CHAPTER 319ff

PRESCRIPTION DRUG ASSISTANCE

Table of Contents

Sec. 17b-490. (Formerly Sec. 17a-340). Definitions.

Sec. 17b-491. (Formerly Sec. 17a-342). Pharmaceutical Assistance Program. Copayments. Reimbursement of prescriptions based on price paid by pharmacy and actual package size. Rebates and utilization review required for participating pharmaceutical manufacturers. Contracts for supplemental rebates.

Sec. 17b-491a. Prior authorization requirements for prescription drugs. Schedule for dispensing of maximum quantities of oral dosage units. Submission of schedule and revisions thereto to General Assembly.

Sec. 17b-491b. Reimbursement formula for drugs used to treat hemophilia A.

Sec. 17b-491c. Rebates for prescription drugs covered under Connecticut AIDS drug assistance program and state medical assistance programs. Calculation of unit rebate amounts. Contracts for supplemental rebates. Pharmaceutical manufacturers’ participation in program. Rebates for new drugs. Payment for medically necessary drugs.

Sec. 17b-492. (Formerly Sec. 17a-343). Eligibility. Application period. Registration fee. ConnPACE program requirements. Payment for original and replacement prescriptions. Application prior to exhausting coverage. Regulations.

Sec. 17b-492a. Participating pharmacy. Requirements.

Sec. 17b-492b. Authority of Commissioner of Developmental Services with respect to the Medicare Part D program.

Sec. 17b-492c. Authority of Commissioner of Mental Health and Addiction Services with respect to the Medicare Part D program.

Sec. 17b-492d. Council to advise on implementation of Medicare Part D program. Duties. Membership. Annual report.

Secs. 17b-493 to 17b-498. (Formerly Secs. 17a-344 to 17a-349). Generic substitution required. Regulations. Contract with fiscal intermediary; reports. Hearing. Penalties. Educational outreach program.

Sec. 17b-499. Pharmacy outreach program: Definitions.

Sec. 17b-499a. Pharmacy outreach program. Established. Purpose. Duties. Report. Medicaid therapy management services pilot program.

Secs. 17b-500 to 17b-519. Reserved


Sec. 17b-490. (Formerly Sec. 17a-340). Definitions. Section 17b-490 is repealed, effective January 1, 2014.

(P.A. 85-573, S. 3, 18; P.A. 87-3, S. 1, 9; 87-12, S. 1, 2; 87-267, S. 3; 87-589, S. 11, 87; P.A. 90-89, S. 1; June Sp. Sess. P.A. 91-8, S. 45, 63; P.A. 92-196, S. 1, 4; P.A. 93-262, S. 1, 87; May Sp. Sess. P.A. 94-5, S. 1, 30; P.A. 05-280, S. 14, 20; P.A. 06-188, S. 11; P.A. 11-44, S. 88; 11-51, S. 134; P.A. 13-234, S. 156.)

Sec. 17b-491. (Formerly Sec. 17a-342). Pharmaceutical Assistance Program. Copayments. Reimbursement of prescriptions based on price paid by pharmacy and actual package size. Rebates and utilization review required for participating pharmaceutical manufacturers. Contracts for supplemental rebates. Section 17b-491 is repealed, effective January 1, 2014.

(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; P.A. 09-14, S. 1; P.A. 11-44, S. 142; P.A. 13-234, S. 156.)

Sec. 17b-491a. Prior authorization requirements for prescription drugs. Schedule for dispensing of maximum quantities of oral dosage units. Submission of schedule and revisions thereto to General Assembly. (a) The Commissioner of Social Services may require prior authorization of any prescription for a drug covered under a medical assistance program administered by the Department of Social Services, including an over-the-counter drug. The authorization for a brand name drug product shall be valid for one year from the date the prescription is first filled. The Commissioner of Social Services shall establish a procedure by which prior authorization under this subsection shall be obtained from an independent pharmacy consultant acting on behalf of the Department of Social Services, under an administrative services only contract.

