Sec. 17b-491. (Formerly Sec. 17a-342). Pharmaceutical Assistance Program. Copayments. Reimbursement of prescriptions based on price paid by pharmacy and actual package size. Application by pharmaceuti
Sec. 17b-491. (Formerly Sec. 17a-342). Pharmaceutical Assistance Program.
Copayments. Reimbursement of prescriptions based on price paid by pharmacy
and actual package size. Application by pharmaceutical manufacturers to participate in program. Rebates and utilization review required for participating pharmaceutical manufacturers. (a) There shall be a "Connecticut Pharmaceutical Assistance Contract to the Elderly and the Disabled Program" which shall be within the
Department of Social Services. The program shall consist of payments by the state to
pharmacies for the reasonable cost of prescription drugs dispensed to eligible persons
minus a copayment charge. The pharmacy shall collect the copayment charge from the
eligible person at the time of each purchase of prescription drugs, and shall not waive,
discount or rebate in whole or in part such amount. The copayment for each prescription
shall not exceed sixteen dollars and twenty-five cents.
(b) On January 1, 2002, and annually thereafter, the commissioner shall increase
the income limits established in subsection (a) of this section that set the appropriate
participant copayment by the increase in the annual inflation adjustment in Social Security income, if any. Each such adjustment shall be determined to the nearest one hundred
dollars.
(c) Notwithstanding the provisions of subsection (a) of this section, effective September 15, 1991, payment by the state to a pharmacy under the program may be based
on the price paid directly by a pharmacy to a pharmaceutical manufacturer for drugs
dispensed under the program minus the copayment charge, plus the dispensing fee, if
the direct price paid by the pharmacy is lower than the reasonable cost of such drugs.
(d) Effective September 15, 1991, reimbursement to a pharmacy for prescription
drugs dispensed under the program shall be based upon actual package size costs of
drugs purchased by the pharmacy in units larger than or smaller than one hundred.
(e) The commissioner shall establish an application form whereby a pharmaceutical
manufacturer may apply to participate in the program. Upon receipt of a completed
application, the department shall issue a certificate of participation to the manufacturer.
Participation by a pharmaceutical manufacturer shall require that the department shall
receive a rebate from the pharmaceutical manufacturer for prescriptions covered under
the program and for prescriptions covered by the department pursuant to subsection (c)
of section 17b-265e. Rebate amounts for brand name prescription drugs shall be equal
to those under the Medicaid program. Rebate amounts for generic prescription drugs
shall be established by the commissioner, provided such amounts may not be less than
those under the Medicaid program. A participating pharmaceutical manufacturer shall
make quarterly rebate payments to the department for the total number of dosage units
of each form and strength of a prescription drug which the department reports as reimbursed to providers of prescription drugs, provided such payments shall not be due until
thirty days following the manufacturer's receipt of utilization data from the department
including the number of dosage units reimbursed to providers of prescription drugs
during the quarter for which payment is due.
(f) All prescription drugs of a pharmaceutical manufacturer that participates in the
program pursuant to subsection (e) of this section shall be subject to prospective drug
utilization review. Any prescription drug of a manufacturer that does not participate in
the program shall not be reimbursable, unless the department determines the prescription
drug is essential to program participants.
(P.A. 85-573, S. 6, 18; P.A. 87-3, S. 3, 9; S.A. 90-18, S. 18, 32; June Sp. Sess. P.A. 91-8, S. 46, 63; P.A. 92-196, S. 2,
4; P.A. 93-80, S. 51, 67; 93-262, S. 1, 87; 93-418, S. 36, 41; P.A. 95-351, S. 19, 30; June 18 Sp. Sess. P.A. 97-2, S. 132,
165; June Sp. Sess. P.A. 00-2, S. 40, 44, 53; May 9 Sp. Sess. P.A. 02-7, S. 15; P.A. 03-2, S. 14; P.A. 04-16, S. 17; 04-104,
