# 144 Ch. 1042: Ch. 1042: Maine Drugs for the Elderly Benefit > Maine · Regulations · In force URL: https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_144_1042 ## Section - **Citation:** 144 Ch. 1042 - **Heading:** Ch. 1042: Maine Drugs for the Elderly Benefit - **Jurisdiction:** Maine - **Kind:** Regulations - **Status:** In force - **Text as of:** August 14, 2026 - **Source:** Compiled text - **Location:** Code of Maine Rules / -144 Department of Health and Human Services Rules / Ch. 1042 ## Text Section. 2.02-6 DEL 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. 2.02-7 Drug 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. 2.02-8 Drug 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. 2.02-9 Generic Drugs are drugs other than those defined as brand-name drugs. 2.02 DEFINITIONS (cont.) 2.02-10 Mail 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. 2.02-11 MaineCare Benefits Manual (MBM) is the MaineCare policy set forth in Department of Health and Human Services, 10-144, Chapter 101, MaineCare Benefits Manual. 2.02-12 MaineCare Member means a person who receives benefits under the MaineCare Program l order pharmacies must process claims through the State’s electronic claims processing system to the standards required by the Department. 2.02-11 MaineCare Benefits Manual (MBM) is the MaineCare policy set forth in Department of Health and Human Services, 10-144, Chapter 101, MaineCare Benefits Manual. 2.02-12 MaineCare Member means a person who receives benefits under the MaineCare Program. 2.02-13 Maine 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. 2.02-14 Medicare Part D means the prescription drug benefit program provided under the Medicare Prescription Drug Improvement and Modernization Act of 2003, Public Law 108-173. 2.02-15 Medicare 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. 2.02-16 Medi-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 DEFINITIONS (cont.) 2.02-17 Metropolitan 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 -name (single-source, cross-licensed or innovator) or generic (multiple-source) drugs for the purposes of calculating reimbursement. 2.02 DEFINITIONS (cont.) 2.02-17 Metropolitan 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. 2.02-18 National 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. 2.02-19 Non-Preferred Drugs are covered drugs that are not preferred drugs. 2.02-20 OBRA 90 is the Omnibus Budget Reconciliation Act of 1990 as amended. 2.02-21 Over-The-Counter Drug (OTC) is a drug that can be purchased without a prescription. 2.02-22 Participant is an individual who is eligible for and is receiving the DEL Benefit. 2.02-23 Pharmacy 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. 2.02-24 Preferred 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. 2.02-25 Preferred 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 recommendation of the Drug Utilization Review Committee. 2.02-25 Preferred 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. 2.02-26 Retail 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. 2.02-27 Telepharmacy 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 2.02 DEFINITIONS (cont.) Maine State Board of Pharmacy rules, including using staff qualified to deliver prescriptions through telepharmacy. 2.02-28 Therapeutic Category is a grouping of drugs by comparable therapeutic effect, as determined by the Department. 2.02-29 Usual & Customary Charge is the amount a pharmacy charges to individuals for prescription drugs for which those individuals do not have insurance coverage. 2.03 ELIGIBILITY An individual is eligible to receive services as set forth in this Section if he or she meets the eligibility requirements established in 10-144 C.M.R. Chapter 333. Some participants may have restrictions on the type and amount of benefits they are eligible to receive under this Section. 2.04 PARTICIPATION IN MEDICARE PART D Participants must exhaust other pharmacy benefits including Medicare Part D and MaineCare before using DEL benefits under this Section. 2.04-1 Authorized Representative The Department may act as an authorized representative for or appoint a designee to act as an authorized representative for participants who are dually eligible for DEL and Medicare Part D 2.04 PARTICIPATION IN MEDICARE PART D Participants must exhaust other pharmacy benefits including Medicare Part D and MaineCare before using DEL benefits under this Section. 