1 Practical Guide to Prescription Access in Massachusetts
2 The MCPHS MedLine program is a community service project of the Massachusetts College of Pharmacy and Health Sciences. 25 Foster Street, Worcester, MA MCPHS MedLine Website: Practical Guide to Prescription Access in Massachusetts - 2 nd Edition Jennifer Syria, MS Donna McCarthy, BA Publication Designer Editor Contributors: Dennis Lyons, RPh, Mary Sullivan, PharmD, RPh, Paula Evans, MS, RPh, Donna Bartlett, RPh, Colleen Massey, MS, Victoria Howard 2010 Massachusetts College of Pharmacy and Health Sciences No part of the material contained in this booklet may be reproduced, transmitted or utilized, in whole or in part, in any form or by any means without the prior written permission of Massachusetts College of Pharmacy and Health Sciences. In preparation of this booklet, care has been taken to offer the most current, correct and clearly expressed information possible. Nevertheless, inadvertent errors in information might have occurred. Massachusetts College of Pharmacy and Health Sciences provide no warranties, nor does it assume any legal liability or responsibility for the accuracy, completeness or usefulness of any of the information supplied in this booklet.
3 Table of Contents Introduction Using This Guide Federal Poverty Guidelines MassHealth: MassHealth Standard MassHealth Basic MassHealth Essential MassHealth Limited Medicare Savings/MassHealth Buy-In MassHealth CommonHealth Massachusetts Elder Service Plan (PACE) Health Safety Net Health Care Reform: Commonwealth Care Commonwealth Choice Commonwealth Care Bridge Medicare: Original Medicare (Part A & Part B). Medigap Medicare Advantage Medicare Part D Prescription Advantage Extra Help (Low Income Subsidy Patient Assistance Programs Copayment Assistance Foundations Generic Pricing Programs Catastrophic Illness in Children Relief Fund HIV Drug Assistance Plan (HADP) Geriatric Considerations: Falls, ADME, Vaccinations Medication Related Issues Appendix
4 Introduction from President Charles F. Monahan Since its inception in 2001, MCPHS MedLine, a program of the Massachusetts College of Pharmacy and Health Sciences, has been providing programs and services to the residents of Massachusetts, helping them find answers to their medication related questions. MCPHS MedLine also works collaboratively with patients, their families and health care providers, to help them secure affordable prescription medications. In this second edition guide, we will share information that has proven to be most useful in ensuring that patients are able to obtain medications they need. This resource and reference manual will aid in expanding your knowledge of and access to programs and benefits for your patients and clients. We are pleased to be able to provide you with this information and encourage you to call the MCPHS MedLine program ( ) as we remain a valuable resource for you, your staff and your patients. Charles F. Monahan President Massachusetts College of Pharmacy and Health Sciences iv The information in this guide is current as of January 2010, but is subject to change at any time. To obtain the most up-to-date information, contact the programs directly.
5 Using This Guide The second edition of the Practical Guide to Prescription Access in Massachusetts is designed to present basic information about programs in Massachusetts that provide and improve access to prescription medications. This reference manual offers informational overviews to screen for these programs, but it is not intended to be an eligibility determination handbook. Individual programs will determine an applicant s eligibility. All reasonable efforts have been made to ensure the accuracy of information in this guide. However some of the information may be subject to correction. This guide will be updated periodically and updates may be obtained by calling MCPHS MedLine at or visiting The Guide is the property of the Massachusetts College of Pharmacy and Health Sciences and the MCPHS MedLine program. It may not be reproduced (in whole or in part) in hard copy, electronically, or posted on any web site or intranet without prior written consent from the Massachusetts College of Pharmacy and Health Sciences. MCPHS pharmacy outreach program v
6 Federal Poverty Guidelines Throughout this guide you will see references to the Federal Poverty Level (FPL). This is a term that refers to the Federal Poverty Income Guidelines published each spring by the federal government. The benefit levels of many low-income assistance programs are based on these guidelines Federal Poverty Guidelines For all states (except Alaska and Hawaii) and for the District of Columbia Size of family unit 100 Percent of Poverty 110 Percent of Poverty 125 Percent of Poverty 150 Percent of Poverty 175 Percent of Poverty 185 Percent of Poverty 200 Percent of Poverty 1 $10,890 $11,979 $13,613 $16,335 $19,058 $20,147 $21,780 2 $14,710 $16,181 $18,388 $22,065 $25,743 $27,214 $29,420 3 $18,530 $20,383 $23,163 $27,795 $32,428 $34,281 $37,060 4 $22,350 $24,585 $27,938 $33,525 $39,113 $41,348 $44,700 5 $26,170 $28,787 $32,713 $39,255 $45,798 $48,415 $52,340 6 $29,990 $32,989 $37,488 $44,985 $52,483 $55,482 $59,980 vi The information in this guide is current as of January 2010, but is subject to change at any time. To obtain the most up-to-date information, contact the programs directly.
