NCSL Health Program
STATE PHARMACEUTICAL ASSISTANCE PROGRAMS
(SUBSIDIES AND DISCOUNTS FOR SENIORS, DISABLED, UNINSURED AND OTHERS)
Updated December 2011; material added March 2013
Prescription drug assistance has been a substantial and growing state interest for a number of years, generally in response to residents who lack insurance coverage for medicines or who were not eligible for other government programs. In fact, the first states to authorize and fund direct subsidy programs did so in 1975. Between 2000 and 2006 at least 26 states authorized and/or started pharmaceutical assistance programs, many intended to aid low-income elderly or persons with disabilities who do not qualify for Medicaid. By 2009, a total of at least 42 states had established or authorized some type of program to provide pharmaceutical coverage or assistance; several of those are not currently operational. The subsidy programs, often termed "SPAPs," utilize state funds to pay for a portion of the costs, usually for a defined population that meets enrollment criteria. In addition, an increasing number of states use discounts or bulk purchasing approaches that do not spend state funds for the drug purchases, listed as "Discount Programs" below.
CHANGING NUMBERS AND FEATURES:
38 states have enacted laws to create programs; others were created by executive branch action only.
28 states and the U.S. Virgin Islands had programs in operation as of 2011.
22 operational programs provide for a direct subsidy using state funds; in the past five years a high point of 36 states' laws (plus DC) authorized such subsidies. Iowa has a temporary program that may close when funds are exhausted. 40 programs in 19 states were certified by CMS/HHS as "SPAPs" for the purpose of determining whether the state-administerd programs were exempt or excluded from calculations of "Medicaid Best Price." This calculation does not constitute federal regulation of these SPAPs.
27 states created or authorized programs that offer a discount only (no subsidy) for eligible or enrolled residents; of these about 16 are in operation. The latest are in Florida and Iowa, starting in 2008. Some of these states also have a separate subsidy program.
Several programs ceased operation: North Carolina was slated to end its subsidy program in June 2011; South Carolina closed its subsidy program in July 2010; Arizona closed its subsidy program March 2009. Five others closed in January 2006, replaced by Medicare Part D plans. These include Florida, Kansas, Michigan, Minnesota and North Carolina, plus discount plans in Arkansas and South Carolina. Recent but non-operational programs are listed below, with details in an NCSL Rx Archive Appendix for comparative and historical reference.
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photo credit: PA PACE
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Federal Health Reform: Pharmaceutical Assistance Features
The Affordable Care Act (ACA) law signed by the President in March 2010 includes the following provision:
Closing the Medicare prescription drug “donut hole”. Sec. 1101. [updated November 2013]
For 2013 and 2014 the ACA provides a 52.5 percent discount for enrollee purchases of brand name pharmaceuticals once they reach the Medicare prescription drug “donut hole” and a separate 21 percent discount on generic drugs.
By comparison, in 2011-2012, the ACA provided a 50 percent discount for enrollee purchases of brand name pharmaceuticals once they reach the Medicare prescription drug “donut hole”.
For calendar year 2010 the law provided a $250 rebate for all Medicare Part D enrollees who enter the donut hole in 2010.
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The Medicare "coverage gap" or "donut hole" in 2013 starts at $2,970 and continues up to $6,733.75 measured on a calendar year basis, with a maximum out-of-pocket per person of $4,750.)
The Effect on Certain States: Although Medicare itself is a federal-only program, about 20 states administer an optional subsidy program that wraps-around or adds to the federal benefit. As of 2011, the following 14 states already authorize covering parts or all of this donut hole: Connecticut, Delaware, Illinois, Maine, Maryland, Massachusetts, Nevada, New Jersey, New York, Pennsylvania, Rhode Island, Vermont andWisconsin. The federal $250 annual subsidy increase in 2010 had a small, incremental effect in these states, lowering the state subsidy expenditure for certain individuals. Overall state budget impact in 2011 and beyond will require calculations based on level of use by current state program enrollees, plus estimates of any new enrollees.
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Previous years history: The Medicare Pharmaceutical Benefit in 2010-11: The federal law establishing Medicare prescription drug benefits, often termed "Part D," became fully operational on January 1, 2006. The Part D program, based on a network of private insurers, has had a sweeping impact on most of the state "SPAP" programs and the people they serve. Most states that had been paying for nearly 100 percent of drug subsidies chose to shift some or all of their programs to provide a supplemental or "wrap around" benefit, so that Medicare-eligible enrollees would receive "primary" coverage through a Part D Prescription Drug Plan, regulated and funded under federal law. These states converted their efforts to "secondary, wrap around coverage," most often paying for some or all of the required enrollee share of:
- monthly premiums (up to a "standard" of $30.36 per month for 2009)
- co-insurance or co-payments (can be 25% of purchase price) In 2010 89% of commercial plans had Rx tiers with some costs lower than 25%.
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- annual deductibles ("standard" $310 in 2011)
- the "gap" or "donut hole" (for 2013-2014, starts at $2,970 and continues up to $6,733.75, with a maximum out-of-pocket of$4,750.in 2013) Part D Donut hole calculator, 2011
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The Part D "base beneficiary premium" for 2011 is $32.34 (an increase from $30.36 in 2009) according to the Centers for Medicare and Medicaid Services. The national average monthly bid amount for 2011 is $87.05 (an increase from $84.33 in 2009). Medicare Part D beneficiaries remain in the Donut Hole until their true out of pocket costs exceeds $4,550. The $4,550 does not include the portion of your prescription expenses paid by the insurance carrier or your monthly premiums. 2012 Enrollment in Medicare Part D prescription plans will be open from October 15, 2011 to December 7, 2011.
NOTE: The actual Part D premiums paid by individual beneficiaries equal the base beneficiary premium adjusted by a number of factors. In practice, premiums vary significantly from one Part D plan to another and seldom equal the base beneficiary premium. [CMS Memorandum, 8/14/2008]
The commercial Part D Prescription Drug Plans (PDPs) are allowed considerable variation in their Medicare enrollee charges, so states' roles and contributions also may vary. State Pharmaceutical Assistance Programs Excluded from Medicaid Best Price - The Medicaid statue allows manufacturers participating in the Medicaid Drug Rebate Program to exclude prices to State pharmaceutical assistance programs (SPAPs) from their Medicaid Best Price calculations. This allows these state-only programs to obtain highly favorable prices without affecting the Medicaid price itself or the private sector market. The Centers for Medicare & Medicaid Services has compiled a list of programs that meet the criteria to be considered federally qualified SPAPs. As of March 2012 19 states had 40 CMS-qualified programs. CMS Qualified SPAP Program List - December 3, 2010. | latest edition: CMS: Qualified SPAP Best Price List. March 13, 2012.
State Discount Programs
Beginning in 1999, a gradually growing number of states established prescription drug discount programs, sometimes termed "Rx Buying Clubs" or Discount Cards. These state-sponsored efforts differ from the "SPAPs" or subsidy plans in at least two ways: Discount programs do not use state or federal funds to actually pay for pharmaceuticals. Instead they generally rely on the large-volume purchasing power of the state, to negotiate a sizable discount on a wide selection of prescription products, brand and generics. A majority of such programs have contracted with a management firm such as a pharmaceutical benefit manager (PBM) to handle the negotiations over price. The consumer still pays the resulting discounted price at the pharmacy counter, and the state is not involved in the individual transactions. Unlike most subsidized SPAP programs, there is no comparable federal program or federal regulation affecting these discount plans. Drugs purchased in this way do not count as part of Medicare or Part D calculations. In the past three years, a growing number of states have emphasized serving residents under age 65, the population segment not eligible for Medicare or Part D. In Table 2 below, this report describes about 19 operational state discount programs and another 10 that are not currently operational.
Special, Limited Eligibility SPAPs
Under the legal authority of the federal Medicare law, the definition of SPAP allows certain limited-function state programs to be treated as "Qualified SPAPs." Usually these program only serve individuals with a single diagnosed medical condition, and they often provide benefits beyond just pharmaceuticals. Examples include: California Genetically Handicapped Persons Program, Colorado Ryan White Aids Drug Assistance Program, Idaho IDAGAP Aids Drug Assistance Program, Texas Kidney Health Care Program, and Virginia HIV/Aids SPAP. These single-disease health programs are mentioned or listed as "special" in this report but may not be tallied equally with the major, open-enrollment pharmaceutical assistance programs.
RECENT HISTORY:
2011 Highlights: North Carolina's NCRx subsidy program was scheduled to end June 2011.
2010 Highlights: The South Carolina Gap Assistance Prescription Program for Seniors closed, due to lack of state funds, on July 1, 2010. The Oklahoma Prescription Drug Discount Program ended September 2010. The Hawai'i Rx Plus discount card program for prescription drug medications was discontinued on August 1, 2010.
2009 Highlights: The West Virginia Rx subsidy program became operational. The Arizona subsidy program closed effective March 1, 2009 due to funding issues. Iowa launched a temporary subsidy program in the fall, using court settlement funds; it may close when funds are exhausted. ColoradoSenate Bill 132 repealed Colorado Cares Rx discount program on February 23, 2009.
2008 Highlights: Colorado Cares Rx became operational February. Florida's discount program began in January. WisconsinCare began a Medicare wrap around benefit in January.
2007 Highlights: Colorado enacted a discount program for uninsured residents in January. Delaware extended their subsidy "DPAP" program, allowing applicants to obtain prescription drug coverage through the state while the applicant pursues Medicare Part D enrollment. Florida launched Florida Discount Drug Card effective January 1, 2008. Maine enacted additional Part D state consumer protections for seniors. Maryland now requires a person to enroll in a specific prescription drug plan or Medicare Advantage Plan in order to get state wrap around benefits. Washington reaffirmed a Part D wrap around program begun in mid-2006 and re-launched an expanded discount plan in mid-March. The Wisconsin SeniorCare program, by special act of Congress in May 2007, is allowed to continue using its Pharmacy+ waiver for federal matching funds instead of transferring enrollees into Part D plans. See NCSL's 2007 Prescription Drug Legislation report.
2006 Highlights: Arizona created a benefit for Medicare dual-eligibles to cover 100% of the patient co-payment. California is providing coverage for drugs not included on the Medicare full-benefit dual eligible beneficiary’s prescription drug plan’s formulary and separately enacted a discount program for residents of any age up to 300% FPL or with Rx expenses at least 10 percent of annual income Illinois expanded SPAP coverage to residents with HIV/AIDS. New Jersey and Pennsylvania enacted comprehensive wrap around features for their state subsidy programs. South Carolina redesigned their subsidy program to focus on Medicare gap coverage for expenses over $2,250 annually. Washington launched a first-time subsidy program covering the prescription drug co-payments for over 100,000 dual-eligible low-income elderly and disabled individuals. North Carolina re-created a limited subsidy wrap around program, covering premiums up to $216 /year. Nevada added eligibility for persons with disabilities. Kansas launched a discount plan for residents not eligible for Medicare or other funded assistance. Tennessee created CoverRX, a prescription drug plan that targets uninsured and poor residents, effective January 2, 2007.
As of December, 2009, 30+ states, including Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Hawaii, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Mississippi, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Vermont, Virginia andWashington - had enacted laws or resolutions responding to or adjusting to the Medicare Rx law provisions.
The 2012 Federal Poverty Guidelines, often termed the federal poverty level (FPL), were released January 26, 2012. The guideline for an individual is $11,170; , a $280 increase from the 2011 figure of $10,890. For a married couple or 2-person household the 2012 figure is $15,130, a $420 increase from the 2010 figure of $14,710 . Higher figures apply for Alaska and Hawaii.
SUMMARY OF STATE PHARMACEUTICAL
ASSISTANCE PROGRAMS, 2010 | KEY:  = Operational |  = Not Operational
Dates indicate earliest enacted law. Click on Rx button for details |
MAP 1: Snapshot of State Rx Subsidy Programs (SPAPs), 2011
Table #1: State Subsidy Programs - provides brief details on each of the individual state programs, including citations and web links to state laws where available, year of creation, basic eligibility requirements and contact telephone numbers within each state for further details. Also see further explanations and notes in Recent Major State Actions, below. Table #2: State Discount Programs - Includes state-negotiated price reductions, discount cards and multi-agency purchase arrangements affecting segments of the public. Note that several states have more than one program.
Information is added to these charts when bills are passed. Further details for many states are included below under "Recent Major Actions". Also see NCSL's other research reports: * Pharmaceuticals Overview - recent activities and list of NCSL publications. * Recent Medicaid Prescription Drug Laws, 2001-10 - describes state Medicaid-only laws, not included in this report.
State Subsidy Programs - TABLE 1
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The Senior Benefits Program
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Alaska was one of six states to create a first-time pharmaceutical subsidy program after the enactment of the Medicare Part D benefit. As such, it was intended primarily as a supplemental, wrap around benefit, aimed only at residents aged 65 and over, with incomes up to 175% of Alaska’s special FPL. The law authorized the state to pay premiums and deductibles toward Part D plan costs or toward equivalent insurance premiums. The program was revised, effective August 1, 2007, to provide a cash benefits instead of a Medicare contribution.
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Eligibility, Fees
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The Senior Benefits Program started Aug. 1, 2007, serving residents up to age 65. The new cash benefit program for Alaska enrollees offers three different benefit levels based on annual income -- See table under Benefits, below. The program no longer directly pays Medicare or insurance premiums. Enrollees receive a cash benefit, which many use for pharmaceutical coverage, but may now use for other needed purchases.
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| Disabilities coverage | No coverage for residents under age 65. |
| Benefits |
Senior Benefits Program Gross Annual Income Limit Effective 3/1/2011
| Household: | $250 monthly payment | $175 monthly payment | $125 monthly payment |
| Individual | $10,200 ($850 per month) | $13,600 ($1,134 per month) | $23,800 ($1,984 per month) |
| Married Couple | $13,785 ($1,149 per month) | $18,380 ($1,532 per month) | $32,165 ($2,680 per month) |
Note: From 1/1/06 to 7/31/07 the SeniorCare Prescription Drug Assistance program covered annual premiums and deductible for Medicare Part D or comparable Prescription Drug insurance; average value: $736. Income limits: $20,913 for an individual and $28,053 for a 2-person household. (based on 2005 FPL, as of 1/1/08) |
| Medicare wrap around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. (as of July 1, 2007). The Senior Benefits Program funds spend on Rx should also qualify, but the program itself may not be considered qualified. |
| Est. # of beneficiaries |
7,112 enrolled in the Cash Assistance program ($120/month subsidy) as of 7/1/06. 122 enrolled in Prescription Drug Assistance program as of 7/1/06.
