2013 Maryland Code
HEALTH - GENERAL
§ 15-124 - Maryland Pharmacy Assistance Program

§15-124.

(a) The Department shall maintain a Maryland Pharmacy Assistance Program for low income individuals not eligible for Medicare whose:

(1) Assets are not more than the level established by the federal Centers for Medicare and Medicaid Services under the Qualified Medicare Beneficiary Program; and

(2) Gross annual income does not exceed 116% of the federal poverty guidelines for an individual, or 100% of the federal poverty guidelines for a family of two or more.

(b) (1) (i) Reimbursement under the Maryland Pharmacy Assistance Program may be limited to maintenance drugs, anti-infectives, and AZT as specified in regulations to be issued by the Secretary after consultation with the Maryland Pharmacists Association.

(ii) 1. For any drug on the Program’s interchangeable drug list, the Program shall reimburse providers in an amount not more than it would reimburse for the drug’s generic equivalent, unless the individual’s physician states, in his or her own handwriting, on the face of the prescription, that a specific brand is “medically necessary” for the particular patient.

2. If an appropriate generic drug is not generally available, the Department may waive the reimbursement requirement under subsubparagraph 1 of this subparagraph.

(2) The reimbursement shall be up to the amount paid for the same items or services under the pharmacy program of the Maryland Medical Assistance Program and shall be subject to a copayment of not more than:

(i) $2.50 for a generic drug or a brand name drug on a preferred drug list established by the Department; and

(ii) $7.50 for a brand name drug not on a preferred drug list established by the Department.

(c) (1) Except as provided under paragraph (4) of this subsection and unless the change is made by an emergency regulation, the Maryland Pharmacy Assistance Program shall notify all pharmacies under contract with the Program in writing of changes in the Pharmaceutical Benefit Program rules or requirements at least 30 days before the change is effective.

(2) Changes that require 30 days’ advance written notice under paragraph (1) of this subsection are:

(i) Exclusion of coverage for classes of drugs as specified by contract;

(ii) Changes in prior or preauthorization procedures; and

(iii) Selection of new prescription claims processors.

(3) If the Maryland Pharmacy Assistance Program fails to provide advance notice as required under paragraph (1) of this subsection, it shall honor and pay in full any claim under the Program rules or requirements that existed before the change for 30 days after the postmarked date of the notice.

(4) Notwithstanding any other provision of law, the notice requirements of this subsection do not apply to the addition of new generic drugs authorized under § 12-504 of the Health Occupations Article.

(d) (1) The Secretary shall adopt rules and regulations that authorize the denial, restriction, or termination of eligibility for recipients who have abused benefits under the Maryland Pharmacy Assistance Program.

(2) As a condition of participation, the Department may require Maryland Pharmacy Assistance Program participants to apply for eligibility in the Maryland Medical Assistance Program within 60 days of notification to do so by the Department.

(3) The rules and regulations shall require that the recipient be given notice and an opportunity for a hearing before eligibility may be denied, restricted, or terminated under this subsection.

(e) The Secretary shall develop a program, in consultation with appropriate agencies, that will provide information to ineligible Maryland Pharmacy Assistance Program applicants regarding other programs that they may be eligible for including the Maryland Medbank Program established under § 15-124.2 of this subtitle and the Senior Prescription Drug Assistance Program established under Title 14, Subtitle 5 of the Insurance Article.

§ 15-124 - 1. Maryland Pharmacy Discount Program

Repealed by Acts 2005, chs. 281 and 282, § 2, effective January 1, 2006.

§ 15-124 - 2. Maryland Medbank Program

(a) "Program" defined. -- In this section, "Program" means the Maryland Medbank Program established under this section.

(b) Established. -- There is a Maryland Medbank Program.

(c) Purpose. -- The purpose of the Program is to improve the health status of individuals throughout the State who lack prescription drug coverage by providing access to medically necessary prescription drugs through patient assistance programs sponsored by pharmaceutical drug manufacturers.

(d) Administration. --

(1) Subject to paragraph (2) of this subsection, the Program shall be administered by the Medbank of Maryland, Inc.

(2) The Medbank of Maryland, Inc. shall contract with one or more government or nonprofit entities to operate the Program.

(e) Funding. --

(1) The Program shall be funded through a grant provided by the Department.

(2) Program funds may be used in part to:

(i) Purchase interim supplies of prescription drugs for enrollees who have applied to participate in a manufacturer's patient assistance program but have not yet received the approved prescription drug; and

(ii) Distribute medication to enrollees who have been approved to participate in a manufacturer's patient assistance program.

(f) Availability; offices. --

(1) The Medbank of Maryland, Inc. shall ensure that the Program is available to residents in each of the following geographic regions of the State:

(i) Western Maryland;

(ii) The Eastern Shore;

(iii) The Baltimore metropolitan area;

(iv) The Maryland counties in the Washington, D.C. metropolitan area; and

(v) Southern Maryland, including Anne Arundel County.