(b) When prior authorization is required for coverage of a prescription drug under a medical assistance program administered by the Department of Social Services and a pharmacist is unable to obtain the prescribing physician’s authorization at the time the prescription is presented to be filled, the pharmacist shall dispense a one-time fourteen-day supply. The commissioner shall process a prior authorization request from a physician or pharmacist not later than two hours after the commissioner’s receipt of the request. If prior authorization is not granted or denied within two hours of receipt by the commissioner of the request for prior authorization, it shall be deemed granted.

(c) The Commissioner of Social Services, not later than October 1, 2012, shall issue a flier to pharmacies for distribution to Medicaid recipients who receive such one-time prescription supplies in the absence of prior prescription authorization. The flier shall notify recipients that (1) prior authorization is required for the prescription to be fully filled, (2) the fourteen-day supply is a one-time supply, and (3) recipients must contact the prescriber to arrange for prior authorization of a full prescription. The commissioner shall require pharmacists who receive Medicaid reimbursements for prescriptions to provide said flier to such Medicaid recipients.

(d) Notwithstanding the provisions of section 17b-262 and any regulation adopted thereunder, on or after July 1, 2000, the Commissioner of Social Services may establish a schedule of maximum quantities of oral dosage units permitted to be dispensed at one time for prescriptions covered under a medical assistance program administered by the Department of Social Services, including prescriptions for over-the-counter drugs, based on a review of utilization patterns.

(e) A schedule established pursuant to subsection (d) of this section and on and after July 1, 2005, any revisions thereto shall be submitted to the joint standing committees of the General Assembly having cognizance of matters relating to public health, human services and appropriations and the budgets of state agencies. Within sixty days of receipt of such a schedule or revisions thereto, said joint standing committees of the General Assembly shall approve or deny the schedule or any revisions thereto and advise the commissioner of their approval or denial of the schedule or any revisions thereto. The schedule or any revisions thereto shall be deemed approved unless all committees vote to reject such schedule or revisions thereto within sixty days of receipt of such schedule or revisions thereto.

(June Sp. Sess. P.A. 00-2, S. 36, 53; P.A. 04-76, S. 21; P.A. 05-280, S. 17; Sept. Sp. Sess. P.A. 09-5, S. 34; P.A. 10-26, S. 3; June 12 Sp. Sess. P.A. 12-1, S. 27.)

History: June Sp. Sess. P.A. 00-2 effective July 1, 2000; P.A. 04-76 amended Subsecs. (a) to (c), inclusive, by deleting references to “general assistance”; P.A. 05-280 amended Subsec. (a) by replacing “establish a plan for the” with “require” re prior authorization, removing former Subdiv. (1) designator, “initial” and “that costs five hundred dollars or more for a thirty day supply or”, redesignating existing Subdiv. (2) as Subdiv. (1), adding new Subdiv. (2) re prior authorization requirement for brand name drugs when a chemically equivalent generic drug product substitution is available, and providing that authorization for brand name drug shall be valid for one year from the date the initial prescription is first filled, amended Subsec. (b) by deleting provision that required commissioner to establish a plan for designating certain suppliers of prescription drugs to be used by pharmacies when ordering prescription drugs and amended Subsec. (d) by adding “on and after July 1, 2005,” re submission of plan revisions to General Assembly, effective July 13, 2005; Sept. Sp. Sess. P.A. 09-5 amended Subsec. (a) by replacing provision re specific medical assistance programs with provision re medical assistance programs administered by department, adding provision allowing commissioner to require prior authorization for over-the-counter drugs, deleting provisions re prior authorization for early refill of prescription drug and for brand name drugs when equivalent generic drug substitution is available, and deleting provision re prior authorization deemed granted if not granted or denied within 2 hours, amended Subsec. (b) by replacing former provisions re designation of specific suppliers with provisions requiring pharmacist to dispense a 14-day drug supply when prior authorization for drug is required and physician’s authorization cannot be obtained and re prior authorization deemed granted if not granted or denied within 2 hours, amended Subsec. (c) by replacing provision re specific medical assistance programs with provision re medical assistance programs administered by department, adding provision allowing commissioner to establish schedule of maximum quantities of oral dosage units for over-the-counter drugs and amended Subsec. (d) by deleting references to plan, effective October 5, 2009; P.A. 10-26 made a technical change in Subsec. (d), effective May 10, 2010; June 12 Sp. Sess. P.A. 12-1 added new Subsec. (c) re flier for Medicaid recipients who receive a one-time supply of a prescription, redesignated existing Subsecs. (c) and (d) as Subsecs. (d) and (e) and substituted “subsection (d)” for “subsection (c)” in redesignated Subsec. (e), effective July 1, 2012.