7 Information obtained from Health and Human Services aspe.hss.gov MassHealth MassHealth is the Massachusetts Medicaid program, a public health insurance benefit for certain qualified low income individuals, jointly funded by the state and federal government. MassHealth provides comprehensive health insurance or in some cases, assistance in paying for private health insurance. There are several different types of MassHealth coverage, each with its own set of criteria for eligibility and benefits. Depending on household size and income levels, some individuals may have to pay a premium and/or co-payments for programs. The following are MassHealth programs reviewed in this resource guide: MassHealth Standard MassHealth Basic MassHealth Essential MassHealth Limited Medicare Savings Program (MassHealth Buy-In) MassHealth CommonHealth Massachusetts Elder Service Plan (PACE) NOTE: for additional MassHealth Programs and Benefits visit: MCPHS pharmacy outreach program vii
8 MassHealth Standard The most comprehensive MassHealth program is MassHealth Standard which provides a full range of health care benefits. MassHealth Standard covers inpatient hospital and outpatient services, mental health and substance abuse services, vision-care, prescription and non-prescription medication coverage, long term care services at home or in a long term care facility, including home health services and transportation services. Eligibility There are a number of groups of people who are eligible for MassHealth Standard. A person who meets the following criteria may be eligible for MassHealth Standard Benefits: Category Income Requirements Pregnant women 200% FPL Children under age 1 200% FPL Children ages 1-18 (inclusive) 150% FPL Children in foster care Automatically enrolled SSI recipients Automatically eligible Parents/Legal Caretakers of children under age % FPL Disabled adults (19-64) 133% FPL Women w/ breast or cervical cancer under age % FPL Refugees (inclusive) 100% FPL w/ assets below $2,000 individual/$3,000 couple Individuals aged 65 and older * 100% FPL w/ assets below $2,000 individual/$3,000 couple *Individuals whose income, assets, or both exceed the above requirements may become eligible by meeting a deductible, reducing their assets, or qualifying for program waivers such as the Frail Elders Community Waiver. Information obtained through 8 The information in this guide is current as of January 2010, but is subject to change at any time. To obtain the most up-to-date information, contact the programs directly.
9 MassHealth Standard How to Apply For families, pregnant women, and people under age 65: Call the MassHealth Customer Service Center at to request a Medical Benefit Request Form (MBR). For women under 65 with breast or cervical cancer: Applications must be filed through the Women s Health Network. Visit or call for more information. For people 65 and over: Call MassHealth Enrollment Center at to request a Senior Medical Benefit Request Form For people seeking long-term-care services: Call the MassHealth Customer Service Center at to request a MassHealth application for seniors and people needing long-term care services Applications may also be obtained by visiting the MassHealth website at or at many local hospitals and clinics. General Contact Phone Number MassHealth Customer Service Center MCPHS pharmacy outreach program
10 MassHealth Standard Prescription coverage for individuals not eligible for Medicare Coverage Beneficiaries of MassHealth Standard have access to coverage for prescription and non-prescription (over-thecounter) medications. The MassHealth Drug List is available online at Prior Authorizations For medications requiring a prior authorization, the physician s office should contact the MassHealth Drug Utilization Review Program at Copayments Most MassHealth Standard beneficiaries pay $1-$3 for each covered medication. There is a $200 cap on prescription costs and $36 for non-pharmacy services each year. Some beneficiaries, such as those under the age 19 or who are pregnant, do not have any copayments for medications. If a MassHealth Standard member is unable to afford their copayments, under law, the pharmacy must still provide the medication. The member is still held responsible for paying the amount and may be billed for such charges. 10 The information in this guide is current as of January 2010, but is subject to change at any time. To obtain the most up-to-date information, contact the programs directly.