2.04-1 Authorized Representative The Department may act as an authorized representative for or appoint a designee to act as an authorized representative for participants who are dually eligible for DEL and Medicare Part D. As an authorized representative, the Department may: deem eligible and enroll and reenroll participants in a Medicare Part D plan; apply for Medicare Part D benefits and subsidies on behalf of participants; establish rules by which participants may opt out of participation in Medicare Part D; and at its discretion, file exceptions and appeals pertaining to Medicare Part D eligibility or benefits on behalf of participants. Participants Dually Eligible for Medicare Part D For participants who are eligible for Medicare Part D, the Department may provide coverage of drugs excluded by Medicare Part D to the same extent that coverage is available to participants who are not eligible for Medicare Part D. 2.05 REQUIREMENTS FOR PHARMACY PARTICIPATION IN DEL A pharmacy that wishes to submit claims for payment under the Drugs for the Elderly Benefit must: 1. Comply with all provider and administrative process requirements set forth in Chapter 104, Section 1; and 2. Be enrolled as a MaineCare pharmacy provider. The Department may issue a request for proposals from labelers or manufacturers and issue a contract for the provision of generic drugs. Participating providers may be required by the Department to obtain a generic drug from labelers or manufacturers with which the Department contracts. The Department will notify providers and give instructions for compliance with this provision. 2.06 BENEFITS Only those drugs of manufacturers that have both a valid rebate agreement with the federal government pursuant to 42 U.S.C. § 1396r-8 and a DEL Rebate Agreement are covered in the DEL Benefit nt to obtain a generic drug from labelers or manufacturers with which the Department contracts. The Department will notify providers and give instructions for compliance with this provision. 2.06 BENEFITS Only those drugs of manufacturers that have both a valid rebate agreement with the federal government pursuant to 42 U.S.C. § 1396r-8 and a DEL Rebate Agreement are covered in the DEL Benefit. A prescription drug of a manufacturer that does not enter into an agreement pursuant to this paragraph is reimbursable only if the Department determines the prescription drug is essential. The Department, at its sole discretion, will determine that a drug is essential based on medical necessity. In addition, drugs may be subject to prior authorization and the step order as set forth in this Section. The Department may refuse coverage for a drug when the prescriber cannot demonstrate medical necessity. 2.06-1 Basic Benefit A. Covered Drugs 1. Prescription Drugs The Basic benefit covers brand-name and generic drugs when administered for the following conditions and illnesses: heart disease, diabetes, high blood pressure, arthritis, chronic lung disease (including emphysema and asthma), anticoagulation, hyperlipidemia (high cholesterol), incontinence, thyroid disease, osteoporosis (bone density loss), Parkinson's disease, glaucoma, and multiple sclerosis/ amyotrophic lateral sclerosis (Lou Gehrig’s Disease). 2.06 BENEFITS (cont.) 2. Over-The-Counter Drugs Some over-the-counter drugs are covered in the DEL Benefit when the Department determines that they are both cost-effective and that they have a National Drug Code (NDC) number. These drugs will be approved only when the prescriber can demonstrate, with appropriate medical justification, that the use of these drugs is medically necessary. The Department may exclude from coverage drugs that are equivalent to drugs that are available over-the-counter. 3. Benefits for Medicare Part D Eligible Beneficiaries st-effective and that they have a National Drug Code (NDC) number. These drugs will be approved only when the prescriber can demonstrate, with appropriate medical justification, that the use of these drugs is medically necessary. The Department may exclude from coverage drugs that are equivalent to drugs that are available over-the-counter. 3. Benefits for Medicare Part D Eligible Beneficiaries. The Department will continue to cover Medicare Part D Excluded Drugs for eligible participants so long as those drugs are covered for other DEL participants. The Department will post a complete list of these drugs on its designated website. The Department will also continue DEL coverage for premiums, deductibles, co-payments, and coverage gaps (donut hole) in Medicare Part D coverage, as defined in Chapter 104, Section 4, to the extent that funds are available. B. Co-Payments 1. For Retail Pharmacies In the Basic benefit, the participant must pay a co payment for services requested and rendered from retail pharmacies of 20% of the reimbursement amount as defined in Section 2.11, plus $2 per prescription, not to exceed a 34-day supply for brand-name drugs, and up to and including a 90-day supply for generics. 2. For Mail Order Pharmacies In the Basic benefit, the participant must pay a co-payment for services requested and rendered from mail order pharmacies of 20% plus $2 of the reimbursement amount as defined in Section 2.11 for up to a 90-day supply of generic drugs or brand-name drugs. 2.06 BENEFITS (cont.) 2.06-2 Supplemental Benefit A. Covered Drugs The Supplemental benefit includes all drugs of those manufacturers that have entered a federal rebate agreement and a DEL rebate agreement that are not covered in the Basic benefit, including those used to treat illnesses and conditions not included in the Basic benefit as set forth above of generic drugs or brand-name drugs. 