(2) Medbank of Maryland, Inc. shall be the central coordinating office for the State.

(g) Eligibility. -- Eligibility for the Program shall be limited only by the criteria established by pharmaceutical manufacturers for their patient assistance programs.

(h) Financial reports. --

(1) The Department shall require detailed financial reports at least quarterly from Medbank of Maryland, Inc.

(2) The Medbank of Maryland, Inc. shall release funds to the entities that operate the Program as needed and justified by the quarterly reports filed in accordance with paragraph (1) of this subsection.

(i) Reports to Executive Branch. -- On or before December 1, 2001, and annually thereafter, the Department and Medbank of Maryland, Inc. shall report to the Governor and, in accordance with § 2-1246 of the State Government Article, to the General Assembly, on the status of the Maryland Medbank Program established under this section, including:

(1) The number and demographic characteristics of the State residents served by the Program;

(2) The types and retail value of prescription drugs accessed through the Program;

(3) The nature and extent of outreach performed to inform State residents of the assistance available through the Program; and

(4) The total volume and retail value of each brand name drug, by manufacturer, accessed through the Program.

§ 15-124 - 3. Medicare Option Prescription Drug Program.

(a) Definitions. --

(1) In this section the following words have the meanings indicated.

(2) "Enrollee" means an individual who is enrolled in the Program.

(3) "Medicare Modernization Act" means the federal Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

(4) "Medicare Part D prescription drug benefit" means the prescription drug benefit established by the Medicare Modernization Act under Part D of the federal Medicare Program.

(5) "Prescription drug plan" means a private health plan that provides a Medicare Part D prescription drug benefit in accordance with the requirements of the Medicare Modernization Act.

(6) "Program" means the Medicare Option Prescription Drug Program established under this section.

(b) Program established. -- There is a Medicare Option Prescription Drug Program within the Maryland Medical Assistance Program.

(c) Purpose. -- The purpose of the Program is to:

(1) Assist low-income Medicare eligible individuals to make a seamless transition to, and coordinate prescription drug coverage with, the Medicare Part D prescription drug benefit; and

(2) Minimize the cost-sharing burden on the individuals.

(d) Administration. -- The Program shall be administered and operated by the Department as permitted by federal law or waiver.

(e) Eligibility. --

(1) The Program shall be open to any individual who:

(i) Is a resident of the State;

(ii) Is a Medicare beneficiary;

(iii) Is not enrolled in a Medicare Advantage Plan or other public or private insurance program, except for Medicaid and the Maryland Pharmacy Assistance Program, that provides prescription drug benefits at the time that the individual applies for enrollment in the Program;

(iv) Has an annual household income below 150 percent of the federal poverty level; and

(v) Meets the asset test established by the Medicare Modernization Act under Medicare Part D.

(2) Individuals who are dually eligible for Medicare and Medicaid, or Medicare and the Maryland Pharmacy Assistance Program, may be enrolled automatically in the Program, provided that they may elect to opt out of the Program.

(3) Enrollment in the Program for individuals who are dually eligible for Medicare and Medicaid shall begin not later than the date on which the auto-enrollment period for the federal Medicare Part D Program begins.

(4) The Department shall determine the procedures for automatic enrollment in, and election to opt out of, the Program.

(5) Individuals who meet the eligibility requirements of paragraph (1) of this subsection but who are not dually eligible for Medicare and either Medicaid or the Maryland Pharmacy Assistance Program may apply for enrollment in the Medicare Option Prescription Drug Program by submitting an application to the Department.

(f) Operation by Department. -- The Department may:

(1) Enter into a contract with one or more prescription drug plans to coordinate the prescription drug benefits provided under the Program and the Medicare Part D prescription drug benefit;

(2) Require a pharmaceutical manufacturer to provide rebates in an amount not less than the rebates provided to the Medicaid Program under § 1927(c) of Title XIX of the Social Security Act (42 U.S.C. § 1396r-8) as a condition of the pharmaceutical manufacturer's products being available to enrollees;

(3) Enroll eligible individuals into a prescription drug plan under contract with the Department, with an opt-out provision at the individual's discretion;

(4) Specify procedures for individuals to apply for enrollment in the Program;

(5) Contract with a private entity to assist in administration of the Program or negotiations with prescription drug plans; and

(6) Pay all or part of the premiums, deductibles, coinsurance payments, and copayments required under the Medicare Part D Program for enrollees.

(g) Scope of Program. -- Subject to available funds, the Program established under this subtitle shall provide benefits to the maximum number of individuals eligible for enrollment in the Program.

(h) Regulations. -- The Secretary shall adopt regulations to implement the Program.