PRESCRIPTION ASSISTANCE PROGRAMS

On January 11, 2002 Admitting hosted a combined presentation entitled "Prescription Programs in Massachusetts". The presenters discussed Prescription Advantage, Massachusetts' prescription drug insurance plan, and Citizen's Health. Both of these programs have been explained in previous MGH Community News articles that can be found at: Basic Needs/Health Care Coverage/Medications & Prescription Drugs. What follows is primarily information that is new or that may clarify any previous misconceptions about each program.

PRESCRIPTION ADVANTAGE
David Morales, its director, spoke first. Prescription Advantage is a prescription drug INSURANCE plan administered by the Executive Office of Elder Affairs. It began operating on April 1, 2001 and is open to elders age 65 and older (regardless of income) and younger disabled individuals whose gross annual household income is at or below 188% FPL (currently $16,152 individual, $21,828 for a couple). As an insurance plan, there is no dollar limit to coverage it provides, but there are premiums, deductibles and co-pays for certain members, depending on their income (Please see page 12 of the application for the specific details- available on the departments website or at www.800ageinfo.com/info/documentsnew/7_31_PAP.pdf). The State pays the cost of premiums and deductibles for individuals whose gross annual household income is at or below 188% FPL.

All members pay co-pays, which vary depending on the member's income (Please see page 12 of the application for the specific details). There is also a mail service option for maintenance drugs that carries a lower co-payment. One of the best features of Prescription Advantage is its annual out-of-pocket spending limit of $2,000 or 10% of gross annual household income, whichever is less. Once a member meets the annual out-of-pocket spending limit, she/he no longer pays deductibles or co-pays, but would continue paying premiums. Mr. Morales noted that this is the "richest (such) benefit nationwide".

Please note that upon joining, members are billed for the premium for the first two months of coverage. This "double bill" ensures that members can access the benefit immediately, without any delays.

Other facts:

• Prescription Advantage has a nationwide network of pharmacies - so members can get drug coverage when out-of-state.
• Mr. Morales assured the audience that in the latest budget $99 million was appropriated for this program, which is more than sufficient for the program's needs in fiscal year 2002. The legislature has pledged its continued support for the program.
• At this time the program has a continuous open enrollment. This means that eligible individuals can join whenever they want. This will end on March 31, 2002. For 2002, open enrollment will be April 1, 2002 to May 31, 2002. More information will be available on this issue in the near future.
• The residency requirement for Prescription Advantage is that one has been a Massachusetts resident for the past six months. Currently this information can be self-report. Note that 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.
• At this time, there is no financial or disability redetermination process - once you join, you remain enrolled (unless you stop paying your premiums). Although there will be a redetermination process in the future. More information will be forthcoming shortly.
• If you apply to the Plan before the 15th of the month, you are enrolled the beginning of the next month.
• The 2001/2002 plan year has been extended 3 months. Members will now have through June 30, 2002 to reach their deductible and the annual out-of-pocket spending limit (stoploss). Members who have met their deductible will continue to pay only co-payments for an additional three months, while those who have met their annual out-of-pocket spending limit will have no costs (excluding premiums) until July 1.
• Former members of The PHARMACY Program and The PHARMACY Program Plus have until March 31, 2002 to exercise their "deemed" eligibility and join Prescription Advantage. It is of special importance that people under age 65 who were previously members of either PHARMACY Program act quickly and preserve their right to join Prescription Advantage. After March 31, this group will lose their eligibility based on PHARMACY Program membership and may no longer be eligible for enrollment in Prescription Advantage.
• 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".

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