Section 119.90  Co-Payments and Cost Sharing

Unless a federal low-income subsidy results in lesser co-payments and cost sharing, a beneficiary enrolled in Illinois Cares Rx shall be responsible for payment of co-payments and cost sharing as follows:

a)         The applicable co-payment shall be equal to that required by Medicare Part D for "other low income subsidy eligibles" pursuant to 42 CFR 423.782(b) (in 2006, those co-payments are $2 for each dispensing of a generic prescription and $5 for each dispensing of a brand name prescription).  For individuals enrolled in Medicare Part D, co-payments are $15 for each dispensing of a non-preferred drug.

b)         Except for cost sharing described in subsection (c), 20 percent of the reimbursable amount of the prescription plus the applicable co-payment for each prescription dispensed after the Illinois Cares Rx benefit amount has reached $1,750 for the calendar year.

c)         Effective January 1, 2007, for individuals enrolled in Medicare Part D who have been identified to the Department as having a diagnosis of HIV or AIDS, the applicable co-payment for drugs that are listed on the ADAP formulary shall be equal to that required by Medicare Part D for "other low income subsidy eligibles" pursuant to 42 CFR 423.782(b).  The co-payments described in this subsection are applicable throughout the Plan Year.

d)         For those enrolled in Medicare Part D, the Illinois Cares Rx benefit amount is the total payments made by the PDP to pharmacies on behalf of the beneficiary, whether paid as a part of the Medicare benefit or the Illinois Cares Rx benefit.  For those not eligible for Medicare Part D, the Illinois Cares Rx benefit amount is the total payments made by the Department to pharmacies on behalf of the beneficiary.

e)         A beneficiary also must pay to an authorized pharmacy an ancillary charge for any covered prescription drug that is a brand name product if the pharmacy is reimbursed at the generic price as provided in Section 119.100(b)(2) and (3).

(Source:  Amended at 31 Ill. Reg. 5537, effective March 26, 2007)