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Prescription Drug Assistance

Prescription Drug Assistance

Last updated: January 2013

Overview

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The State of Connecticut and some drug manufactures offer programs that help certain persons who need prescription medications.

Medicare now offers a separate, voluntary drug benefit program called Medicare Part D.  Because of this program, Medicaid no longer pays for most prescription drugs needed by those with Medicaid and Medicare (called "the dually-eligible").  Medicare Part D is a requirement for the dually-eligible and for ConnPACE recipients.

Medicare Prescription Drug Benefit

With the federal passage of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173), Medicare has been drastically changed to include a voluntary prescription drug benefit.

In Connecticut, the legislature enacted laws covering ConnPACE and Medicaid to "wrap-around" the Medicare Part D benefit.  It is one of the most comprehensive wrap-around laws in the nation.

Basic benefit

Medicare Part D is the new voluntary prescription drug benefit that provides Medicare beneficiaries with assistance in paying for their prescriptions.   Private insurance companies offer several different Medicare Part D Prescription Drug Plans (PDP’s), all of which must include a standard drug benefit package. A person must be eligible for Medicare Part A or enrolled in Part B to enroll in a Medicare PDP. There are several costs associated with Medicare PDP’s: deductibles, co-payments and monthly premiums. For those individuals who need extra help with these costs, Medicare offers low-income subsidies. Dually-eligible nursing home residents (those with Medicare and Title 19) do not have co-payments.

If one wants to take part in the Medicare drug benefit, Medicare beneficiaries must enroll in Medicare Part D and in a Prescription Drug Plan (PDP).  Generally, an individual can only change PDP's once per year, but those who are eligible for the low income subsidies can change plans every month.

If a person is eligible for Part D, but enrolls after the open enrollment period, he may be penalized through imposition of a higher monthly premium.  Those with "creditable coverage" for prescription drugs through employer-based health plans are exempt from this penalty.  Click here to read the CMS explanation of "creditable coverage."

Medicaid (Title 19) no longer pays for prescription drugs covered under Medicare Part D, but for limited exceptions.  The dually-eligible are automatically enrolled in Medicare Part D and into a PDP if they do not do so voluntarily.  The dually-eligible will also be automatically enrolled in the full low-income subsidy.

Costs

In a standard PDP, in addition to the monthly premium, there will be an annual deductible.  Once this deductible is met, an individual pays 25% of the cost of each prescription until he spends an additional out of pocket amount.  At this point, one falls into the doughnut hole -- where there is no Medicare drug coverage but premium payments are still required.  During time in the doughnut hole, one must pay 100% of prescription drug costs until he spends out of it.  Unfortunately, if one incurs costs for prescriptions not on the PDP's formulary, those expenses do not count toward the amount needed to escape the hole.

If an individual climbs out of the doughnut hole, he pays only 5% of prescription costs.  This is called "catastrophic coverage."  Thus, in addition to monthly premiums, a person must incur thousands of dollars in out of pocket prescription drug costs before obtaining catastrophic coverage.

The entire scenario occurs every year, with costs increasing due to inflation.

Many PDPs with no doughnut hole can be purchased but they generally have higher monthly premiums.

For a thorough review of Medicare Part D, please visit the following web sites:

Low-income subsidies

Fortunately, for those individuals with low income and assets, full or partial subsidies are available.  ConnPACE now requires one to enroll in Medicare Part D and a Medicare PDP if eligible.  As a result, income and asset information will be necessary to complete both ConnPACE and Part D applications.

The dually-eligible, SSI recipients and those persons enrolled in the Medicare Savings Programs (MSP) automatically receive a low income subsidy - which is substantial (see chart below).  In Connecticut, the MSP's are the QMB, SLMB and ALMB (also known as QI) programs.

Medicaid (Title 19)

Medicaid covers most prescriptions drugs for beneficiaries living in the community.  For those who are both Medicare and Medicaid eligible - called "dual-eligibles" - Medicaid will no longer cover most drugs.  Rather, prescription drugs must be obtained through a Medicare Part D drug plan.

In Connecticut, the co-payments under Medicare Part D for dual eligible individuals are limited to $15 per month. After a dual eligible incurs that amount of co-payments, the Connecticut Department of Social Services will cover their Part co-payments for the rest of the month. Those other low income individuals, such as those persons enrolled in a Medicare Savings Program, can be charged Medicare Part D co-payments of $2.50 for generics and $6.30 for brand name prescriptions on their formulary.  For those dual-eligibles in nursing homes and some other long-term care institutions, no co-payments will be imposed.

Free and Low-Cost Prescription Drugs

Volunteers in Health Care has developed RxAssist, an on-line, searchable database of pharmaceutical company patient assistance programs for providers. The database includes eligibility requirements, application procedures and other information for hundreds of medications.

The Pharmaceutical Research and Manufacturers of America (PhRMA) have brought together public and private patient assistance programs into one comprehensive resource.  Call 1-888-4PPA-NOW or visit the Partnership for Prescription Assistance web site to find help with drug costs.

In addition, many national retail stores and pharmacies sell highly discounted generic prescription drugs.

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