248 - Cost-sharing responsibilities of eligible program participants for catastrophic coverage.
§ 248. Cost-sharing responsibilities of eligible program participants for catastrophic coverage. 1. Deductible. Eligible individuals meeting the deductible requirements of this section may purchase prescribed covered drugs for an amount specified by subdivision three of this section, subject to the limits on point of sale co-payments specified by subdivision four of this section. 2. Deductible schedule. Eligible individuals electing to meet the requirements of this subdivision shall incur an amount of personal covered drug expenditures during any annual coverage period which are not reimbursed by any other public or private third party payment source or insurance plan, and shall be deemed to have met their deductible requirements for the remainder of such annual coverage period. The amount of personal covered drug expenditures to be incurred by eligible program participants for catastrophic coverage under this option shall be in accordance with the following schedule: (a) Annual personal covered drug expenditures for unmarried individual eligible program participants: individual income of $20,001 to $21,000.......................... $530 individual income of $21,001 to $22,000.......................... $550 individual income of $22,001 to $23,000.......................... $580 individual income of $23,001 to $24,000.......................... $720 individual income of $24,001 to $25,000.......................... $750 individual income of $25,001 to $26,000.......................... $780 individual income of $26,001 to $27,000.......................... $810 individual income of $27,001 to $28,000.......................... $840 individual income of $28,001 to $29,000.......................... $870 individual income of $29,001 to $30,000.......................... $900 individual income of $30,001 to $31,000.......................... $930 individual income of $31,001 to $32,000.......................... $960 individual income of $32,001 to $33,000........................ $1,160 individual income of $33,001 to $34,000........................ $1,190 individual income of $34,001 to $35,000.........................$1,230 (b) Annual personal covered drug expenditures for each married individual eligible program participant: joint income of $26,001 to $27,000............................... $650 joint income of $27,001 to $28,000............................... $675 joint income of $28,001 to $29,000............................... $700 joint income of $29,001 to $30,000............................... $725 joint income of $30,001 to $31,000............................... $900 joint income of $31,001 to $32,000............................... $930 joint income of $32,001 to $33,000............................... $960 joint income of $33,001 to $34,000............................... $990 joint income of $34,001 to $35,000............................. $1,020 joint income of $35,001 to $36,000............................. $1,050 joint income of $36,001 to $37,000............................. $1,080 joint income of $37,001 to $38,000............................. $1,110 joint income of $38,001 to $39,000............................. $1,140 joint income of $39,001 to $40,000............................. $1,170 joint income of $40,001 to $41,000............................. $1,200 joint income of $41,001 to $42,000............................. $1,230 joint income of $42,001 to $43,000............................. $1,260 joint income of $43,001 to $44,000............................. $1,290 joint income of $44,001 to $45,000............................. $1,320 joint income of $45,001 to $46,000............................. $1,575 joint income of $46,001 to $47,000............................. $1,610 joint income of $47,001 to $48,000............................. $1,645 joint income of $48,001 to $49,000............................. $1,680 joint income of $49,001 to $50,000..............................$1,715(c) In the event that the state expenditures per participant electing to meet the deductible requirements of this subdivision, exclusive of expenditures for program administration, in the program year commencing October first, nineteen hundred eighty-eight, and in each program year thereafter, exceed such expenditures in the previous program year by a minimum of ten percent, the annual personal covered drug expenditures set forth in this subdivision may, unless otherwise provided by law, be increased, pro-rata, for the subsequent program year, provided that such increase shall not exceed eight percent of the prior year personal covered drug expenditures as may have been adjusted in accordance with this paragraph. (d) In the event that the state expenditures per such participant, incurred pursuant to this subdivision, exclusive of expenditures for program administration, in the program year commencing October first, nineteen hundred eighty-eight, and in each program year thereafter, are less than such expenditures in the previous program year by a minimum of ten percent, the annual personal covered drug expenditures set forth in this subdivision may, unless otherwise provided by law, be decreased, pro-rata, for the subsequent program year, provided that such decrease shall not exceed eight percent of the prior year personal covered drug expenditures as may have been adjusted in accordance with this paragraph. (e) The determination to adjust annual personal covered drug expenditures set forth in this subdivision, shall follow a review of such factors as the relative financial capacity of the state and such eligible program participants to support such adjustments and changes in the consumer price index. The frequency of such adjustments shall not exceed once in any twelve month period and such adjustments shall not become effective for individual program participants prior to the first day of the next annual coverage period for each participant. 3. Point of sale co-payment. (a) Upon satisfaction of the deductible requirements pursuant to subdivision two of this section, an eligible program participant shall pay a point of sale co-payment as set forth in paragraph (b) of this subdivision at the time of each purchase of a covered drug prescribed for such individual. Such co-payment shall not be waived or reduced in whole or in part, subject to the limits provided by subdivision four of this section. (b) The point of sale co-payment amounts which are to be charged eligible program participants shall be in accordance with the following schedule: For each prescription of covered drugs costing $15.00 or less.....