Sec. 17b-491b. Reimbursement formula for drugs used to treat hemophilia A. The maximum allowable cost paid for Factor VIII pharmaceuticals under the Medicaid program shall be the actual acquisition cost plus eight per cent. The Commissioner of Social Services may designate specific suppliers of Factor VIII pharmaceuticals from which a dispensing pharmacy shall order the prescription to be delivered to the pharmacy and billed by the supplier to the Department of Social Services. If the commissioner so designates specific suppliers of Factor VIII pharmaceuticals, the department shall pay the dispensing pharmacy a handling fee equal to eight per cent of the actual acquisition cost for such prescription.

(June Sp. Sess. P.A. 00-2, S. 35, 53; P.A. 04-76, S. 22; P.A. 11-44, S. 131; P.A. 13-234, S. 100.)

History: June Sp. Sess. P.A. 00-2 effective July 1, 2000; P.A. 04-76 deleted reference to “general assistance”; P.A. 11-44 deleted “state-administered general assistance”, effective July 1, 2011; P.A. 13-234 deleted reference to ConnPACE program, effective January 1, 2014.

Sec. 17b-491c. Rebates for prescription drugs covered under Connecticut AIDS drug assistance program and state medical assistance programs. Calculation of unit rebate amounts. Contracts for supplemental rebates. Pharmaceutical manufacturers’ participation in program. Rebates for new drugs. Payment for medically necessary drugs. (a) On and after February 1, 2008, any pharmaceutical manufacturer of a prescription drug covered by the Department of Social Services under the Connecticut AIDS drug assistance program or a state medical assistance program administered by the department that is a federally qualified state pharmacy assistance program shall provide rebates to the department for prescription drugs paid for by the department under such program in unit rebate amounts equal to the unit rebate amounts paid under the Medicaid program.

(b) On and after February 1, 2008, any pharmaceutical manufacturer of a prescription drug covered by the department under a state medical assistance program that is not a federally qualified state pharmacy assistance program shall provide rebates to the department. The unit rebate amount shall be calculated as follows: (1) For noninnovator multiple source drugs, the average manufacturer’s price multiplied by eleven per cent, and (2) for single source or innovator drugs, the greater of the average manufacturer’s price multiplied by fifteen and one-tenth per cent or the average manufacturer’s price minus best price. In the event the calculated rebate would establish a new Medicaid best price, the unit rebate amount will be capped at the average manufacturer’s price minus best price.

(c) The department may enter into contracts for supplemental rebates for drugs that are on a preferred drug list or formulary established by the department.

(d) Pharmaceutical manufacturers shall submit written confirmation of participation on a form prescribed by the Commissioner of Social Services, that states the terms of participation, including, but not limited to, the process by which a manufacturer may discontinue participation. The department shall provide advance notice to participating manufacturers if a new pharmacy assistance program is established and shall provide the manufacturers with the opportunity to discontinue participation. The department shall promptly notify participating manufacturers if a state pharmacy assistance program becomes disqualified. If a program becomes disqualified and a manufacturer has paid rebates at the rate for a qualified program, the department shall reimburse the manufacturer the amount overpaid as a result of disqualification.

