Vermont § 2003 - Pharmacy discount plans

§ 2003. Pharmacy discount plans

• (a) The Commissioner of Vermont Health Access shall implement pharmacy discount plans,
  to be known as the Healthy Vermonters Program, for Vermonters without adequate coverage
  for prescription drugs. The provisions of subchapter 8 of this chapter shall apply
  to the Commissioner’s authority to administer the pharmacy discount plans established
  by this section. (b) The Healthy Vermonters Program shall offer beneficiaries an initial discounted cost
  for covered drugs. Upon approval by the Centers for Medicare and Medicaid Services
  of a Section 1115 Medicaid waiver program, and upon subsequent legislative approval,
  the Healthy Vermonters Program shall offer beneficiaries a secondary discounted cost,
  which shall reflect a State payment toward the cost of each dispensed drug as well
  as any rebate amount negotiated by the Commissioner. (c) As used in this section: (1) “Beneficiary” means any individual enrolled in the Healthy Vermonters Program. (2) “Healthy Vermonters beneficiary” means any individual Vermont resident without adequate
  coverage: (A) who is at least 65 years of age, or is disabled and is eligible for Medicare or Social
  Security disability benefits, with household income equal to or less than 400 percent
  of the federal poverty level, as calculated using modified adjusted gross income as
  defined in 26 U.S.C. § 36B(d)(2)(B); or (B) whose household income is equal to or less than 350 percent of the federal poverty
  level, as calculated using modified adjusted gross income as defined in 26 U.S.C. § 36B(d)(2)(B). (3) [Repealed.] (4) “Initial discounted cost” means the price of the drug based on the Medicaid fee schedule. (5) “Labeler” means an entity or person that receives prescription drugs from a manufacturer
  or wholesaler and repackages those drugs for later retail sale and that has a labeler
  code from the federal Food and Drug Administration under 21 C.F.R. § 207.20. (6) “Participating retail pharmacy” means a retail pharmacy located in this State or another
  business licensed to dispense prescription drugs in this State that participates in
  the Program according to rules established by the Department and provides discounted
  prices to eligible beneficiaries of the Program. (7) “Rebate amount” means the rebate negotiated by the Director and required from a drug
  manufacturer or labeler under this section. In determining the appropriate rebate,
  the Director shall: (A) take into consideration the rebate calculated under the Medicaid rebate program under
  42 U.S.C. § 1396r-8, the average wholesale price of prescription drugs, and any other information on
  prescription drug prices and price discounts; (B) use his or her best efforts to obtain an initial rebate amount equal to or greater
  than the rebate calculated under the Medicaid program under 42 U.S.C. § 1396r-8; and (C) use his or her best efforts to obtain an amount equal to or greater than the amount
  of any discount, rebate, or price reduction for prescription drugs provided to the
  federal government. (8) “Secondary discounted cost” means, under the Healthy Vermonters Program, the price
  of the drug based on the Medicaid fee schedule, less payment by the State of at least
  two percent of the Medicaid rate, less any rebate amount negotiated by the Director
  and paid for out of the Healthy Vermonters Dedicated Fund established under subsection
  (h) of this section and, under the Healthy Vermonters Plus Program, the average wholesale
  price of the drug, less payment by the State of at least two percent of the Medicaid
  rate, less any rebate amount negotiated by the Director and paid for out of the Healthy
  Vermonters Dedicated Fund established under subsection (h) of this section. (9) “Without adequate coverage” includes beneficiaries with no coverage for prescription
  drugs or certain types of prescription drugs and beneficiaries whose annual maximum
  coverage limit under their health benefit plan has been reached. (d) Drugs covered by the pharmacy discount plans shall include all drugs covered under
  the Medicaid program. (e) The Vermont Board of Pharmacy shall adopt standards of practice requiring disclosure
  by participating retail pharmacies to beneficiaries of the amount of savings provided
  as a result of the pharmacy discount plans. The standards must consider and protect
  information that is proprietary in nature. The Department of Vermont Health Access
  may not impose transaction charges under this Program on pharmacies that submit claims
  or receive payments under the plans. Pharmacies shall submit claims to the Department