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| State laws |
Subsidy law initially enacted in 2004; Wrap around enacted in HB 106, as Chapter 89, signed August 8, 2005. 2007: SB 4 Extends the Senior Care cash assistance program, but repealed the existing stand-alone Rx wrap around benefit. Signed into law as 1st Special Session. Chapter 1, 8/2/07 |
| Special features & issues | Parts of the SeniorCare program sunset in June 2007 unless extended by the legislature. Annual funding is subject to available funds and legislative appropriations. The separate Senior Care Prescription Drug Benefit Program ended July 2007. |
| Other Rx programs | SeniorCare Cash Assistance can be used for Medicare co-pays, non-covered Rx products, or non-health needs such as housing or food. |
| Contact & online information |
Alaska Department of Health and Social Services: (907) 465-3030; Fax: (907) 465-3068
Senior Benefits Office: 1-888-352-4150 or (907) 352-4150; Fax: 907-357-2561
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Sources: NCSL summary of law Updated: 2/2007; 2/2008; 5/2009; 6/2011
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Medicare Co-payment Program - No longer operational, as of February 1, 2009 -- See Archive
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Genetically Handicapped Persons Program
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This limited eligibility health program serves only persons diagnosed as genetically handicapped.
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| Medicare wrap around | No; It was approved by CMS as a "Qualified SPAP"in 2006, but is no longer qualified as of February 2009. |
| Contact & online information: | Web: http://www.dhcs.ca.gov/services/ghpp/Pages/default.aspx |
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Sources: CMS list of Qualified SPAPs, 2/17/2009 Updated: 3/2011
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Colorado Ryan White Title II ADAP
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This limited eligibility health program serves only persons diagnosed with HIV/AIDs.
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| Benefits | The Ryan White Title II ADAP provides only pharmaceuticals used to treat HIV/AIDs |
| Medicare wrap around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. added by CMS only as of February 2009 |
| Contact & online information: | Web: http://www.careacttarget.org/community/StateProfiles/Colorado.pdf |
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Sources: CMS list of Qualified SPAPs, 2/17/2009 Updated: 3/10/2010
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ConnPACE (Connecticut Pharmaceutical Assistance Contract to the Elderly and the Disabled)
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Connecticut’s long-time subsidy program, ConnPACE, provides wrap around and coordinated benefits between ConnPACE and Medicare Part D, including allowing the state to apply on behalf of current state subsidy enrollees. All enrollees eligible for Medicare must join Part D, with the state covering all premiums, all but $30 of the deductible, and costs above the Part D gap.
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Eligibility, Fees
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State residents 65 and older or disabled age 18-64. For single people, the income limit is $25,100. For married couples, the income limit is $33,800. Must have “no other plan of insurance or assistance” except Medicare Part D. An annual inflation adjustment is tied to Social Security income, to the nearest $100. A $45 annual registration fee is required.
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| Disabilities coverage | Yes; ages 18-64 are eligible, including coverage during the 2-year waiting period for federal Medicare eligibility. |
| Benefits |
As of January 2010, the state pays 100% of the Part D premiums (average $370 year) for members enrolled in a "benchmark" Part D plan, plus all out-of-pocket coinsurance and deductible above the standard ConnPACE $45 annual fee and during the "donut hole" for co-pay costs that exceed $16.25 per prescription. There is no yearly dollar limit on the amount of prescriptions covered. Effective January 2010, ConnPACE requires dispensing of generic medications when available and ‘prior authorization’ of brand-name medications in all Connecticut prescription drug assistance programs.
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| Medicare wrap around | Yes; state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. Authorizes automatic application for low income subsidy benefit and state-initiated enrollment in Part D plans, with the state selecting a Part D plan designated by the Commissioner if a recipient has not done so. |
| Est. # of beneficiaries |
34,057 enrolled (29,665 elderly + 4,392 disabled), 9,919 in Medicare Savings Group and 4,122 in low income subsidy group, as of June 2009.
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| State laws |
1986: Program established by CGL sec 17b-491 et seq. 2005: Public Act 05-280, signed June 27, 2005. |
| Special features & issues |
For the first half of fiscal year 2009, the ConnPACE Program subsidized the cost of 232,421 prescriptions totaling $14,512,019 for an average of 34,514 ConnPACE clients. Approximately thirty percent of prescription drugs paid for during this period were for generic products. In addition to the prescription benefit, the ConnPACE Program subsidized Medicare Part D premiums in the amount of $4.8 million for an average of 33,560 clients with Medicare Part D, which is an increase from last reporting period. Enrollment numbers for the ConnPACE program have continued to decline by approximately 2% this reporting period.
Between July 1, 2008 and December 31, 2008, total expenses in the following categories were: Subsidy: $17,239,768; Fees: $396,693; Rebates: $1,414,163; Premium Payments: $4,225,225; Net Expenditure: $19,654,137. Total paid claims in this period were: 230,459; average cost per claim: $74.80; and average prescription claim per client per month: $1.09.
For the fiscal year July1, 2006-June 30, 2007, there was an average of 42,431 clients that received subsidized costs of $34,365,040 for 990,023 paid prescription claims through the ConnPACE Program, as well as Medicare Part D premium payments totaling $8,248,657. For the six-month period of Jan-Jun 2007, the ConnPACE Program subsidized the cost of 521,660 prescriptions totaling $14,635,235 for an average of 40,702 clients. 44 percent of prescription drugs paid for during this period were for generic products. In addition to the prescription benefit, the ConnPACE Program subsidized Medicare Part D premiums in the amount of $3.9 million for an average of 41,000 clients per month. For comparison, in FY 2006. ConnPACE paid for 995,943 prescriptions costing $95,951,969 annually.
As of January 1, 2010, the Program no longer covers products that are not on a Part D Plan's formulary. The state payment rate “may be made at (A) the lowest price established” by a PDP for a preferred drug in the same class, with the beneficiary responsible for any higher balance; (B) the ConnPACE price if lower than the PDP price. Provides that the applicant or recipient “shall appoint the (state) commissioner” for the purpose of appeals and denials.
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| Other Rx programs | California had a large discount pharmaceutical program serving Medicare enrollees, 2000-2006. A new CA discount plan is scheduled to go into effect in February 2008. See Rx Archive; also CA Children's Services program was certified as a CMS Qualified SPAP. |
| Contact & online information |
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1.) Prescription Drug Assistance Program (DPAP)
2.) Chronic Renal Disease Program (CRDP)
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Delaware’s Rx subsidy program has established a wrap around benefit for Medicare enrollees, to cover premiums, deductibles and drugs purchased in the coverage gap over $2,400, up to a maximum of $2,500 in state funds per calendar year.
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Eligibility
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DPAP: State residents, at least 65 years old or qualified for Social Security Disability benefits. Maximum annual income: up to 200% FPL; individual = $21,780 (2011 rate). Couples are counted as two individuals; $29,420 (2011 rate). In addition, individuals with income over 200% of FPL can qualify if they have prescription costs exceeding 40% of their income. Requires that Medicare benefits be the primary source of benefits for those who are Medicare eligible.
CRDP: Must be diagnosed with End Stage Renal Disease (ESRD), receive dialysis or have had a renal transplant. Individual's gross countable income must be below 300% of the Federal Poverty Level ($32,670 for 2011). |
| Disabilities coverage | Yes; up to age 64 are eligible, including coverage during the 2-year waiting period for federal Medicare eligibility. |
| Benefits |
DPAP will pay for premiums, deductibles and drugs purchased during the Medicare Part D coverage gap. Enrollees must copay $5 or 25% of the cost of each prescription, whichever is greater; the state will not pay any portion of Medicare Part D copayments. Example: An individual with $5,000 in prescription costs annually could receive $370 for premiums, $250 for the annual deductible and up to $1,880 for gap coverage for a total up to $2,500 annually in state funds.
CRDP can provide payment for the unreimbursed cost of medications (prescription and over-the-counter) and nutritional supplements, including the cost of Medicare Part D prescription drug coverage. Transportation may be provided to and from the dialysis unit, transplant center or possible related medical appointments. The State of Delaware provides 100% of the funding for this program, which is administered by the Division of Medicaid & Medical Assistance.
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| Medicare wrap around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. |
| Est. # of beneficiaries |
7,368 enrollees as of 7/2007; an estimated 95% are eligible for Medicare.
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| State laws |
DPAP: 1999: SB 6; benefits and enrollment began in 2000; 2005: SB 18 established the wrap around program, effective January 1, 2006.
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| Special features & issues | The state law restricts covered drugs to those from manufacturers that agree to provide a drug rebate back to the state, based on Medicaid rebate methodology. [NOTE: This rebate requirement is not consistent with the structure of Medicare PDP plans.] May cover some drugs that are excluded from Part D that have received prior authorization, including OTC drugs, benzodiazepines and barbiturates. Funding: Tobacco settlement funds. |
| Other Rx programs | Benefits are coordinated with the private Nemours Foundation prescription benefit; their enrollees are not eligible for DPAP. |
| Contact & online information |
The Division of Medicaid and Medical Assistance; Phone # 1-800-372-2022 or (302) 255-9500; Fax #: (302) 255-4454
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Sources: DPAP program materials 1/2007; NCSL summary of law Updated: 2/2007; 6/2011
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Florida Comprehensive Health Association - No longer operational, as of 2008 -- See Archive
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State Pharmacy Assistance Program - Not operational -- See Archive
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IDAGAP: Idaho AIDS Drug Assistance Program
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The Idaho HIV State Prescription Assistance Program, IDAGAP, pays an eligible client’s Medicare Part D Prescription Drug Plan co-pays and out-of-pocket responsibilities during the coverage gap (donut-hole) period of each plan for all medications covered under the plan.
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Eligibility
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Must be an Idaho resident. Must be HIV positive. Must be eligible for Medicare. Must be enrolled in Medicare Part D Prescription Drug Plan.
Must have income between 151% to 200% (2011 FPL; $16,443.90 to $21,780) of Federal Poverty Level (clients who have incomes 150% FPL or below may qualify for an exception, please call 208-334-6527). Must be participating in an Idaho HIV Medical Case Management Program.
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| Disabilities coverage | Coverage only for people with HIV. |
| Benefits |
IDAGAP works with all Idaho Medicare Part D Plans. IDAGAP uses the formulary of the Medicare Part D plans. Any drug covered by a member's Medicare Drug plan will also be covered by IDAGAP. IDAGAP will pay co-pay and coverage gap amounts until such time as individual reaches the Catastrophic Coverage Portion of the Part D Plan.
IDAGAP will not pay premiums or deductibles. IDAGAP assistance will cease when the Catastrophic Coverage Portion of Part D Plan is reached. Medicare Part D excludible drugs are not covered by IDAGAP.
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| Medicare wrap around | Yes |
| Contact & online information |
Idaho Department of Health and Welfare
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Updated: 6/2011
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1) Illinois Cares Rx Plus (formerly SeniorCare)
2) Illinois Cares Rx Basic (formerly Circuitbreaker)
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A 2005 state law updated three existing state pharmacy assistance programs and created the “No Senior or Person with Disabilities Left Behind” plan as a Medicare wrap around that allows the state to pay premiums, deductibles and gap coverage for up to 241,000 seniors and persons with disabilities. The state also continues coverage programs for non-Medicare adults.
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Eligibility
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Illinois Cares Rx Plus is available to residents age 65 or older, with income up to $27,066 for individuals or $36,560 for a married couple. Illinois Cares Illinois Cares Rx Basic is available up to $27,610 for individual, up to $36,635 for a couple, or up to $45,657 for a qualified household of three. Medicare eligibility is not a requirement.
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| Disabilities coverage | Yes; up to age 64 are eligible, including coverage during the 2-year waiting period for federal Medicare eligibility. |
| Benefits |
A senior with annual income above 150% of federal poverty level (2011; $16,335) with $5,000 in drug expenses could receive 100% of the standard Part D premium and deductible costs, including the 25% co-insurance and gap coverage, totaling about $3,000 in state-paid costs. Coverage includes some drugs that are excluded from federal Medicare coverage such as benzodiazepines. While in the coverage gap members are responsible for 20% of the cost of each drug plus co-pay of $2.50 generic, $6.30 preferred brand, $15 non-preferred brand, and $15 for specialty drugs.
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| Medicare wrap around | Yes; most state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. |
| Est. # of beneficiaries |
247,592 enrollees as of 6/30/06.
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| State laws |
2005: SB 973, signed 6/29/05; effective 1/1/06. IL also had a Pharmacy Plus Medicaid 1115 waiver for residents under 200% FPL.
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| Special features & issues |
State law authorizes auto-assignment; 2005 state enrollees will be automatically enrolled in wrap around features, with one application for all programs; the state will use its preferred drug list where applicable. The state’s Pharmacy Plus 1115 waiver presents special conditions for some enrollees under 200% of FPL (2011; $21,780). IL has two qualified SPAPs for TrOOP calculations. Enrollees with incomes between 200% and 225% of FPL (2011; $21,780 and $24,502.50) are covered only for drugs for treatment of 11 conditions including: Alzheimer’s, arthritis, cancer, diabetes, glaucoma, cardiovascular disease, lung and smoking-related diseases, osteoporosis, Parkinson’s or multiple sclerosis.
All Illinois Cares Rx clients enrolled in a PDP must follow their PDP’s formulary. "Illinois Cares Rx will not cover Part D covered drugs just because they are not on the client’s PDP’s formulary."
People with Original Medicare must apply for Low Income Subsidy (“Extra Help”) and must enroll in one of two Medicare prescription drug plans coordinating with Illinois Cares Rx: PacifiCare Saver Plan or the AARP Medicare Rx of United HealthCare Insurance Company.
Governor’s Administrative Initiatives: (as of January 2008) with SB 5 stalled in the Senate, the Governor has used his executive authority to expand health coverage. The Governor has said the following: “Unfortunately, the Illinois General Assembly failed to act on expanding access to healthcare this session. In the face of that inaction, I am using my executive authority to expand
healthcare to over 500,000 more Illinoisans.” As a result, in the summer of 2007, Gov. Blagojevich announced that he planned to
use his executive authority to implement five initiatives, some of which were part of Illinois Covered (SB5). Included is Assist Primary Care, Rx, Hospital: This program would provide a medical home, prescription drugs and hospital reimbursements for those without access under 100% of the Federal Poverty Level. The Governor has initiated “All Kids Bridge” program and an expansion of “Family Care,” despite having no statutory authorization, and despite the disapproval of the Joint Committee on Administrative Rules of proposed rules attempting to implement the Family Care expansion. A lawsuit is pending challenging the Governor’s authority, but the program has been enrolling families in the meantime. (1/08)
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| Other Rx programs | Discount Program: Illinois Rx Buying Club Member Services. Tel. Toll-free 866-215-3463; (TTY) 866-215-3479
http://www.illinoisrxbuyingclub.com/
Illinois Covered Assist: A state program focused on access to primary care and disease management for those who are very low-income—under 100% of the federal poverty level (FPL) (for 2011 a single person who makes less than $10,890 annually, or a couple making less than $14,710 annually)—and who do not have health insurance or access to current Medicaid programs. Assist will provide access to a medical home through a community health center, a prescription drug benefit, and reimburse hospitals for non-elective in-patient services for Assist beneficiaries.
