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Health Care Coverage
Medications/Prescription Drugs

 

Does your client qualify for any of these programs?

      1. MassHealth
      2. For those eligible for Medicare:  Medicare Prescription Drug coverage - Medicare Part D
      3. For those under 65 and uninsured, subsidized health insurance through The Connector
      4. The Health Safety Net: Under limited circumstances HSN can assist with prescriptions. Contact the CRC or patient financial services for more information.

Other programs and resources for prescription Drug coverage for the uninsured or underinsured are below:

SECTIONS (click to jump there):

See also: Partners Social Determinants of Health handout- briefoverview, but available in Spanish, Portuguese, Chinese, Arabic and Russian. See CARMA then Social Services/Community Resources

Prescription Advantage

  Prescription Advantage
Administration
Contact
800-AGE-INFO
  • Website
  • Apply online (Available in multiple languages)
    		•
    Description
    Insurance plan
    Eligibility

    Enrollment is now open year-round!  No need to wait for an open enrollment period!
    Income
    • For Massachusetts residents age 65 or older and eligible for Medicare, gross annual household income cannot be greater than 500% of the Federal Poverty Guidelines. For 2018, single applicants can have income up to about $60,700 and married applicants up to about $82,300.
    • For Massachusetts residents age 65 or older who are NOT eligible for Medicare, there are no income limits for the Prescription Advantage Program. Anyone may join, regardless of income.
    • For disabled Massachusetts residents under age 65, gross annual household income must be no greater than 188% of the Federal Poverty Guidelines. For a single person (or living apart from a spouse), this limit is roughly $22,500 in 2018. For a married couple living together, the limit is roughly $30,750.
    Age/Disability
    65 or older or disabled
    Citizenship
    No immigration status requirements
    Other criteria
    Must be MA resident; If have Medicare must purchase Medicare D and apply for Low Income Subsidy if eligible.
    Benefits
    Primarily now a supplement to Medicare D- offering assistance in the “donut hole” coverage gap.
    Fees/costs
    • Covers Medicare drug plan monthly premium for members below certain incomes
    • Members with income between 300-500% Federal Poverty Level will pay an annual enrollment fee
    • No monthly premium is required for those who use Prescription Advantage as their primary coverage. However, members will pay a quarterly deductible and co-payments until an annual out-of-pocket spending limit is reached. At that time, Prescription Advantage will pay the full cost of the member’s covered prescription drugs through the end of the plan year
    Pharmacies
    • Can be used nationwide.
    Limitations
    • Prescription Advantage will not cover diabetic supplies or prescription drugs that are not covered by Medicare Part B (except for benzodiazepines)

    PHARMACEUTICAL COMPANY PROGRAMS

    There are two major categories of assistance from Pharmaceutical Companies. One is commonly referred to as "Indigent Patient" programs and the other is a recent advent of discount cards for low-income Medicare recipients.

    Indigent patient programs:
    Generally these programs require a physician to request a supply of the medications for the patient from the pharmaceutical company.

      Eligibility, application procedures and benefits vary from company to company and drug to drug. The following websites (and there are others) attempt to help streamline the process of accessing these programs.

      Vouchers, Coupons, "Smart Cards":  learn more

       

    PRIVATE AND DISEASE-SPECIFIC ASSISTANCE

    • MA HIV Drug Assistance Program (HDAP) 617-502-1700 www.crine.org
      • --This DPH funded program is available to qualified individuals with income below 500% of the Federal Poverty Level- roughly $60,700 per year. People who are undocumented may qualify if they are Massachusetts residents.
    • National Organization of Rare Disorders (NORD) 800-999-6673        www.rarediseases.org
      --Provides a co-pay assistance programs for medications for rare diseases. Locate the applicable program and contact them.

    • Good Days (formerly Chronic Disease Fund) 877-968-7233   www.mygooddays.org/
      --Provides direct and immediate financial assistance to underinsured patients with chronic disease, cancers or life-altering conditions who cannot afford the co-payments for the expensive medications they need.

    • Patient Access Network Foundation (PANF)  866-316-7263 www.panfoundation.org
      --Provides assistance to patients who cannot access the treatments they need due to out-of-pocket health care costs (deductibles, copayments, and coinsurance). Apply online or by phone.
    • Patient Advocate Foundation 866-512-3861       www.patientadvocate.org
      --Co-pay relief program at www.copays.org. Also offers mediation and case-management services.

    • NeedyMeds Drug Discount Card (for those without Medicare or Medicaid) - MGH Community News, July/August 2009, Rev. December 2018

       

    COMMERCIAL DISCOUNT CARDS

    For the uninsured or underinsured who are ineligible for MassHealth or Prescription Advantage there are some commercial discount programs that might help with prescription drug costs.