(e) A manufacturer shall not be required to provide a rebate for a prescription drug that is new to the marketplace until the quarter in which the manufacturer has established a Medicaid best price for the product.

(f) No payment shall be made by the department for the prescription drugs of a manufacturer that does not provide rebates to the department pursuant to this section unless a specific drug is determined by the department to be medically necessary for an individual client.

(P.A. 08-1, S. 3; P.A. 09-14, S. 3.)

History: P.A. 08-1 effective April 4, 2008; P.A. 09-14 designated existing provisions as Subsec. (a) and amended same to require payment of rebates for drugs covered under Connecticut AIDS drug assistance program or state medical assistance program that is a federally qualified state pharmacy assistance program in amounts equal to unit rebate amounts under Medicaid program, added Subsec. (b) re method for calculating unit rebate amounts under state medical assistance program that is not a federally qualified state pharmacy assistance program, added Subsec. (c) re contracts for supplemental rebates, added Subsec. (d) re pharmaceutical manufacturers’ participation in program and pharmacy assistance program disqualification, added Subsec. (e) re rebates for new drugs and added Subsec. (f) re payment for drugs that are medically necessary, effective April 23, 2009.

Sec. 17b-492. (Formerly Sec. 17a-343). Eligibility. Application period. Registration fee. ConnPACE program requirements. Payment for original and replacement prescriptions. Application prior to exhausting coverage. Regulations. Section 17b-492 is repealed, effective January 1, 2014.

(P.A. 85-573, S. 7, 18; P.A. 87-3, S. 4, 9; June Sp. Sess. P.A. 91-8, S. 47, 63; P.A. 92-196, S. 3, 4; P.A. 93-262, S. 1, 87; P.A. 95-160, S. 1, 69; P.A. 96-139, S. 12, 13; June 18 Sp. Sess. P.A. 97-2, S. 128, 165; P.A. 98-194, S. 1, 2; June Sp. Sess. P.A. 01-2, S. 22, 69; June Sp. Sess. P.A. 01-9, S. 129, 131; May 9 Sp. Sess. P.A. 02-7, S. 16; P.A. 03-2, S. 15; June 30 Sp. Sess. P.A. 03-3, S. 58; P.A. 04-6, S. 1; 04-101, S. 2; 04-104, S. 2; 04-258, S. 12; P.A. 05-280, S. 22; Nov. 2 Sp. Sess. P.A. 05-2, S. 3, 4; Nov. 2 Sp. Sess. P.A. 05-3, S. 2; P.A. 09-2, S. 15; Sept. Sp. Sess. P.A. 09-5, S. 33, 47; P.A. 10-26, S. 4; 10-179, S. 59; P.A. 11-44, S. 89; P.A. 12-208, S. 4; P.A. 13-234, S. 156.)

Sec. 17b-492a. Participating pharmacy. Requirements. Section 17b-492a is repealed, effective July 1, 2011.

(P.A. 04-6, S. 2; P.A. 11-44, S. 178.)

Sec. 17b-492b. Authority of Commissioner of Developmental Services with respect to the Medicare Part D program. The Commissioner of Developmental Services, or the commissioner’s designee, may be the authorized representative of an applicant or recipient of services provided by the Department of Developmental Services for the purpose of submitting an application to the Social Security Administration to obtain the low income subsidy benefit provided under Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. As the authorized representative for this purpose, the commissioner, or the commissioner’s designee, may also sign required forms and enroll the applicant or recipient in a Medicare Part D plan on the applicant’s or recipient’s behalf. The applicant or recipient shall have the opportunity to select a Medicare Part D plan and shall be notified of such opportunity by the commissioner. In the event that such applicant or recipient does not select a Medicare Part D plan within a reasonable period of time, as determined by the commissioner, the department shall enroll the applicant or recipient in a Medicare Part D plan designated by the commissioner in accordance with said act. The applicant or recipient shall appoint the commissioner, or the commissioner’s designee, as such applicant’s or recipient’s authorized 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.