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| Contact & online information |
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Source: State web site, conversation with IL House. Updated: 1/22/2008; 5/2009; 6/2011
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HoosierRx
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The Hoosier Rx program, founded in 2000, continues in 2007. The current structure provides up to $1,200 per year for seniors age 65 and over with annual incomes up to 150 percent of federal poverty guidelines. The program now offers wrap around benefits for Medicare PDP monthly premiums for plans working with HoosierRx .
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Eligibility
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Must be a resident, age 65 and older, have Medicare Part A and/or Part B, and have a yearly income up to, $16,485 or less for a single person, or $22,095 or less for a married couple living together. (Approximately 151% FPL for 2011) Participants must enroll in one of the Medicare Prescription Drug Plans working with HoosierRx. Participants must apply with the Social Security Administration for extra help from Medicare. HoosierRx can assist those that get partial extra help from Medicare and those denied for Medicare’s extra help due to resources.
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| Disabilities coverage |
Persons with disabilities under age 65 are not eligible for state benefits, as of 11/05.
|
| Benefits |
HoosierRx will help low-income seniors make up the difference between their out-of-pocket costs and the Medicare coverage. For individuals with partial Medicare extra help, HoosierRx "can help pay the monthly Part D premium, up to $70 per month," that is not covered by Medicare, within one of the plans that are working with HoosierRx. For individuals with no Medicare extra help, HoosierRx will pay the monthly premium of one of the nine plans working with HoosierRx: AARP/United Healthcare, CIGNA Healthcare, Coventry AdvantraRx, First Health, Humana, MemberHealth, Prescription Pathway, SilverScript and WellCare. [2008 list]
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| Medicare wrap around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. |
| Est. # of beneficiaries |
2,300 enrollees as of 7/2007 (no non-Medicare, no full dual-eligibles).
|
| State laws |
|
| Special features & issues |
HB 1325 seeks coverage for Medicare deductibles, premiums and drug costs not covered by the federal benefit or federal PDP plans. HoosierRx currently does not require the use of prior authorization, preferred drug lists or mandatory generics. The 2005 law authorizes future coverage up to 200 percent of federal poverty if recommended and approved. HoosierRx has restructured the program and, as of 7/1/06, there is no more wrap around benefit ($250 for co-pays and premium). HoosierRx will now pay a higher premium amount for enrollees instead of using the wrap around benefit. Funding: Money from the Tobacco Settlement Fund has been allotted for this program, it does not receive Indiana General Fund dollars. State legislators will have to approve a budget that includes money allotted to this program for its continuation. [2/08]
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| Other Rx programs | "Rx for Indiana" is a separate "collaborative effort by Gov. Mitch Daniels, local and statewide organizations and the pharmaceutical industry" and is not a subsidy program, but rather a clearinghouse that pulls together all federal, state and private companies that offer discounted drugs and services. Rx for Indiana helps people of all ages find and apply for assistance through pharmaceutical manufacturers for help with brand name drugs. Each company program has different benefits and covers different drugs, providing free or discounted prescription drugs to eligible patients. As of 7/11/06, the Rx for Indiana telephone hotline logged 76,649 calls and the website logged 99,148 hits. 141,592 patients initially qualified for assistance and approximately 81% were eventually matched to a program. |
| Contact & online information |
|
Sources: Hoosier Rx website (3/4/2008); Interview with Governor's office 12/29/2005; HB 1325; HB 1251; IAC Title 405, Art. 6; e-mail and telephone correspondence with Brian Smith, PhRMA. Updated: 7/17/2007, 3/4/2008.
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Iowa Medication Voucher Program
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The Iowa Medication Voucher Program is designed to help lower-income Iowans has been created with funds paid by two pharmaceutical benefit manager companies for alleged consumer fraud violations. Coverage is for hypertension/high blood pressure, diabetes, elevated cholesterol, depression and pregnancy prenatal care medications.
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Eligibility
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Must be an Iowa resident, uninsured, underinsured and in financial need. Eligible residents need to obtain a voucher, present it with a prescription to a participating Iowa pharmacy. A valid prescription good for 90 days must be presented to any participating Iowa pharmacy located in 94 Iowa counties. The consumer will be asked to pay the $3 co-pay; the remaining cost will be paid by the program.
|
| Disabilities coverage | Yes. |
| Benefits |
The Attorney General’s Office awarded $420,000 in settlement funds to the Iowa Prescription Drug Corporation to create the new Iowa Medication Voucher Program. The program will help eligible lower-income Iowans pay for medications for hypertension/high blood pressure, diabetes, elevated cholesterol, depression and pregnancy prenatal care. The program will fund up to 52,000 prescriptions.
|
| Medicare wrap around | No; Not a qualified SPAP; payments do not count toward TrOOP. |
| Special features & issues |
“This program will use $420,000 paid by the companies to provide thousands of lower-income Iowans with a 90-day supply of certain medications for an out-of-pocket cost of just $3 per prescription,” Miller said. “The program will pay the remaining cost of the drugs.”
|
| Other Rx programs | Yes, discount program. The Iowa Prescription Drug Corporation provides coordination among programs; seehttp://www.iowapdc.org. |
| Contact & online information |
To obtain a voucher, Iowans can inquire at their local safety net provider including community health centers, free clinics, family planning clinics and rural health clinics. They may also contact their county board of health. Information is available on the Iowa Prescription Drug Corporation web site at http://www.iowapdc.org/Voucher%20Program.htm. The web link provides a county coordinator or “point of contact” for each county, as well as participating pharmacies and the list of medications available. |
Sources: state Rx web site; also http://www.reducedrugprices.org/read.asp?news=4311 Updated: 10/3/2009
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Kentucky Pharmaceutical Assistance Program - Not yet operational -- See Archive
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Low Cost Drugs for the Elderly and Disabled Program
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Maine has run one or more senior pharmacy assistance programs since 1975. For 2006, the state will offer wrap around benefits for Medicare eligibles, including coverage for premiums, one-half of the deductible and 80% of the coverage gap.
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Eligibility
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For subsidized benefits: Maine residents age 62 and older, or persons with disabilities age 19-61, with annual income of 185% ($20,146 for 2011). Income at or less than 185% FPL (income limit is 25% higher if at least 40% of yearly income is spent on prescription drugs). 185% of 2011 FPL for 1 person is $20,146 and $ 27,213.50 for a 2 person household annually.
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| Disabilities coverage |
Persons with disabilities under age 65 are eligible for state benefits, including coverage during the 2-year waiting period for federal Medicare eligibility.
|
| Benefits |
Wrap around benefits apply to dual eligibles & three levels based on income. Some pharmaceuticals excluded by Medicare will continue to be covered for everyone, as covered in 2005. The state will pay 1/2 of the copay up to $10 - $15 for all dual eligibles. For those in assisted living, the state will pay 100% of all copays. The program has eliminated its asset limit, which will qualify an estimated 9,000 new residents. Those residents for whom the state pays Part B Medicare premiums, the state also will now cover Part D premiums. Copays are covered 50% with a cap of $10; also will cover 100% premium; 50% of deductible; and 80% of the coverage gap (doughnut hole) after a member spends $1000 on eligible prescription drugs, for the 14 categories of treatments specified in state law. Enrollees pay 20% of the coverage gap (over $2,250).
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| Medicare wrap around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. |
| Est. # of beneficiaries |
86,000 (47,876 are Dual Eligible; 38,133 are non-Dual or non-Medicare) 7/2007
|
| State laws |
2005: LB 1325, signed by governor as Chapter 401, 6/17/2005;
State agency given emergency regulatory authority
|
| Special features & issues |
The Department of Human Services has emergency regulatory authority to make further adjustments in benefits and eligibility.
In April '06, a Supplemental Budget was enacted with broad bipartisan support. It includes $10.7 million to ensure that seniors who received prescription drug benefits under MaineCare or the state’s Drugs for the Elderly program would not lose benefits or have to pay more because they were switched to the federal Medicare Part D program. The budget provides extensive ongoing wraparound benefit for Medicare Part D enrollees including both Medicaid dual eligibles and participants in the state elderly low-cost drug program members who are transitioning to Medicare Part D. Also provides for the state purchase of a higher than benchmark plan when a person needs a drug that is not on their plan's formulary and they have an initial denial of an exception for coverage; eliminates all co-payments for persons in all levels of private non-medical institutions (boarding and group homes); and eliminates all co-pays on generics. MSP program-asset test converted 9,000 enrollees.
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| Other Rx programs | Yes, Maine Rx Plus Discount Plan, see below |
| Contact & online information |
|
Sources: Chapter 401 of 2005; Interview with Jude Walsh, Maine Special Asst for RX, 6/2007. Updated: 6/1/2007; 5/2009; 6/2011
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|
Maryland Senior Prescription Drug Assistance Program (SPDAP)
Primary Care Program
|
Maryland has provided some state Rx assistance since 1979. A 2005 law integrated previous state programs by providing Medicare Part D beneficiaries who meet program requirements with a state subsidy authorized for a portion of their Medicare Part D premiums, deductibles, coinsurance payments, and/or copayments and gap coverage. For 2008 the benefit covers up to $25 of the monthly premiums.
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Eligibility
|
Resident for 6 months; at or below 300% FPL ($32,670 for individual, based on 2011 rate) and enrolled in Medicare; but must not be qualified for full federal "extra help" LIS benefit. 2005 members grandfathered in as of 12/31/05.
|
| Disabilities coverage |
Persons with disabilities under age 65 are eligible for state benefits, including coverage during the 2-year waiting period for federal Medicare eligibility.
|
| Benefits |
Successful applicants can receive up to $25 per month ($300 annually) towards the cost of their monthly Medicare Rx or Medicare Advantage Prescription Drug premium. Gap coverage: those eligible can receive a subsidy of up to $1,200 per year for 2010, available through 22 selected companies [ Gap coverage plan list. 2011] SPDAP will pay 95% of the entire drug costs for members while in the coverage gap (if enrolled in a plan that has agreed to offer the coverage gap subsidy). |
| Medicare wrap around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. |
| Est. # of beneficiaries |
35,500 enrollees, as of 7/1/06
|
| State laws |
2005: HB 324 & SB 282, enacted into law May 2005. Authorizes a state subsidy for a portion of their Medicare Part D premiums, deductibles, coinsurance payments, and/or copayments. |
| Special features & issues |
1) The MD discount and subsidy programs of 2005 were folded into the new Primary Care Program. The new Primary Care Program was authorized under Maryland's revised 1115 waiver renewed earlier this year. People enrolled now get prescription drugs and more replacing need for a separate drug program. Maryland also has an Rx discount plan, changed as of 1/1/06 to serve non-Medicare residents, mostly under age 65. 2) The Maryland Pharmacy Program (MPP) Provides services for the following programs: Medicaid, HealthChoice receive most mental drugs; all other drugs are provided by HealthChoice Managed Care Organizations (MCOs); Primary Adult Care (PAC); Family Planning receive only contraceptives and Medicare Part D fully dual eligible Medicare beneficiaries receive most drugs excluded from Medicare Coverage. 3) SPDAP will attempt to coordinate with an individuals' selected Medicare Rx or Medicare Advantage plan for the direct subsidy of the monthly premium, so that enrollees are only billed by the Medicare plan for any premium which exceeds the state’s monthly subsidy of $25. During the 2006 session, the Maryland Legislature passed HB 702, which prohibits the subsidy required under the Senior Prescription Drug Assistance Program from exceeding a specified amount in specified fiscal years. The bill also authorizes a subsidy for copayments and deductibles. |
| Other Rx programs | Yes, see MD Discount plan below |
| Contact & online information |
|
Updated: 2/21/2008; 3/18/2010; 6/2011
Sources: Text of MD 2005 law; Maryland web site 3/18/2010.
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|
Prescription Advantage
|
Massachusetts is one of two states which had a sliding-scale subsidized prescription insurance plan, with no income limit for seniors but with a low-income limit for persons with disabilities. The recently authorized wrap around begun in 2006 makes Medicare Part D the required primary coverage, with state help for deductible, copayment and coverage gap payments. The state was the first to gain approval in 2005 for automatic enrollment in Part D on a random basis.
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Eligibility
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Open to all non-Medicaid seniors age 65 and older of all incomes, and low income persons with disabilities (see below). No asset test. For persons with Medicare, income limit is up to 500% FPL (2011; $54,450); without Medicare, there is no income limit. Prescription Advantage will continue to offer prescription drug insurance coverage for people not eligible for Medicare.
|
| Disabilities coverage |
Persons with disabilities under age 65 with a special maximum income of 188% FPL (2011; $20,473.20) and not more than 40 work hours per month are eligible for state benefits, including coverage during the 2-year waiting period for federal Medicare eligibility.
|
| Benefits |
The state will help pay deductible, copayment and coverage gap payments, with at least six categories of income levels receiving sliding scale financial benefits. Program will pay all Part D copayments after annual out-of-pocket spending reaches $1625 to $3250. The details are not specified in statute. See the full 2011 copayment schedule online. Examples: > Full duals (under 135% FPL; 2011, $14,701.50) will not receive state help. > Between 135%-188% FPL (2011; $14,701.50 - $20,473.20): state pays premiums up to $363.24 annually and copays above $7 generic or $18 brand-name. Out-of pocket expenses capped at $1,300 to $1,440. > Between 188%-225% FPL (2011; $20,473.20 - $24,502.50): State may pay premium share up to $360 annually and copays (only above the "donut hole)" above $12 generic or $30 brand-name. Out of pocket expenses capped at $1,800 annually. (Member Category S3) > Between 225% FPL-300% FPL (2011; $24,502.50 - $32,670): State pays only copays above $12 generic or $30 brand-name. Out of pocket expenses capped at $2,150 annually. > Between 300%-500% FPL (2011; $32,670 - $54,450): State may provide gap coverage after a cap of $2,870.
>
|
| Medicare wrap around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. |
| Est. # of beneficiaries |
Total enrollment in Prescription Advantage is 68,364 as of 7/2007.
