(a)The department may apply for a demonstration waiver
under section 1115 of the federal Social Security Act to allow
individuals with income or assets in excess of limits generally
established in the state plan to receive services under a
pharmacy plus program provided that:
(i)The individual is a beneficiary under the federal
Medicare program who has not been determined to be eligible for
full Medicaid benefits under the state plan;
(ii)The total family income of the individual does
not exceed one hundred seventy-five percent (175%) of the
federal poverty level in effect on April 1 of that calendar
year;
(iii)The total family net assets of the individual
do not exceed three hundred fifty thousand dollars
($350,000.00); and
(iv)An individual determined eligible to receive
services un
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(a) The department may apply for a demonstration waiver
under section 1115 of the federal Social Security Act to allow
individuals with income or assets in excess of limits generally
established in the state plan to receive services under a
pharmacy plus program provided that:
(i) The individual is a beneficiary under the federal
Medicare program who has not been determined to be eligible for
full Medicaid benefits under the state plan;
(ii) The total family income of the individual does
not exceed one hundred seventy-five percent (175%) of the
federal poverty level in effect on April 1 of that calendar
year;
(iii) The total family net assets of the individual
do not exceed three hundred fifty thousand dollars
($350,000.00); and
(iv) An individual determined eligible to receive
services under this section shall not be eligible for other
services under W.S. 42-4-103, unless the individual otherwise
qualifies for the services. Eligibility for assistance under the
program created by this section shall not constitute an
entitlement and services shall be provided under this section
only to the extent funds are available.
(b) The department is directed to negotiate the terms and
conditions of the waiver with the United States secretary of
health and human services as necessary to implement this
section.
(c) Upon approval of the final terms and conditions by the
United States secretary of health and human services and the
legislature of the waiver applied for under this section, the
department shall implement the pharmacy plus program to assist
eligible individuals with payment and management of prescription
drug costs. In implementing the pharmacy plus program, the
department may use private sector benefit management approaches,
including pharmacy benefit managers, preferred drug lists, prior
authorization, pharmacist consultation, provider education,
disease state management and variable enrollee cost sharing in
the form of annual or monthly premium assessments, per
prescription copayment requirements, coinsurance, deductibles
and coverage limits. The department shall establish through
rules and regulations variable enrollee cost sharing provisions
under this subsection on a graduated basis, taking into
consideration the differing income levels of enrollees and the
funding available to the program.
(d) If the federal Medicare program is amended to provide
pharmaceutical benefits for recipients under that program, the
pharmacy plus program authorized under this section shall
terminate upon implementation of the federal Medicare
pharmaceutical benefits program.
(e) The department shall project costs of the program
created by this section at least quarterly and compare those
projected costs against the funds appropriated for the program.
If the funds available to the program are insufficient to meet
the projected costs of the program, the department shall take
action to prevent the program from incurring costs beyond
available funds, including taking any of the actions specified
in W.S. 42-4-118(e).