2.06 BENEFITS (cont.) 2.06-2 Supplemental Benefit A. Covered Drugs The Supplemental benefit includes all drugs of those manufacturers that have entered a federal rebate agreement and a DEL rebate agreement that are not covered in the Basic benefit, including those used to treat illnesses and conditions not included in the Basic benefit as set forth above. A prescription drug of a manufacturer that does not enter into an agreement pursuant to this paragraph is reimbursable only if the Department determines the prescription drug is essential. The Department, at its sole discretion, will determine that a drug is essential based on medical necessity. B. Co-Payments Under the Supplemental benefit, whether obtained through retail or mail order pharmacies, participants must pay 100% of the MaineCare prescription rate for brand-name drugs, as set forth in Subsection 2.11 of this Section, minus $2 per prescription. For generic drugs, participants must pay the sum of $2 plus 20% of the DEL prescription rate as set forth in Section 2.11. 2.06-3 Catastrophic Benefit A. Covered Drugs All drugs covered by either the Basic benefit or the Supplemental benefit are covered in the Catastrophic benefit. B. Eligibility for the Catastrophic Benefit Participants eligible for Medicare Part D are not eligible for catastrophic benefits under this Section. Participants who are not Medicare Part D eligible are eligible for the Catastrophic benefit once that participant has paid total co-payments in the DEL benefit of at least $1,000 between August 1 and July 31 of any year(s) in which the participant is eligible, provided that: Only co-payments for those drugs that were included in the DEL Benefit on or before May 31, 2001 apply 2.06 BENEFITS (cont.) toward the Catastrophic benefit. A list of those drugs is available from the Department and on the Department’s designated website; and 2 n the DEL benefit of at least $1,000 between August 1 and July 31 of any year(s) in which the participant is eligible, provided that: Only co-payments for those drugs that were included in the DEL Benefit on or before May 31, 2001 apply 2.06 BENEFITS (cont.) toward the Catastrophic benefit. A list of those drugs is available from the Department and on the Department’s designated website; and 2. Only those co-payments that are tracked through the Department’s automated pharmacy management information Point of Purchase System apply toward the Catastrophic benefit. Co-Payments After the participant has paid a total of $1,000 in co-payments as set forth in 2.06-3(B), the participant may purchase any drugs covered by either the Basic or Supplemental benefit by paying 20% of the reimbursement rate described in Section 2.11 until the next July 31. 2.06-4 Prior Authorization (PA) A. Determining Which Drugs May Be Subject to Prior Authorization The Department may require prior authorization for certain drugs in the DEL benefit as set forth in this sub-section. In determining when prior authorization will be required, the Department will consider the recommendations of the DUR Committee. The determination to impose prior authorization will be based on the efficacy, safety, and net cost of any given drug and of the other drugs within the therapeutic category. The Department's determination of a drug's efficacy and safety shall be consistent with the standards set forth in (1) the peer-reviewed literature, and (2) the following compendia: the American Hospital Formulary Service Drug Information, the United States Pharmacopoeia-Drug Information, the DRUGDEX Information System, and American Medical Association Drug Evaluations. The Department's determination of a drug's net cost shall consider the pharmacy reimbursement amount as set forth at section 2.10 of this rule, as adjusted by any manufacturer rebates and or supplemental rebates to be paid to the Department for that drug Information, the United States Pharmacopoeia-Drug Information, the DRUGDEX Information System, and American Medical Association Drug Evaluations. The Department's determination of a drug's net cost shall consider the pharmacy reimbursement amount as set forth at section 2.10 of this rule, as adjusted by any manufacturer rebates and or supplemental rebates to be paid to the Department for that drug. The Department may not consider net cost when imposing prior authorization unless it determines that the drug to be subject to prior authorization has no significant clinical or safety advantages over one or more alternative drugs, when used for a given purpose. The Department may also consider the indications for which the drug may be prescribed, where appropriate. 