Estimated 70,229 eligible for Medicare; 774 are non-Medicare.
|
| State laws |
MGL Ch. 19A, §39 H 4200, §27 signed into law by governor as Chapter 45 of 2005 on 6/30/05. Chapter 175 of 2005 signed into law by governor on 12/30/05 H 5000 of 2006 signed into law by governor on 7/8/06 |
| Special features & issues |
Important Note: effective January 1, 2010, Reductions to the current fiscal year budget for Prescription Advantage require that benefits be changed Prescription Advantage will no longer pay any part of the Medicare Part D plan premium for members in categories S1, S2 and S3. Members in these categories will be responsible for paying the premium invoices from their Medicare Part D plans to ensure that their Medicare Part D coverage continues. Co-payment assistance from Prescription Advantage is only available to members enrolled in a Medicare Part D drug plan or creditable coverage plan.
On August 29, 2005, CMS formally approved the Massachusetts plan to automatically enroll state members into lower cost drug plans, with 5 plans initially approved for this process. Members in “Medicare Advantage” plans (Tufts, Fallon, Harvard Pilgrim and Blue Cross) will not be automatically enrolled. Prescription Advantage will pay for benzodiazepines (excluded from Medicare coverage) but will not cover other drugs excluded from Medicare coverage, such as barbiturates and over-the-counter drugs. The multi-level sliding scale benefits may be examined to simplify the structure. The state-only insurance product for the much smaller pool of 3,000 people may be subject to evaluation as well.
As of January 1, 2009, enrollees with incomes above 188% FPL have significant increases in the cost of some prescription drug copayments, the result of an $11 million cut in the program annonced by the Governor in October '08.
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| Other Rx programs | MassMedLine is a free, confidential pharmaceutical information clearinghouse available to all Massachusetts residents who are seeking information regarding their medications. Using the toll-free help line, 1-866-633-1617, residents can speak to pharmacists and case managers one-on-one to receive personal assistance with pharmacy related questions or finding programs to help with the cost of medications. The program was created in a law (now MGL Chapter 19A, sec. 4C) passed by Sen. Richard Moore in 2000. Website: http://www.massmedline.com | Spanish language site. |
| Contact & online information |
|
Updated: 7/28/2006, 1/20/2009; 5/2009; 6/2011 Sources: presentation by Beth Waldman, MA Medicaid 6/7/2005; CMS statement 8/1/2008; websites of EOEA 12/2005; e-mail correspondence with Randy Garten, Dir. of Prescription Advantage (Exec. Office of Elder Affairs) 7/28/2006.
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"MoRx"; Missouri Rx Plan (replaced Missouri Senior Rx)
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Missouri's 2005 law coordinates state pharmaceutical assistance with MMA. It establishes a newly defined "Missouri RX" subsidy plan for residents with income up to 200% of federal poverty. The Plan "may pay all or some of the deductibles, coinsurance, payments, premiums and copayments" required by Part D; the state may select one or more preferred PDP plans for purposes of the coordination of benefits between the program and the Medicare Part D drug benefit. Beginning 2006, Medicare disabled under 65 were added as eligible.
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Eligibility
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Single Missouri residents with an annual gross household income of $21,660 or less and married Missouri residents with an annual gross household income of $29,140 or less. The old Senior Rx Program members and all dual eligibles (eligible for both Medicare and Medicaid) were automatically enrolled into MoRx. There is no cost for this enrollment, nor is there any additional paperwork. To receive the benefits of the MoRx program, its members must be enrolled in a Medicare Prescription Drug Plan. Non-duals must not be enrolled in Medicaid.
|
| Disabilities coverage |
As of 2006 persons with disabilities under age 65 are eligible for state benefits, once they fully qualify for Medicare after the federal two-year waiting period.
|
| Benefits |
"MoRx pays for 50% of members' out of pocket costs remaining after their Medicare Prescription Drug Plan pays. It pays for 50% of the deductible, 50% of the co-pays before the coverage gap, 50% of the coverage gap, and 50% of the co-pays in the catastrophic coverage."
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| Medicare wrap around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. |
| Est. # of beneficiaries |
172,000 as of 7/2007.
148,348 are dual-eligibles transferred from State Medicaid Program in 2006;
13,297 were members of former program called Missouri Senior Rx (auto-enrolled into Missouri Rx Program)
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| State laws |
2005: SB 539 was signed into law by governor on April 26, 2005.
The old “Senior Rx Plan” is being phased out as soon as the MMA Part D benefit is “fully implemented” as certified by the state.
|
| Special features & issues |
The new Missouri Rx Plan will no longer require an enrollment fee or deductible. It will provide "wrap around" coverage to those who have Medicare A and/or B and are enrolled in a Medicare Rx Prescription Drug plan. Missouri Rx benefits will help pay a percentage of member's out of pocket drug costs remaining after using their Medicare Rx Prescription Drug plan.
2005 enrollees over 150% FPL were expected to transfer to a federal-only benefit plan in 2006, where the costs of benefits will be somewhat similar to their old benefit, with higher premium but 25% copay instead of 40%. On November 1, 2006, Governor Blunt announced expansion to cover residents up to 200% of FPL.
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| Contact & online information |
Missouri Rx,
205 Jefferson Street, Room 1310, Jefferson City, MO 65101
Telephone: 1-800-375-1406 (Toll-free)
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Sources: MO legislative and agency web sites, 12/2005; telephone conversation with Jerry Simons, Executive Director of Missouri Rx Plan. Updated: 11/2/2006; 5/2009
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1.) Big Sky Rx Program
2.) Montana Aids Drug Assistance Program (ADAP)
|
The Montana Big Sky Rx program is designed to help qualified Medicare residents pay for Medicare prescription drug premiums, up to $449 annually. The Montana STD/HIV Section administers the AIDS Drug Assistance Program (also known as ADAP) with funding provided by the Ryan White Part B CARE Act which is administered through the federal Health Resources and Services Administration.
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Eligibility
|
Big Sky Rx: MT Resident, enrolled in Medicare Part D plan, with annual family income less than about $21,780 if single or about $29,420 if married and living together (200% FPL).
ADAP: MT Resident, income less than 330% of the federal poverty level (adjusted gross taxable income). Ineligible for any other assistance programs that would pay for such treatments. |
| Disabilities coverage |
Big Sky Rx: As of 2006 persons with disabilities under age 65 are eligible for state benefits, once they fully qualify for Medicare after the federal two-year waiting period.
ADAP: Provides anti-retrovirals, protease inhibitors, hydroxyurea and pentamidine to qualified individuals at no cost.
|
| Benefits |
Pays up to $37.47 of Medicare Part D premium, for an annual maximum of $449.64.
|
| Medicare wrap around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. |
| Est. # of beneficiaries |
4,031 as of 7/2007.
|
| State laws |
2005: SB 324, signed into law as Chapter 282 of 2005, 5/10/05. |
| Special features & issues |
funded by the tobacco tax revenue. Concerned about growth factor in premiums and other unknowns.
|
| Other Rx programs | Yes, Montana PharmAssist Program, see below |
| Contact & online information |
|
Updated: 7/18/2006; 6/2011
Sources: Website; interview with Bureau Chief; interview with Gayle Shirley, MT Public Information Office 7/18/0206.
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|
1) Nevada Senior Rx
2) Nevada Disability Rx
|
Nevada’s first-in-the-nation state-negotiated Rx insurance subsidy program was one model for the federal Medicare benefit, with its reliance on private insurers. State law enacted in 2005 requires the state to wrap around and coordinate prescription drug services provided by the state with those provided by Medicare, with a goal of maintaining present coverage "to the extent allowed by federal law," as well as maximizing prescription drug coverage and the use of federal funds.
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Eligibility
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Senior Rx is available for residents age 62 or older at the time of application with annual income not more than $25,477 for individual or $33,963 for a married household (effective July 2010).
Disability Rx is available for residents age 18-61 with annual income not more than $25,477 for individual or $33,963 for a married household (figures current as of May 2009).
For those eligible for Medicare, Senior Rx and Disability Rx will help pay for Part D PDP premiums and prescription drug costs after Part D coverage limit is reached. For those not eligible for Medicare, there is no monthly premium, no deductible, drug coverage of $10 for generics and $25 for brand, and an annual coverage limit of $5,100. The State provides assistance with Medicare Part D expenses for members who are eligible for Part D and a cost-sharing benefit for members who are not eligible for Part D.
|
| Disabilities coverage |
Persons with disabilities under age 65 are eligible for state benefits, including coverage during the 2-year waiting period for federal Medicare eligibility.
|
| Benefits |
The state will pay up to $281.52 annually toward annual Part D premiums (100% of $23.46/month for a basic plan) and will provide gap coverage for 100% of the expenditures over $2250 /per year as long as the medications are on the formulary of the member’s Part D plan (a state contribution up to $2,850). Maximum annual state benefit = $5,100.00.
|
| Medicare wrap around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. |
| Est. # of beneficiaries |
5,756 enrolled in Senior Rx as of 7/2007
526 active enrollees in Disability Rx
|
| State laws |
|
| Special features & issues |
The department may waive the eligibility requirements for an individual based on income, disability or extreme financial hardship, certified in a written request. State-only insurance policies remain available for non-Medicare enrollees. For 2006 only there may be a special emergency fund to assist with deductibles. “We want to make sure no one is worse off” said Mike Willden, Director of Health and Human Services.
The legislature requested a departmental report by 11/05 regarding the state amount for premium payments. The state program continues to serve a small population of non-Medicare residents (age 62-64 or with certain disabilities) with an insurance policy product.
[NOTE: A Notice to members on the NV website states that deductibles and copayments will not be paid.]
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| Contact & online information | Senior Rx: Toll Free 1-866-303-6323; http://dhhs.nv.gov/SeniorRx.htm
 Application: http://dhhs.nv.gov/DisabilityRx/Docs/DisabilityRxApp_Interactive.pdf |
Updated: 7/21/2006; 5/2007; 5/2009; 6/2011
Sources: Senior Rx website; text of Nevada law; statement by Department 7/21/2006
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N.H. Pharmaceutical Assistance Program - Not yet operational -- See Archive
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1) PAAD - Pharmaceutical Assistance for the Aged and Disabled
2) Senior Gold
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New Jersey's two operational pharmacy assistance programs served over 200,000 residents in 2005, and celebrated a 30th anniversary since they enacted their original, first-in-the nation senior program in 1975. For 2006, N.J. requires that Medicare eligibles enroll in a Part D plan, with the state covering cost-sharing, deductibles and coverage gap costs in Medicare Part D, as well as premiums for those eligible for PAAD.
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Eligibility
|
Age 65 or older or over 18 and disabled receiving SSDI benefits.
PAAD: Annual income for 2011 up to $24,432 if single (approximately224% of FPL in 2011) and up to $29,956 if married (income limits are increased each January by the same percentage as the Social Security cost-of-living increase). PAAD beneficiaries are also required to enroll in a Medicare Part D Prescription Drug Plan. They will not have to pay premiums, deductibles, or any out-of-pocket costs beyond the regular PAAD $5.00 generic and $7.00 brand co-payments.
Senior Gold: Annual income for 2010 between $24,432 and $34,432 annually if single and between $29,956 and $39,956 if married. Members pay a co-payment of $15 plus 50% of the remaining cost of each covered prescription. Once members reach annual out-of-pocket expenses exceeding $2,000 for a single person or $3,000 for married couples, they pay only a flat $15 co-payment per prescription.
|
| Disabilities coverage |
Persons with disabilities under age 65 are eligible for state benefits, including coverage during the 2-year waiting period for federal Medicare eligibility.
|
| Benefits | NJ will pay all premiums, deductibles and cost-sharing above the $5 or $7 per prescription copayment for PAAD enrollees. A person with $5,000 in annual Rx expenses might receive up to $3,600 in state-funded benefits. Coverage for deductibles, co-insurance, and the coverage gap. |
| Medicare wrap around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. Part D prescription "excluded drugs" are covered by PAAD and Senior Gold. |
| Est. # of beneficiaries |
172,807 enrolled in PAAD as of 7/2007
26,237 enrolled in Senior Gold as of 7/2007
|
| State laws |
|
| Special features & issues |
The state PAAD benefit "shall only be available to cover the beneficiary cost share to in-network pharmacies and for deductible and coverage gap costs associated with enrollment in Medicare Part D for beneficiaries of the PAAD and Senior Gold programs, and for Medicare Part D premium costs for PAAD beneficiaries.
|
| Other Rx programs | No other subsidies or discounts; New Jersey has a Prescription Drug Retail Price Registry to help consumers compare the retail prices charged by many pharmacies for the 150 most-frequently prescribed prescription drugs. |
| Contact & online information | Dept. of Health & Senior Services
Telephone: 609-292-7837; Toll-free in NJ: 1-800-367-6543
PAAD: http://www.state.nj.us/health/seniorbenefits/pbp/paad-home.shtml
Senior Gold: http://www.state.nj.us/health/seniorbenefits/pbp/senior-gold.shtml |
Updated: 10/23/2007, 7/9/2008; 6/2011 Sources: NJ Department web site; text of S 3000, now Chapter 132 of 2005.
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Elderly Pharmaceutical Insurance Coverage (EPIC)
|
New York’s EPIC plan, the nation’s largest state subsidy program, has enacted a wrap around plan that will pay for most drug costs not paid by Medicare, including deductibles, co-insurance or copayments, the gap in coverage above $2,250 and products not covered by Medicare. Enrollees remain responsible for state-established copayments up to $20, fees or deductibles (up to $1,200).
