Del. Code tit. 16, ch. 30B — Prescription Drug Payment Assistance Program | Delaware Code — Delaware

Del. Code tit. 16, § 3001B Short title.

This chapter is known and may be cited as the “Delaware Prescription Drug Payment Assistance Program.”

Del. Code tit. 16, § 3002B Purpose.

The purpose of this chapter is to provide payment assistance for prescription drugs and certain Medicare Part D costs to Delaware’s low-income senior and disabled citizens who are ineligible for, or do not have, prescription drug benefits or coverage through federal, excluding Medicare Part D coverage; state; or private sources.

Del. Code tit. 16, § 3003B Definitions.

As used in this chapter: (1) “Department” means the Department of Health and Social Services. (2) “Eligible person” means an individual eligible for the Delaware Prescription Drug Payment Assistance Program under § 3004B of this title. (3) “Medicare Part D costs” means monthly premiums, deductibles, and those drug costs falling into Part D coverage gap up to the Program benefit limits and subject to program co-pay requirements as described in § 3005B(a)(4) of this title. Medicare Part D costs do not include Medicare Part D co-payments. (4) “Prescription drugs” means drugs that are self-administered or administered by a lay person that have been approved as safe and effective by the Federal Food and Drug Administration or are otherwise legally marketed in the United States. Medications administered only by a clinically trained person are not covered under this program. Prescription drugs covered under this chapter are limited and subject to the provisions of § 3005B of this title and the rules and regulations adopted under § 3005B of this title. (5) “Program” means the Prescription Drug Payment Assistance Program.

Del. Code tit. 16, § 3004B Eligibility.

To be eligible for the Program an individual must meet all of the following: (1) Be a U.S. citizen or a lawfully admitted alien. (2) Have income that is less than 200% of the Federal Poverty Level (FPL) or have prescription drug expenses that exceed 40% of the individual’s annual income. (3) Be a resident of this State. (4) Be ineligible for Medicaid prescription benefits. (5) Be ineligible for or not receiving a prescription drug benefit or any third party payer prescription benefit, excluding Medicare Part D coverage. (6) Be enrolled in Medicare Part D and Medicare Part D Low Income Subsidy, if eligible, or qualify for a Medicare Part D Special Enrollment Period as an eligible person under the Program (7) Be an individual aged 65 or over or be an individual between the ages 19 and 64 who is otherwise eligible for benefits under Title II of the Social Security Act (Federal Old Age, Survivors and Disability Insurance Benefits) (42 U.S.C. § 401 et seq.).

Del. Code tit. 16, § 3005B Program administration.

(a) The Department shall administer the Program. The Department shall promulgate and adopt rules and regulations as are necessary to implement the Program in a cost-effective manner and to ensure the Program is the payer of last resort for prescription drugs. The Department shall adopt rules and regulations that include all of the following: (1) Payment assistance may not exceed $3,000 in a benefit year to assist each eligible person in the purchase of prescription drugs and the payment of certain Medicare Part D costs. (2) Medicare Part D coverage must be primary to payment assistance under the Program. (3) The Department shall restrict covered prescription drugs covered under the Program to those manufactured by pharmaceutical companies that agree to provide manufacturer rebates under the drug rebate program established for non-Medicaid programs. The Department shall establish a state rebate program that it determines is in the best interests of the citizens who are being served. The rebate amount must be calculated using the full methodology prescribed by the federal government for the Medicaid program. Notwithstanding any provisions of the Delaware Code to the contrary, the Department shall deposit any drug rebate funds received into the Program’s account and shall use these funds to meet Program costs. (4) The Department shall develop a copayment requirement, which may not exceed 25% of the acquisition cost but which must be no lower than $5.00. The copayment requirement under this paragraph applies to prescription drug costs not covered by Medicare Part D. (5) The Department shall provide a clear, written explanation defining the scope of the Program’s coverage, the amount of the cost-sharing requirements, and any limitations on access to covered prescription drugs. The Department shall provide notice, when 75% of the cap has been expended. The Department shall also notify individuals of the process to appeal a decision denying reimbursement for prescription drugs or denying an individual’s eligibility for the Program. Services are to begin on the first day of the month, following the month that eligibility is determined. An eligible person must be provided an identification card for the Program. (6) A system of administration may not make direct cash payment to any eligible person. (b) The Department may promulgate and adopt rules and regulations that do any of the following: (1) Limit application to the Program to a specific open-enrollment period. (2) Limit Medicare Part D plan options to align with federal Low Income Subsidy benchmarks. (3) Develop prescription quantity limits. (4) Impose an annual enrollment fee in an amount not to exceed $20 that must be paid by all eligible persons in the Program to defray administrative expenses. Payment of any such fee must be credited to a special fund to be designated as the Prescription Assistance Fund. For each year, the maximum unencumbered balance that may remain in the Prescription Assistance Fund at the end of any year may not be more than the administrative cost of the Program in the subsequent year. (5) Determine income eligibility of an individual by any reasonable means, including a review of the individual’s most recent federal and state income tax returns and copies of income checks. Determine residency, age, and disability eligibility by submission of documents the Department deems reasonable. (6) Otherwise enable the Department to implement the Program consistent with the purposes outlined in this chapter and the appropriations provided to implement the Program.

Del. Code tit. 16, § 3006B Annual report.

The Department shall maintain data to evaluate the cost and effectiveness of the Program and shall produce an annual report summarizing participant demographics, utilization, utilization review results, and other available information as may be needed to evaluate the costs and benefits of the Program.

Del. Code tit. 16, § 3007B Pharmacist duty.

A pharmacist may not dispense or provide a covered prescription drug to an eligible person under this chapter until the eligible person makes the required copayment.