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department of health and social services

Division Of Social Services



Client Cost Sharing for Pharmaceutical Services Cumulative Maximum

In compliance with the State's Administrative Procedures Act (APA - Title 29, Chapter 101 of the Delaware Code) and under the authority of Title 31 of the Delaware Code, Chapter 5, Section 512, Delaware Health and Social Services (DHSS) / Division of Social Services (DSS) provides notice of intent. This notice is being given to provide information of public interest with respect to the intent of DSS to amend the Title XIX Medicaid State Plan and the Division of Social Services Manual (DSSM) regarding the Pharmaceutical Services Program.

The purpose of this action is to give public notice of the agency’s intent to submit an amendment to the Title XIX Medicaid State Plan to the Centers for Medicare and Medicaid Services (CMS) and to amend the Division of Social Services Manual (DSSM) to establish a cumulative maximum on pharmacy co-payments.

Statutory Basis

42 CFR §447.54(d)

Amending the Following Title XIX Medicaid State Plan Pages

Page 56a
Attachment 4.18-A, Page 3

Amending the Following Sections of the Division of Social Services Manual


Summary of Amendment Provisions

To ensure that the state delivers an accessible medical assistance prescription drug program, the following describes the proposed change for pharmacy co-payments, effective July 1, 2005:

A cumulative maximum is established as described below:

$15.00 – $25.00* cumulative monthly maximum co-payment amount aggregated for pharmacy services.

*The specific amount to be determined.

Once a client has met the individual monthly maximum co-payment for his or her prescriptions, the Point of Sale (POS) System will NOT indicate a co-payment is due. Medicaid will keep track of the cumulative number of prescriptions for a client with co-payments. Any prescriptions dispensed after the cumulative maximum monthly co-payment amount is met are not subject to a co-payment. Reversal of a previously filled prescription with a co-payment will require a refund of the co-payment to the individual, and will cause the next prescription filled for that client to be adjudicated with a co-payment.

By implementing this process, the Department ensures that a cumulative maximum is likely to benefit all eligible Medicaid clients with continued access to prescription medications.

DSS will notify affected Medicaid clients prior to implementation.

The proposed cumulative maximum pharmacy requirements are subject to approval by the Centers for Medicare and Medicaid Services (CMS).

8 DE Reg. 1737 (6/1/05)