(P.A. 05-280, S. 28; P.A. 07-73, S. 2(a), (b).)

History: P.A. 05-280 effective July 1, 2005; pursuant to P.A. 07-73 “Commissioner of Mental Retardation” and “Department of Mental Retardation” were changed editorially by the Revisors to “Commissioner of Developmental Services” and “Department of Developmental Services”, effective October 1, 2007.

Sec. 17b-492c. Authority of Commissioner of Mental Health and Addiction Services with respect to the Medicare Part D program. (a) The Commissioner of Mental Health and Addiction Services, or the commissioner’s designee, may be the authorized representative of an applicant or recipient of services provided by the Department of Mental Health and Addiction Services for the purpose of submitting an application to the Social Security Administration to obtain the low income subsidy benefit provided under Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. As the authorized representative for this purpose, the commissioner, or the commissioner’s designee, may also sign required forms and enroll the applicant or recipient in a Medicare Part D plan on the applicant’s or recipient’s behalf. The applicant or recipient shall have the opportunity to select a Medicare Part D plan and shall be notified of such opportunity by the commissioner. In the event that such applicant or recipient does not select a Medicare Part D plan within a reasonable period of time, as determined by the commissioner, the department shall enroll the applicant or recipient in a Medicare Part D plan designated by the commissioner in accordance with said act. The applicant or recipient shall appoint the commissioner, or the commissioner’s designee, as such applicant’s or recipient’s authorized 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.

(b) Notwithstanding the provisions of section 4a-12, the Commissioner of Mental Health and Addiction Services, after consultation with the Commissioner of Administrative Services, may (1) bill or enter into a contract with a private entity to bill for prescriptions under the Medicare Part D program, and (2) enter into agreements and other contractual arrangements, including negotiated reimbursement rates for Medicare Part D plans, for the support of persons aided, cared for or treated by the Department of Mental Health and Addiction Services.

(P.A. 05-280, S. 29; Sept. Sp. Sess. P.A. 09-3, S. 53.)

History: P.A. 05-280 effective July 1, 2005; Sept. Sp. Sess. P.A. 09-3 designated existing provisions as Subsec. (a) and added Subsec. (b) re authority of Commissioner of Mental Health and Addiction Services to bill for prescriptions under Medicare Part D program and enter into agreements and other contractual arrangements, including negotiated reimbursement rates for Medicare Part D plans, for support of persons assisted by Department of Mental Health and Addiction Services, effective October 6, 2009.

Sec. 17b-492d. Council to advise on implementation of Medicare Part D program. Duties. Membership. Annual report. Section 17b-492d is repealed, effective October 5, 2009.

(P.A. 06-170, S. 1; Sept. Sp. Sess. P.A. 09-5, S. 89.)

Secs. 17b-493 to 17b-498. (Formerly Secs. 17a-344 to 17a-349). Generic substitution required. Regulations. Contract with fiscal intermediary; reports. Hearing. Penalties. Educational outreach program. Sections 17b-493 to 17b-498, inclusive, are repealed, effective January 1, 2014.

(P.A. 85-573, S. 8–12, 14, 18; P.A. 86-403, S. 92, 132; P.A. 87-3, S. 5–7, 9; P.A. 88-364, S. 78, 123; P.A. 90-89, S. 2; P.A. 91-190, S. 2, 9; June Sp. Sess. P.A. 91-8, S. 48–50, 63; P.A. 93-262, S. 1, 87; P.A. 95-264, S. 69; P.A. 96-169, S. 14; June Sp. Sess. P.A. 00-2, S. 41, 53; P.A. 03-268, S. 10; P.A. 04-16, S. 13; 04-104, S. 3; P.A. 07-217, S. 76; P.A. 11-44, S. 151; P.A. 13-234, S. 156.)

