Practical Guide to Prescription Access in Massachusetts

Transcription

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

28 Massachusetts Elder Services Plan How to Apply To apply, call the ESP/PACE site nearest you. Massachusetts PACE sites are listed below: Elder Service Plan of the Cambridge Health Alliance 270 Green Street Cambridge, MA Elder Service Plan of the East Boston Neighborhood Health Center 10 Gove Street East Boston, MA Elder Service Plan of Harbor Health Services 2216 Dorchester Avenue Dorchester, MA Summit ElderCare of the Fallon Community Health Plan 10 Chestnut Street Worcester, MA (TTY: ) Elder Service Plan of the North Shore 37 Friend Street Lynn, MA Upham's Elder Service Plan 1140 Dorchester Avenue Boston, MA 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.

29 Massachusetts Health Care Reform Massachusetts Health Care Reform was enacted in This law requires that adult Massachusetts residents obtain creditable health insurance coverage when financially affordable. Creditable coverage is determined by the Commonwealth Health Insurance Connector Authority (Health Connector). The Health Connector oversees the two programs: Commonwealth Care and Commonwealth Choice. Commonwealth Care provides subsidized or partially subsidized health care for eligible residents with an income below 300% of the Federal Poverty Level. Commonwealth Choice provides coverage for individuals with higher incomes or individuals who do not meet the criteria for subsidized insurance. The Connector acts as a clearinghouse for enrollment into Commonwealth Choice insurance programs. If an individual fails to obtain health insurance coverage for 63 or more consecutive days and have been deemed able to afford health insurance by the Connector, they are subject to tax penalties. The tax penalty is accessed based on one-half the cost of the lowest-priced plan currently available, per month for every month the individual went without creditable coverage. Penalties also vary by age and income. Tax penalties are collected through the personal income tax return. Individuals have the opportunity to file appeals with the Connector asserting that hardship prevented them from purchasing health insurance. Commonwealth Care and Commonwealth Choice are described in more detail on the following pages as well as a description of the Commonwealth Care Bridge, a special program to assist legal immigrants with special status who lost their coverage through Commonwealth Care in August 2009 because of changes in state law. MCPHS pharmacy outreach program

30 Commonwealth Care The Commonwealth Care Health Insurance Program, better known as Commonwealth Care, was created by the Massachusetts Health Reform Law. This program provides subsidized health insurance to eligible Massachusetts adults whose gross income is at or below 300% of the federal poverty level. Commonwealth Care provides comprehensive benefits comparable to private insurance plans. As a Commonwealth Care member, you choose your own doctor and health plan. Each health plan works with a set group of providers, hospitals, and other health care professionals to provide specific health care services. The Commonwealth Care benefit year starts July 1 and ends June 30. Not all Commonwealth Care plans are available in every region of the state. The benefits provided by each MCO must meet guidelines set by the Commonwealth Health Insurance Connector Authority. Plans may also provide additional services beyond the standard guidelines. Commonwealth Care consists of three different plan types: Type 1, 2 and 3. Each plan type has different levels of premiums and copayments for medical and prescription coverage. The plan type an individual is placed in is dependent upon family size and income. For a chart of costs affiliated with each plan type visit the Health Connector website at Information obtained through 30 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.

31 . Commonwealth Care Eligibility Massachusetts Residents U.S. citizens or noncitizens who are lawfully residing in the US as a qualified alien o Effective September 1, 2009 aliens with special status are no longer eligible for Commonwealth Care. For more information please refer to the CWC Bridge Program section. Uninsured o Insured individuals who pay the full cost of insurance themselves such as those paying for COBRA or nongroup coverage are treated as uninsured. o Individuals who are in the waiting period for employersponsored insurance to begin are considered uninsured. Not eligible for employer-sponsored insurance provided in the last six months by a current employer of the applicant or a family member in which an employer pays at least 33% of the cost of an individual premium or 20% of the cost of a family premium Household income below 300% FPL o If income is great than 150% a month premium will be accessed. Those not eligible for Commonwealth Care: College students who are eligible for qualifying health insurance through their school Individuals (and their spouses) collecting unemployment and eligible for the Medical Security Plan Individuals eligible for TRICARE or Medicare MCPHS pharmacy outreach program