2.06 BENEFITS (cont.) The Department may require prior authorization of any generic drug that has a net cost that is greater than the net cost of its brand-name version. The Department, in consultation with the DUR Committee, may determine that the prior authorization requirement may be waived on a case-by-case basis for patients who are established on a drug that otherwise might be subject to prior authorization. Exemptions From Prior Authorization The Department has the discretion to exempt providers and/or participants from prior authorization requirements. The Department may discontinue these PA compliance exemptions any time with written notice. Exemptions are as described in this Section: Provider Exemptions from Prior Authorization: a. Three-Month PA Compliance Exemptions Providers may receive a 3-month exemption from prior authorization requirements for certain categories of drugs when they demonstrate high compliance with the Department’s PDL. The Department runs quarterly reports to identify providers who prescribe 95% or more of their prescriptions, within certain categories of drugs, in compliance with the PDL ization: a. Three-Month PA Compliance Exemptions Providers may receive a 3-month exemption from prior authorization requirements for certain categories of drugs when they demonstrate high compliance with the Department’s PDL. The Department runs quarterly reports to identify providers who prescribe 95% or more of their prescriptions, within certain categories of drugs, in compliance with the PDL. When providers are thus identified, they may receive a 3-month exemption from PA requirements when prescribing drugs for participants within the identified drug categories. The Department will notify providers in writing which drug categories are included and what dates apply to the exemption. b. Twelve-Month PA Compliance Exemptions When providers have met all requirements for the 3-month compliance exemption described above, and have received that exemption for 3 out of 4 quarters of a year, the Department may grant a 1-year exemption for prior authorization requirements when prescribing drugs for participants within certain categories of drugs. The Department will notify providers in writing which drug categories are included and what dates apply to the exemption. 2.06 BENEFITS (cont.) c. Exemptions for Specialty Providers The Department, in consultation with the DUR Committee, and consistent with standards set forth in 2.06-4(A), may waive the prior authorization requirements for specific provider specialists on a drug-by-drug basis. Provider Exemptions from Prior Approval a. Primary Insurance Exemptions from Prior Authorization The Department may waive the prior authorization requirements for participants receiving non-preferred drugs when DEL or MaineCare is the secondary payer. b th standards set forth in 2.06-4(A), may waive the prior authorization requirements for specific provider specialists on a drug-by-drug basis. Provider Exemptions from Prior Approval a. Primary Insurance Exemptions from Prior Authorization The Department may waive the prior authorization requirements for participants receiving non-preferred drugs when DEL or MaineCare is the secondary payer. b. Other Special Exemptions from Prior Authorization for Participants The Department, in consultation with the DUR Committee, and consistent with standards set forth in 2.06-4(A), may waive the prior authorization requirement for specific drugs or medical conditions, on a drug-by-drug basis for participants who have been established for at least 1 year on a drug that otherwise might be subject to prior authorization. 3. Open-Ended Participant Prior Approval Participants may receive open-ended PAs for specific drugs after having been established on a non-preferred drug and meeting all other prior authorization requirements for at least 1 year. These open-ended PAs do not need to be renewed on an annual basis. These PAs may be issued after the Department determines that the participant’s condition is stable, and will remain unchanged if continued on the specific drug. The Department reserves the right to review the PA status should a new and more efficacious alternative become available. C. Process for Seeking Prior Authorization When the Department requires prior authorization, the participant’s physician must complete and submit a written form, including any 2.06 BENEFITS (cont.) required attachments, documenting the medical necessity of the prescribed drug. The Department may seek information such as documentation of other measures that have been attempted to correct the risk/condition, the timeframe in which those other measures were attempted, and the reason for failure. The prescriber is also required to submit documentation that other drugs in the same therapeutic category are contraindicated umenting the medical necessity of the prescribed drug. The Department may seek information such as documentation of other measures that have been attempted to correct the risk/condition, the timeframe in which those other measures were attempted, and the reason for failure. The prescriber is