11 MassHealth Standard Prescription coverage for individuals eligible for Medicare Individuals receiving both MassHealth and Medicare Benefits are required to enroll into a Medicare Part D Prescription Drug Plan for full access to prescription benefits. MassHealth will continue to provide direct coverage for select medications in the following drug classes: benzodiazepines, barbiturates, select prescription vitamins, supplements and over-the-counter medications. As a secondary benefit, MassHealth will cover the 20% copayment for Medicare Part B covered medications and devices (i.e.: oxygen, some cancer medications, and diabetes testing supplies). Self- and Auto-Enrollment into Prescription Coverage Dual eligible individuals, those with both MassHealth and Medicare benefits, have an opportunity to enroll into a Medicare Part D Prescription Plan and if they do not, a plan will be randomly selected this is referred to as auto-enrollment. Select plans will have no premium payment for a dual eligible member and copayments and deductibles will be subsidized and costs will be similar to MassHealth. In 2011 the copayments are $1.10/generic and $3.20/name brand, for medications from a retail pharmacy, and a $0 copayment for each covered medication for those in a long-term facility. MCPHS pharmacy outreach program
12 MassHealth Standard Prescription coverage for individuals eligible for Medicare Facilitated Enrollment into Prescription Coverage MassHealth and Medicare dual eligible individuals who do not choose to enroll into a plan on their own will be randomly assigned to one of the select plans available with no premium. This auto-assignment process may take up to three months to complete, and an individual may find themselves with no prescription coverage during that period. To ensure a beneficiary does not go without prescription medications, LiNet (Limited Newly Eligible Transition program), can be accessed. This billing process will provide a member with a supply of medication for the typical MassHealth copayment. The process will work for up to two months. At the end of two months, the beneficiary is randomly assigned to a Medicare Prescription Drug Plan. The billing codes needed for the LiNet program are: BIN #: PCN: Cardholder ID: individual s Medicare claim number/letter Group Number: individual s Social Security Number *See Appendix E for additional information on LiNet* Beneficiaries that are enrolled into a Medicare Drug Plan through the auto-assignment or facilitated process may experience difficulties with their plans because every plan uses a different formulary. To ensure that a client will be in a plan that will cover his/her medications they should contact MassMedLine for a prescription drug plan review. 12 The information in this guide is current as of January 2010, but is subject to change at any time. To obtain the most up-to-date information, contact the programs directly.
13 MassHealth Standard Prescription coverage for individuals eligible for Medicare Prior Authorizations If coverage for a medication is denied by because of prior authorization, quantity limit, or step therapy for a beneficiary of both MassHealth and Medicare, the prescribing physician will need to contact the Medicare Part D plan for approval, not MassHealth. A list of plans and prior authorization numbers can be found in Appendix F. If a prior authorization isdenied, the individual is allowed to change their plan to one that will cover the medication. The change can occur at any time in the year, and will have an effective date of the first day of the following month. Beneficiaries of both MassHealth and Medicare who are unable to access a medication because of a prior authorization must contact their Medicare Part D plan directly for approval. If denied they can call MassMedLine for assistance in choosing a new plan that will cover all of their medications. Copayments Individuals who are dual eligible should not pay more than the MassHealth Standard copayment for their medications. Individuals in a long term care facility are charged $0 copayment for their medications. Some dual eligible members are charged more than these copayments by their Medicare Part D plan, however this can and should be corrected by the pharmacist. MCPHS pharmacy outreach program
14 MassHealth Standard Prescription coverage for individuals eligible for Medicare If a Medicare prescription drug plan charges a dual eligible member a copayment (up to $6.30) that is higher than what the individual would have paid under MassHealth, a member should be charged the typical MassHealth amount and the pharmacist can submit a claim to MassHealth for the difference. In the event that the drug plan assesses a copayment in excess of $6.30 for a dual eligible member, the pharmacy staff can contact the Part D plan in order for the plan to correct the copayment amount. Part D plans are required to accept Best Available Evidence (BAE) as proof that an individual has Medicaid (MassHealth) and should therefore be charged the low-income-subsidy level copayments. Verbal confirmation may be sufficient for a plan to change the copayment levels for the member but some plans may request that a copy of the MassHealth Card or a computer printout showing eligibility be faxed. 14 The information in this guide is current as of January 2010, but is subject to change at any time. To obtain the most up-to-date information, contact the programs directly.
