For clients who are dually eligible for medical assistance and medicare benefits, the following applies:
(1) Medicare Part B, the department pays providers for:
(a) An amount up to the department's maximum allowable fee for drugs medicare does not cover, but the department covers; or
(b) Deductible and/or coinsurance amounts up to medicare's or the department's maximum allowable fee, whichever is less, for drugs medicare and the department cover; or
(c) Deductible and/or coinsurance amounts for clients under the qualified medicare beneficiary (QMB) program for drugs medicare covers but the department does not cover.
(2) Medicare Part D:
(a) For payment of medicare Part D drugs:
(i) Medicare is the primary payer for covered Part D drugs;
(ii) The department pays only the copayment up to a maximum amount set by the Centers for Medicare and Medicaid Services (CMS); and
(iii) The client is responsible for copayments above the maximum amount.
(b) For drugs excluded from the basic medicare Part D benefits:
(i) The department offers the same drug benefit as a nondual eligible client has within those same classes;
(ii) If the client has another third party insurer, that insurer is the primary payer; and
(iii) The department is the payer of last resort.
[11-14-075, recodified as § 182-530-7700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 07-20-049, § 388-530-7700, filed 9/26/07, effective 11/1/07.]