Sec. 17b-499. Pharmacy outreach program: Definitions. As used in this section and section 17b-499a:

(1) “Eligible person” means any person who is a resident of Connecticut at the time such person files an application for prescription medications or nonprescription medications with a participating manufacturer;

(2) “Department” means the Department of Social Services;

(3) “Participating manufacturer” means a pharmaceutical manufacturer that offers prescription medications or nonprescription medications at a reduced cost or at no cost to persons pursuant to a voluntary drug assistance program established by such manufacturer;

(4) “Prescription medications” means prescription drugs that have been approved as safe and effective by the federal Food and Drug Administration or that are otherwise legally marketed and manufactured in the United States and manufactured and offered by pharmaceutical companies.

(P.A. 05-269, S. 1.)

History: P.A. 05-269 effective July 13, 2005.

Sec. 17b-499a. Pharmacy outreach program. Established. Purpose. Duties. Report. Medicaid therapy management services pilot program. (a) There is established a pharmacy outreach program, administered by participating manufacturers through a toll-free telephone number, for the purpose of assisting residents of this state in obtaining reduced cost or no cost prescription medications or nonprescription medications from participating manufacturers and educating such residents about all available programs in Connecticut relating to such medications. The department, within available appropriations, shall oversee such program.

(b) The pharmacy outreach program shall assist eligible persons in procuring free or low cost prescription medications or nonprescription medications by: (1) Evaluating the likelihood that such eligible person will qualify to receive reduced cost or no cost prescription medications or nonprescription medications from a participating manufacturer based upon such participating manufacturer’s eligibility requirements for participation in such manufacturer’s voluntary drug assistance program; (2) aiding eligible persons who qualify to receive such reduced cost or no cost prescription medications or nonprescription medications in receiving such medications from such participating manufacturers; and (3) assisting any physician licensed in this state with communications to any such participating manufacturer that concern the application of any such eligible person for participation in such participating manufacturer’s voluntary drug assistance program.

(c) The pharmacy outreach program shall: (1) Create and maintain a state-wide toll-free telephone number staffed by individuals who are qualified to advise eligible persons on questions such persons may have about access to reduced cost or no cost prescription drugs or nonprescription drugs; (2) sponsor and organize materials and information, in conjunction with other organizations, concerning issues relating to access to affordable prescription medications; and (3) offer and provide information on prescription medications and nonprescription medications, including, but not limited to, information on drug interactions and drug abuse.

(d) Not later than January 15, 2006, and annually thereafter, upon the request of the joint standing committees of the General Assembly having cognizance of matters relating to human services and general law, the Department of Social Services shall report, in accordance with section 11-4a, on the number of telephone calls received by the pharmacy outreach program, the number of prescriptions requested and issued through the program and any other information relating to the program that the department deems relevant.

(e) The Commissioner of Social Services, in coordination with the Connecticut Pharmacists Association and a community health center in the greater New Haven region, shall provide Medicaid therapy management services in a pilot program to be administered in greater New Haven by the community health center. Said program shall be operated in cooperation with the medication therapy management activities of the administrative services organization and include, but not be limited to, (1) a review of the medical and prescription history of recipients of benefits under the Medicaid program, and (2) the development of patient medication action plans to reduce adverse medication interaction and related health problems.

(P.A. 05-269, S. 2; P.A. 11-44, S. 143; 11-61, S. 127; P.A. 13-234, S. 110.)

History: P.A. 05-269 effective July 13, 2005; P.A. 11-44 added Subsec. (e) re contract for Medicaid therapy management services, effective July 1, 2011; P.A. 11-61 amended Subsec. (e) by adding provision allowing commissioner to contract with a patient-centered medical home or health home, effective July 1, 2011; P.A. 13-234 substantially revised Subsec. (e) to require Commissioner of Social Services in coordination with a community health center and the Connecticut Pharmacists Association to provide Medicaid therapy management services in a pilot program located in the greater New Haven region, effective July 1, 2013.

Secs. 17b-500 to 17b-519. Reserved for future use.

Note: Chapter 319gg is also reserved for future use.