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

individual income of $35,001 to $36,000 $1,260

individual income of $36,001 to $37,000 $1,290

individual income of $37,001 to $38,000 $1,320

individual income of $38,001 to $39,000 $1,350

individual income of $39,001 to $40,000 $1,380

individual income of $40,001 to $41,000 $1,410

individual income of $41,001 to $42,000 $1,440

individual income of $42,001 to $43,000 $1,470

individual income of $43,001 to $44,000 $1,500

individual income of $44,001 to $45,000 $1,530

individual income of $45,001 to $46,000 $1,560

individual income of $46,001 to $47,000 $1,590

individual income of $47,001 to $48,000 $1,620

individual income of $48,001 to $49,000 $1,650

individual income of $49,001 to $50,000 $1,680

individual income of $50,001 to $51,000 $1,710

individual income of $51,001 to $52,000 $1,740

individual income of $52,001 to $53,000 $1,770

individual income of $53,001 to $54,000 $1,800

individual income of $54,001 to $55,000 $1,830

individual income of $55,001 to $56,000 $1,860

individual income of $56,001 to $57,000 $1,890

individual income of $57,001 to $58,000 $1,920

individual income of $58,001 to $59,000 $1,950

individual income of $59,001 to $60,000 $1,980

individual income of $60,001 to $61,000 $2,010

individual income of $61,001 to $62,000 $2,040

individual income of $62,001 to $63,000 $2,070

individual income of $63,001 to $64,000 $2,100

individual income of $64,001 to $65,000 $2,130

individual income of $65,001 to $66,000 $2,160

individual income of $66,001 to $67,000 $2,190

individual income of $67,001 to $68,000 $2,220

individual income of $68,001 to $69,000 $2,250

individual income of $69,001 to $70,000 $2,280

individual income of $70,001 to $71,000 $2,310

individual income of $71,001 to $72,000 $2,340

individual income of $72,001 to $73,000 $2,370

individual income of $73,001 to $74,000 $2,400

individual income of $74,001 to $75,000 $2,430

(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

joint income of $50,001 to $51,000 $1,745

joint income of $51,001 to $52,000 $1,775

joint income of $52,001 to $53,000 $1,805

joint income of $53,001 to $54,000 $1,835

joint income of $54,001 to $55,000 $1,865

joint income of $55,001 to $56,000 $1,895

joint income of $56,001 to $57,000 $1,925

joint income of $57,001 to $58,000 $1,955

joint income of $58,001 to $59,000 $1,985

joint income of $59,001 to $60,000 $2,015

joint income of $60,001 to $61,000 $2,045

joint income of $61,001 to $62,000 $2,075

joint income of $62,001 to $63,000 $2,105

joint income of $63,001 to $64,000 $2,135

joint income of $64,001 to $65,000 $2,165

joint income of $65,001 to $66,000 $2,195

joint income of $66,001 to $67,000 $2,225

joint income of $67,001 to $68,000 $2,255

joint income of $68,001 to $69,000 $2,285

joint income of $69,001 to $70,000 $2,315

joint income of $70,001 to $71,000 $2,345

joint income of $71,001 to $72,000 $2,375

joint income of $72,001 to $73,000 $2,405

joint income of $73,001 to $74,000 $2,435

joint income of $74,001 to $75,000 $2,465

joint income of $75,001 to $76,000 $2,495

joint income of $76,001 to $77,000 $2,525

joint income of $77,001 to $78,000 $2,555

joint income of $78,001 to $79,000 $2,585

joint income of $79,001 to $80,000 $2,615

joint income of $80,001 to $81,000 $2,645

joint income of $81,001 to $82,000 $2,675

joint income of $82,001 to $83,000 $2,705

joint income of $83,001 to $84,000 $2,735

joint income of $84,001 to $85,000 $2,765

joint income of $85,001 to $86,000 $2,795

joint income of $86,001 to $87,000 $2,825

joint income of $87,001 to $88,000 $2,855

joint income of $88,001 to $89,000 $2,885

joint income of $89,001 to $90,000 $2,915

joint income of $90,001 to $91,000 $2,945

joint income of $91,001 to $92,000 $2,975

joint income of $92,001 to $93,000 $3,005

joint income of $93,001 to $94,000 $3,035

joint income of $94,001 to $95,000 $3,065

joint income of $95,001 to $96,000 $3,095

joint income of $96,001 to $97,000 $3,125

joint income of $97,001 to $98,000 $3,155

joint income of $98,001 to $99,000 $3,185

joint income of $99,001 to $100,000 $3,215

(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 $75,000 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 $100,000 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 commissioner 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.