32 Commonwealth Care How to Apply To enroll into Commonwealth Care individuals must complete a Medical Benefit Request (MBR) form. This is the same application form for standard MassHealth benefits. All MBRs are reviewed for eligibility into MassHealth programs, Commonwealth Care, and Health Safety Net. To request an application call the MassHealth Enrollment Center at or the MassHealth Customer Service Center at Once eligibility is confirmed an individual is informed that they must select a MCO. Coverage begins on the first of the month after an individual has chosen a health plan and has paid the first month s premium. Individuals may switch MCOs within the first 60 days of enrollment only or during the annual open enrollment period. Some exceptions are made based on special circumstances that are determined by the Connector Authority. Once an individual is deemed eligible for Commonwealth Care they are provided coverage under Health Safety Net for 90 days while they select a Managed Care Plan and are fully enrolled. Through Health Safety Net (HSN) individuals may be able to access necessary medical and prescription assistance. For more information about HSN see page 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.

33 Commonwealth Care You can contact the Commonwealth Health Insurance Connector Authority for more information by visiting their website: or by calling MA-Enroll. Prescription Coverage Beneficiaries of Commonwealth Care receive prescription coverage through their Managed Care Organization (MCO). Each MCO has a unique formulary. For medications requiring a prior authorization the physician s office should contact the MCO directly. Copayments for medications under Commonwealth Care are dependent upon the Plan Type. Copayment waivers are available to individuals who have an income less than 150% FLP on hardship grounds. These individuals must apply for a waiver through the Connector Authority. Copayment waivers are available to individuals who have an income less than 150% FPL and who meet certain criteria. Contact Commonwealth Care for more information MCPHS pharmacy outreach program

34 Commonwealth Choice Commonwealth Choice is a health insurance program for uninsured adult Massachusetts residents who do not otherwise qualify for subsidized health insurance. The program is administered by the Commonwealth Health Insurance Connector Authority (Health Connector). The private insurance plans provided under Commonwealth Choice offer benefits that meet the coverage and cost standards set by the Health Connector, including coverage for pre-existing conditions. Costs for plan coverage and for services depend on age, where you live, and which plan level and insurance company you choose. There are four types of plans offered by each company: Gold plans: higher monthly premiums, no deductibles and low out-of-pocket costs Silver plans: moderate monthly premiums, some deductibles and moderate out-of-pocket costs Bronze Plans: lower monthly premiums, deductibles and higher out-of-pocket costs Young Adult Plans: for independent 18 and 26 year olds including part time students. Young adult plans have lower monthly premiums, deductibles and higher out-of-pocket costs. Most plans have an annual benefit maximum and prescription coverage is optional. 34 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.

35 Commonwealth Choice Eligibility Massachusetts Resident Aged 18 or older There are no income or asset limits for the program. Individuals who are offered health insurance through their employer may instead elect to join a Commonwealth Choice insurance plan. How to Apply To enroll and learn about Commonwealth Choice options visit the Health Connector website or call MA- ENROLL ( ). College students living in Massachusetts temporarily are not eligible to enroll into a Commonwealth Choice plan. People who move out of state are ineligible to keep their Commonwealth Choice insurance. Prescription Coverage All Commonwealth Choice plans must provide prescription coverage. Some plans may have a prescription drug deductible. Coverage for prescriptions is determined by the individual insurance company s formulary. If a prior authorization is needed, the plan should be contacted directly. MCPHS pharmacy outreach program

