1. (1) Group 1 and 2 clients are eligible for assistance with:

   1. (a) The cost of health insurance premiums if applicable, provided the coverage, at a minimum includes pharmaceutical benefits equivalent to the HIV antiretroviral and opportunistic infection-related medications on the CAREAssist formulary as well as coverage for other essential medical benefits as defined by the Affordable Care Act.
   2. (b) Copays, coinsurance and deductibles on prescription drugs covered by the client’s primary health insurance, with the exception of medications prescribed to treat erectile dysfunction.
   3. (c) Copays, coinsurance and deductibles on medical services covered by the client’s primary health insurance, up to a maximum amount set by the program each calendar year. Eligible medical services include but are not limited to laboratory tests, office visits, emergency room visits, X-rays, and hospital stays.

   4. (d) The full cost of CAREAssist formulary prescriptions, filled at an in-network pharmacy when:

      1. (A) The client has successfully enrolled in insurance but coverage is not yet active; or
      2. (B) The client’s insurance policy does not cover the cost of the prescription; and
      3. (C) The prescribing provider submitted a Prior Authorization Request to the client’s primary insurance, the request was denied and there is no acceptable therapeutic substitution.
   5. (e) Prescription drugs if the required copay exceeds the cost of the prescription medication and the insurance policy therefore does not pay.
   6. (f) Medication therapy management.
2. (2) CAREAssist clients who smoke or chew tobacco may be eligible to receive additional and enhanced services from the Oregon Tobacco Quit Line (1-800-QUIT-NOW), if funding is available.
3. (3) A client on restricted status may not be entitled to some of the benefits described in section (1) and (2) of this rule.
4. (4) The Authority shall only make payments directly to a service provider or benefits administrator. No reimbursements or direct payments may be made to a client or an individual who pays on behalf of a client.

Statutory/Other Authority

ORS 413.042, 431.250 & 431.830

Statutes/Other Implemented

ORS 431.250 & 431.830

History

PH 30-2014, f. 11-10-14, cert. ef. 12-1-14