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Eligibility
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New York state seniors age 65 or older with annual income up to $35,000 if single or $50,000 if married (equal to approximately 321% and 340% of FPL in 2011). As of July 1, 2007 a new EPIC Law Requires Medicare Part D Enrollment. There is a sliding scale annual fee from $8 to $300 annually for lower income enrollees; a deductible is required for individuals over $20,000 annual income. Seniors who receive full Medicaid benefits are not eligible for EPIC benefits.
|
| Disabilities coverage |
Persons with disabilities under age 65 are not eligible for state benefits.
|
| Benefits |
Members of the EPIC Fee Plan receive free Medicare Part D coverage because EPIC will pay the monthly premiums (up to $24.45 a month, the average cost of a basic Medicare drug plan) for any Part D plan. The EPIC Deductible plan is available to single seniors with income between $20,001 and $35,000, and married seniors with income between $26,001 and $50,000. Those enrolled pay full price for their prescriptions until they meet an annual deductible which is also based on income. An enrollee with annual income of 200% of FPL with $5,000 in Rx expenses might receive up to $2,900 in gap coverage and partial copayment assistance. Coverage for deductibles, co-payments/coinsurance, and coverage gap (donut hole) claims for drugs that are covered by the Part D plan.
|
| Medicare wrap around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. Part D prescription "excluded drugs" are covered by EPIC. |
| Est. # of beneficiaries |
360,000 enrolled as of 6/2007; of the total, 162,000 are enrolled in a Medicare Part D plan. Of those 162,000, there are approx. 62,000 eligible for full Low Income Subsidy (LIS).
|
| State laws |
2005: S 3668 signed as Chapter 58 on 4/12/05.; 2006: A 9554; sections became law by veto override as Chapter 54, 4/26/06 |
| Special features & issues |
EPIC fee will be waived for those with Medicare Low Income Subsidy. EPIC can be combined with other plans to lower costs at the retail counter. For example, if a PDP requires a $25 copay for a $100 product, EPIC will cover the $25 expense and charge the enrollee only $7 as a copay. Co-branding agreements are being sought with all PDPs willing to meet criteria for seamless coordination with EPIC benefits. The state is using “Intelligent Random Assignment” for all low income Subsidy members. EPIC is considered “creditable drug coverage” at least equal to Part D, so state enrollees will not face a premium penalty if they do not enroll in Part D by May 2006. The complex financial sliding scales of fees and deductibles in EPIC may present special challenges in calculating costs and benefits among private plans. The legislature's FY 2006-07 budget, A 9554, authorizes continuing Medicaid wraparound coverage for duals until January 14, 2007. Separate from EPIC, the NY Medicaid program, in limited circumstances "will provide an additional Medicaid 'wrap around' benefit for drugs not covered by the PDP in addition to the federally excludable drug categories. This will only occur after the prescriber has requested an exception (the first step in an appeal) with the PDP and has received a denial . To assure that the Medicare prescription benefit has been maximized prior to billing NYS Medicaid, the Medicare Verification System (MVS) was developed." [ View description online] |
| Contact & online information |
|
Sources: Presentation by Director Julie Naglieri 9/26/2005; NY EPIC web site; NY law text; interview with Scott Franko, EPIC Program 7/21/2006. Updated: 3/6/2008; 6/2011
|
|
NC Senior Care Program
|
The North Carolina Senior Rx program closed on January 1, 2006, with all enrollees encouraged to join a Part D plan instead. In November 2006, the state launched "NC Rx," to be operational January 1, 2007. The new program offers state subsidized help Part D premiums.
The NC Senior Care Program was certified by CMS (update as of March 13, 2012) to be exempt from Medicaid Best Price as a qualified SPAP.
|
| Eligibility | NC resident age 65 or over, enrolled in Medicare Part D plan that participates in NCRx. No other form of drug coverage that is as good or better than Medicare Part D. Not eligible for the full federal "Extra Help" subsidy for Medicare Part D. Income requirements are at or below $18,952 for individuals and $25,497 for married couples. Combined savings, investments and real estate (other than home, car, and $1,500 per person to cover burial expenses) of $22,092 or less for individuals and $33,139 less for married couples. |
| Disabilities Coverage | Persons with disabilities under age 65 are not eligible for state benefits. |
| Benefits | A senior may receive up to $18 a month or $216 annually toward premiums. |
| Medicare Wrap Around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. |
| Est. # of Beneficiaries | Enrollment opened mid-November, 2006 |
| State Laws | |
| Special Features & Issues |
New program started January 1, 2007. The program may require further legislative authorization and appropriations in 2007.
NCRx is slated to end in June 2011, for more information see link: http://www.seniorpharmassist.org/_resources/Threat.pdf |
| Other Rx Programs | NC HIV SPAP (a "qualified SPAP" meeting CMS criteria (update as of March 13, 2012) |
| Contact & Online Information | For consumer assistance, call 1-888-488-6279
Web site: www.ncrx.gov |
|
|
1.) Senior Prescription Drug Assistance Program - Never became operational -- See Archive
2.) CAREAssist: AIDS drug assistance program (ADAP)
|
| The CAREAssist program (Oregon's AIDS Drug Assistance Program) provides people living with HIV or AIDS with assistance to pay for medical care expenses. |
| Eligibility | New enrollees at less than 200% ($1,815 for an individual; $2,452 for a couple, for 2011) FPL (not Medicaid/OHP or VA eligible). |
| Benefits | CAREAssist pays full Rx, co-pays, deductibles, insurance premiums, lab procedure co-pays, and other service co-pays at an annual capped amount. |
| Contact and Online Information |
CAREAssist
Phone (971) 673-0144; 1-800-805-2313
Application: http://dhsresources.hr.state.or.us/WORD_DOCS/DE8406.doc |
|
|
1.) Pharmaceutical Assistance Contract for the Elderly (PACE)
2.) PACE Needs Enhancement Tier (PACENET)
3.) Chronic Renal Disease Program and General Assistance Program
4.) Special Pharmaceutical Benefits Program
|
The Pennsylvania subsidy plan has operated since 1985 and will continue in 2006. PACE Plus Medicare is a new program designed toconvert the state’s drug assistance plans into a supplemental program that will “wrap around” private Medicare Part D prescription drug plans. It gives the state the authority to act as a representative for its PACE and PACENET enrollees in matters relating to Medicare Part D, enrolling beneficiaries into Medicare Part D plans, pay Part D premiums, and apply for low-income subsidies on behalf of PACE and PACENET members.
|
State law(s)
|
1985 law 2006: SB 1188, signed as Act 111 on 7/7/06. |
Eligibility
|
Pennsylvania residents age 65 and older, for at least 90 days prior to the date of application, and not enrolled in the Department of Public Welfare's Medicaid prescription benefit.
PACE: A single person's annual income up to $14,500; a married couple's combined annual income up to $17,70.
PACENET: A single person's annual income can be between $14,500 and $23,500; a married couple's combined total income can be between $17,700 and $31,500.
CRDP: Currently on dialysis or received a renal transplant. Must be within 0% - 300% of the Federal Poverty Guidelines. Must be in End Stage Renal Disease. Must be a US Citizen or Legal Alien. Must be a resident of PA for at least 90 days - or show intent to be a PA resident.
SPBP HIV/AIDS: Must be a resident of Pennsylvania, have a gross annual income of less than or equal to 337% of the Federal Poverty Level (FPL), and have a diagnosis of HIV/AIDS to qualify for the program.
SPBP Mental Health: Pennsylvania resident, gross income limit up to $35,000 per year for individuals and $35,000 gross income per year for families, plus an allowance of $2,893 for each additional family member. Must have a medical need with a DSM diagnosis of schizophrenia. The prescription must include the DSM diagnosis, the ICD-9-CM diagnosis code number and the physician must sign and date the certification on the application.
|
Disabilities coverage
|
Persons with disabilities under age 65 are not eligible for these state benefits.
|
Benefits
|
The Legislature made changes to law in order for PACE to pay premiums; as the wraparound portion of PACE and PACENET. PACE members pay an average of 14% of total drug costs, which average $2,400 per person annually. For the first nine months of 2006, PACE members paid a co-payment of $6 for generic and $9 for brand-name drugs. PACENET members pay a co-payment of $8 for generic and $15 for brand-name drugs. The new PACE Plus Medicare program will drop the $40 monthly deductible PACENET enrollees pay in favor of a monthly premium, not to exceed the regional benchmark Part D premium of $32.54. The premium will be treated like a deductible and will be collected by pharmacies. About 15,000 PACENET enrollees who do not normally use drugs may face higher costs under this new plan design.
Donut Hole: Program will fill in coverage gaps so that members can continue to get prescriptions by only paying the PACE co-pays; no more than $6 for each generic prescription and no more than $9 for each brand name prescription for a 30 day supply.
SPBP HIV/AIDS: Provides pharmaceutical assistance and specific lab services to low to moderate income individuals living with a diagnosis of HIV/AIDS who are not eligible for pharmacy services under the Medical Assistance (MA) Program.
SPBP Mental Health: Provides service to individuals with schizophrenia who do not respond to first-line drug therapies and who are not eligible for pharmaceutical coverage under the MA Program.
|
| Medicare wrap around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. Part D prescription "excluded drugs" are covered, only for Benzodiazepines, barbiturates, vitamins and weight loss. |
| Emergency gap coverage - 2006 | Executive action allowed state Medicaid to pay the excess copay, the amount individuals are inappropriately charged over the low-income subsidy level. State expects to spend no more than $2 million during January and expects to be reimbursed by CMS and the plans for the costs. |
Special features
|
The program allows members to be also enrolled in another prescription or heath plan. PACE is “creditable coverage,” meaning that enrollees who choose not to enroll in a Part D plan by May 15, 2005 will not face a premium penalty later. PA law requires a manufacturer rebate for PACE purchases. For 2006 the program is "intending to collect 'best price' rebates on any claim that PACE pays in full during the deductible period, coverage cap, or off formulary. On all other claims PACE will not be seeking a rebate." (4/4/06). Enrollment in Part D is optional for new PACE Plus Medicare. There will be six selected stand-alone Part D plans for the new auto-assign/auto-enroll process. Auto-assignment began on 7/19/06 and auto-enrollment began on 8/8/06. Enrollments were effective on 9/1/06.
In September 2005, Pennsylvania launched the Independent Drug Information Service in 28 counties, including Allegheny, Beaver and Lawrence, aiming to educate doctors about prescription drug benefits by helping them choose the most clinically appropriate medications for their patients. The goal is to improve the prescription process by informing physicians on various drugs, rather than promoting a certain product. The concept was designed by Dr. Jerry Avorn, a professor of medicine at Harvard University. In conjunction with the PACE program, eight specially trained drug information consultants began meeting with doctors at their practices last year. The consultants visit 25 to 30 doctors a month, mainly physicians whose prescribing habits don't mesh with their peers. The doctors are given evidence-based information on various types of drugs and brand-name alternatives are discussed. As of April 2006 there have been 2,300 visits to physicians and about 420 educational sessions.
|
Requirements & Limits
|
Medicaid enrollees and public Retired Employees Health Plan (REHP) enrollees are not allowed to enroll in PACE or PACENET.
|
SPAP legal status
|
Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 7/2007
|
Est. # of beneficiaries
|
311,000 total
184,049 in PACE as of 7/2007 (an estimated 80,000 eligible for extra help in 2006)
127,881 in PACENET as of 7/2007.
|
Funding source
|
PA State Lottery and tobacco settlement funds; also a small part covered by general funds.
|
future issues
|
State law on PACE was changed in July 2006 by the legislature's SB 1188 of 2006 (Act 111 of '06). The state discussed choosing to have an “unqualified SPAP” by selecting a preferred plan or plans. State will base premium assistance from average of standard PA plans. It was anticipated that, because of the new PACE Plus Medicare program, the PACE and PACENET programs will be expanded by 35 percent to cover an additional 120,000 enrollees by 2007. |
Contact & information
Web site
|
PA Dept. of Aging
555 Walnut Street, 5th Floor, Harrisburg, PA 17101
Residents toll-free 1-800-225-7223 or (717) 787-7313; FAX: 717-772-2730
The Chronic Renal Disease Program - The Pennsylvania Department of Health – Division of Child and Adult Services
Phone 1-800-225-7223; Fax (717) 651-3664
Special Pharmaceutical Benefits Program – Pennsylvania Department of Public Welfare
SPBP Customer Service Line 1-800-922-9384
|
Updated: 6/2007, 2/2008; 6/2011
Sources: Director Tom Snedden presentation and statements 8/18/05; 4/4/06; 5/8/06; PACE web site, 11/27/05; Theresa Brown, PA Dept of Aging, 12/2005.
|
|
RIPAE - Rhode Island Pharmaceutical Assistance for the Elderly
|
The currently operational RIPAE subsidy program pays a portion of the cost of prescription drugs for about 16 medical conditions, ranging from 15 to 60% of the price. All other drugs are available at a 15% discount. RIPAE members can receive help in paying for their Part Dmedications during the plan deductable or coverage gap phases, if applicable.
|
Eligibility
|
Minimum age is 65, or between 55 and 64 if disabled and receiving Social Security Disability Income (SSDI) payments. There are three levels of coverage, based on annual income: 15% discount if over 65 or age 55-64 and disabled with an annual income of $26,280 - $45,991 (individual) and $32,852 - $52,561 (couple); 30% discount for over 65 with an annual income $20,935 - $26,279 (individual) and $26,171 - $32,851 (couple); and 60% discount for over 65 with an annual income up to $20,934 (individual) and up to $26,170(couple). (income limits are effective as of 2010)
|
| Disabilities coverage |
Disabled individuals under age 55 are not eligible for state benefits.
|
| Benefits |
The details of Part D wrap around and coordination of benefits were not available as of the publication date of this report. The RIPAE program pays "a portion of the cost of prescriptions used to treat Alzheimer’s disease, arthritis, diabetes (including insulin and syringes for insulin injections), heart problems, depression, anti-infectives, Parkinson’s disease, high blood pressure, cancer, urinary incontinence, circulatory insufficiency, high cholesterol, asthma and chronic respiratory conditions, osteoporosis, glaucoma, and prescription vitamins and mineral supplements for renal patients for eligible Rhode Island residents 65 and older. RIPAE also offers limited coverage for the cost of injectable prescription drugs used to treat multiple sclerosis. " RIPAE enrollees can purchase all other FDA-approved "Category B" prescriptions (except for those used to treat cosmetic conditions) at a 15% discount. RIPAE members can receive help in paying for their Part D medications during the plan deductable or coverage gap phases, if applicable.
|
| Medicare wrap around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. |
| Est. # of beneficiaries |
18,469 enrollees as of 3/2009; Filed claims = 134,000 annually.
|
| State laws |
|
| Special features & issues |
Excludes income spent on medical expenses if greater than 3% of total income. Residents between 55 and 64 who are receiving SSDI payments can purchase medications at a 15% discount. There is no state co-payment for these medications. Income limits for SSDI recipients are $41,136 for individuals and $47,012 for a married couple. The details of wrap around and coordination of benefits may require legislative and executive branch action and approval in 2006. Income limits will increase each year to reflect the annual Cost-of-Living Adjustment (COLA) as determined by the Social Security Administration. For 2009 the Governor's budget proposes cutbacks in the program; these changes are not yet enacted. News article: RI: Carcieri's budget includes cut in prescription drug aid for the elderly , 3/19/09. |
| Other Rx programs | Yes, RI Prescription Drug Discount for the Uninsured, see below |
| Contact & online information |
|
Updated: 5/1/2009; 6/2011 Sources: RIPAE website; RI Legislative website 5/15/2009
| TENNESSEE | Cover Rx (subsidy) |
| CoverRx is a statewide pharmaceutical assistance program for adults ages 19-64 lacking pharmacy coverage, providing a sliding scale subsidy for generics for residents with incomes up to 250 percent of federal poverty. Selected brand name products may be available at a discount. |
| Eligibility and charges |
State residents, ages 19-64 with household income up to 250% FPL (2011; $27,225) [Cover Rx Income Guidelines]. Must be U.S. citizen or qualified legal alien, residing in the state at least six months. Must not have prescription drug coverage, including Medicare, TennCare/Medicaid or employer sponsored drug coverage. There is no enrollment fee or premium; copayments are required for each purchase. Operational as of 1/2/2007. "Due to high demand," CoverRx enrollment was temporarily suspended in February 2007, but reopened in April 2007 for 3,500 on a waiting list and new applicants. |
| Disabilities coverage | No, only if ages 19-64 and otherwise qualified. |
| Benefits |
Approximately 250 generic drugs are available, with a three-tier copayment based on income.