  to verify the amount charged to beneficiaries under the plans. On a weekly or biweekly
  basis, the Department must reimburse pharmacies for the difference between the initial
  discounted price or the average wholesale price and the secondary discounted price
  provided to beneficiaries. (f) The names of drug manufacturers and labelers who do and do not enter into rebate agreements
  under pharmacy discount plans are public information. The Department of Vermont Health
  Access shall release this information to health care providers and the public on a
  regular basis and shall publicize participation by manufacturers and labelers. The
  Department shall impose prior authorization requirements in the Medicaid program,
  as permitted by law, to the extent the Department determines it is appropriate to
  do so in order to encourage manufacturer and labeler participation in the pharmacy
  discount plans and so long as the additional prior authorization requirements remain
  consistent with the goals of the Medicaid program and the requirements of Title XIX
  of the Social Security Act. (g) The Commissioner of Vermont Health Access shall establish, by rule, a process to resolve
  discrepancies in rebate amounts claimed by manufacturers, labelers, pharmacies, and
  the Department. (h) The Healthy Vermonters Dedicated Fund is established to receive revenue from manufacturers
  and labelers who pay rebates as provided in this section and any appropriations or
  allocations designated for the Fund. The purposes of the Fund are to reimburse retail
  pharmacies for discounted prices provided to individuals enrolled in the pharmacy
  discount plans and to reimburse the Department of Vermont Health Access for contracted
  services, including pharmacy claims processing fees, administrative and associated
  computer costs, and other reasonable program costs. The Fund is a nonlapsing dedicated
  fund. Interest on Fund balances accrues to the Fund. Surplus funds in the Fund must
  be used for the benefit of the Program. (i) [Repealed.] (j) The Department of Vermont Health Access shall undertake outreach efforts to build
  public awareness of the pharmacy discount plans and maximize enrollment. Outreach
  efforts shall include steps to educate retail pharmacists on the purposes of the Healthy
  Vermonters Dedicated Fund, in particular as it relates to pharmacy reimbursements
  for discounted prices provided to Program enrollees. The Department may adjust the
  requirements and terms of the pharmacy discount plans to accommodate any new federally
  funded prescription drug programs. (k) The Department of Vermont Health Access may contract with a third party or third parties
  to administer any or all components of the pharmacy discount plans, including outreach,
  eligibility, claims, administration, and rebate recovery and redistribution. (l) The Department of Vermont Health Access shall administer the pharmacy discount plans
  and other medical and pharmaceutical assistance programs under this title in a manner
  advantageous to the programs and enrollees. In implementing this section, the Department
  may coordinate the other programs and the pharmacy discount plans and may take actions
  to enhance efficiency, reduce the cost of prescription drugs, and maximize benefits
  to the programs and enrollees, including providing the benefits of pharmacy discount
  plans to enrollees in other programs. (m) The Department of Vermont Health Access may adopt rules to implement the provisions
  of this section. (n) The Department of Vermont Health Access shall seek a waiver from the Centers for Medicare
  and Medicaid Services (CMS) requesting authorization necessary to implement the provisions
  of this section, including application of manufacturer and labeler rebates to the
  pharmacy discount plans. The secondary discounted cost shall not be available to beneficiaries
  of the pharmacy discount plans until the Department receives written notification
  from CMS that the waiver requested under this section has been approved and until
  the General Assembly subsequently approves all aspects of the pharmacy discount plans,
  including funding for positions and related operating costs associated with eligibility
  determinations. (Added 2001, No. 127 (Adj. Sess.), § 1, eff. June 13, 2002; amended 2003, No. 122 (Adj. Sess.), § 128o; 2005, No. 174 (Adj. Sess.), § 105; 2007, No. 80, § 7; 2009, No. 156 (Adj. Sess.), § I.66; 2011, No. 171 (Adj. Sess.), § 41c; 2013, No. 79, § 31, eff. Jan. 1, 2014; 2013, No. 131 (Adj. Sess.), § 47, eff. May 20, 2014; 2013, No. 142 (Adj. Sess.), § 99.)