15 MassHealth Basic MassHealth Basic is health insurance that offers a full range of health care benefits and/or premium assistance. MassHealth Basic is for Emergency Aid to Elders, Disabled and Children (EAEDC) recipients and for lowincome Department of Mental Health clients who are long-term unemployed. Individuals qualify for direct coverage if they have no health coverage or their coverage does not meet MassHealth standards. Direct coverage provides a full range of inpatient and outpatient services. Individuals qualify for premium assistance if they have health insurance that meets MassHealth standard. These individuals will receive either full or partial premium assistance towards their insurance plan. Eligibility Individuals or couples who receive EAEDC cash assistance Department of Mental Health clients (or on the waiting list) less than 65 years of age that are not eligible for unemployment compensation, and have been unemployed or underemployed for more than a year. If there is a spouse, he/she must be working less than 100 hours a month. MassHealth Basic excludes college students. Students are required to obtain student health insurance from their college or university or have comparable coverage. MCPHS pharmacy outreach program
16 MassHealth Basic How to Apply Call the MassHealth Customer Service Center at to request a Medical Benefit Request Form (MBR). Prescription Coverage For those who qualify for direct coverage: Beneficiaries of MassHealth Basic direct coverage who are not eligible for Medicare have access to prescription and non-prescription (over-the-counter) medications through MassHealth. The MassHealth Drug List determines coverage for medications and is available online at Most MassHealth Basic beneficiaries pay $1/generic and $3/name brand for each covered medication. For medications requiring a prior authorization, the physician s office should contact the MassHealth Drug Utilization Review Program at For those who qualify for premium assistance: Beneficiaries of MassHealth Basic premium assistance receive prescription coverage through their private health insurance program. They do not receive assistance with copayments or deductibles and covered medications are determined by their private health insurance program. Information obtained through 16 The information in this guide is current as of January 2010, but is subject to change at any time. To obtain the most up-to-date information, contact the programs directly.
17 MassHealth Essential MassHealth Essential offers direct benefits or premium assistance to certain long-term unemployed adults who are not eligible for MassHealth Basic as well as noncitizens with special status who are 65 or older and meet all of the eligibility requirements for MassHealth Standard except for immigration status. Individuals qualify for direct coverage if they have no previous health coverage or their coverage does not meet MassHealth standards. Direct coverage provides inpatient and outptient services, medical services, behavior health and well-child screenings, and pharmacy benefits at no premium. Individuals qualify for premium assistance if they have health insurance that meets MassHealth standards. These individuals will receive either full or partial premium assistance towards their insurance plan. Benefits are then determined by the insurance plan. Eligibility For individuals under age 65: An income below 100% of the federal poverty level (FPL) Currently not working and are not eligible for unemployment benefits Not eligible for MassHealth Basic College students who can receive health insurance from his or her college or university and a person whose spouse works more than 100 hours a month are not eligible for MassHealth Essential MCPHS pharmacy outreach program
18 MassHealth Essential Eligibility For individuals over age 65: An income below 100% of the FPL asset limit of $2000 for an individual and $3000 for a married couple living together How to Apply Call the MassHealth Enrollment Center at to request a Medical Benefit Request (MBR) or if over the age of 65, request a Senior Medical Benefit Request Form (SMBR). Prescription Coverage For those who qualify for direct coverage: Beneficiaries of MassHealth Essential direct coverage who are not eligible for Medicare have access to prescription and non-prescription (over-the-counter) medications through MassHealth. The MassHealth Drug List determines coverage for medications and is available online at Most MassHealth Basic beneficiaries pay $1-$3 for each covered medication. 18 The information in this guide is current as of January 2010, but is subject to change at any time. To obtain the most up-to-date information, contact the programs directly.