36 Commonwealth Care Bridge Currently, Commonwealth Care Bridge members are certain legal immigrants (also known as aliens with special status or AWSS) who were dis-enrolled from Commonwealth Care on August 31, 2009 due to a change in state law. Pending Massachusetts Legislative and Executive budget approval is the appropriation for the continuation of health benefits for current Commonwealth Care Bridge members beyond June 30, 2010; and for the establishment of a Waiting List to open up Bridge enrollment for AWSS applicants who would otherwise be eligible for Commonwealth Care Bridge enrollment as space becomes available. On Monday, May 31st a MA21 generated notice was sent to individuals that are eligible but not enrolled, providing advance notice that they will be added to a Waiting List for Commonwealth Care Bridge enrollment. These individuals will be able to continue to receive services through their current health benefits, either the Health Safety Net or MassHealth Limited, as long as they continue to meet the eligibility requirements. Applicants will be added to the Waiting List in the order of when they applied for benefits. Individuals who are legal immigrants, but were not enrolled in Commonwealth Care, will not be eligible for this program. However they may be eligible to receive MassHealth Limited, MassHealth Essential, or Health Safety Net. 36 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.

37 Commonwealth Care Bridge Eligibility Disenrolled from Commonwealth Care on August 31, 2009 Special status legal immigrant How to Apply Effective July 1, 2010 if the member continues to meet eligibility requirements, they will continue to receive benefits. Prescription Coverage Under the Commonwealth Care Bridge program generic medications have a $0 copayment, non-generic medications a $50 copayment. Unlike Commonwealth Care insurance, copayments are not determined by income and there is no annual cap to prescription copayments. Medications covered under this plan are determined by CeltiCare. For prior authorizations or coverage questions please contact CeltiCare. For more information about this program contact the Commonwealth Health Connector Member Service Center at MA Enroll ( ). Information obtained through: mahealthcaretrainingforum.ehs.state.ma.us MCPHS pharmacy outreach program

38 Medicare Medicare is a federal health insurance program that began in The program is administered by the Centers for Medicare and Medicaid services and eligibility is determined by the Social Security Administration. Medicare coverage is available to qualifying individuals 65 years of age and older, people with disabilities, and people with kidney failure receiving dialysis or a kidney transplant. Eligibility is not based on financial need. Medicare coverage is offered in a number of different service delivery options. Beneficiaries have the option to receive services through the Original Medicare program: Medicare Part A and Part B also referred to as Traditional Medicare, or through a number of privately sponsored Medicare Advantage plans. Medicare Part D provides drug coverage either through privately-sponsored prescription drug plans (PDPs) or through Medicare Advantage plans that include Part D drug coverage (MAPDs). The following sections will review the different service options for Medicare medical and prescription drug benefits including: Original Medicare (Part A and Part B) Original Medicare with a supplemental insurance policy (Part A, Part B, & Medigap) Medicare Advantage Plans (also known as Part C) Medicare Part D In 2003, Congress enacted the Medicare Modernization Act (MMA) and created the Medicare Part D prescription drug program. 38 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.

39 Original Medicare (Part A & Part B) Original Medicare coverage has two components: Medicare Part A and Medicare Part B. Medicare Part A is hospital insurance which pays for a portion of hospital stays, skilled nursing facilities, hospice care and home health care if certain conditions are met. Most beneficiaries receive Part A coverage at no cost. Medicare Part B is medical insurance and is optional. It helps pay for doctors services, durable medical equipment and other outpatient care. Some preventive services, like annual check-ups and flu shots may be covered. Most Medicare beneficiaries pay a monthly premium for Part B insurance and premiums can change each year. The Medicare Part B premium is increasing for some beneficiaries in 2011 due to possible increases in Part B costs. This yearly rate change is called the INCOME RELATED MONTHLY ADJUSTMENT AMOUNT or IRMAA. If your income is above $85,000 (single) or $170,000 (married couple), then your Medicare Part B premium may be higher than $ per month. For more detailed information visit Eligibility Several categories of people qualify for Medicare benefits: People 65 and older who are entitled to receive benefits or are a spouse or ex-spouse (marriage lasted at least 10 years), widow or widower (age 65 and over) of a person who qualifies. MCPHS pharmacy outreach program