90-day supply - below 100% FPL (2011; $10,890) is $3; up to 149% FPL (2011; $16,226) is $10; 150% to 250% FPL ($16,335 to $27,225) is $16.
30-day supply - below 100% FPL (2011; $10,890) is $3; up to 149% FPL (2011; $16,226) is $5; 150% to 250% FPL ($16,335 to $27,225) is $8. All other drugs (including available brand names) are available at a flat discount, defined as "lesser of Discount, 'Maximum Allowable Cost' or 'usual and customary' price; no prior authorization program for drugs off formulary . Online [ Rx product list; formulary] |
| Medicare wrap around | No, Medicare Part D eligibles and enrollees are disqualified. |
| Est. # of beneficiaries | 47,140 as of 9/2011 |
| State laws | 2006: Signed 6/12/06 |
| Special features & issues | Cover Rx combines features of a discount-only program with features of a subsidy (SPAP) program. It is part of a 5-part health program called "Cover Tennessee." The formulary list is administered by ExpressScripts. |
| Other Rx programs | Yes. Cover Rx -Discounts, see below |
| Contact & online information |
|
Sources: CoverTN web site, accessed 4/12/07; NCSL summary of law Updated: 9/13/2007; 5/2009; 6/2011
|
|
1.) Kidney Health Care Program (KHC)
2.) HIV SPAP
|
The Kidney Health Care Program is limited to individuals diagnosed with end-stage renal disease; the HIV SPAP Program helps HIV-positive individuals with their out-of-pocket costs associated with Medicare Part D prescription drug plans, including co-payments, deductibles, coinsurance, and during the coverage gap (the “donut hole”). The programs are listed primarily because they are recognized by CMS as "qualified SPAPs."
|
Eligibility
|
KHC: State residency and ESRD must be certified; applicant must be receiving a regular course of chronic renal dialysis treatments or have received a kidney transplant; an application for benefits must be submitted through a Medicare approved hospital, VA facility, or KHC approved facility; an application for ESRD benefits must be filed with Medicare; and KHC-established financial criteria must be met.
HIV SPAP: Must be a Texas resident, eligible for the Texas HIV Medication Program and all other THMP eligibility requirements; have an adjusted gross income less than 200% of the federal poverty level ($20,800 for a single person or $28,000 for a married couple in 2008); be eligible for Medicare; enrolled in a Medicare Part D Prescription Drug Plan; and denied the full Low Income Subsidy or approved for the partial subsidy for prescription drug assistance by the Social Security Administration.
|
| Benefits |
KHC: Provides assistance to Texas residents with a diagnosis of End-Stage Renal Disease (ESRD) from a licensed physician, receiving regular dialysis treatments or has received a kidney transplant, can NOT get Medicaid medical, drug, or travel benefits, and has an income of less than $60,000 per year. The KHC program services include: prescription drug benefits, coordination of benefits and premium reimbursements for Medicare Part D Prescription Drug Program, co-insurance for immunosuppressive drugs covered under Medicare Part B, limited travel reimbursement and certain medical expenses. KHC will pay for up to four (4) prescriptions per month for Part B and D coverage. The drug must be on the KHC drug list andthe Medicare Part D plan’s drug list.
HIV SPAP: The SPAP will pay for covered medications up to a maximum annual allowable amount per enrollee. For
2009 the annual allowable amount is $10,995.The SPAP will pay the out-of-pocket costs during the coverage gap (donut hole), for covered medications.
|
| Medicare wrap around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. |
| Est. # of beneficiaries | KHC: 18,877 as of 7/2007. |
| Special features & issues | Beginning on January 1, 2008, KHC will not reimburse enrollees directly for premium payments. The Part D plans will bill KHC for enrollee premiums. See Regulations: 25 TAC §§61.1 – 61.14 of 2005. |
| Contact & online information | Kidney Health Care Program, Texas Department of State Health Services
P.O. Box 149347, Austin, Texas 78714-9347
Texas Department of State Health Services – HIV/STD Program
|
Sources: NCSL summary of program; Kidney program website. Updated: 2/22/2008; 6/2011
|
|
VPharm, VHAP-Pharmacy, VScript
|
VPharm is a recent program that is a hybrid of the previously operating Vermont Rx assistance programs, which first started in 1989. The wrap around features allow the state to pay enrollee out-of-pocket costs; it started January 1, 2006.
|
Eligibility
|
Residents on Medicare or SSDI with a 2010 annual income up to $22,164 for individuals and up to $29,820 for couples. For those between 150% and 225% FPL (2010; $16,245 to $24,367.5), only maintenance drugs in those classes are covered. For those on Medicaid and those below 150% FPL (2010; $16,245), both maintenance and acute drugs are covered. VPharm also covers most cost-sharing that is not paid by the federal Medicare Part D low-income subsidy.
|
| Disabilities coverage |
Persons with disabilities under age 65 are eligible for state benefits, including coverage during the 2-year waiting period for federal Medicare eligibility. Must be eligible for Medicare Part A or enrolled in Medicare Part B.
|
| Benefits |
VPharm assists Vermonters who are enrolled in Medicare Part D with paying for prescription medicines. This includes people age 65 and older as well as people of all ages with disabilities. For Medicare-Medicaid dual eligibles, it covers all non-part D drugs. For pharmaceuticals-only benefit, will cover all costs of premium, copay, coinsurance and doughnut hole. Those above the dual eligible income cutoff pay on a sliding scale: 150-175% FPL (2010; $16,245 - $18,952.50) pay $17 VPharm premium; 175-200% FPL (2010;$18,952.50 - $21,660) pay $23 premium; 200-225% FPL (2010; $21,660 - $24,367.50) pay $50 premium. VPharm pays all other costs.
- VHAP-Pharmacy helps Vermonters age 65 and older and people with disabilities who are not enrolled in Medicare pay for eye exams and prescription medicines for short-term and long-term medical problems and includes an affordable monthly premium.
- VScript helps Vermonters age 65 and older and people of all ages with disabilities who are not enrolled in Medicare pay for prescription medicines for long-term medical problems. There is also an affordable monthly premium based on your income.
|
| Medicare wrap around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. |
| Est. # of beneficiaries |
Total = 30,000 (Rx + duals)
14,285 enrolled in VPharm as of 7/2007.
|
| State laws |
2005: H 516
|
| Special features & issues |
Programs operate within Green Mountain Care, which "is a family of low-cost and free health coverage programs for uninsured Vermonters."
VPharm Program started January 1, 2006. Received CMS approval to do auto assignment of duals into a few commercial Part D plans. Covers all costs (other than VPharm premium) for Rx only benefit side. The state has additional pharmaceutical assistance programs for non-Medicare populations.
VHAP-Pharmacy, VScript and VScript expanded will continue only for those who are 65 and older or who receive disability benefits from Social Security, but who are not eligible for Medicare. VPharm was created as a wraparound for Part D.
[Source: "State Part D Wrap Around for SPAP Beneficiaries," Report by the Centers for Medicare and Medicaid Services, April 5, 2006.]
|
| Other Rx programs | Yes. Healthy Vermonters, see below |
| Contact & online information |
|
Sources: VT Legislative website; text of H 516; Interview with program & legislative staff, 2/08; 11/20/08 Updated: 12/19/2005; 11/20/2008; 5/2009; 6/2011
|
|
Virginia Department of Health SPAP
|
The Virginia SPAP pays Medicare Part D costs for people diagnosed with HIV/AIDS who get medicines through the Virginia AIDS Drug Assistance Program (ADAP).
|
Eligibility
|
Must be Medicare eligible, diagnosed with HIV/AIDS and enrolled in both ADAP and a Medicare Part D plan. Must not be eligible for Medicaid. Yearly family income cannot be more than 400% (2011; $43,560) of the federal poverty level (FPL).
|
| Disabilities coverage | No, unless diagnosed with HIV/AIDS and enrolled in both ADAP and a Medicare Part D plan. |
| Benefits | As of 1/07 the SPAP will help pay for monthly Part D premiums, and "will soon pay all medication copays/coinsurance, deductibles and medication costs during gaps in coverage." |
| Medicare wrap around | Yes; all state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. |
| Est. # of beneficiaries |
100 enrollees as of 7/2007.
|
| Special features & issues | Current enrollees will be notified when the program will start paying for copays/coinsurance, deductibles and gaps in coverage. "When SPAP starts covering copays, you will be able to use your Medicare Part D plan to get all your medicines (including medicines you currently receive from ADAP). Participants can use a retail or mail order pharmacy to fill all medicines covered by a Part D plan."
Patient Services Incorporated (PSI)
manages the SPAP under a contract with the Virginia Department of Health effective 2008. |
| Other Rx programs | no. |
| Contact & online information | Virginia SPAP
P.O Box 2448, Richmond, VA 23218;
Hotline: (800) 533-4148 FAX: (804) 864-8050
Web: http://www.vdh.state.va.us/Epidemiology/DiseasePrevention/spap.htm [2/08]
Fact sheet : http://www.vdh.state.va.us/Epidemiology/DiseasePrevention/documents/SPAP%20Fact%20Sheet%20June%202007%20Update.pdf [2/08] |
Sources: state web site Updated: 2/2008; 6/2011
|
|
Medicare Copayment plan - No longer operational, funded through June 30, 2007 -- See Archive
|
|
|
West Virginia Rx
|
West Virginia Rx is a program that provides prescription drugs at no cost to patients who are uninsured, between the ages of 18 and 65.
|
Eligibility
|
Must be a resident of West Virginia who is uninsured, age 18 to 65 years, with annual income up to 200% of federal poverty (individual $21,780/year; two persons $29,420/year for 2011).
A $30 enrollment fee is required but may be waived in cases of hardship.
|
| Disabilities coverage |
Yes, if age and income requirements are met.
|
| Benefits |
|
| Medicare wrap around | No, Medicare Part D eligibles and enrollees are disqualified unless they are under age 65 and uninsured. |
| Est. # of beneficiaries |
n/a
|
| Special features & issues |
West Virginia Rx is sponsored by the office of West Virginia Governor Joe Manchin, the Heinz Family Philanthropies and the Claude Worthington Benedum Foundation. Two of the state’s premier free health care clinics, West Virginia Health Right in Charleston and Beckley Health Right, are administering the project.
|
| Other Rx programs |
WV Pharmaceutical Discount Program and Golden Mountaineer Discount Program
|
| Contact & online information |
|
Updated: 5/7/2009; 6/2011 Source: WV web site
|
|
1.) SeniorCare Rx
2.) Chronic Renal Disease Program
3.) Cystic Fibrosis Program
4.) Hemophilia Home Care
|  |
A senior subsidy program serving residents up to 240% of federal poverty. Includes a voluntary Medicare Part D wrap around benefit was negotiated but not agreed to in 2006. SeniorCare Rx does not offer any "donut-hole" coverage for those up to about 240% FPL, but does have sliding scale cost-sharing as income rises. The WI federal "Pharmacy Plus" Medicaid waiver, was extended to December 31, 2009.
|
Eligibility
|
SeniorCare Rx: Wisconsin residents age 65 or older with a 2011 annual income up to 160% FPL ($17,424, individual; $23,563 couple) for Level 1 benefits; 160% - 200% FPL ($17,425 - $21,780 individual; $23,537 - $29,420 couple) for Level 2a benefits; 200% - 240% ($21,781 - $26,136 individual; $29,421 - $35,304 couple) for Level 2b benefits; and more than 240% FPL ($26,137+ individual; $35,305+ couple) for Level 3 benefits. If over $24,961 per individual (level 3), the enrollee must "spend down" below that amount. There is no asset limit. A $30 annual enrollment fee per person is required. Program participants are subject to certain annual out-of-pocket expense requirements depending on their annual income.
Chronic Renal Disease Program: Wisconsin residents diagnosed as having end-stage renal disease, paying Medicare part b premiums if eligible for Medicare.
Cystic Fibrosis Program: Wisconsin resident diagnosed by the medical director of a cystic fibrosis treatment center as having cystic fibrosis and be 18 years of age or older.
Hemophilia Home Care: Wisconsin resident diagnosed by a comprehensive hemophilia treatment center as having hemophilia. The participant must also enter into a written agreement with a comprehensive hemophilia treatment center for compliance with a maintenance program.
|
| Disabilities coverage |
Excludes the disabled, whether or not eligible for Medicare.
|
| Benefits |
SeniorCare Rx: An individual whose gross annual income is greater than 160% of the current FPL and less than or equal to 200% of the current FPL (level 2a) will have an annual deductible of $500, meaning participant(s) pay for the first $500 of covered prescription drug costs at participating pharmacies each year. After the $500 deductible is met, covered prescription drugs can be purchased at the co-payment amounts for the remainder of the annual benefit period. The co-payments are $5 for each covered generic prescription drug, and $15 for each covered brand name prescription drug.
Chronic Renal Disease Program: Inpatient and outpatient dialysis and transplant treatments. One pre-transplant dental examination, and X-rays. Kidney donor transplant-related medical services. Certain prescription medications. Certain home supplies. Certain laboratory and X-ray services.
Cystic Fibrosis Program: Inpatient and outpatient services directly related to the disease. Certain physician services. Certain laboratory and x-ray services. Certain prescription medications. Certain home supplies.