19 MassHealth Essential Prescription Coverage For medications requiring a prior authorization, the physician s office should contact the MassHealth Drug Utilization Review Program at Beneficiaries of MassHealth Essential direct coverage who are Medicare eligible receive prescription coverage through a Medicare Prescription Drug Plan (Part D). For those who qualify for premium assistance: Beneficiaries of MassHealth Basic premium assistance receive prescription coverage through their private health insurance program. They do not receive assistance with copayments or deductibles, and covered medications are determined by their private health insurance program. Information obtained through MCPHS pharmacy outreach program
20 MassHealth Limited MassHealth Limited provides emergency health services to people who, under federal law, have an immigration status that makes them ineligible for full MassHealth benefits. An emergency medical condition is defined as a "medical condition with acute symptoms (including severe pain) such that absence of immediate medical attention can reasonably be expected to result in serious jeopardy to health. Included in these emergency services are visits to a hospital emergency room, inpatient hospital emergencies including labor and delivery, ambulance transportation, and pharmacy services to treat an emergency medical condition. Eligibility There are several groups of people who are eligible for MassHealth Limited. A person must fall into one of the following categories and their household income and asset levels must be below the following guidelines: Category Income Requirements Asset Pregnant women 200% FPL none Children under age 1 200% FPL none Children ages 1-18 (inclusive) 150% FPL none Applicants immigration status will not be reported to the U.S. Citizenship and Immigration Service (USCIS). Undocumented noncitizens may apply without fear of deportation. Caretakers of children under age % FPL none Disabled adults (19-64) 133% FPL none Individuals ages % FPL $2,000 individual /$3,000 couple 20 The information in this guide is current as of January 2010, but is subject to change at any time. To obtain the most up-to-date information, contact the programs directly.
21 MassHealth Limited How to Apply Call the MassHealth Enrollment Center at to request a Medical Benefit Request (MBR) or if over the age of 65, request a Senior Medical Benefit Request Form (SMBR). Prescription Coverage MassHealth Limited beneficiaries prescription services are typically limited to only antibiotics and emergency medications that are determined to be medically necessary by a physician. Emergency medications may also include oxygen equipment and supplies, insulin, and dialysis. MassHealth Limited beneficiaries may be eligible to receive additional services through Health Safety Net. Included in these services are primary care services and possibly coverage for chronic prescription medications When a member with MassHealth Limited coverage is attempting to get an emergency prescription filled, the pharmacist is required to contact the MassHealth Drug Utilization Review at for approval. If the medication is being requested outside the normal operating hours for Drug Utilization Review, the pharmacist may enter an emergency override code of 3 in the Level of Service Field. Information obtained through MCPHS pharmacy outreach program
22 Medicare Savings Program MassHealth Buy-In Medicare Savings Programs, known as MassHealth Buy-In programs in Massachusetts, provide direct financial assistance to low-income Medicare beneficiaries for their Medicare Part B premiums and, for certain individuals, assistance with deductibles and coinsurance with Part A and Part B. For more information about Medicare Part A, Part B, and the copayments and coinsurance related to these programs, please see Medicare section of the guide. There are three different MassHealth Buy-In programs and eligibility is dependent upon income and asset levels. Individuals who qualify for MassHealth Buy-In for Specified Low-Income Medicare Beneficiaries (SLMB) and MassHealth Buy-In for Qualifying Individuals receive assistance for the full Medicare Part B premium. Individuals qualified for the MassHealth Buy-In, also known as a Qualified Medicare Beneficiary (QMB), receive assistance for Medicare Part B premiums, as well as other Medicare cost-sharing, including the Part A hospital deductible and Part B coinsurance. 22 The information in this guide is current as of January 2010, but is subject to change at any time. To obtain the most up-to-date information, contact the programs directly.