    Q: Will the discount card always give me the lowest price?
    A: You may pay more for some brand name medicine, even with a discount, than you would pay for the generic version or you may find the medicine for a lower cost at a different pharmacy.

    Q: Will all my medicines be discounted?
    A: Not necessarily. This is a consideration if you are paying a fee. Contact the program to see what medicine is available before making a payment.

    More Information: Free Pharmacy Discount Cards - Cost Relief or a Scam?

      Some journalists and consumers have posited that an additional, if not the main, way these cards make money is by selling your personal information for marketing purposes. A couple of journalist have consulted pharmacists who said the various discount cards typically provide a price reduction of about 10 – 16% off the full retail price.

      Also see description under USA Rx below to see one financial mechanism behind this type of card (i.e., who pays and who profits).

    • NeedyMeds

    Needymeds.org is a non-profit organization with the mission of helping people who cannot afford medicine or health care costs. Their website provides information about government run programs (federal and state), pharmaceutical company patient assistance programs, discount cards and coupons. They also have their own discount card, profits from which strengthen and support their services. More information or download a card at www.needymeds.org.

    USA Rx, administered by HealthTrans, is a discount card that can be used at participating pharmacies for discounts of between 10% and 75% off retail prices for drugs and health supplies (such as smoking cessation aids and diabetes supplies). The exact discount varies, but members can look up the price and participating pharmacies online prior to going to the pharmacy. The website also claims to list lower-cost alternatives where applicable.

    This is not an insurance plan, and there are no membership costs to use the card. How it works behind the scenes and who pays is complex . Here’s the money trail: pharmacies pay a pharmacy benefit manager (PBM) to be listed in the network (in this case USA Rx- but there are others). The PBM brokers a discounted price with the stores. The store is counting on this program driving consumers to their site and is willing to offer a loss-leader in the hope that the consumer will make additional purchases. The PBM then sends a payment to National Benefits Builders, Inc. (NBBI). Then a card distributor purchases cards and distributes them widely. This distributor then gets paid from NBBI every time the card is used to fill a prescription (75 cents per filled prescription as of April 1, 2010).

    • Similar discount card - Community Assistance Program's America's Drug Card program- www.americasdrugcard.org. No fee discount card ("discount of 10% - 85%"). Check website for local pharmacy participation.

     

    DRUG COUPONS- Now Legal in MA

     

     

    BUYING MEDICATIONS FROM CANADA

    • Is it Legal?  

      In most circumstances, it is illegal for individuals to import drugs into the United States for personal use. FDA has a policy explaining that it typically does not object to personal imports of drugs that FDA has not approved under certain circumstances, including the following situations:

      • The drug is for use for a serious condition for which effective treatment is not available in the United States;
      • There is no commercialization or promotion of the drug to U.S. residents;
      • The drug is considered not to represent an unreasonable risk;
      • The individual importing the drug verifies in writing that it is for his or her own use, and provides contact information for the doctor providing treatment or shows the product is for the continuation of treatment begun in a foreign country; and
      • Generally, not more than a 3-month supply of the drug is imported.

      From the US Food & Drug Administration (FDA)

      • Is it Safe?
        • www.nabp.net The website of the National Association of Boards of Pharmacy provides a list of Verified Internet Pharmacy Practice Sites.
        • BeSafeRx: Know Your Online Pharmacy  is an FDA site that gives consumer tips on what to look for in an online pharmacy, and what may be indications of fraudulent claims or dangerous practices.
      Pharmacies:
      You can search for Canadian pharmacies online. Because only half of the online pharmacies are licensed, PharmacyChecker.com, attempts to rate them. Note: PharmacyChecker.com's revenues come from fees generated by its Verification Program, and online pharmacy information, drug price and prescription discount card listings on its site. It does not make money from the online sale of medication.

    INFORMATION AND REFERRAL

    • Drug coverage (Part D)
      Provides information on insurance options and programs that offer discounts or free medication. This includes Medicare managed care plans, Medigap plans and pharmaceutical companies' drug assistance programs. You can search by manufacturer or disease.
    • MCPHS Pharmacy Outreach Program - Toll-Free Help Line: 866-633-1617
      The MCPHS University Pharmacy Outreach Program is a community service program offered by the University. They provide information that includes assistance with accessing affordable prescription drug programs through the Medicare Drug Benefit, as well as medication assistance options for other uninsured or underinsured residents of Massachusetts. MCPHS serves all Massachusetts residents free of charge.

       

    NEWSLETTER ARTICLES

    SEE ALSO:

    Basic Needs/Health Care Coverage/Medigap

    Basic Needs/Public Policy

    Rev 12/18