compound drug is
				based on the primary drug in the compound. The primary drug in a compound is
				the most expensive prescription drug in the mix. If any ingredient in the
				compound is excluded by the plan, the compound will be denied;
K. If the copayment amount is more than the
				cost of the drug, the member is only responsible for the cost of the
				drug;
L. If the physician allows
				for generic substitution and the member chooses a brand-name drug, the member
				is responsible for the generic copayment and the cost difference between the
				brandname and generic drug which shall not apply to the out-of-pocket
				maximum;
M. Preferred select brand
				drugs, as determined by the PBM: Ten dollars ($10) for up to a thirty-one-
				(31-) day supply; twenty dollars ($20) for up to a sixty- (60-) day supply; and
				twenty-five dollars ($25) for up to a ninety- (90-) day supply; and
N. Prescription drugs and prescribed
				over-the-counter drugs as recommended by the U.S. Preventive Services Task
				Force (categories A and B) and, for women, by the Health Resources and Services
				Administration 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:
(I) Vaccine
				recommended by the Advisory Committee on Immunization Practices of the Centers
				for Disease Control and Prevention;
(II) Prescribed preferred diabetic test
				strips and lancets; and
(III) One
				(1) preferred glucometer.