Medicare Compliance & Reimbursement

Maine Governor John Baldacci has proposed a revised version of the state's Maine Rx initiative, designed to provide access to affordable prescription drugs to Mainers without pharmaceutical coverage. The Governor said the new initiative, dubbed Maine Rx Plus, would be open to fewer people but would provide bigger discounts.

Baldacci announced his proposal May 29, a week and a half after the U.S. Supreme Court struck down a lower court injunction against the original Maine Rx program. The injunction, imposed as a result of a pharmaceutical industry legal challenge, had prevented Maine Rx from ever going into effect after it was passed in 2000.

Maine Rx Plus differs from its predecessor in several ways. Eligibility is capped at 350 percent of the federal poverty level, or, according to a state press release, about $31,400 for an individual and $64,400 for a family of four. Maine Rx was open to all state residents without drug coverage, regardless of income. The Supreme Court "had indicated that the program could be less viable without an income cap," Newell Augur, Director of Public and Legislative Affairs for Maine's Department of Human Services, told M&H. "In addition to that, we're a lot smarter than we were three years ago in setting up these kinds of programs, and it only makes sense to target the benefit to those who need it most."

Because of the income limitation, approximately 275,000 Mainers are expected to be eligible, about 50,000 fewer than Maine Rx covered.

Maine Rx Plus offers a discount for any drug considered "preferred" under a list that MaineCare, the state's Medicaid program, is compiling. In the first stage of Maine Rx Plus, according to state documents, enrollees will be able to purchase preferred drugs at the Medicaid price, ranging from 15 to 60 percent below retail.

After an estimated 10 months, discounts would be augmented in cases where the state was able to negotiate an additional rebate agreement with a manufacturer, using as leverage the threat that noncooperative manufacturers would find their products facing prior authorization requirements before they could be prescribed to MaineCare enrollees. This leveraging of Medicaid's buying power, central to Maine Rx, "remains as the core of the ... program," said DHS Commissioner Peter Walsh in a press release.

Maine Rx Plus discounts exceed those offered by Maine Rx "in all cases," according to the state.

Augur said that there is "very, very broad bipartisan support" for Maine Rx Plus in the state legislature, and he predicted approval of the program "in short order." The harder hurdle, however, may be the federal Department of Health and Human Services, which sees Maine Rx Plus as a Medicaid state plan amendment that must be approved - or disapproved - by the Secretary.

"We want to work with the Centers for Medicare & Medicaid Services, whether or not the Supreme Court has legally directed us to do so," Augur said, but he declined to say whether Maine planned to seek approval for Maine Rx Plus as a Medicaid amendment.