§ 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 months
apart 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.
Last modified: November 19, 2006