Hemophilia Home Care: Eligible to receive services for blood derivatives and supplies necessary for home infusion. A $10 participant co-pay will be applied to each prescription and blood product covered by the program.
|
| Medicare wrap around | Yes, but only for enrollees above 200% of FPL; these state benefits are provided in coordination with federal Medicare. Qualified SPAP; payments count toward TrOOP. |
| Est. # of beneficiaries |
111,267 enrolled, as of 7/16/06 (includes 79,523 waiver and 31,744 non-waiver enrollees)
|
| State laws |
|
| Special features & issues |
Individuals with prescription drug coverage under other health plans are eligible to enroll in SeniorCare. If an enrollee already has a health insurance plan, SeniorCare will coordinate benefit coverage with that plan. The Department of Health and Family Services has determined that the prescription drug coverage offered by SeniorCare is "creditable coverage." This means that SeniorCare coverage, on average, is as good as the standard Medicare drug coverage. "Non-risk based lump sum approach. Those in spend down are not eligible for the wraparound benefit; will not cover drugs not already covered by Part D or drugs not included in PDP formulary."
[Source: "State Part D Wrap Around for SPAP Beneficiaries," Report by the Centers for Medicare and Medicaid Services, April 5, 2006.]
|
| Other Rx programs | Badger Rx gold provides a retail counter discount for any resident that lacks prescription drug insurance coverage if the person enrolls and pays the annual enrollment fee. |
| Contact & online information |
The help desk can be reached (Toll-free) at 1-866-908-1363 between the hours of 8:30 AM — 4:30 PM Monday through Friday.
|
Sources: SeniorCare website; e-mail correspondence with WI DHFS; WI Admin. Code. Updated: 6/6/2010; 6/2011
|
|
Prescription Assistance Program
|
Wyoming's state-only coverage continues for those under 100% FPL and not qualified for Medicare. Pharmaceutical coverage of Medicare Part D eligibles was discontinued May 31, 2006.
|
Eligibility
|
Any resident with annual income up to 100% FPL ($10,890 individual; $14,710, 2 person household) with no other Rx coverage (includes Medicare Part D). Also has a vehicle value limit of $15,000 and cash asset maximum limit of $2,500. No age restriction. Medicare Part D enrollees were disqualified as of June 1, 2006.
|
| Disabilities coverage | The state will continue to include persons with disabilities with the same income and asset requirement as others. |
| Benefits | The state program will cover up to three prescriptions per month, requiring enrollee copay of $25 brand, or $10 generic products. Uses state Medicaid preferred drug list: http://www.wyequalitycare.org/ |
| Medicare wrap around |
No, Medicare Part D eligibles and enrollees are disqualified unless they are under age 65 and uninsured.
|
| Est. # of beneficiaries |
269 enrollees, as of 8/1/06.
|
| State laws |
|
| Special features & issues |
Also covers prescribed oxygen.
Agency officials are "waiting to see what legislature will do with the program, since it currently has a capped enrollment." As of 7/1/06, the program reopened to new enrollment for people earning less than the federal poverty level. The program is not limited by age or disability.
|
| Contact & online information |
Prescription Assistance Program
Pharmacist Consultant - Telephone 307-777-8699.
|
Updated: 12/19/05; 7/31/06; 6/2011
Source: WY Pharmacist Consultant 307-777-8699 alewis@state.wy.us
STATE DISCOUNT PROGRAMS - TABLE 2
In almost half the states, programs created in the past six years provide for a reduced or discounted retail price for eligible participants, but do not provide a state subsidy for the purchase of prescription drugs. In several states, discount programs have been added to or integrated with subsidy programs - see related details in chart one above. In several other states, such as Arkansas, Colorado, Connecticut, Massachusetts and Oklahoma, enacted program features have not yet been established or implemented.
Other cost-related programs and proposals, including multi-state projects, inter-agency purchasing, coordination of industry charity programs, evaluating pharmaceutical advertising, and regulating commercial discount cards, are listed separately - see NCSL Pharmaceutical Reports menu page.
|
|
CoppeRx Card
|
The CoppeRx Card program was launched in 2003 as a discount plan aimed at seniors and disabled; in 2005 eligibility was expanded to include all residents.
|
Eligibility
|
All Arizona state residents are eligible. There is no enrollment fee for CoppeRX.
|
| Disabilities coverage |
Yes, any state resident is included in the discount program.
|
| Benefits | After expanding the program, participating pharmacies will offer discounted prices negotiated by the state with manufacturers and pharmacies for those who present the card upon picking up any prescriptions. |
| Medicare wrap around | No; Not a qualified SPAP; payments do not count toward TrOOP. |
| Est. # of beneficiaries | 1,000,057 Arizona residents are enrolled in the program. Approximately 59,000 people use the card each month. |
| State laws | Governor Janet Napolitano announced the program in January 2004http://www.rxamerica.com/media/pdf/az_press_copperx.pdf (hyperlink to news release from Governor office). |
| Special features & issues | Hundreds of Arizona pharmacies present the card upon picking up any prescription drug medications. It is intended to serve those without prescription drug coverage and to fill gaps that Medicare Prescription plans have. |
| Other Rx programs | Yes. Medicare Co-Payment Plan |
| Contact & online information | Program administered by AHCCCS: Tel: 602-417-4000;
Tel. for CoppeRx Card Holders: 1-888-227-8315
http://www.rxamerica.com/az_discount_home.htm |
| Sources: AZ website; interview with Governor Health Policy Advisor Updated: 7/2007; 6/2011 |
|
|
Arkansas Rx Program - Enacted Law HB 1241; Act 538, signed 3/3/05; Not operational, never implemented -- See Archive
|
|
|
1) California Prescription Drug Discount Program for Medicare Recipients (2000-)
2) California Discount Prescription Drug Program - Not yet operational -- See Archive
|
Eligibility
|
California Prescription Drug Discount Program for Medicare Recipients includes anyone who is eligible for Medicare, seniors over the age of 65 and those under the age of 65 who are disabled. There is a 15 cent processing fee per prescription filled.
|
| Disabilities coverage | Yes, for disabled that otherwise qualify |
| Benefits | Medicare: Prescription drugs are at the Medi-Cal prescription rates with over 500 pharmacies throughout California. No prior authorization is needed on prescription drugs and virtually all prescriptions are covered. |
| Medicare wrap around | No; Not a qualified SPAP; payments do not count toward TrOOP. |
| Est. # of beneficiaries |
Program has no enrollment process. No information on number of beneficiaries. (9/2011)
|
| State laws | Medicare enrollee programs: 1999 law SB 393; 2001 law SB 696 |
| Special features & issues | The program was contentious during the legislative and ballot question phase. Funding eliminated August 21, 2007: $6.3 million from the California Discount Prescription Drug Program Fund: The Governor zeroed out the money to implement this program that would negotiate with drug companies to provide discounts to uninsured and underinsured Californians. In his veto statement, he directed the Department to identify ways to start the work, but the program is likely to be delayed.
The pricing structure includes these features: "Consider three different benchmarks in negotiations with drug manufacturers: the Medicaid Best Price, the lowest price offered to private payers, and the average manufacturers’ price minus 15 percent. For the first three years, gives drug manufacturers the ability to voluntarily negotiate discounts. If after August 1, 2010, manufacturers do not provide discounts at the benchmark levels, the state may, upon federal approval, tie participation in Medi-Cal with participation in this program as long as imposing this linkage does not disrupt care of California’s Medi-Cal enrollees and budget neutrality is maintained." |
| Other Rx programs |
1) Genetically Handicapped Persons Program is a single-condition limited eligibility program certified as a "qualified SPAP" by CMS.
2) California Discount Prescription Medication Program (1999-2006) California was one of the first to launch a statewide prescription drug discount program, aimed at the Medicare population. With no income or enrollment requirements, residents just show a Medicare Card to be eligible for a calculated price reduction at the counter, based on the state Medi-Cal (Medicaid) negotiated price. The need for this program reduces substantially once individuals enroll in the federal Medicare Part D drug plans, but those not using Part D or facing a gap in coverage may use this plan.
|
| Contact & online information |
|
| Sources: CA websites; conversation with agency 10/07. Updated: 2/2007; 1/22/2008; 2/22/2008; 9/2011 |
|
|
Colorado Cares Rx - Enacted Law SB 07-001, signed 2/1/2007; Program repealed, February 2009 -- See Archive
|
|
|
AccessRx program - Enacted Law 15-569, signed 3/25/2004; Not operational -- See Archive
|
| FLORIDA |
Florida Discount Drug Card
|
The Florida Discount Drug Card is designed to lower the cost of prescriptions for Florida residents without drug insurance coverage. Enrollees save an estimated 5 to 40 percent on Rx purchases.
|
Eligibility
|
All Florida residents are eligible. The Florida Discount Drug Card offers additional savings for Florida residents who are: Age 60 to 64, without prescription drug coverage, and do not belong to a Medicare Part D plan; Or, under age 60, without prescription drug coverage and with an annual family income of less than 300% of the federal poverty level. Qualifying incomes include: $32,670 per year for an individual, $44,130 per year for a family of two, and $67,050 per year for a family of four. Qualifying incomes for families larger than four are available upon request.
|
| Disabilities coverage | Yes, all who qualify under income and age requirements above. |
| Benefits |
"Savings will vary depending on the quantity, type and brand of the drug purchased. Average savings on 10 commonly used prescription drugs ranged from 5 to 42 percent; "virtually all prescription drugs" may be available. Click here to check Drug Pricing. Member card may Be used at all participating pharmacies: Pharmacy Locator |
| Medicare wrap around | No; Not a qualified SPAP; payments do not count toward TrOOP. |
| Est. # of beneficiaries |
n/a
|
| State laws | Created by executive agency action, December 2007. |
| Other Rx programs | No. In 2000 Florida enacted a subsidy program and another discount plan, named Senior Prescription Affordability Act - they were phased out in 2005 and are not operational -- see ARCHIVE |
| Contact & online information |
|
Sources: Gov. Christ news release; agency web site, 12/27/07; 1/22/08 Updated: 12/27/2007; 6/2011
|
|
Hawaii Rx+ Discount Program - Enacted Law 2002 HB 2834; Program discontinued, effective August 1, 2010 --See Archive
|
|
|
IL Rx Buying Club
|
The Rx Buying Club began as a Governor's initiative in 2003 for seniors and disabled. As of 2006 it was expanded by the legislature to allow residents of any age, with incomes up to 300% of federal poverty guidelines, to buy prescriptions at a discount.
|
Eligibility
|
Any in-state resident who has a household income equal to or les than 300% of federal poverty level. A single person household annual income must be equal to or less than $32,670. The income limit is $44,130 for a couple. Annual administrative enrollment fee is $10.00 and non-refundable.
|
| Disabilities coverage | Yes, if otherwise qualified. |
| Benefits | Senior citizens and person with disabilities can receive discounts on all FDA approved prescription drugs. |
| Medicare wrap around | No; Not a qualified SPAP; payments do not count toward TrOOP. |
| Est. # of beneficiaries |
77,589 as of September 2011
|
| State laws | 2003 law: SB 3; 2005: HB 973 |
| Other Rx programs | Also offers Illinois Cares RX Plus, see above |
| Contact & online information |
Illinois Rx Buying Club Member Services: 1-866-215-3463
|
Sources: Interview with Drug Advocate for the Governor;NCS: Summary of Law Updated: 8/2007; 5/2009; 9/2011
|
|
Maine Rx Plus Program
|
Maine Rx Plus was originally created by a 2000 state law; it became operational in 2004 after a largely favorable ruling by the U.S. Supreme Court. The program offers retail counter savings of 15 percent on name brands and up to 60 percent on generics.
|
Eligibility
| Most Maine residents without prescription drug coverage will be eligible for the Maine Rx Plus Card. A single person household must have a gross monthly income less than $2,978; a two person household monthly income less than $3,993; a three person household monthly income less than $5,008; a four person household monthly income less than $6,023; and a five person household monthly income less than $7,038. |
| Disabilities coverage | Yes, if otherwise qualified. |
| Benefits |
All members save up to 15% on name brand drugs and up to 60% on generic drugs. Low Cost Drugs for the Elderly and Disabled also receive cost savings as Maine Rx Plus Members
|
| Medicare wrap around | No; Not a qualified SPAP; payments do not count toward TrOOP. |
| Est. # of beneficiaries |
51,436 as of September 2011
|
| State laws | 2003 LD 1634/ SP 560 (signed 6/13/03)
U.S. Supreme Court favorable ruling 5/19/03 Operational 4/2004
|
| Special features & issues | This program was initially authorized in 2000 but implementation was delayed by challenges in federal court and ultimately upheld by the U.S, Supreme Court in May 2003. |
| Other Rx programs | Yes. Also offers a subsidy program, Low-Cost Drugs for the Elderly and Disabled Program |
| Contact & online information |
Bureau of Medical Services
To enroll: 1-866-796-2463
207 287-2674
|
Sources: Interview with Director of Pharmaceuticals Updated: 7/2007; 5/2009; 9/2011
|
|
Primary Adult Care Program
|
Beginning in July 2006, the Primary Adult Care Program (PAC) replaced the Maryland Pharmacy Assistance Program. If you were in the Pharmacy Assistance Program you will be in PAC.
|
Eligibility
|
This program replaced the Maryland Pharmacy Assistance Program, effective July 2006. State residents between the ages of 19 and 65 who do not qualify for Medicare or Medicaid and meet the income requirements. For families with a household of more than one person call 1-800-226-2142 for income guidelines. Your assets can't be more than $6,000. For individuals, call 1-800-226-2142 for income guidelines. Your assets can't be more then $4,000.
|
| Disabilities coverage | Yes, if otherwise qualified. |
| Benefits | Free office visits to a Primary Care Provider, allso called a PCP. Free office visits to a counselor or psychiatrist for mental health services. Prescription drugs, although you may need to pay a co-pay for some prescriptions. Community-based substance abuse treatment services. |
| Medicare wrap around | No; Medicare enrollees are disqualified; Not a qualified SPAP; payments do not count toward TrOOP. |
| State laws |
|
| Special features & issues | The 2005 law allows for qualify residents to be within 175% of federal poverty level; see "eligibility" above for current requirements. Maryland Pharmacy Discount Program |
| Other Rx programs | Yes, see MD subsidy program above. Maryland Senior Prescription Drug Assistance Program (SPDAP) |
| Contact & online information |
|
Sources: NCSL summary of law Updated: 2/2007; 2/2008; 6/2011
|
|
MI Rx Prescription Savings Program (MiRx)
|
The Michigan MiRx program provides retail counter discounts to residents of all ages who lack Rx coverage. Estimated average savings are 20 percent per month.
|
Eligibility
|
No minimum age; must have no prescription drug coverage and must be a state resident. Eligibility is based upon sliding income scale. Income must be at or below Michigan Median Income. Current rate for individual is $31,200; two person household is $42,000. There is no enrollment fee for this program.
