Prescription Advantage

Prescription Advantage has ongoing/rolling enrollment.  Applicants may apply at any time of the year!

Note:  Prescription Advantage now primarily offers Medicare Part D wrap-around coverage for those eligible for Medicare.  They still provide more comprehensive coverage for those ineligible for Medicare.

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Information:   Prescription Advantage website

Application:    Application is available in English and 8 other languages here.

Type:  INSURANCE plan.

Administration:  Massachusetts Executive Office of Elder Affairs.

Eligibility:  
  Must be a resident of Massachusetts and not a MassHealth or CommonHealth member AND

• either age 65 and older with a gross annual income equal to or less than 500% of the Federal Poverty Guidelines (For 2015, single applicants can have income up to about $58,850 and married applicants up to about $79,650.).
  OR
• are under age 65 and:
  - work 40 or fewer hours per month
  - are disabled*, and
  -gross annual household income must be less than 188% of the Federal Poverty Guidelines. For a single person (or living apart from a spouse), this limit is roughly $22,069 in 2015. For a married couple living together, the limit is roughly $29,869

*Disabled definition:

• receive SSI or SSDI benefits
• receive Medicare benefits
• have a certificate of blindness from the Massachusetts Commission for the Blind OR
• have a determination of disability from MassHealth

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If Medicare eligible, applicants/members are required to join a Medicare Part D drug plan or a creditable coverage plan (coverage that is equal to or better than Medicare prescription drug coverage). Members enrolled in creditable coverage plans only receive assistance with prescription drug co -payments.

Prescription Advantage also requires lower-income, Medicare-eligible members to apply for the Medicare Low Income Subsidy (also known as “Extra Help from Medicare”).

How Prescription Advantage Works with the Medicare Prescription Drug Coverage (Part D) FOR 2012 (Effective 1/1/12. Most recent version as of 2/15.)

Coverage:

• Depending on income, Prescription Advantage may cover portions of co-payments
• Prescription Advantage will not cover diabetic supplies or prescription drugs that are not covered by Medicare Part B (except for benzodiazepines) -as of March 31, 2006.
• Secondary coverage to seniors with prescription coverage through employer or union

Fees:

• Premiums: No premium for those not eligible for Medicare. With Medicare, no monthly premium for members with income below a certain level.
• Annual Enrollment Fee- No annual enrollment fee for those not eligible for Medicare or those with Medicare with incomes below 300% of FPL. Members with Medicare with income between 300-500% Federal Poverty Level pay an annual enrollment fee.
• Deductibles and Co-Pays- Those not eligible for Medicare 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.
• 2015 Rate Schedule (See Side 1 for those with Medicare and Side 2 for those without.)

Enrollment:  Prescription Advantage accepts applications year-round.  No more waiting for an annual open-enrollment period.

Additional Information:

• Prescription Advantage will continue to provide primary prescription coverage to those not eligible for Medicare. Prescription Advantage will provide secondary coverage to members who are not in a Medicare Part D plan, but have “creditable coverage,” meaning that Medicare has determined that the prescription drug coverage is as good as Medicare Part D coverage. Creditable coverage is typically provided through an employer or union.

• The Plan does not inquire about immigration status; those who are undocumented may be eligible for the Plan as long as they are Massachusetts residents.

• Appeals- If a member wants to appeal their income category (and therefore assigned premiums, deductibles and co-pays), benefits, tier placement of their medication, etc., they should ask for "Reconsideration". There is an additional "appeal" step if this outcome is unsatisfactory- which is called a "Review".

• Prescription Advantage requires Medicare eligible members to apply for Extra Help through Social Security.

• Drugs Not Covered by the Medicare Drug Plan- Prescription Advantage will cover a one-time, 72-hour supply of any medication that cannot be billed to a member’s Medicare Part D drug plan or is rejected by the plan.
  
  • Prescription Advantage Regulations
  • Prescription Advantage Changes- Nov 2008, MGH Community News