C.M.R. 10, 144, ch. 104, § 144-104-3, subsec. 144-104-3.09
There is no maximum frequency, number, or cost of the prescriptions filled for an individual participant. When drugs are obtained through a mail order pharmacy, participants may obtain only up to a 90-day supply.
Under the Maine Rx Plus Benefit, the Department will cover and reimburse only for drugs that are both prescribed by an authorized prescriber and listed as preferred in the MaineCare preferred drug list (PDL) established pursuant to Chapter II, Section 80, Pharmacy Services of the MaineCare Benefits Manual.
Initial Discount. Until October 1, 2004 Maine Rx Plus participants will pay the initial discounted price (as defined above) for all covered drugs.
Secondary Discount. After October 1, 2004 the Department will further reduce the cost of some covered drugs with a secondary discount. A drug will receive a secondary discount if the manufacturer or labeler of that drug has entered into a Maine Rx Plus rebate agreement with the Department. The amount of the Secondary Discount will be an average of all the rebates the Department has negotiated for Maine Rx Plus, after deducting certain administrative expenses incurred by the Department.
Maine Rx Plus participants must pay the entire initial discounted price or secondary discounted price, whichever is in effect. There are no exceptions. If the participant refuses to pay the entire discounted price, the pharmacy will deny the service.
The Department will negotiate with manufacturers of covered drugs to obtain rebates for the Maine Rx Plus Benefit. As consideration for such rebates, the Department will offer manufacturers or labelers that are willing to pay rebates preferred status within the Maine Rx Plus list of covered drugs. The drugs of manufacturers or labelers that do not agree to pay rebates will remain covered drugs in Maine Rx Plus but will not be given the preferred designation in Maine Rx Plus.
The rebate agreements will require each pharmaceutical manufacturer or labeler to make quarterly rebate payments to the Department for the total number of dosage units of each form and strength of a prescription drug that the Department reports as reimbursed to participating pharmacies. Such payments shall be due thirty (30) days following the date the manufacturer receives utilization data from the Department summarizing the number of dosage units of drugs during the period for which payment is due.
When the pharmaceutical manufacturer or labeler receives the pharmacy reimbursement data, the pharmaceutical manufacturer or labeler shall calculate the quarterly payment. The Department may, at its expense, hire a mutually agreed upon independent auditor to verify the calculation and payment.
In the event that an independent audit discovers a discrepancy between the pharmaceutical manufacturer's or labeler's calculation and the independent auditor's calculation that benefits the Department, the pharmaceutical manufacturer or labeler shall justify its calculation or make payment to the Department for any additional amount due. The pharmaceutical manufacturer or labeler may, at its expense, hire a mutually agreed upon independent auditor to verify the accuracy of the utilization data provided by the Department.
In the event that a discrepancy is discovered that benefits the pharmaceutical manufacturer or labeler, the Department shall justify its data or refund any excess payment to the pharmaceutical manufacturer or labeler.
C.M.R. 10, 144, ch. 104, § 144-104-3, subsec. 144-104-3.09