Subsection 144-104-2.02 - DEFINITIONS2.02-1Authorized Representative refers to the Department's authority pursuant to 22 M.R.S.A. § 254-D to enroll and reenroll DEL participants into a Medicare Part D plan, apply for Medicare Part D benefits and subsidies on their behalf, and at the Department's discretion, file exceptions and appeals on behalf of participants. The Department may also identify a designee for this function.2.02-2Beneficiary under Medicare Part D means a person who is eligible for and enrolled in a Medicare Part D plan.2.02-3Brand Name Drug is defined as a single-source drug, a cross-licensed drug, or an innovator drug.2.02-4Coverage Gap (donut hole) is the portion of the standard Medicare Part D benefit where the Part D plan provides no coverage and the enrollee pays 100% of the prescription after the deductible is met.2.02-5Covered Drug is a drug for which the Department reimburses under the DEL Benefit. See Subsection 2.05 of this Section.2.02-6DEL Rebate Agreement is an agreement between the Department and a drug manufacturer that provides that the drug manufacturer will make rebate payments for both the basic and supplemental components of the Benefit.2.02-7Drug Utilization Review (DUR) means a process designed to ensure that prescriptions are appropriate, medically necessary, cost-effective, and not likely to result in adverse medical results.2.02-8Drug Utilization Review Committee (DUR Committee) means an advisory committee to the Department of Health and Human Services for the MaineCare Benefit and DEL Benefit, comprised of physicians and pharmacists who are licensed to prescribe or dispense drugs in Maine. The DUR Committee conducts drug utilization review for the Department.2.02-9Generic Drugs are drugs other than those defined as brand-name drugs.2.02-10Mail Order Pharmacy is a pharmacy provider that dispenses prescription medications by U.S. mail or private carrier. Mail order pharmacies must have a NABP (National Association of Boards of Pharmacy) provider number uniquely identifying the provider as a mail order pharmacy for purposes of billing. Mail order pharmacies must be licensed by the Maine Board of Pharmacy, enrolled as Medicare and MaineCare providers, and be operating under contract with the Department. Mail order pharmacies must dispense prescription medications from within the United States. Mail order pharmacies must process claims through the State's electronic claims processing system to the standards required by the Department.2.02-11MaineCare Benefits Manual (MBM) is the MaineCare policy set forth in Department of Health and Human Services, 10-144, Chapter 101, MaineCare Benefits Manual.2.02-12MaineCare Member means a person who receives benefits under the MaineCare Program.2.02-13Maine Maximum Allowable Cost (MMAC) is the maximum reimbursement amount that is established by the Maine Department of Health and Human Services for certain multiple source drugs.2.02-14Medicare Part D means the prescription drug benefit program provided under the Medicare Prescription Drug Improvement and Modernization Act of 2003, Public Law 108-173.2.02-15Medicare Part D Excluded Drugs are those drugs not covered by Medicare Part D pursuant to Title XIX, Section 1927 of the Social Security Act [ 42 U.S.C. § 1396r-8] , which the Department will continue to reimburse if otherwise covered under this Section. The Department will post a complete list of these covered drugs on its designated website, and the list will include but not be limited to the following categories of drugs: over the counter drugs, certain weight loss drugs, agents when used for the symptomatic treatment of cough and cold, vitamins/minerals, outpatient drugs for which associated tests or monitoring must be purchased exclusively from manufacturers, barbiturates, and benzodiazepines.2.02-16Medi-Span is a nationally recognized drug database. The Department uses this database to determine which drugs are defined as brand-name (single-source, cross-licensed or innovator) or generic (multiple-source) drugs for the purposes of calculating reimbursement.2.02-17Metropolitan Statistical Area (MSA) is a federal standardized designation using postal zip codes to define rural areas. The Department will define rural by applying MSA/Non-MSA designation to the zip code of the member's residence.2.02-18National Drug Code (NDC) is a universal drug coding system for human drugs established by the Federal Food and Drug Administration, as set forth in 21 C.F.R § 207. The FDA assigns each drug a unique identification number specifying the labeler/vendor, product, and package.2.02-19Non-Preferred Drugs are covered drugs that are not preferred drugs.2.02-20OBRA 90 is the Omnibus Budget Reconciliation Act of 1990 as amended.2.02-21Over-The-Counter Drug (OTC) is a drug that can be purchased without a prescription.2.02-22Participant is an individual who is eligible for and is receiving the DEL Benefit.2.02-23Pharmacy Provider is a corporation, association, partnership, or individual that either provides pharmacy services pursuant to a provider agreement with MaineCare or is related by ownership or control to an entity that provides MaineCare or DEL Benefit services, and is also a Medicare pharmacy provider.2.02-24Preferred Drugs are covered drugs that are clinically efficacious and which have a lower therapeutic category as determined by the Department after reviewing the recommendation of the Drug Utilization Review Committee.2.02-25Preferred Drug List (PDL) is a listing of covered drugs setting forth such information as their status as preferred or non-preferred, whether prior authorization may be required, step order, and any other information as determined by the Department to be helpful to participants, pharmacists, prescribers and other interested parties.2.02-26Retail Pharmacy is a pharmacy that possesses a valid outpatient pharmacy license issued by the Board of Pharmacy, accepts Medicare assignment, and which serves DEL participants.2.02-27Telepharmacy is a method of delivering prescriptions dispensed by a pharmacist to a remote site. Pharmacies using telepharmacy delivery of prescriptions must follow all applicable State and Federal regulations and Maine State Board of Pharmacy rules, including using staff qualified to deliver prescriptions through telepharmacy.2.02-28Therapeutic Category is a grouping of drugs by comparable therapeutic effect, as determined by the Department.2.02-29Usual & Customary Charge is the amount a pharmacy charges to individuals for prescription drugs for which those individuals do not have insurance coverage. C.M.R. 10, 144, ch. 104, § 144-104-2, subsec. 144-104-2.02