C.M.R. 10, 144, ch. 104, § 144-104-4, app 144-104-A

Current through 2024-51, December 18, 2024

Appendix 144-104-A - MAINE PART D WRAP BENEFITS COVERAGE CHART

Eligibility Group	Co-Payment	Premiums	Deductible	Gap	Part D Excluded Drugs*
Dual Eligibles Residing in Nursing Facilities	N/A	N/A	N/A	N/A	Covered as reimbursed under Maine Care Benefits Manual, Chapter II, Section 80 P harmacy Services
Dual Eligibles residing in Assisted Living and Level I, II, III and IV PNMI Eligibles (as reimbursed under Maine Care Benefits Manual, Chapter III, Appendices C and F, Section 97, Private Non-Medical Institution Services), or who are co-pay exempt under Chapter 1, Section 1.09-2 of the Maine Care Benefits Manual.	100% of all co-payments	N/A	N/A	N/A	Covered as reimbursed under Maine Care Benefits Manual, Chapter II, Section 80 P harmacy Services
All other Dual Eligibles	50% of the cost of Brand Name drugs with a cap of $10 per prescription, and 100% of the cost of generics up to $2.50.	N/A	N/A	N/A	Covered as reimbursed under Maine Care Benefits Manual, Chapter II, Section 80 P harmacy Services
Medicare Savings Program DEL Eligibles (QMB, SLMB, QI)	50% of the cost of Brand Name drugs with a cap of $10 per prescription, and up to $2.50 per generic.	N/A	N/A	N/A	Covered as paid under Chapter 104, Section 2, DEL Policy
DEL members eligible for Medicare Part D	Not covered	100% of Part D Premiums	50% of the Part D deductible	Members will have co-pay of 20% plus $2.	Covered as paid under Chapter 104 DEL Policy
*Please see the following website for a list of covered Part D excluded drugs: www.Maine Carepdl.org (under "General Pharmacy Info")