department of health and social services
Division of Medicaid and Medical Assistance
PROPOSED
PUBLIC NOTICE
3000 Delaware Prescription Assistance Program
In compliance with the State's Administrative Procedures Act (APA - Title 29, Chapter 101 of the Delaware Code), and with 42CFR §447.205, and, under the authority of Title 31 of the Delaware Code, Chapter 5, Section 512, Delaware Health and Social Services (DHSS) / Division of Medicaid and Medical Assistance (DMMA) is proposing to amend the Division of Social Services Manual related to the Delaware Prescription Assistance Program (DPAP).
Any person who wishes to make written suggestions, compilations of data, testimony, briefs or other written materials concerning the proposed new regulations must submit same to Sharon L. Summers, Policy and Program Development Unit, Division of Medicaid and Medical Assistance, 1901 North DuPont Highway, P.O. Box 906, New Castle, Delaware 19720-0906 or by fax to (302) 255-4454 by October 2, 2006.
The action concerning the determination of whether to adopt the proposed regulation will be based upon the results of Department and Division staff analysis and the consideration of the comments and written materials filed by other interested persons.
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.
30000 Delaware Prescription Assistance Program
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.
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)
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)
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.
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)
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.