40 Original Medicare (Part A & Part B) Eligibility People with disabilities who have been receiving Social Security or Railroad Disability payments for 24 months. (Exception: persons with Lou Gehrig s disease (ALS) are eligible for Medicare in the sixth month of disability.) People with end-stage renal disease (ESRD), kidney disease that requires dialysis or transplant. How and When to Apply For persons entitled to retirement benefits: have worked 40 quarters or at least 10 years and are aged 65 or over Those who choose to receive Social Security or railroad retirement benefits at age 65 do not need to apply separately for Medicare. They will be contacted a few months before they become eligible for Medicare and given the information they will need. Social Security automatically enrolls these individuals in Medicare Part A and Medicare Part B unless they formally opt out of the benefit. 40 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.

41 Original Medicare (Part A & Part B) Individuals who delay collecting Social Security benefits, (for instance, because they are working) have a Special Enrollment Period and can contact Social Security during the 8-month period that begins the month after the employment ends or the group health plan coverage ends, whichever happens first, to coordinate their Medicare benefits People with disabilities or end-stage renal disease People who receive or are eligible to receive SSDI benefits or Railroad Retirement Disability benefits are automatically eligible for Medicare Part A and Medicare Part B, twenty-four months after being determined eligible for disability benefits from Social Security or Railroad Retirement Boards. Coverage for Medicare Part B begins on the 25th month. How to apply If you have questions about Medicare eligibility, visit a local Social Security Office or call the Social Security Administration at or TTY/TTD: MCPHS pharmacy outreach program

42 Original Medicare (Part A & Part B) Prescription Coverage Medicare Part A Part A provides coverage for reasonable and necessary medications while a beneficiary is hospitalized in acute care hospitals, skilled nursing facilities, and hospice. Medicare Part B Medicare Part B does not cover most outpatient prescription drugs. Medications that are covered by Part B have a 20% copayment for the patient. The specific categories of medications that are covered under Part B include: Durable Medical Equipment (DME) supply drugs (medications used in pumps, nebulizers, as well as oxygen) Immunosuppressive Drugs Hemophilia clotting factors Oral Anti-Cancer Drugs Oral Anti-emetic Drugs Pneumococcal, Hepatitis B, and Influenza Vaccine Antigens Erythropoietin Parenteral Nutrition Intravenous Immune Globulin Provided in the Home Medicare Part B also covers drugs that are administered at a physician s office as long as the drugs are not typically self-administered by the patients in their home. These Part B covered drugs and biologicals include: Erythropoietin for kidney failure Certain oral medications for cancer patients, Epoietin Alfa (Epogen or Procrit) for severe including anti-nausea drugs anemia Osteoporosis medications for homebound Blood clotting factors patients Immunosuppressive drugs Whole blood (except for the first three pints) 42 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.

43 Medigap Original Medicare with a supplemental insurance policy Medigap is medical insurance that is supplemental to original Medicare and can be purchased through private insurance companies. This insurance is a secondary payer to original Medicare and enrollees will pay a monthly premium for this coverage. Medigap plans may help with the cost of deductibles and coinsurance experienced with original Medicare. In Massachusetts there are two Medigap policy types available through several insurance companies: Core and Supplement 1. For more information on Medigap plans in Massachusetts visit: Eligibility Individuals must have both Medicare Part A and Medicare Part B Medigap companies are not required to sell to beneficiaries under age 65 with End Stage Renal Disease. How to Apply Individuals apply directly with the insurance company offering the Medigap policy. Currently, Medicare beneficiaries in Massachusetts may enroll in a Medigap policy at any time throughout the year. Prescription Coverage Medigap plans provide full supplemental coverage for Medicare Part B prescription medication copayments. These medications have a 20% copayment under Medicare Part B, however with the coverage from Medigap plans individuals pay a $0 copayment for these medications (Part B deductible must be met first with Core Plans). MCPHS pharmacy outreach program

