§ 2073. VPharm assistance program
[Subsection (a) contingently effective until the later of January 1, 2022 or federal
approval of VPharm coverage expansion; see also subsection (a) contingently effective
on the later of January 1, 2022 or federal approval of VPharm coverage expansion set
out below.]
(a) Effective January 1, 2006, the VPharm program is established as a State pharmaceutical
assistance program to provide supplemental pharmaceutical coverage to Medicare beneficiaries.
The supplemental coverage under subsection (c) of this section shall provide only
the same pharmaceutical coverage as the Medicaid program to enrolled individuals whose
income is not greater than 150 percent of the federal poverty guidelines and only
coverage for maintenance drugs for enrolled individuals whose income is greater than
150 percent and no greater than 225 percent of the federal poverty guidelines.
[Subsection (a) contingently effective January 1, 2022 or federal approval of VPharm
coverage expansion; see also subsection (a) contingently effective until the later
of January 1, 2022 or federal approval of VPharm coverage expansion set out above.]
(a) The VPharm program is established as a State pharmaceutical assistance program to
provide supplemental pharmaceutical coverage to Medicare beneficiaries. The supplemental
coverage under subsection (c) of this section shall provide the same pharmaceutical
coverage as the Medicaid program to enrolled individuals whose income is not greater
than 225 percent of the federal poverty guidelines.
[Subsection (b) contingently effective until the later of January 1, 2022 or federal
approval of VPharm coverage expansion; see also subsection (b) contingently effective
on the later of January 1, 2022 or federal approval of VPharm coverage expansion set
out below.]
(b) Any individual with income no greater than 225 percent of the federal poverty guidelines
participating in Medicare Part D, having secured the low income subsidy if the individual
is eligible and meeting the general eligibility requirements established in section 2072 of this title, shall be eligible for VPharm.
[Subsection (b) contingently effective on the later of January 1, 2022 or federal approval
of VPharm coverage expansion; see also subsection (b) contingently effective until
the later of January 1, 2022 or federal approval of VPharm coverage expansion set
out above.]
(b) Any individual with income not greater than 225 percent of the federal poverty guidelines
participating in Medicare Part D, having secured the low-income subsidy if the individual
is eligible and meeting the general eligibility requirements established in section 2072 of this title, shall be eligible for VPharm.
(c) VPharm shall provide supplemental benefits by paying or subsidizing:
(1) The actual Medicare Part D premium for the standard prescription drug benefit offered
by Medicare Part D prescription drug programs, except for any late enrollment penalties,
provided that DVHA may pay or subsidize a higher premium for a Medicare Part D prescription
drug plan offering expanded benefits if it is cost-effective to do so.
(2) Any other cost-sharing required by Medicare Part D, except for co-payments for individuals
eligible for Medicaid and as provided for in subdivision (d)(1) of this section.
(3) The following pharmaceuticals if they are not covered by the individual’s Medicare
Part D prescription drug plan: pharmaceuticals or classes of pharmaceuticals, or their
medical uses, which may be excluded from coverage or otherwise restricted under Medicaid
under Section 1927(d)(2) or (3) of the Social Security Act.
(4) Pharmaceuticals that are not covered after the individual has exhausted the Medicare
Part D prescription drug plan’s appeal process or the prescription drug plan’s transition
plan approved by the Centers for Medicare and Medicaid Services, and that are deemed
medically necessary by the individual’s prescriber in a manner established by the
Commissioner of Vermont Health Access. The coverage decision under this subdivision
shall not be subject to the exceptions process established under Medicaid. An individual
may appeal to the Human Services Board or pursue any other remedies provided by law.
(d)(1) An individual shall contribute a co-payment of $1.00 for prescriptions where the cost-sharing
amount required by Medicare Part D is less than $30.00, and a co-payment of $2.00
for prescriptions where the cost-sharing amount required by Medicare Part D is $30.00
or more. A pharmacy may not refuse to dispense a prescription to an individual who
does not provide the co-payment.
(2) An individual shall contribute the following base cost-sharing amounts that shall
be indexed to the increases established under 42 C.F.R. § 423.104(d)(5)(iv) and then rounded to the nearest dollar amount:
(A) in the case of recipients whose household income is no greater than 150 percent of
the federal poverty level, such premium shall be $15.00 per month;
(B) in the case of recipients whose household income is greater than 150 percent of the
federal poverty level and no greater than 175 percent of the federal poverty level,
the premium shall be $20.00 per month; and
(C) in the case of recipients whose household income is greater than 175 percent of the
federal poverty level and no greater than 225 percent of the federal poverty level,
the premium shall be $50.00 per month.
(e) In order to ensure the appropriate payment of claims, DVHA may expand the Medicare
advocacy program established under chapter 67 of this title to individuals receiving
benefits from the VPharm program.
(f) A manufacturer of pharmaceuticals purchased by individuals receiving assistance from
VPharm established under this section shall pay to DVHA, as required by section 1901 of this title, a rebate on all pharmaceutical claims for which State-only funds are expended in
an amount that is in proportion to the State share of the total cost of the claim,
as calculated annually on an aggregate basis, and based on the full Medicaid rebate
amount as provided for in Section 1927(a) through (c) of the federal Social Security
Act, 42 U.S.C. § 1396r-8. (Added 2005, No. 71, § 314; amended 2007, No. 172 (Adj. Sess.), § 11a; 2007, No. 192 (Adj. Sess.), § 6.017; 2009, No. 1 (Sp. Sess.), §§ E.309.6, E.309.7; 2009, No. 156 (Adj. Sess.), § E.309.16, eff. June 3, 2010; 2009, No. 156 (Adj. Sess.), §§ E.309.9, I.71; 2011, No. 162 (Adj. Sess.), §§ E.307, E.307.7; 2019, No. 140 (Adj. Sess.), § 6.)