Section 409.9065, Florida Statutes 2004
409.9065 Pharmaceutical expense assistance.--
(1) PROGRAM ESTABLISHED.--There is established a program to provide pharmaceutical expense assistance to eligible low-income elderly individuals, which shall be known as the "Ron Silver Senior Drug Program" and may be referred to as the "Lifesaver Rx Program."
(2) ELIGIBILITY.--Eligibility for the program is limited to individuals who:
(a) Are Florida residents age 65 and over;
(b) Have an income equal to or less than 200 percent of the federal poverty level;
(c) Are eligible for Medicare;
(d) Have exhausted pharmacy benefits under Medicare, Medicaid, or any other insurance plan; and
(e) Request to be enrolled in the program.
(3) BENEFITS.--Eligible individuals shall receive a discount for prescription drugs covered under the Medicaid program in s. 409.906(20).
(a) Eligible individuals with incomes equal to or less than 120 percent of the federal poverty level shall receive a discount of 100 percent for the first $160 worth of prescription drugs they receive each month, subject to copayments that the agency requires on these benefits. For all other prescription drugs received each month, eligible individuals shall receive a discount of 50 percent.
(b) Eligible individuals with incomes of more than 120 percent but not more than 150 percent of the federal poverty level shall receive a discount of 50 percent.
(c) Eligible individuals with incomes of more than 150 percent but not more than 175 percent of the federal poverty level shall receive a discount of 41 percent.
(d) Eligible individuals with incomes of more than 175 percent but not more than 200 percent of the federal poverty level shall receive a discount of 37 percent.
(4) ADMINISTRATION.--The pharmaceutical expense assistance program shall be administered by the agency, in collaboration with the Department of Elderly Affairs and the Department of Children and Family Services.
(a) The agency shall, by rule, establish for the pharmaceutical expense assistance program eligibility requirements; limits on participation; benefit limitations, including copayments; a requirement for generic drug substitution; and other program parameters comparable to those of the Medicaid program. Individuals eligible to participate in this program are not subject to the limit of four brand name drugs per month per recipient as specified in s. 409.912(40)(a). There shall be no monetary limit on prescription drugs purchased with discounts of less than 51 percent unless the agency determines there is a risk of a funding shortfall in the program. If the agency determines there is a risk of a funding shortfall, the agency may establish monetary limits on prescription drugs which shall not be less than $160 worth of prescription drugs per month.
(b) By January 1 of each year, the agency shall report to the Legislature on the operation of the program. The report shall include information on the number of individuals served, use rates, and expenditures under the program. The report shall also address the impact of the program on reducing unmet pharmaceutical drug needs among the elderly and recommend programmatic changes.
(5) NONENTITLEMENT.--The pharmaceutical expense assistance program established by this section is not an entitlement. Enrollment levels are limited to those authorized by the Legislature in the annual General Appropriations Act. If, after establishing monetary limits as required by paragraph (4)(a), funds are insufficient to serve all eligible individuals seeking coverage, the agency may develop a waiting list based on application dates to use in enrolling individuals in unfilled enrollment slots.
(6) PHARMACEUTICAL MANUFACTURER PARTICIPATION.--In order for a drug product to be covered under Medicaid or this program, the product's manufacturer shall:
(a) Provide a rebate to the state equal to the rebate required by the Medicaid program; and
(b) Make the drug product available to the program for the best price that the manufacturer makes the drug product available in the Medicaid program.
(7) REIMBURSEMENT.--Total reimbursements to pharmacies participating in the pharmaceutical expense assistance program established under this section shall be equivalent to reimbursements under the Medicaid program.
(8) PHARMACEUTICAL EXPENSE ASSISTANCE PROGRAM.--In the absence of federal approval for the Lifesaver Rx Program to provide benefits to higher income groups and additional discounts as described in subsections (2) and (3), the Agency for Health Care Administration may, subject to federal approval and continuing state appropriations, operate a pharmaceutical expense assistance program that limits eligibility and benefits to Medicaid beneficiaries who do not normally receive Medicaid benefits, are Florida residents age 65 and older, have an income less than or equal to 120 percent of the federal poverty level, are eligible for Medicare, and request to be enrolled in the program. Benefits under the limited pharmaceutical expense assistance program shall include Medicaid payment for up to $160 per month for prescribed drugs, subject to benefit utilization controls applied to other Medicaid prescribed drug benefits and the following copayments: $2 per generic product, $5 for a product that is on the Medicaid Preferred Drug List, and $15 for a product that is not on the preferred drug list.
(9) FEDERAL APPROVAL.--The benefits provided in this section are limited to those approved by the Federal Government pursuant to a Medicaid waiver or an amendment to the state Medicaid plan.
History.--s. 2, ch. 2000-254; s. 5, ch. 2001-377; s. 20, ch. 2002-400; s. 10, ch. 2003-405; s. 52, ch. 2004-5; s. 10, ch. 2004-270; s. 19, ch. 2004-344.