State Codes and Statutes
Statutes > Connecticut > Title17b > Chap319v > Sec17b-265eSec. 17b-265e. Medicare Part D Supplemental Needs Fund. Payment by department for nonformulary prescription drugs. Rebates required for pharmaceutical manufacturers. (a) There is established a fund to be known as the "Medicare Part D Supplemental Needs Fund" which shall be an account within the General Fund under the Department of Social Services. Moneys available in said fund shall be utilized by the Department of Social Services to provide assistance to Medicare Part D beneficiaries who are enrolled in the ConnPACE program or who are full benefit dually eligible Medicare Part D beneficiaries, as defined in section 17b-265d, and whose medical needs require that they obtain nonformulary prescription drugs. A beneficiary requesting such assistance from the department shall be required to make a satisfactory showing of the medical necessity of obtaining such nonformulary prescription drug to the department. If the department, in consultation with the prescribing physician, determines that the prescription is medically necessary, the department shall cover the cost of the original prescription and any prescribed refills of the original prescription, less any applicable copayments. The department shall require as a condition of receiving such assistance that a beneficiary establish, to the satisfaction of the department, that the beneficiary has made good faith efforts to: (1) Enroll in a Medicare Part D plan recommended by the commissioner or the commissioner's agent; and (2) utilize the exception process established by the prescription drug plan in which the beneficiary is enrolled. The commissioner shall implement policies and procedures to administer the provisions of this section and to ensure that all requests for, and determinations made concerning assistance available pursuant to this section are expeditiously processed.
(b) Assistance provided in accordance with the provisions of subsection (a) of this section shall be subject to available funds. All expenditures for prescription drugs under subsection (a) of this section shall be charged to the Medicare Part D Supplemental Needs Fund.
(c) The Department of Social Services shall, in accordance with the provisions of this section, pay claims for prescription drugs for Medicare Part D beneficiaries, who are also either Medicaid or ConnPACE recipients and who are denied coverage by the Medicare Part D plan in which such beneficiary is enrolled because a prescribed drug is not on the formulary utilized by such Medicare Part D plan. Payment shall initially be made by the department for a thirty-day supply, subject to any applicable copayment. Pharmaceutical manufacturers shall pay rebate amounts established pursuant to section 17b-491 to the department for prescriptions paid by the department pursuant to this section on or after January 1, 2007. The beneficiary shall appoint the commissioner as such beneficiary's representative for the purpose of appealing any denial of Medicare Part D benefits and for any other purpose allowed under said act and deemed necessary by the commissioner.
(d) Notwithstanding any provision of the general statutes, not later than July 1, 2006, the Commissioner of Social Services shall implement a plan for pursuing payment under Medicare Part D by Part D plans for prescriptions denied as nonformulary drugs, including remedies available through reconsideration by an independent review entity, review by an administrative law judge, the Medicare Appeals Council or Federal District Court. Reimbursement secured from the Medicare Part D plan shall be returned to the Department of Social Services.
(e) The Department of Social Services, pursuant to subsection (d) of this section, may authorize appeals beyond the independent review entity. Upon determination by the department that it is not cost-effective to pursue further appeals, the department shall pay for the denied nonformulary drug for the remainder of the calendar year, provided the beneficiary remains enrolled in the Part D plan that denied coverage. Pending the outcome of the appeals process, the department shall continue to pay claims for the nonformulary drug denied by the Part D plan until the earlier of approval of such drug by the Part D plan or for the remainder of the calendar year.
(Nov. 2 Sp. Sess. P.A. 05-2, S. 2; P.A. 06-188, S. 13; June Sp. Sess. P.A. 07-2, S. 4; June Sp. Sess. P.A. 07-5, S. 26; P.A. 08-1, S. 2.)
History: Nov. 2 Sp. Sess. P.A. 05-2 effective December 1, 2005; P.A. 06-188 designated existing provisions as Subsec. (a), added Subsec. (b) re department's authority to pay for nonformulary prescription drugs, added Subsec. (c) re department's authority to contract with an entity for the purpose of pursuing Medicare Part D appeals and added Subsec. (d) re limitations on appeals and payment for nonformulary prescription drugs, effective July 1, 2006; June Sp. Sess. P.A. 07-2 amended Subsec. (a) by deleting provision re designation of moneys to fund by commissioner within available appropriations, by replacing "financial assistance" with "assistance" and "who lack the financial means to obtain medically necessary" with "whose medical needs require that they obtain", by adding provision re department covering cost of original prescription and any prescribed refills, less any applicable copayments, by changing "may" to "shall" re requirements to receive assistance, and by deleting provision re department expeditiously reviewing request for assistance and notifying beneficiary not later than two hours after receiving request, added new Subsec. (b) re assistance provided subject to available funds and not to exceed amounts appropriated in P.A. 06-186, S. 1, redesignated existing Subsecs. (b) to (d) as Subsecs. (c) to (e), amended redesignated Subsec. (d) by deleting provision re department contracting with entity specializing in Medicare appeals and adding "implement a plan" re pursuing payment under Medicare Part D and by making technical changes, and amended redesignated Subsec. (e) by deleting provision re entity contracting with department and by making technical changes, effective July 1, 2007; June Sp. Sess. P.A. 07-5 deleted requirement in Subsec. (b) that expenditures not exceed amount appropriated in P.A. 06-186, S. 1, effective October 6, 2007; P.A. 08-1 amended Subsec. (c) to require pharmaceutical manufacturers to pay rebate amounts established under Sec. 17b-491 to department for prescriptions paid by department on or after January 1, 2007, effective April 4, 2008.