S. 1; P.A. 05-280, S. 21; P.A. 07-217, S. 75; P.A. 08-1, S. 1.)
History: P.A. 87-3 deleted reference to "pilot", expanded the program to include the disabled and restated the payments
to pharmacies to be the reasonable cost of prescription drugs minus a $4 copayment charge; S.A. 90-18 raised copayment
charge $6 and added provisions re calculation of annual increases in charged amount on and after July 1, 1991; Sec. 17-513 transferred to Sec. 17a-342 in 1991; June Sp. Sess. P.A. 91-8 raised copayment and prescription charges from $6 to
$10, deleted the language re the commissioner's authority to increase the copayment charges, and added Subsecs. (b) to
(f), inclusive, basing payment made by the state to a pharmacy on the price paid by a pharmacy to the pharmaceutical
manufacturer, basing reimbursement to the pharmacy on the actual package size of the prescription and detailing implementation and review of a prescription drug rebate agreement program; P.A. 92-196 amended Subsec. (d) by deleting provisions
requiring the commissioner to enter into rebate agreements with manufacturers and adding provisions re application process
for manufacturers to participate in program and amended Subsec. (f) for consistency; P.A. 93-80 amended Subsec. (a) to
increase copayment charge from $10 to $15, and amended Subsec. (d) to change rebate paid to department by participating
pharmaceutical manufacturer from 11% of the average manufacturer price to the basic rebate supplied by the manufacturer
under Section 1927 of Title XIX of the Social Security Act, effective July 1, 1993; P.A. 93-262 authorized substitution of
commissioner and department of social services for commissioner and department on aging, effective July 1, 1993; P.A.
93-418 reduced the copayment charge from $15 to $12 for each prescription, effective July 1, 1993; Sec. 17a-342 transferred
to Sec. 17b-491 in 1995; P.A. 95-351 required the department to receive a rebate from a pharmaceutical manufacturer in
an amount equal to the Medicaid rebate, deleting former Subsec. (e) re quarterly payments, payment discrepancies and
independent audits and relettering Subsec. (f) as (e), effective July 1, 1995; June 18 Sp. Sess. P.A. 97-2 amended Subsec.
(e) by deleting provision requiring that all prescription drugs of a pharmaceutical manufacturer participating in the program
pursuant to Subsec. (d) be immediately available, the cost of such drug reimbursed and not be subject to any restrictions
and added provision requiring that such drugs be subject to prospective drug utilization review, effective July 1, 1997;
June Sp. Sess. P.A. 00-2 amended Subsec. (d) by deleting references to the rebate supplied under the Social Security Act
and by adding language re rebate amounts for brand name drugs equaling those under the Medicaid program and provision
allowing the commissioner to establish rebate amounts for generic drugs, and amended Subsec. (e) by deleting provisions
exempting prescription drugs of participating manufacturers from prior authorization, effective July 1, 2000; May 9 Sp.
Sess. P.A. 02-7 amended Subsec. (a) by deleting provision re $12 copayment charge and adding Subdivs. (1) to (3) re
copayment requirements for individuals determined eligible for program on or after September 1, 2002, added new Subsecs.
(b) and (c) re copayment rates for individuals determined eligible for program prior to September 1, 2002, and re increased
income limits, respectively, and redesignated existing Subsecs. (b) to (e) as Subsecs. (d) to (g), effective September 1,
2002; P.A. 03-2 amended Subsec. (a) by deleting "For an individual who is determined eligible to participate in the program
on or after September 1, 2002, said" re copayment rates, by changing copayment rate from $12 to $16.25, changing income
threshold for unmarried participants from $15,900 to $20,300 and changing income threshold for married participants,
with combined spousal income, from $12,500 to $27,500 in Subdiv. (1), by deleting former Subdiv.(2) re middle tier of
copayment rates, and by redesignating existing Subdiv. (3) as new Subdiv. (2), amending said Subdiv. to increase income
thresholds from $20,000 to $20,300 in Subpara. (A) and from $27,100 to $27,500 in Subpara. (3) and adding "equals or"
in both Subparas., deleted former Subsec. (b) re differing copayments for those determined eligible for the program prior
to September 1, 2002, redesignated existing Subsecs. (c) to (g), inclusive, as Subsecs. (b) to (f), inclusive, and changed
internal references contained therein, effective February 28, 2003; P.A. 04-16 made a technical change in Subsec. (a)(1);
P.A. 04-104 amended Subsec. (a) to add "Except for a replacement prescription dispensed pursuant to section 17b-492"
re required copayments, effective July 1, 2004; P.A. 05-280 amended Subsec. (a) by deleting former Subdivs. (1) and (2)
re copayments under program and substituting provision that such copayments shall not exceed $16.25 and by deleting
provision that excepted replacement prescriptions dispensed pursuant to Sec. 17b-492 from copayment requirement, effective July 1, 2005; P.A. 07-217 made a technical change in Subsec. (c), effective July 12, 2007; P.A. 08-1 amended Subsec.
(e) to require pharmaceutical manufacturer participating in program to provide rebate to department for prescriptions
covered by department pursuant to Sec. 17b-265e(c), effective April 4, 2008.