44 Medigap Prescription Coverage Medigap policies do not cover most outpatient drugs. For outpatient prescription coverage an individual should enroll into a standalone (drug coverage benefits only) Medicare Part D prescription drug plan. SPECIAL NOTE: Supplement 2 plans, which are no longer sold in Massachusetts but still have members, provide full prescription coverage. Copayments and medications covered are determined by the Supplement 2 plan. Individuals who are in Supplement 2 plans have creditable coverage. If they elect to leave a Supplement 2 plan they will be unable to return to the plan and may only enroll into a Medicare Part D plan during the Annual Election Period or if they qualify for a Special Enrollment Period. For more information regarding Special Enrollment Period (SEP) qualifications contact the Pharmacy Outreach Program at or visit 44 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.

45 Medicare Advantage Plans (Also known as Medicare Part C) Medicare Advantage Plans, sometimes called Part C, are offered through private health insurers that contract with Medicare to deliver all medical services instead of Original Medicare. Most Medicare Advantage plans provide coverage beyond the benefits provided by Medicare Part A and Part B. Eligibility Individuals must have both Medicare Part A and Medicare Part B Individuals must not have End-Stage Renal Disease (ESRD). Medicare members who are currently enrolled in a Medicare Advantage plan and have ESRD can remain in their current plan. Individuals must live in the service area of the insurance plan. How to Apply Individuals must apply directly with the insurance company. A list of Medicare Advantage plans available in Massachusetts is found in Appendix B. MCPHS pharmacy outreach program

46 Medicare Advantage Plans Prescription Coverage Most Medicare Advantage plans provide supplemental coverage for prescription medications covered under Medicare Part B. These medications typically have a 20% copayment, however with coverage from Medicare Advantage plans individuals may pay as little as a $0 copayment for these medications. Medicare Advantage plans typically also include a Medicare Part D prescription benefit and individuals may not join a prescription drug plan outside of their Medicare Advantage Plan. If a Medicare Advantage member enrolls in a standalone Medicare Part D plan they will be disenrolled from the Medicare Advantage Plan and returned to Original Medicare. If you want prescription drug coverage and it s offered by your plan, in most cases you must get it through your plan. If your plan doesn't offer drug coverage, you can choose and join a Medicare Prescription Drug Plan. 46 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.

47 Medicare Part D Beginning in 2006, Medicare began offering prescription drug coverage, Part D, to everyone with Medicare. This is an optional benefit provided through private companies that have contracted with the federal government. If an individual decides not to join a drug plan when they first become eligible and do not have creditable prescription coverage - another source of drug coverage through a current or former employer or union that is at least as good as the Medicare drug benefit - they will face a lifetime penalty of a 1% increase in their monthly premium for each month they have gone without coverage. There are two ways to get Medicare Prescription drug coverage: Standalone Medicare Prescription Drug Plans Medicare Advantage Plans Eligibility Have Medicare Part A or Medicare Part B. Live in the service area of the Medicare drug plan you want to join Enroll during a valid enrollment period Individuals can enroll into Medicare Part D only during open enrollment or special enrollment time periods. Starting in 2011, the Annual Open Enrollment is from October 15 th to December 7th. MCPHS pharmacy outreach program

48 Medicare Part D How to Apply There are a number of ways to apply for Part D: individuals may apply directly with the insurance company offering the Medicare Prescription Drug Plan or by calling Medicare at They can also apply through Medicare s website: For a list of companies offering Medicare Part D policies in 2011 including contact information, see Appendix C. Prescription Coverage Benefit Structure Exact coverage and costs are different for each Medicare Drug Plan, but all plans must provide at least a standard level of coverage set by Medicare each year. A benefit year runs from January 1 st December 31 st. Financial Assistance Both the Federal and State Government offer programs to reduce the costs of Medicare Prescription Drug Plan costs. The following section includes information about the Massachusetts State Pharmacy Assistance Program (SPAP) called Prescription Advantage. In 2011 there are 34 Medicare Part D plans to choose from, each offering a variety of benefits. Medicare beneficiaries can contact Pharmacy Outreach program for assistance in finding their best options based on the costs and coverage of their medications. 48 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.

