Missouri Rx Plan Benefits and Limitations

PURPOSE: This rule establishes the benefits and limitations for administering the Missouri Rx Plan and Missouri’s State Pharmacy Assistance Program. (1) Administration. The Missouri Rx Plan shall be administered by the Department of Social Services, MO HealthNet Division. (2) Definitions. (A) Dual eligible—An individual who is eligible for both Medicare and Medicaid. (B) Missouri Rx Plan—The state pharmacy assistance program administered by the Department of Social Services, MO HealthNet Division. (C) Out-of-pocket costs—The co-pays required for prescription drug. The Missouri Rx Plan does not pay for the Medicare Part D monthly premium. (3) Individuals who are enrolled in Medicare and MO HealthNet (dual eligibles) are deemed to have enrolled in the Missouri Rx Plan. (4) Benefit Limits. (A) The Missouri Rx Plan shall pay fifty percent (50%) of the member’s out-of-pocket costs for prescription drugs covered by the Medicare Prescription Drug Program and by the members Medicare Part D Plan formulary. (B) Members with a MO HealthNet spenddown requirement must meet the spenddown at least once during the calendar year for the Missouri Rx Plan to pay fifty percent (50%) of the member’s out-of-pocket costs. (C) The Missouri Rx Plan shall have the authority to change the benefit limits at any time to achieve program cost control. (5) Termination from the Program. (A) A member shall be terminated from the Missouri Rx Plan if he or she no longer meets the MO HealthNet or Medicare eligibility requirements. AUTHORITY: sections 208.201, 208.782, 208.786, and 660.017, RSMo 2016.* Original rule filed Aug. 15, 2014, effective Feb. 28, 2015. Amended: Filed Sept. 22, 2021, effective April 30, 2022. *Original authority: 208.201, RSMo 1987, amended 2007; 208.782, RSMo 2005; 208.786, RSMo 2005; and 660.017, RSMo 1993, amended 1995.