42 CFR 423.782 - Cost-sharing subsidy.
(a)Full subsidy eligible individuals. Full subsidy eligible individuals are entitled to the following:
(1) Elimination of the annual deductible under § 423.104(d)(1).
(2) Reduction in cost-sharing for all covered Part D drugs covered under the PDP or MA-PD plan below the out-of-pocket limit (under § 423.104), including Part D drugs covered under the PDP or MA-PD plan obtained after the initial coverage limit (under § 423.104(d)(4)), as follows:
(i) Except as provided under paragraphs (a)(2)(ii) and (a)(2)(iii) of this section, copayment amounts not to exceed the copayment amounts specified in § 423.104(d)(5)(A). This applies to both:
(ii) Full-benefit dual-eligible individuals who are institutionalized or who are receiving home and community-based services have no cost-sharing for Part D drugs covered under their PDP or MA-PD plans.
(iii) Full-benefit dual eligible individuals with incomes that do not exceed 100 percent of the Federal poverty line applicable to the individual's family size are subject to cost-sharing for covered Part D drugs equal to the lesser of:
(A) A copayment amount of not more than $1 for a generic drug or preferred drugs that are multiple source (as defined under section 1927(k)(7)(A)(i) of the Act) or $3 for any other drug in 2006, or for years after 2006 the amounts specified in this paragraph (a)(2)(iii)(A) for the percentage increase in the Consumer Price Index, rounded to the nearest multiple of 5 cents or 10 cents, respectively; or
(B) The copayment amount charged to other individuals under this paragraph (a)(2)(i) of this section.
(b)Other low-income subsidy eligible individuals. Other low-income subsidy eligible individuals are entitled to the following:
(1) In 2006, reduction in the annual deductible to $50. This amount is increased each year beginning in 2007 by the annual percentage increase in average per capita aggregate expenditures for Part D drugs, rounded to the nearest multiple of $1.
(3) For covered Part D drugs above the out-of-pocket limit (under § 423.104(d)(5)(iii)), in 2006, copayments not to exceed $2 for a generic drug or preferred drugs that are multiple source drugs (as defined under section 1927(k)(7)(A)(i) of the Act) and $5 for any other drug. For years beginning in 2007, the amounts specified in section paragraph (b)(3) for the previous year increased by the annual percentage increase in average per capita aggregate expenditures for covered Part D drugs, rounded to the nearest multiple of 5 cents.
(c) When the out-of-pocket cost for a covered Part D drug under a Part D sponsor's plan benefit package is less than the maximum allowable copayment, coinsurance or deductible amounts under paragraphs (a) and (b) of this section, the Part D sponsor may only charge the lower benefit package amount.
- 42 CFR 423.104 — Requirements Related to Qualified Prescription Drug Coverage.
- 42 CFR 423.120 — Access to Covered Part D Drugs.
- 42 CFR 423.308 — Definitions and Terminology.
- 42 CFR 423.772 — Definitions.
- 42 CFR 423.315 — General Payment Provisions.
- 42 CFR 423.343 — Retroactive Adjustments and Reconciliations.
- 42 CFR 423.100 — Definitions.
- 42 CFR 423.336 — Risk-Sharing Arrangements.
- 20 CFR 418.3001 — What Is This Subpart About?