49 Prescription Advantage Prescription Advantage is a state pharmacy assistance program (SPAP) offered by the Commonwealth of Massachusetts. This program provides eligible residents with primary or secondary coverage for prescription medications. The benefits provided by Prescription Advantage are dependent upon an individual s age, household size and income, and eligibility for Medicare. Eligibility For those under the age of 65: Must receive Social Security Disability Have a household income below 188% FPL o There is no monthly premium for Prescription Advantage For those over the age of 65: Have a household income below 500% FPL o Households with an income below 300% FPL will pay no enrollment fee for Prescription Advantage Prescription Advantage is FREE to individuals who are 65 or over with Medicare and have an income below 300% FPL. The program provides co-payment assistance for medications when an individual reaches the Coverage Gap or Donut Hole with their Medicare Part D benefit. MCPHS pharmacy outreach program

50 Prescription Advantage How to Apply Prescription Advantage is open to new members. For an application, call Prescription Advantage customer service at AGE- INFO or Prescription Coverage For individuals without Medicare: Prescription Advantage offers primary prescription drug coverage for individuals who are not eligible for Medicare. This coverage has no monthly premium. Copayments, quarterly deductibles, and annual out-ofpocket spending limits are dependent upon income and are on a sliding fee scale. Coverage for medications is determined by Prescription Advantage. For formulary information, contact customer service at For individuals with Medicare Creditable Coverage (Prescription coverage that is as good as Medicare, offered by an employer, retiree benefit, or other source) Prescription Advantage members enrolled in creditable coverage plans may receive assistance. In this case, Prescription Advantage is a secondary benefit. The secondary benefit works as it does with individuals who have Medicare as their primary benefit. Beneficiaries have an out-of-pocket spending limit and copayments will be reduced once an individual has received $2,840 worth of medications (actual cost of medication not the co-payment paid by the beneficiary) for the year The out of pocket spending limit amount and copayment level for prescriptions are dependent upon income. 50 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.

51 Prescription Advantage Prescription Coverage For individuals with Medicare: Prescription Advantage provides supplemental assistance for individuals with Medicare prescription drug coverage. Medicare is the primary drug insurance for Prescription Advantage members with Medicare. Prescription Advantage is a secondary payer. Prescription Advantage offers six levels of benefits based on household size and income and eligibility for federal assistance: Category S0 Members in this group have been determined by Social Security to have a low level of income and assets and have been granted Extra Help. For this group of individuals, Prescription Advantage also provides extended prescription coverage during the entire year for benzodiazepines, a group of medications typically excluded by Medicare Part D plans. Members of Prescription Advantage are provided a special enrollment opportunity to either enroll into a Medicare Part D Plan or change plans. The MCPHS MedLine program can provide assistance and recommendations for the best plan options. MCPHS pharmacy outreach program

52 Prescription Advantage Category S1 Members in this group have been provided partial Extra Help through the Social Security Administration. They will receive assistance throughout the entire year for copayments and will also have extended coverage for benzodiazepines. Prescription Advantage caps the amount a member will spend out of pocket for copayments during a calendar year. Categories S2, S3 & S4 Members in this group receive coverage for benzodiazepines throughout the year. Copayment assistance begins once an individual has reach the coverage gap or donut hole with their Part D plan. In 2011, the gap is reached when the individual has received Prescription Advantage provides coverage for benzodiazepines for its members, a drug class that is currently excluded from Medicare Part D plans. Medications in this class include lorazepam, alprazolam, and clonazepam. $2,840 worth of medications. Prior to reaching the coverage gap, members are responsible for their Medicare Part D plan deductible and copayments. Prescription Advantage also caps the amount a member will spend annually out of pocket for copayments. Category S5 Members in this group are charged a $200 annual enrollment fee. They will not receive copayment assistance from Prescription Advantage until they have paid $3,250 out of pocket for prescription medications, as a Prescription Advantage member, during the calendar year. At this point, Prescription Advantage will cover copayments until the end of the year. 52 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.

