2005 Connecticut Code - Sec. 17b-491. (Formerly Sec. 17a-342). Pharmaceutical Assistance Program. Copayments. Reimbursement of prescriptions based on price paid by pharmacy and actual package size. Application by pharmaceutical manufacturers to participate in program. Rebates and utilization review required for participating pharmaceutical manufacturers.

      Sec. 17b-491. (Formerly Sec. 17a-342). Pharmaceutical Assistance Program. Copayments. Reimbursement of prescriptions based on price paid by pharmacy and actual package size. Application by pharmaceutical manufacturers to participate in program. Rebates and utilization review required for participating pharmaceutical manufacturers. (a) There shall be a "Connecticut Pharmaceutical Assistance Contract to the Elderly and the Disabled Program" which shall be within the Department of Social Services. The program shall consist of payments by the state to pharmacies for the reasonable cost of prescription drugs dispensed to eligible persons minus a copayment charge. The pharmacy shall collect the copayment charge from the eligible person at the time of each purchase of prescription drugs, and shall not waive, discount or rebate in whole or in part such amount. Except for a replacement prescription dispensed pursuant to section 17b-492, the copayment for each prescription shall be as follows:

      (1) Sixteen dollars and twenty-five cents if the participant is (A) not married and has an annual income of less than twenty thousand three hundred dollars, or (B) married and has an annual income that, when combined with the participant's spouse, is less than twenty-seven thousand five hundred dollars.

      (2) Upon the granting of a federal waiver to expand the program in accordance with section 17b-492, the copayment shall be twenty dollars for a participant who is (A) not married and has an annual income that equals or exceeds twenty thousand three hundred dollars, or (B) married and has an annual income that, when combined with the participant's spouse, equals or exceeds twenty-seven thousand five hundred dollars.

      (b) On January 1, 2002, and annually thereafter, the commissioner shall increase the income limits established in subsection (a) of this section that set the appropriate participant copayment by the increase in the annual inflation adjustment in Social Security income, if any. Each such adjustment shall be determined to the nearest one hundred dollars.

      (c) Notwithstanding the provisions of subsection (a), effective September 15, 1991, payment by the state to a pharmacy under the program may be based on the price paid directly by a pharmacy to a pharmaceutical manufacturer for drugs dispensed under the program minus the copayment charge, plus the dispensing fee, if the direct price paid by the pharmacy is lower than the reasonable cost of such drugs.

      (d) Effective September 15, 1991, reimbursement to a pharmacy for prescription drugs dispensed under the program shall be based upon actual package size costs of drugs purchased by the pharmacy in units larger than or smaller than one hundred.

      (e) The commissioner shall establish an application form whereby a pharmaceutical manufacturer may apply to participate in the program. Upon receipt of a completed application, the department shall issue a certificate of participation to the manufacturer. Participation by a pharmaceutical manufacturer shall require that the department shall receive a rebate from the pharmaceutical manufacturer. Rebate amounts for brand name prescription drugs shall be equal to those under the Medicaid program. Rebate amounts for generic prescription drugs shall be established by the commissioner, provided such amounts may not be less than those under the Medicaid program. A participating pharmaceutical manufacturer shall make quarterly rebate payments to the department for the total number of dosage units of each form and strength of a prescription drug which the department reports as reimbursed to providers of prescription drugs, provided such payments shall not be due until thirty days following the manufacturer's receipt of utilization data from the department including the number of dosage units reimbursed to providers of prescription drugs during the quarter for which payment is due.

      (f) All prescription drugs of a pharmaceutical manufacturer that participates in the program pursuant to subsection (e) of this section shall be subject to prospective drug utilization review. Any prescription drug of a manufacturer that does not participate in the program shall not be reimbursable, unless the department determines the prescription drug is essential to program participants.

      (P.A. 85-573, S. 6, 18; P.A. 87-3, S. 3, 9; S.A. 90-18, S. 18, 32; June Sp. Sess. P.A. 91-8, S. 46, 63; P.A. 92-196, S. 2, 4; P.A. 93-80, S. 51, 67; 93-262, S. 1, 87; 93-418, S. 36, 41; P.A. 95-351, S. 19, 30; June 18 Sp. Sess. P.A. 97-2, S. 132, 165; June Sp. Sess. P.A. 00-2, S. 40, 44, 53; May 9 Sp. Sess. P.A. 02-7, S. 15; P.A. 03-2, S. 14; P.A. 04-16, S. 17; 04-104, S. 1.)