also required to submit documentation that other drugs in the same therapeutic category are contraindicated. The Department will notify prescribers of the drugs that are subject to prior authorization and will provide them with forms for requesting authorization setting forth the information needed to approve a request. The list of drugs requiring PA and forms will be available on a website designated by the Department. The requesting prescriber must complete the form applicable to the drug for which prior authorization is sought. The prescriber must send the completed form to the Department or its designee, as instructed by the Department, by mail, fax or by hand delivery. During regular business days, the Department or its designee will respond to a completed request for prior authorization by fax, telephone or other telecommunications device within 24 hours of receipt. In an emergency situation, including weekends, holidays, or any other time that the Department or its designee is not able to respond to a completed prior authorization request within 24 hours of receipt, the pharmacist is authorized to provide a one-time 96-hour supply of any prescribed drug that is a covered drug. The Department or its designee shall respond to a completed request under this subpart on the next regular business day. The provision of a 96-hour supply under this subpart does not relieve the prescriber of the obligation to complete and submit the prior authorization request form. In the event that a prescriber fails to submit a completed form for a drug requiring prior authorization, the Department or its designee may authorize the pharmacy to dispense a one-time 34-day supply of the prescribed drug siness day. The provision of a 96-hour supply under this subpart does not relieve the prescriber of the obligation to complete and submit the prior authorization request form. In the event that a prescriber fails to submit a completed form for a drug requiring prior authorization, the Department or its designee may authorize the pharmacy to dispense a one-time 34-day supply of the prescribed drug. The authorization of a 34-day supply under this provision does not relieve the prescriber of the obligation to complete and submit the prior authorization request form. If the prescriber has still failed to submit a completed prior authorization request by the end of the additional 34-day period, the Department will consider any refills of that prescription on a case-by-case basis. The Department may require a provider to redo the prior authorization process every 12 months, or sooner if the participant’s medical condition or the prior authorization criteria change. 2.06 BENEFITS (cont.) 2.06-5 Preferred Drug List A. General In order to facilitate appropriate utilization, the Department will establish a list of covered drugs, ordered by therapeutic category. Within each therapeutic category, the Department may designate some or all drugs as preferred on the basis of efficacy, safety, and net cost. The Department's determination of a drug's efficacy and safety shall be consistent with the standards set forth in (1) the peer-reviewed literature, and (2) the following compendia: The American Hospital Formulary Service Drug Information, the United States Pharmacopoeia-Drug Information, the DRUGDEX Information System, and American Medical Association Drug Evaluations. The Department's determination of a drug's net cost shall consider the pharmacy reimbursement amount as set forth at Section 2.10 of this rule, as adjusted by any manufacturer rebates and or supplemental rebates to be paid to the Department for that drug Information, the United States Pharmacopoeia-Drug Information, the DRUGDEX Information System, and American Medical Association Drug Evaluations. The Department's determination of a drug's net cost shall consider the pharmacy reimbursement amount as set forth at Section 2.10 of this rule, as adjusted by any manufacturer rebates and or supplemental rebates to be paid to the Department for that drug. The Department may not consider net cost when imposing prior authorization unless it determines that the drug to be subject to prior authorization has no significant clinical or safety advantages over one or more alternative drugs, when used for a given purpose. This listing will be known as the Preferred Drug List or PDL. In addition to the preferred/non-preferred designation, the PDL may include information such as generic name, strength/unit, National Drug Code identification number, and brand name. All covered drugs, whether preferred or non-preferred, are available to any eligible participant for whom those drugs are medically necessary. Some drugs must have their medical necessity confirmed for a given participant through the prior authorization process before the Department will provide reimbursement. B. Step Order In addition to the preferred/non-preferred designations, the Department may assign some drugs on the PDL a