DEPARTMENT OF HEALTH AND SOCIAL SERVICES

Division of Medicaid and Medical Assistance

Statutory Authority: 31 Delaware Code, Ch. 5, Section 512 (31 Del.C. §512)

FINAL

REGULATORY IMPLEMENTING ORDER

Revision of the Regulation of the

Delaware Prescription Assistance Program DSSM 30501

Nature of the Proceedings:

Delaware Health and Social Services (“Department”) / Division of Medicaid & Medical Assistance (DMMA) initiated proceedings to amend the Division of Social Services Manual (DSSM) related to the Delaware Prescription Assistance Program (DPAP). The Department’s proceedings to amend its regulations were initiated pursuant to 29 Delaware Code Section 10114 and its authority as prescribed by 31 Delaware Code Section 512.

The Department published its notice of proposed regulation changes pursuant to 29 Delaware Code Section 10115 in the September 2006 Delaware Register of Regulations, requiring written materials and suggestions from the public concerning the proposed regulations to be produced by October 2, 2006 at which time the Department would receive information, factual evidence and public comment to the said proposed changes to the regulations.

Summary of Proposed Amendment

Statutory Authority

• 16 Delaware Code, Ch 30B

• Senate Bill #297, 143rd General Assembly (signed into State law on July 6, 2006)

Background

The 140th General Assembly amended Title 16, Delaware Code, by adding Chapter 30B to enact the Delaware Prescription Drug Payment Assistance Program. The purpose of the act is to provide payment assistance for prescription drugs and certain Medicare Part D costs to low-income seniors and individuals with disabilities who are ineligible for, or do not have, prescription drug benefits or coverage through federal (excluding Medicare Part D coverage), state, or private sources.

The program is administered by the Fiscal Agent under contract with the Delaware Department of Health and Social Services. The Delaware Prescription Assistance Program (DPAP) was implemented January 1, 2000, with benefits beginning January 14, 2000.

Summary of Proposal

DSSM §30501: The proposed amendment would implement Senate Bill (SB) #297, which increases the maximum annual benefit under the Delaware Prescription Assistance program to assist eligible individuals in the purchase of prescription drugs and the payment of certain Medicare Part D costs from $2,500 to $3,000.

SUMMARY OF COMMENTS RECEIVED WITH AGENCY RESPONSE

The State Council for Persons with Disabilities (SCPD) endorses this proposed regulation.

Agency Response: DMMA appreciates the endorsement.

Findings of Fact:

The Department finds that the proposed changes as set forth in the September 2006 Register of Regulations should be adopted.

THEREFORE, IT IS ORDERED, that the proposed regulation to amend the Division of Social Services Manual (DSSM) related to the maximum benefit limit of the Delaware Prescription Assistance Program (DPAP) is adopted and shall be final effective November 10, 2006.

Vincent P. Meconi, Secretary, DHSS, 10/12/06

DMMA FINAL ORDER REGULATION #06-47

REVISIONS:

30000 Delaware Prescription Assistance Program

30500 Benefits

Prescription drugs covered under DPAP are restricted to medically necessary products manufactured by pharmaceutical companies that agree to provide manufacturer rebates. Policy and guidelines will follow the existing Delaware Medical Assistance Program limitations. Services covered include generic and brand name prescription drugs that have been approved as safe and effective by the Federal Food and Drug Administration as well as cost effective over-the-counter drugs prescribed by a practitioner. Necessary diabetic supplies not covered by Medicare will also be covered. Medications that are covered by Medicare are not covered under DPAP.

30500.1 Benefits for Individuals with Medicare Part D Coverage

DPAP will provide payment assistance for Medicare Part D monthly premiums, yearly deductible, those drug costs that fall into the Part D coverage gap, and drugs that are excluded from Medicare Part D.

Medicare Part D coverage will be primary to payment assistance under DPAP.

9 DE Reg. 774 (11/01/05)

30501 Limitations on Benefits

Payment assistance to each eligible individual shall not exceed $2,500.00 $3,000.00 per benefit year. Individuals will receive a notice when 75% of the $2,500.00 $3,000.00 cap has been expended.

9 DE Reg. 774 (11/01/05)

30502 Co-payment Requirement

There is a co-payment of $5.00 or 25% of the cost of the prescription whichever is greater. The pharmacy will not dispense or provide the prescription until the co-payment is collected.

30502.1 Co-payment Requirement for Individuals with Medicare Part D Coverage

There is a co-payment of $5.00 or 25% of the cost of the prescription (whichever is greater) during the Part D deductible and coverage gap and for drugs that are excluded from Part D. DPAP will not provide payment assistance for Medicare Part D co-payments. When the individual receives a prescription drug that is covered under Medicare Part D, the individual is responsible for the Medicare Part D co-payment.

9 DE Reg. 774 (11/01/05)

30503 Waiver of Co-payment for Good Cause

At the written request of the individual, the co-pay requirement may be waived for good cause.

Good cause for waiver of the co-payment is:

The individual has experienced a catastrophic situation resulting in unexpected, extraordinary expenses related to loss or significant damage to shelter or the well being of the individual or his immediate family.

The written request must explain the circumstances that led to the request. Verification of the circumstances is required in the form of collateral evidence that may include, but is not limited to, repair bills and police or insurance reports. The DPAP will provide written notification to the individual regarding the good cause decision. If good cause is granted, the co-payments will be waived for the remainder of the fiscal year.

10 DE Reg. 866 (11/01/06) (Final)