|
| Disabilities coverage | No, intended for people without coverage. |
| Benefits | Beneficiaries will save approximately 20% on each prescription. |
| Medicare wrap around | No; Not a qualified SPAP; payments do not count toward TrOOP. |
| Est. # of beneficiaries |
Est. 50,000-200,000-- updated number pending as of 7/07
|
| State laws |
|
| Other Rx programs | No; the previous MI senior subsidy program was terminated December 31, 2005 and replaced by federal Medicare Part D. |
| Contact & online information |
Michigan Dept. of Community Health:
|
Sources: MI RX Website; NCSL summary of law Updated: 8/2007; 6/2011
|
|
Prescription Drug Plus Program - Enacted Law SB 324, signed 4/19/05; Not operational, never implemented -See Archive
|
|
|
New Mexico Discount Prescription Drug Program
|
In 2006, The New Mexico Discount Prescription Drug Program was expanded to all New Mexico residents, also replacing an earlier New Mexico SenioRX program. It provides a retail counter discount averaging 13 percent on brand names and up to 50 percent on generics.
|
Eligibility
|
All New Mexico state resident are eligible for the program. State residents who already have prescription drug coverage are still eligible for the program and can choose to use whichever program whether it be their prescription drug coverage or the New Mexico Discount Prescription Drug Program that benefits them the most. There is no enrollment fee or premium costs for the program. Once a state resident signs up there is no need to reapply annually, residents are enrolled in the program until they request to cancel.
|
| Disabilities coverage | Yes, every state resident is eligible and can choose which is more beneficial if they have multiple options on prescription drugs. |
| Benefits | Enrollees can save up to 50% on generic drugs and an average of 13% on brand name drugs. Over 300 pharmacies participate in the program and accept the discount card. |
| Medicare wrap around | No; Not a qualified SPAP; payments do not count toward TrOOP. |
| Est. # of beneficiaries | 6,625 enrollees as of 7/25/07 |
| State laws | 2005: SB 689, signed as Chapter 160, 4/5/05 |
| Other Rx programs | Not currently. See archive |
| Contact & online information |
|
Sources: NCSL summary of law; Interview with Representative of New Mexico Health Care Authority Updated: 8/2007; 6/2011
|
|
Ohio Best Rx - Formerly Golden Buckeye Prescription Drug Savings Program
|
The Golden Buckeye Prescription Drug Savings Program has merged into the Ohio Best RX Program. Seniors with a Golden Buckeye card receive prescription drug discounts through the Ohio Best RX Program. Legislation that enacted the Ohio Best RX program has since been amended to expand eligibility requirements to include all state residents, with annual income limits only for those under age 60, set as up to $32,670 for an individual.
|
Eligibility
|
State residents over the age of 60 are automatically enrolled regardless of income. State residents under the age of 60 cannot have any insurance coverage to be eligible for the program. In order to be eligible under the age of 60 a state residents must meet the an income requirement which requires them to make equal to or less than 300% of federal poverty guidelines, which equal $32,670 for an individual and $44,130 for a family of two and $67,050 for a family of four. There is no enrollment fee.
|
| Disabilities coverage | Yes, if otherwise qualified; no age limit applies. |
| Benefits | Average savings to each enrollee is approximately 34% monthly for each participant. Seniors who are also covered by Medicare Part D can still use the card for saving on out of pocket expenses. |
| Medicare wrap around | No; Not a qualified SPAP; payments do not count toward TrOOP. |
| State laws | 2002: SB 261, §173.06 signed 6/5/02; Summary of 2006 statute amendments |
| Special features & issues | As of July 2007 the Ohio Best RX Program is administered by the Department of Aging. Amendments to the original program have expanded eligibility from 250% of FPL to 300% of FPL; prior to the amended requirements state residents under the age of 60 had to wait three months before being eligible for the program if they went without health insurance. Now state residents who once had health insurance and no longer do, do not need to wait the three months to be eligible for the program. |
| Other Rx programs |
(Sec. 185.02.) Created the Office of Pharmaceutical Purchasing Coordination in the Department of Administrative Services. [2/2008]
|
| Contact & online information |
Operational as of October 2003
Ohio Best RX Program participant help desk: 1-866-923-7879
|
Sources: Interview with Representative from the Ohio Department of Aging;NCSL summary of law Updated: 7/2007, 2/2008; 5/2009; 6/2011
|
|
Oklahoma Prescription Drug Discount Program - Enacted Law SB 547 Chapter 419, signed 6/6/05; No longer operational, program ended September 2010 -- See Archive
|
|
|
Oregon Prescription Drug Program (OPDP)
|
A 2003 state discount program was significantly expanded by a 2006 binding ballot measure. Beginning January 2007, any state resident lacking prescription drug coverage may enroll, with no age or income limits.
|
Eligibility
|
All Oregonians are eligible to join. There is no enrollment fee and there is no maximum income requirement.
|
| Disabilities coverage | Yes; see eligibility above. |
| Benefits | Enrolled residents receive a card with an average savings of 50%. Persons enrolled in Medicare Part D prescription coverage are still eligible for this program. |
| Medicare wrap around | No; Not a qualified SPAP; payments do not count toward TrOOP. |
| Est. # of beneficiaries |
375,420 through August 2011.
|
| State laws | 2006 expansion: Ballot Measure 44 approved by voters 11/7/06. Expanded program began 12/8/06 |
| Special features & issues | Effective February 1, 2007, OPDP joined the Washington Prescription Drug Program to form the Northwest Prescription Drug Consortium. The Consortium entered into a contract with The ODS Companies for pharmacy benefit administration. |
| Other Rx programs | Not in 2007 - see archive. |
| Contact & online information |
Agency contact: Betty Wilton Phone: 503-945-7833 ; Toll-free: 888-411-6737 |
on-line description - http://www.oregon.gov/OHPPR/OPDP/index.shtml |
Sources: OPDP Website; Interview with Representative; NCSL summary of law Updated: 9/2008; 9/2011
|
|
South Carolina Retirees and Individuals pooling together for Savings (SCRIPTS) - Enacted Law H 3586, signed 6/18/03;
Not operational, never launched; repealed by H3221 of 2006 -- See Archive
|
|
|
Senior citizen prescription drug benefit program - Enacted Law S 216 (2003); Not operational; repealed 9/1/04 --See Archive
|
|
|
Cover Rx (discounts)
|
Cover Rx was enacted into law in 2006 as part of a broader state health coverage package. The prescription drug discount component applies to drugs not on the Covered Drug List. CoverRx was launched in January 2007.
|
Eligibility
|
Any Tennessee resident of at least six months between the ages of 19 to 64, who is a US resident or qualified alien, with an income at or below 250% of poverty level, and with no prescription drug coverage may be eligible. A single person household income level must be under $27,225 and a couple must be under $36,775. Costs to participate vary according to income level. For covered generics, a 30 or 90 day supply for a person below the federal poverty level is $3; a person between FPL and 149% of FPL pays $5 for a 30 day supply and $10 for a 90 day supply; and participants between 150% to 250% of FPL pay $8 per prescription for a 30 day supply or $16 for a 90 day supply.
|
| Disabilities coverage | No, unless otherwise qualified as uninsured or underinsured. See Eligibility above |
| Benefits | Affordable access to approximately 250 medications, mostly generic. There is a five script limit per month, however, insulin and diabetic supplies do not count against the limit. Drugs not on the covered list or beyond the limit are available for full payment of the discounted price (price varies by drug) |
| Medicare wrap around | No; Not a qualified SPAP; payments do not count toward TrOOP. |
| # of beneficiaries |
47,140 (as of 7/31/2011)
|
| State laws |
Signed 6/12/06. Operational Jan. 2, 2007; CoverRx enrollment was temporarily suspended in February 2007, but reopened in April 2007.
|
| Special features & issues | Cover Rx is part of a 5-part health program called "Cover Tennessee." The formulary list is administered by ExpressScripts. |
| Other Rx programs | |
| Contact & online information |
|
Sources: Cover Rx Website; NCSL summary of law Updated: 9/13/2007; 5/2009; 9/2011
|
|
Healthy Vermonters Discount Program
|
This 2002 state discount program was aimed at residents over 65; the current program defines eligibility as any age, with income at or below 300 percent of federal poverty.
|
Eligibility
|
The program is intended for people without prescription drug coverage or those who have commercial plans with an annual limit.
For residents of any age with income at or below 300 percent of federal poverty. This translates to monthly income of $2245 for a household of one, $3030 for a household of two, and $3815 for a household of three.
If a resident is over the age of 65, or disabled and receiving Medicare or social security benefits and have an income at or below 400% of FPL. A monthly income equal to or less than $2,994 for an individual or $4,004 for a couple.
|
| Disabilities coverage | Yes, if otherwise qualified for Medicare or social security benefits. |
| Benefits | Beneficiaries are able to receive discounts equal to those of Medicaid rates. |
| Medicare wrap around | No; Not a qualified SPAP; payments do not count toward TrOOP. |
| Est. # of beneficiaries | For SFY 2010, the Healthy Vermonters program had a caseload of 4,753. (9/2011) |
| State laws | 2002: H.31 signed as Act 127; Program was implemented July 2002 |
| Other Rx programs | Yes. VT also offers VPharm as a subsidy, see above. |
| Contact & online information | Department of PATH, Tel: 802-241-2992 Members: 1-800-250-8427
Healthy Vermonters Discount Program
|
Sources: State web site; conversation with PATH agency; NCSL summary of law Updated: 7/2007; 5/2009; 9/2011
|
|
Washington Prescription Drug Program (WPDP)
|
In March 2007, the Prescription Drug Program was launched with a goal of offering state-negotiated discounts to all interested residents, regardless of income, age or current insurance coverage.
|
Eligibility
|
State residents of all ages, all incomes. No restriction based on current insurance coverage. No enrollment fee. Note: Persons with Medicaid or comprehensive employer-based insurance are eligible but will not be able to use a state discount and an insurance payment for the same purchase.
|
| Disabilities coverage | Yes, no restrictions as above. |
| Benefits | Stated goal is to negotiate discount prices for "average savings" of 20 -percent on brand-name drugs and 60 percent on generic drugs. Actual discounts depend on agreements with individual manufacturers and distributors. Purchases can be made at participating local pharmacies or by mail-order. Average savings described as $26 per prescription. (10/07) |
| Medicare wrap around | No; Not a qualified SPAP; payments do not count toward TrOOP. |
| Est. # of beneficiaries |
Approximately 160,000 (9/2011)
|
| State laws | 2005 bulk purchasing law, SB 5471, now: RCW 70.14.060 (1): |
| Special features & issues |
The program is the first to use multi-state bulk purchasing as a strategy for obtaining discounts, in partnership with Oregon. The multi-state bulk purchasing partnership with Oregon is called the Northwest Prescription Drug Consortium. Total prescription drug charges : $11,065,041 * Total spent by Card members: $6,418,209 Total number of prescriptions filled: 195,908 Total savings by Card members : $4,646,831; Average savings per prescription: $22 or 41%; Average percentage of generic Rx: 81% The WPDP Discount Card group is saving over $300,000 each month** News: " Governor Gregoire Announces Washingtonians Have Saved Over $1 Million on Prescriptions" 10/25/07. |
| Other Rx programs | Yes. Washington offers a special-purpose subsidy program: Medicare Copayment Plan, see subsidy above. |
| Contact & online information |
|
Sources: **Interview with Washington State Health Care Authority 9/29/08; NCSL summary of 2005 law & 2006 Northwest. Updated: 5/2008; 9/2008; 9/2011
|
|
Badger Rx Gold
|
Badger Rx gold provides a retail counter discount for any resident that lacks prescription drug insurance coverage if the person enrolls and pays the annual enrollment fee.
|
Eligibility
|
Any state resident that does not have health insurance, resident that has health insurance that does not cover prescription medications, the specific medication they need, or the co-payment is too high. There is no minimum age requirement or any other type of screening. Enrollment fees are $25 for an individual or $75 for a family.
|
| Disabilities coverage | Yes, any state resident if otherwise qualified. |
| Benefits | Badger Rx Gold saves enrollees 25-40% on prescription medications |
| Medicare wrap around | No; Not a qualified SPAP; payments do not count toward TrOOP. |
| Est. # of beneficiaries |
7,000 as of March 2006
|
| State laws | 2003 Act 33; 2005 expansion to allow businesses to participate. |
| Other Rx programs | Wisconsin is one of six states in the I-Save-Rx program that provides a portal for purchase of prescription drugs from state-approved Canadian venders. |
| Contact & online information |
|
Sources: Interview with Pharmacy Representative on Legislative Council Updated: 8/2007; 6/2011
NCSL Sources and Archive Resources:
APPENDIX I: Federal Definition of "SPAP" roles and MMA
"The MMA allows SPAPs to “wrap around” the Medicare benefit to fill gaps in coverage and for State programs that meet the definition of “SPAP,” the program’s wrap-around payments will count as if they were paid by the beneficiary for purposes of filling the coverage gap and meeting the catastrophic limit. As a result, SPAPs will be able to provide the same or better coverage for beneficiaries who receive coverage through state programs now, at a lower cost per beneficiary for the states because of the availability of the Medicare drug benefit. Coordinating with Medicare frees up significant amount of state funds, allowing for the expansion of the population served by state SPAP programs. In fact, we estimate that the savings that will accrue to States as a result of Medicare Part D displacing SPAP expenditures for low-income beneficiaries will be approximately $600 million per year, or about $3 billion over the five-year period from CY 2006-2010. A State program may still be considered an SPAP if some or all of its program funding is from private sources (for example, from charities or independent foundations), and payments made by SPAPs will count towards an enrollee’s true out-of-pocket costs (TrOOP). This will allow the enrollee to reach the catastrophic coverage faster, at which point the Medicare program pays for at least 80% of the costs." -Source: SPAP Assistance for Low Income Subsidy Eligible Individuals under the Medicare Prescription Drug Benefit, Leslie Norwalk, CMS, 2005
Eligibility standards: The figures listed in these charts are based on language in state statutes or other state regulations. They are examples of the scope of individual programs; they are not intended as full descriptions of eligibility requirements for individuals. Please consult state program links and contacts for additional details and conditions.
Federal Poverty Guidelines are issued annually, and are used widely by federal and state programs as a measure of income eligibility. Many state laws and programs, and some federal programs refer to the specific maximum amount as a percentage of the "Federal Poverty Level" abbreviated as FPL. Tables and descriptions in this report use the term "FPL" to describe a percentage amount based on guidelines. HHS Federal Poverty Guidelines Description, 2012
Social Security Disability Income (SSDI) federal standards and descriptions of disability are available on-line; see State Assistance Programs for SSI Recipients, 2010. The link includes state-specific tables. Many states have adopted the federal definition of disability as a standard for state Rx eligibility. |
]