C.M.R. 10, 144, ch. 104, § 144-104-3, subsec. 144-104-3.10

Current through 2024-51, December 18, 2024

Subsection 144-104-3.10 - REIMBURSEMENT

A. Eligible Claims

Maine Rx Plus provides benefits for discounted drugs only when participants do not have coverage under a comparable or superior prescription drug plan. Participating pharmacies must always determine the existence of and seek reimbursement from an individual's comparable or superior prescription drug benefit prior to submitting claims to the Maine Rx Plus Benefit.

B. Amount of Reimbursement for Retail Pharmacies

For each eligible prescription filled, the participating retail pharmacy will be reimbursed a $3.35 dispensing fee plus the lowest of the following:

1. Federal Upper Limits (FUL) as defined in Chapter II, Section 80, Pharmacy Services, of the MaineCare Benefits Manual (MBM); or

2. Maine Maximum Allowable Cost (MMAC) as defined in Chapter II, Section 80, Pharmacy Services, of the MBM; or

3. Average Wholesale Price minus 13%; or

4. The participating pharmacy's Usual and Customary (U & C) Price; or

5. The State Upper Limit (250% of Average Manufacturer's Cost for multi-source generic drugs) plus a $2.35 professional fee.

The Department will not pay any costs for payments for which the participant is responsible.

The Department will also reimburse the participating pharmacy in the amount of any applicable secondary discount, which the pharmacy will pass along in full as an additional discount to the Maine Rx Plus participant.

C. Amount of Reimbursement for Mail Order Pharmacies

For mail order pharmacies, the amount of reimbursement will be the lowest of the following:

1. For Generic Drugs

The reimbursement rate for covered generic drugs obtained through mail order pharmacies shall be the lowest of the following:

a. The Usual and Customary Price; or

b. The Average Wholesale Price minus 60% plus $1.00 professional fee except as otherwise noted below, or

c. The Maine Maximum Allowable cost plus $1.00 professional fee except as noted in Section 3.10.

2. For Brand Name Drugs

The reimbursement rate for covered brand name drugs obtained through mail order pharmacies shall be the lowest of the following:

a. The Usual and Customary Price; or

b. The Average Wholesale Price minus 20% plus $1.00 professional fee except as otherwise noted below, or

c. The Maine Maximum Allowable Cost plus $1.00 professional fee except as noted in Section 3.10.

D. Billing Instructions

Participating pharmacies must bill in accordance with the Department's billing instructions set forth in the pharmacy's MaineCare agreement. A pharmacy licensed both as a retail and mail order pharmacy must bill for mail order services at the mail order rate.

C.M.R. 10, 144, ch. 104, § 144-104-3, subsec. 144-104-3.10