further designation of preference within a therapeutic category. This further designation will be known as step order. The step order is a means of reducing the need to obtain prior authorization. When a participant has been prescribed all drugs at 2.06 BENEFITS (cont.) a higher step(s) within a therapeutic category, the drug at the next lower step will automatically be reimbursed for that participant without requiring prior authorization. Only drugs prescribed to the participant since enrollment and reflected in the Department’s automated pharmacy management information Point of Purchase System will be considered in applying the step order. C BENEFITS (cont.) a higher step(s) within a therapeutic category, the drug at the next lower step will automatically be reimbursed for that participant without requiring prior authorization. Only drugs prescribed to the participant since enrollment and reflected in the Department’s automated pharmacy management information Point of Purchase System will be considered in applying the step order. C. Notification The Department will post the PDL on the Department's designated web site. The Department will also provide quarterly notification of the drugs selected for placement on the PDL, and any other changes in the PDL. The list will be provided upon request to participants and providers who do not have Internet access. 2.07 DISPENSING PRACTICES Retail pharmacy providers may dispense up to a 34-day supply of brand name drugs and up to a 90-day supply of generic drugs. Mail order pharmacies may only dispense up to 90-day supplies of generic or brand-name drugs. When refilling a prescription through mail order, refills may be provided only at a participant’s request; mail order pharmacies may not automatically refill prescriptions for participants. Providers dispensing prescriptions via telepharmacy must obtain approval from the Department. Providers must assure that participant counseling is available at the remote site from the dispensing provider or the provider delivering the prescription, and that only qualified staff, as defined by the Maine State Board of Pharmacy, deliver prescriptions. 2.08 FINANCIAL PARTICIPATION (CO-PAYMENT) When the DEL Benefit level requires a co-payment, the Department requires each DEL participant to pay the co-payment for drugs, as set forth above. There are no exceptions. If the participant refuses to pay the co-payment, the pharmacy will deny the service. 2.09 ELIGIBILITY CARD The Department of Health and Human Services issues an eligibility card to each eligible participant enrolled in the DEL Benefit Benefit level requires a co-payment, the Department requires each DEL participant to pay the co-payment for drugs, as set forth above. There are no exceptions. If the participant refuses to pay the co-payment, the pharmacy will deny the service. 2.09 ELIGIBILITY CARD The Department of Health and Human Services issues an eligibility card to each eligible participant enrolled in the DEL Benefit. A participant must present the eligibility card to the participating pharmacy upon request. 2.10 AMOUNT AND DURATION OF BENEFITS The Department may stop reimbursing for covered drugs if, in any fiscal year, all the funds appropriated for DEL have been expended. When necessary, the Department will provide participants and participating pharmacies with prior notice of the date upon which reimbursement will cease. 2.11 REIMBURSEMENT The Department will reimburse participating pharmacies only for drugs that are covered drugs as set forth above. The DEL Benefit is the payor of last resort. If the participant has another prescription drug coverage plan, that plan must be billed first. A. The Department may establish the Maine Maximum Allowable Cost (MMAC) for covered drugs, considering the following factors: Multiple manufacturers; Broad wholesale price span; Availability of drugs to retailers at the selected cost; High volume of utilization; and Bioequivalence or interchangability. B. For retail pharmacies the amount of reimbursement will be the lowest of the following: For Generic Drugs The usual and customary charge; or The Maine Maximum Allowable Cost plus a $2.35 professional fee; or The Average Wholesale Price minus 14% plus a $2.35 professional fee; or The State Upper Limit (250% of Average Manufacturer’s Cost for multi-source generic drugs) plus a $2.35 professional fee. For Brand-Name Drugs The usual and customary charge; or The Average Wholesale Price minus 15% plus a $2.35 professional fee. C or The Maine Maximum Allowable Cost plus a $2.35 professional fee; or The Average Wholesale Price minus 14% plus a $2.35 professional fee; or The State Upper Limit (250% of Average Manufacturer’s Cost for multi-source generic drugs) plus a $2.35 professional fee. For Brand-Name Drugs The usual and customary charge; or The Average Wholesale Price minus 15% plus a $2.35 professional fee. C. For mail order pharmacies, the amount of reimbursement will be the