23 Medicare Savings Program MassHealth Buy-In Eligibility There are several groups of people who are eligible for MassHealth Standard. A person must fall into one of the following categories and their household income and asset levels must be below the following guidelines: Program MassHealth Senior Buy-In (QMB) MassHealth Buy-In for Specified Low-Income Medicare Beneficiaries (SLMB) MassHealth Buy-In for Qualifying Individuals (QI-1) Income Requirements under 100% FPL 100% to 120% FPL 120% to 135% FPL Asset Limit On January 1, 2010 assets limits more than doubled because of the Medicare Improvements for Patients and Providers Act (MIPPA). This act requires that asset levels be equal to the asset guidelines of Full Extra Help. In 2011 the asset limits are $6,680 for individuals and $10,020 for couples. MCPHS pharmacy outreach program
24 Medicare Savings Program MassHealth Buy-In How to Apply Call the MassHealth Enrollment Center at to request a Medical Benefit Request (MBR) Prescription Coverage The Medicare Savings Program does not provide direct prescription coverage. Eligibility in any of the Medicare Savings Programs automatically deems a member for full Low Income Subsidy/Extra Help towards a Medicare Part D Prescription Drug Plan. This means the member may enroll into a Medicare Prescription Drug Plan and pay no premium (if the premium is below the benchmark), no deductible, and their copayments for medications will be $ $6.30. If an individual does not select a Medicare Part D plan on their own, one will be randomly assigned to them. For more information turn to the Low Income Subsidy/Extra Help program section of the guide. 24 The information in this guide is current as of January 2010, but is subject to change at any time. To obtain the most up-to-date information, contact the programs directly.
25 MassHealth CommonHealth MassHealth CommonHealth offers health care benefits to disabled adults and disabled children whose income exceeds the maximum amount for MassHealth Standard. Benefits offered are similar to those offered under MassHealth Standard, including inpatient and outpatient services, mental health and transportation support. Eligibility There are several groups of people who are eligible for MassHealth Commonwealth. A person must fall into one of the following categories and their household income and asset levels must be below the following guidelines: Disabled children under age 18 Income: Must exceed 150% FPL You may pay a small monthly premium for CommonHealth. Disabled persons ages who work 40 more or more a month Income: There are no income requirements. If income is greater than 150% FPL, you may pay a small monthly premium for CommonHealth. There are NO INCOME GUIDELINES for disabled individuals under 65 applying for MassHealth CommonHealth. If an individual s household income is higher than 133%FPL than there may be a monthly premium to pay or a one-time deductible. MCPHS pharmacy outreach program
26 MassHealth CommonHealth Disabled persons ages who do not work or, if working meet certain state and federal rules Income: There are no income requirements. If income is greater than 133% FPL, there will be a one time deductible that must be met before CommonHealth begins. How to Apply Call the MassHealth Enrollment Center at or the MassHealth Customer Service Center at to request a Medical Benefit Request Form (MBR). Prescription Coverage MassHealth CommonHealth members receive the same prescription coverage as those who receive MassHealth Standard benefits. Members who are ineligible for Medicare will receive direct coverage through MassHealth and copayments will range from $1-$3. For those eligible for Medicare, enrollment into a Medicare Part D Prescription Drug Plan will be necessary to receive prescription coverage. Information obtained through 26 The information in this guide is current as of January 2010, but is subject to change at any time. To obtain the most up-to-date information, contact the programs directly.
27 Massachusetts Elder Services Plan Program of All-Inclusive Care for the Elderly (PACE) The Massachusetts Elder Services Plan is a comprehensive health program designed to keep frail, older individuals who would otherwise be living in a nursing facility, living at home. Medical benefits, similar to benefits received through MassHealth Standard, and social services are coordinated by a team of health professionals at a designated community-based program. Services are usually provided in an adult day health center, but may also be conducted in the home. PACE plans provide direct prescription coverage for all members, even individuals who have Medicare. Medication coverage is determined by each individual PACE Plan and includes over-the-counter and prescription medications. There are no copayments for prescription medications. Eligibility Aged 55 or older Live in the service area of a PACE organization Are able to live safely in the community Are certified by the state as eligible for nursing home care Agree to receive health services exclusively through the PACE organization An income three times below the federal SSI benefit amount Countable assets no greater than $2000 A spouse s income and assets are not considered in determining eligibility for the Massachusetts Elder Services Plan MCPHS pharmacy outreach program
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