$3.00 For each prescription of covered drugs costing $15.01 to $35.00...$7.00 For each prescription of covered drugs costing $35.01 to $55.00..$15.00 For each prescription of covered drugs costing $55.01 or more....$20.00 (c) For the purposes of the foregoing schedule of point of sale co-payments, "costing" shall mean the amount of reimbursement which shall be paid by the state to a participating provider pharmacy in accordance with section two hundred fifty of this title plus the point of sale co-payment, calculated as of the date of sale. 4. Annual limits on point of sale co-payments. During each annual coverage period, no point of sale co-payments as set forth in subdivision three of this section shall be required to be made for the remainder of such period by any eligible program participant meeting the personal covered drug expenditure requirements of subdivision two of this section in excess of the limits set forth in the following schedule: (a) Limits on co-payments by unmarried individual eligible program participants:individual income of $20,001 to $21,000........... no more than $1,050 individual income of $21,001 to $22,000........... no more than $1,100 individual income of $22,001 to $23,000........... no more than $1,150 individual income of $23,001 to $24,000........... no more than $1,200 individual income of $24,001 to $25,000........... no more than $1,250 individual income of $25,001 to $26,000........... no more than $1,300 individual income of $26,001 to $27,000........... no more than $1,350 individual income of $27,001 to $28,000........... no more than $1,400 individual income of $28,001 to $29,000........... no more than $1,450 individual income of $29,001 to $30,000........... no more than $1,500 individual income of $30,001 to $31,000........... no more than $1,550 individual income of $31,001 to $32,000........... no more than $1,600 individual income of $32,001 to $33,000........... no more than $1,650 individual income of $33,001 to $34,000........... no more than $1,700 individual income of $34,001 to $35,000........... no more than $1,750 (b) Limits on co-payments by each married individual eligible program participant: joint income of $26,001 to $27,000................ no more than $1,080 joint income of $27,001 to $28,000................ no more than $1,120 joint income of $28,001 to $29,000................ no more than $1,160 joint income of $29,001 to $30,000................ no more than $1,200 joint income of $30,001 to $31,000................ no more than $1,240 joint income of $31,001 to $32,000................ no more than $1,280 joint income of $32,001 to $33,000................ no more than $1,320 joint income of $33,001 to $34,000................ no more than $1,360 joint income of $34,001 to $35,000................ no more than $1,400 joint income of $35,001 to $36,000................ no more than $1,440 joint income of $36,001 to $37,000................ no more than $1,480 joint income of $37,001 to $38,000................ no more than $1,520 joint income of $38,001 to $39,000................ no more than $1,560 joint income of $39,001 to $40,000................ no more than $1,600 joint income of $40,001 to $41,000................ no more than $1,640 joint income of $41,001 to $42,000................ no more than $1,680 joint income of $42,001 to $43,000................ no more than $1,720 joint income of $43,001 to $44,000................ no more than $1,760 joint income of $44,001 to $45,000................ no more than $1,800 joint income of $45,001 to $46,000................ no more than $1,840 joint income of $46,001 to $47,000................ no more than $1,880 joint income of $47,001 to $48,000................ no more than $1,920 joint income of $48,001 to $49,000................ no more than $1,960 joint income of $49,001 to $50,000................ no more than $2,000 (c) Effective October first, nineteen hundred eighty-eight, the limits on point of sale co-payments as set forth in this subdivision may be adjusted by the panel on the anniversary date of each program participant's annual coverage period, and such adjustment shall be in effect for the duration of that annual coverage period. Any such annual adjustment shall be made using a percentage adjustment factor which shall not exceed one-half of the difference between the year-to-year percentage increase in the consumer price index for all urban consumers, as published by the United States Department of Labor, and, if larger, the year-to-year percentage increase in the aggregate average cost of covered drugs purchased under this title, which year-to-year percentage increase in such cost shall be determined by comparison of such cost in the same month of each of the appropriate successive years; provided, however, that for any such adjustment based wholly on experience in the program year commencing October first, nineteen hundred eighty-seven, the year-to-year percentage increase in such cost shall be determined by comparison of such cost in each of two months no less than five monthsapart and within such program year, which comparison shall be annualized. Such percentage adjustment factor shall be the same as that used to determine any similar annual adjustment for the same annual coverage periods pursuant to the provisions of subdivision four of section two hundred forty-seven of this title. Such annual adjustments shall be calculated by multiplying the percentage adjustment factor by (1) ten percent and applying the resulting percentage to the upper income limitation of each income level for unmarried individuals contained in this subdivision, and by (2) seven and one-half percent and applying the resulting percentage to the upper income limitation of each income level for married individuals contained in this subdivision; each result of such calculations, minus any applicable deductible increases made pursuant to subdivision two of this section and plus the result of applying the percentage adjustment factor to the sum of any such annual adjustments applicable thereto for any prior annual coverage period, shall be the amount by which the limit on co-payments for each such income level may be adjusted, and such amount shall be in addition to any such amount or amounts applicable to prior annual coverage periods. (d) The determination to adjust the limits on point of sale co-payments set forth in this subdivision shall follow a review of such factors as the relative financial capacity of the state and such eligible program participant to support such adjustments.