Subsection 144-104-4.02 - DEFINITIONS4.02-1Authorized Representative refers to the Department's authority pursuant to 22 M.R.S.A. §254-D to enroll and reenroll 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 their behalf. The Department may also identify a designee for this function. 4.02-2Beneficiary under Medicare Part D means a person who is eligible for benefits and enrolled in a Medicare Part D plan.4.02-3Brand Name Drug is defined as a single-source drug, a cross-licensed drug, or an innovator drug.4.02-4Covered Drug is a drug for which the Department reimburses under this benefit. See Subsection 4.05 and Appendix A of this Section.4.02-5Generic Drugs are drugs other than those defined as brand-name drugs.4.02-6Mail 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 Maine Care 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.4.02-7Maine Care Benefits Manual (MBM) is the Maine Care policy set forth in Department of Health and Human Services, 10-144, Chapter 101, Maine Care Benefits Manual.4.02-8Maine Care Member means a person who receives benefits under the Maine Care Program.4.02-9Medicare Part D means the prescription drug benefit program provided under the Medicare Prescription Drug Improvement and Modernization Act of 2003, Public Law 108-173.4.02-10Medicare 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] , for 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 benzodiazepins.
4.02-11Medicare Savings Program Eligible refers to a participant who is also eligible for Maine Care through the Medicare Buy-In Program, as defined in the Maine Care Eligibility Manual (MEM) and designated as QMB, SLMB, or QI.4.02-12National 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.4.02-13Non-Preferred Drugs are covered drugs that are not preferred drugs.4.02-14OBRA 90 is the Omnibus Budget Reconciliation Act of 1990 as amended.4.02-15Over-The-Counter Drug (OTC) is a drug that can be purchased without a prescription.4.02-16Participant is an individual who is eligible for and is receiving this benefit.4.02-17Pharmacy Provider is a corporation, association, partnership, or individual that either provides pharmacy services pursuant to a provider agreement with Maine Care or is related by ownership or control to an entity that provides Maine Care or DEL Benefit services, and is also a Medicare pharmacy provider.4.02-18Preferred 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.4.02-19Preferred 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. This benefit utilizes the PDL referenced in Chapter 104, Section 2, Drugs for the Elderly.4.02-20Prescription Drug Plan (PDP) is a Medicare Part D plan provider that is also an approved contractor under contract with the DHHS.4.02.21Retail 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.4.02-22Therapeutic Category is a grouping of drugs by comparable therapeutic effect, as determined by the Department.4.02-23Usual & Customary Charge is the amount a pharmacy charges to individuals for prescription drugs for which those individuals do not have insurance coverage.4.02-24Wrap Benefits are benefits offered through this Section that may include assistance with co-payments, deductibles, premiums and gaps in coverage. Wrap benefits vary for some members, and details of the benefit are outlined in the table in Appendix A. C.M.R. 10, 144, ch. 104, § 144-104-4, subsec. 144-104-4.02