      History: P.A. 87-3 deleted reference to "pilot", expanded the program to include the disabled and restated the payments to pharmacies to be the reasonable cost of prescription drugs minus a four-dollar copayment charge; S.A. 90-18 raised copayment charge from four to six dollars and added provisions re calculation of annual increases in charged amount on and after July 1, 1991; Sec. 17-513 transferred to Sec. 17a-342 in 1991; June Sp. Sess. P.A. 91-8 raised copayment and prescription charges from six dollars to ten dollars, deleted the language re the commissioner's authority to increase the copayment charges, and added Subsecs. (b) to (f), inclusive, basing payment made by the state to a pharmacy on the price paid by a pharmacy to the pharmaceutical manufacturer, basing reimbursement to the pharmacy on the actual package size of the prescription and detailing implementation and review of a prescription drug rebate agreement program; P.A. 92-196 amended Subsec. (d) by deleting provisions requiring the commissioner to enter into rebate agreements with manufacturers and adding provisions re application process for manufacturers to participate in program and amended Subsec. (f) for consistency; P.A. 93-80 amended Subsec. (a) to increase copayment charge from ten to fifteen dollars, and amended Subsec. (d) to change rebate paid to department by participating pharmaceutical manufacturer from eleven per cent of the average manufacturer price to the basic rebate supplied by the manufacturer under Section 1927 of Title XIX of the Social Security Act, effective July 1, 1993; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department on aging, effective July 1, 1993; P.A. 93-418 reduced the copayment charge from fifteen to twelve dollars for each prescription, effective July 1, 1993; Sec. 17a-342 transferred to Sec. 17b-491 in 1995; P.A. 95-351 required the department to receive a rebate from a pharmaceutical manufacturer in an amount equal to the Medicaid rebate, deleting former Subsec. (e) re quarterly payments, payment discrepancies and independent audits and relettering Subsec. (f) as (e), effective July 1, 1995; June 18 Sp. Sess. P.A. 97-2 amended Subsec. (e) by deleting provision requiring that all prescription drugs of a pharmaceutical manufacturer participating in the program pursuant to Subsec. (d) be immediately available, the cost of such drug reimbursed and not be subject to any restrictions and added provision requiring that such drugs be subject to prospective drug utilization review, effective July 1, 1997; June Sp. Sess. P.A. 00-2 amended Subsec. (d) by deleting references to the rebate supplied under the Social Security Act and by adding language re rebate amounts for brand name drugs equaling those under the Medicaid program and provision allowing the commissioner to establish rebate amounts for generic drugs, and amended Subsec. (e) by deleting provisions exempting prescription drugs of participating manufacturers from prior authorization, effective July 1, 2000; May 9 Sp. Sess. P.A. 02-7 amended Subsec. (a) by deleting provision re twelve dollar copayment charge and adding Subdivs. (1) to (3) re copayment requirements for individuals determined eligible for program on or after September 1, 2002, added new Subsecs. (b) and (c) re copayment rates for individuals determined eligible for program prior to September 1, 2002, and re increased income limits, respectively, and redesignated existing Subsecs. (b) to (e) as Subsecs. (d) to (g), effective September 1, 2002; P.A. 03-2 amended Subsec. (a) by deleting "For an individual who is determined eligible to participate in the program on or after September 1, 2002, said" re copayment rates, by changing copayment rate from twelve dollars to sixteen dollars and twenty-five cents, changing income threshold for unmarried participants from fifteen thousand nine hundred dollars to twenty thousand three hundred dollars and changing income threshold for married participants, with combined spousal income, from twenty-one thousand five hundred dollars to twenty-seven thousand five hundred dollars in Subdiv. (1), by deleting former Subdiv.(2) re middle tier of copayment rates, and by redesignating existing Subdiv. (3) as new Subdiv. (2), amending said Subdiv. to increase income thresholds from twenty thousand dollars to twenty thousand three hundred dollars in Subpara. (A) and from twenty-seven thousand one hundred dollars to twenty-seven thousand five hundred dollars in Subpara. (3) and adding "equals or" in both Subparas., deleted former Subsec. (b) re differing copayments for those determined eligible for the program prior to September 1, 2002, redesignated existing Subsecs. (c) to (g), inclusive, as Subsecs. (b) to (f), inclusive, and changed internal references contained therein, effective February 28, 2003; P.A. 04-16 made a technical change in Subsec. (a)(1); P.A. 04-104 amended Subsec. (a) to add "Except for a replacement prescription dispensed pursuant to section 17b-492" re required copayments, effective July 1, 2004.