lowest of the following: 2.11 REIMBURSEMENT (cont.) 1. For Generic Drugs The usual and customary charge; or The Average Wholesale Price minus 60% plus $1.00 professional fee except as otherwise noted below, or The Maine Maximum Allowable Cost plus $1.00 professional fee. 2. For Brand-Name Drugs a. The usual and customary charge; or b. The Average Wholesale Price minus 20% plus $1.00 professional fee. 2.12 PHARMACY RURAL DISPENSING FEE ADJUSTMENT The Department will pay a supplemental dispensing fee for prescriptions provided to members residing in rural areas in an attempt to assure continuing access to prescription services for these members. The rural dispensing fee will range from 55¢ to 65¢ per prescription dispensed to rural members, and will change on a quarterly basis to reflect the prior quarter’s number of prescriptions filled. The Department will distribute the rural dispensing fee adjustment retrospectively on a quarterly basis. The Department will calculate the quarterly adjustment for each pharmacy by taking that quarter’s total allotment and dividing the total allotment for the quarter by the number of prescriptions filled for rural members in the quarter. The Department will then group these by pharmacy and distribute in the quarter following. Pharmacies will be notified on a quarterly basis on the Department’s designated website the amount of the adjustment for the quarter. Rural members will be defined using a standard and federally recognized definition of rural using Metropolitan Statistical Area (MSA) designations ural members in the quarter. The Department will then group these by pharmacy and distribute in the quarter following. Pharmacies will be notified on a quarterly basis on the Department’s designated website the amount of the adjustment for the quarter. Rural members will be defined using a standard and federally recognized definition of rural using Metropolitan Statistical Area (MSA) designations. The Department will determine MSA/Non-MSA designation based on the zip code of the member’s residence. 2.13 APPEALS Each participant has the right to an administrative hearing to appeal any decision by the Department that adversely affects that participant’s benefit. These appeal rights are set forth in Chapter 104, Section 1. 2.14 BILLING INSTRUCTIONS Participating pharmacies must bill in accordance with the Department’s billing instructions set forth in the pharmacy’s MaineCare agreement. DEPARTMENT OF HEALTH AND HUMAN SERVICES 10-144 Chapter 104 MAINE STATE SERVICES MANUAL SECTION 2 MAINE DRUGS FOR THE ELDERLY BENEFIT ESTABLISHED 9/29/03 LAST UPDATED 3/1/07 PAGE PAGE i Effective 3/1/07 Effective 3/1/07 Effective 3/1/07 Effective 3/1/07 Effective 3/1/07 Effective 3/1/07 Effective 3/1/07 Effective 3/1/07 ## Nearby sections - [144 Ch. 1 Ch. 1: Administrative Hearings Regulations](https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_144_1.md) - [144 Ch. 2 Ch. 2: Community Services Block Grant Program](https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_144_2.md) - [144 Ch. 5 Ch. 5: Head Start Program Rules](https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_144_5.md) - [144 Ch. 24 Ch. 24: Purchase of Service Rules](https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_144_24.md) - [144 Ch. 30 Ch. 30: Maine Uniform Accounting and Auditing Practices for Community Agencies](https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_144_30.md) - [144 Ch. 50 Ch. 50: Department of Human Services Exceptions to OMB (Office of Management and Budget) Circulars](https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_144_50.md) - [144 Ch. 52 Ch. 52: Responsibilities of Physicians and Hospitals Re: Required Request for Organ Donation](https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_144_52.md) - [144 Ch. 60 Ch. 60: Maine Background Check Center Rule](https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_144_60.md) - [144 Ch. 103 Ch. 103: Maine Health Program Rules](https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_144_103.md) - [144 Ch. 105 Ch. 105: Catastrophic Illness Program](https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_144_105.md) - [144 Ch. 108 Ch. 108: Home and Community Support Service Agencies Licensing Rule](https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_144_108.md) - [144 Ch. 109 Ch. 109: Quality Oversight for Commercial Health Maintenance Organizations (HMOs)](https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_144_109.md) - [144 Ch. 110 Ch. 110: Regulations Governing the Licensing and Functioning of Skilled Nursing Facilities and Nursing Facilities](https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_144_110.md) - [144 Ch. 111 Ch. 111: Temporary Nurse Agency Registration Rule](https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_144_111.md) --- Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_ME_CMR_00_144_1042. Check the current official text before relying on it. Not legal advice.