Pharmacy Employer Group Waiver Plan for Medicare Primary Members

PURPOSE: This rule establishes the policy of the board of trustees in regard to the benefit provisions, covered charges, limitations, and exclusions of the pharmacy benefit for Medicare-primary members of the Missouri Consolidated Health Care Plan. (1) The pharmacy benefit for Medicare primary non-active members is provided through a Pharmacy Employer Group Waiver Plan (EGWP) as regulated by the Centers for Medicare & Medicaid Services, hereinafter referred to as the Medicare Prescription Drug Plan. (A) Non-active subscribers that have Medicare primary cov erage and their dependents that have Medicare primary cov erage enrolled in the Medicare Advantage Plan shall receive their pharmacy benefit through the Medicare Prescription Drug Plan. (B) The non-Medicare dependents of Medicare primary non-active subscribers will not be in the Medicare Prescription Drug Plan but will have pharmacy benefit coverage as defined by 22 CSR 10-2.090. (C) Foster parent members that have Medicare primary cov erage and their dependents that have Medicare primary cover age will not be in the Medicare Prescription Drug Plan but will have pharmacy benefit coverage as defined by 22 CSR 10-2.090. (D) A retiree Medicare primary member who chooses not to be in the Medicare Prescription Drug Plan will lose MCHCP eligibility and will not be allowed to enroll in a medical or Medicare Prescription Drug Plan at a later date. (E) MCHCP will pay the Medicare financial penalty incurred by a Medicare primary member who has had a continuous gap in prescription drug coverage of sixty-three (63) days or more after the Medicare Initial Election Period (IEP) and was not cov ered by any creditable prescription drug coverage and failed to enroll into Part D. (F) The Medicare Prescription Drug Plan is comprised of a Medicare Part D prescription drug plan contracted by MCHCP and some non-Part D medications that are not normally cov ered by a Medicare Part D prescription drug plan. The require ments for the Medicare Part D prescription drug plan are as follows: 1. The Centers for Medicare & Medicaid Services regulates the Medicare Part D prescription drug program. The Medicare Prescription Drug Plan abides by those regulations; 2. Initial coverage stage. Until a member’s total yearly Part D prescription drug costs reach two thousand one hundred dollars ($2,100), the member will pay the following copayments: A. Preferred formulary generic drugs: thirty-one- (31-) day supply has a ten dollar ($10) copayment; sixty- (60-) day supply has a twenty dollar ($20) copayment; ninety- (90-) day supply at retail has a thirty dollar ($30) copayment; and a ninety- (90-) day supply through home delivery has a twentyfive dollar ($25) copayment; B. Preferred formulary brand drugs: thirty-one- (31) day supply has a forty dollar ($40) copayment; sixty- (60-) day supply has an eighty dollar ($80) copayment; ninety- (90) day supply at retail has a one hundred twenty dollar ($120) copayment; and a ninety- (90-) day supply through home delivery has a one hundred dollar ($100) copayment; and C. Non-preferred formulary drugs and approved excluded drugs: thirty-one- (31-) day supply has a one hundred dollar ($100) copayment; sixty- (60-) day supply has a two hundred dollar ($200) copayment; ninety- (90-) day supply at retail has a three hundred dollar ($300) copayment; and a ninety- (90-) day supply through home delivery has a two hundred fifty dollar ($250) copayment; 3. Catastrophic coverage stage. After a member’s total yearly out-of-pocket Part D prescription drug costs reach two thousand one hundred dollars ($2,100), the member will pay zero dollars ($0); and 4. Amounts paid by the member or the plan for nonPart D prescription drugs will not count toward total Part D prescription drug costs or total Part D prescription drug outof-pocket costs. (G) Medications covered under 22 CSR 10-2.090 will be cov ered under the Medicare Prescription Drug Plan as non-Part D medications when they are not a Part D covered drug. (H) Medicare Part B Prescription Drugs are excluded from the Medicare Prescription Drug Plan. (I) Prescription drugs and prescribed over-the-counter drugs as recommended by the U.S Preventive Services Task Force (categories A and B) are covered at one hundred percent (100%) when filled at a network pharmacy. The following are also cov ered at one hundred percent (100%) when filled at a network pharmacy: 1. Vaccines and administration as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; and 2. Preferred formulary brand contraception and non-pre ferred contraception when the provider determines a generic is not medically appropriate or a generic version is not avail able. AUTHORITY: section 103.059, RSMo 2016.* Emergency rule filed Oct. 30, 2013, effective Jan. 1, 2014, expired June 29, 2014. Original rule filed Oct. 30, 2013, effective June 30, 2014. Emergency amend ment filed Oct. 29, 2014, effective Jan. 1, 2015, terminated May 30, 2015. Amended: Filed Oct. 29, 2014, effective May 30, 2015. Emergency amendment filed Oct. 28, 2015, effective Jan. 1, 2016, expired June 28, 2016. Amended: Filed Oct. 28, 2015, effective May 30, 2016. Emergency amendment filed Oct. 28, 2016, effective Jan. 1, 2017, expired June 29, 2017. Amended: Filed Oct. 28, 2016, effective May 30, 2017. Emergency amendment filed Oct. 27, 2017, effective Jan. 1, 2018, expired June 29, 2018. Amended: Filed Oct. 27, 2017, effective May 30, 2018. Emergency amendment filed Oct. 31, 2018, effective Jan. 1, 2019, expired June 29, 2019. Amended: Filed Oct. 31, 2018, effective May 30, 2019. Emergency amendment filed Oct. 30, 2019, effective Jan. 1, 2020, expired June 28, 2020. Amended: Filed Oct. 30, 2019, effective May 30, 2020. Emergency amendment filed Oct. 26, 2020, effective Jan. 1, 2021, expired June 29, 2021. Amended: Filed Oct. 26, 2020, effective May 30, 2021. Emergency amendment filed Oct. 29, 2021, effective Jan. 1, 2022, expired June 29, 2022. Amended: Filed Oct. 29, 2021, effective May 30, 2022. Emergency amendment filed Oct. 28, 2022, effective Jan. 1, 2023, expired June 29, 2023.Amended: Filed Oct. 28, 2022, effective May 30, 2023. Emergency amendment filed Oct. 27, 2023, effective Jan. 1, 2024, expired June 28, 2024. Amended: Filed Oct. 27, 2023, effective May 30, 2024. Emergency amendment filed Oct. 25, 2024, effective Jan. 1, 2025, expired June 29, 2025. Amended: Filed Oct. 25, 2024, effective May 30, 2025. Emergency amendment filed Nov. 12, 2025, effective Jan. 1, 2026, expired June 29, 2026. Amended: Filed Nov. 12, 2025, effective May 30, 2026. *Original authority: 103.059, RSMo 1992.