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)         Except for the cost-sharing described in subsection (c) of this Section, Medicare-eligible beneficiaries shall pay a co-payment equal to the greater of the co-payments required under Medicare Part D for "other low-income subsidy eligible individuals" pursuant to 42 CFR 423.782(b) (2005), or $5 for each prescription of a Tier 1 drug, $20 for each prescription of a Tier 3 drug, and $15 for each prescription of a Tier 2 or 4 drug on the Medicare Part D plan's formulary.  Beneficiaries shall pay $5 for each prescription of a generic drug and $15 for each prescription of a brand name drug when the drug is a Medicare Part D-excluded drug covered by the Department.  Beneficiaries not eligible for Medicare shall pay a co-payment of $5 for each prescription of a generic drug and $15 for each prescription of a brand name drug when the drug is covered by the Department.

b)         Except for cost sharing described in subsection (c), 25 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 or the beneficiary has reached the Medicare Part D Coverage Gap phase.

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 36 Ill. Reg. 1516, effective January 23, 2012)