53 Extra Help (Low Income Subsidy) Extra Help, also known as the low income subsidy (LIS), is a program of the federal government that assists Medicare beneficiaries with costs affiliated with Medicare Part D. Extra Help does not provide direct prescription coverage. Individuals who qualify for Extra Help receive a subsidy towards the cost of their Medicare plan s monthly premium, annual deductible, copayments, and coverage gap. The level of assistance provided is based on household size, income and resources. Eligibility Individuals qualify for Extra Help by either being classified for automatic eligibility because they are already receiving government assistance or by applying directly to the program. Individuals qualify for automatic (deemed) eligibility if they: have Medicare have full MassHealth benefits; or have MassHealth assistance for Medicare Part B premiums; or receive Supplemental Security Income (SSI) General eligibility guidelines: Medicare Eligible Countable income below 150% FPL Countable resources below: $12,640* if a household of one $25,260* if a household of two *New resource figures are released each October. The above figures represent limits for Extra Help allows for a $20/month allowance for unearned income, $65 a month allowance for earned income and a $1,500 asset allowance for burial. If an individual s income is close to the guidelines then they should still apply. MCPHS pharmacy outreach program

54 Extra Help (Low Income Subsidy) What are countable income and resources? Countable income includes: Unearned income: pensions, annuities, disability, worker s compensation, veterans benefits, spousal support, and rental income. (Interest and dividends are not included) Earned income: wages, net earnings from self-employment, royalties and other sources. Countable resources include: All bank accounts, stocks, bonds, Individual Retirement Accounts (IRA), mutual funds and other cash and liquid assets Real estate other than primary home As of January 1, 2010, more individuals qualify for Extra Help because of changes in the way income and assets are counted. If an individual has applied in the past and was denied they are encouraged to apply again. As of January 1, 2010, under the Medicare Improvements for Patients and Providers Act (MIPPA), changes were made in calculating income and assets for Extra Help. Life insurance is no longer considered an asset In-kind support is no longer considered as countable income. 54 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.

55 Extra Help (Low Income Subsidy) Eligibility Redetermination Eligibility is based on a calendar year. Each September and October, individuals who are currently receiving Extra Help will be notified if they must reapply to continue benefits. Failure to do so may result in the loss of the extra help benefit. Additional Assistance Applications for Extra Help will also initiate the application for the Medicare Savings Programs (MassHealth Buy-in), unless an individual opts out on the application form. Medicare Savings Programs provide assistance with Medicare Part B premiums. Individuals who are qualified for Extra Help have a continuous special enrollment period (SEP) for their Medicare Part D plan. This means that they can enroll or change plans at any time. Individuals who lose Extra Help also receive a special enrollment period to make plan changes. How to Apply The preferred method for applying for Extra Help is online through the Social Security Administration website at Individuals can also apply in person at a local Social Security Office or by contacting Social Security Customer Service to apply over the phone or to request a paper application. MCPHS pharmacy outreach program

56 Extra Help (Low Income Subsidy) Prescription Coverage Extra Help does not provide direct prescription coverage. Coverage for medications is determined by the beneficiary s drug plan. Extra Help does provide a subsidy towards the cost of a Medicare Part D prescription drug plan. There are two levels of Extra Help: full and partial help. Individuals who qualify for Full Extra Help, and do not have MassHealth, pay the following: $0 towards the deductible $2.50* for generic medications $6.30* for brand name medications $0 towards a monthly premium of a basic plan with a premium below the benchmark (the 2011 benchmark in MA is $33.66) Individuals who qualify for Partial Extra Help pay the following: $63* toward the deductible 15% copayment for all covered medications 25%-75% towards the monthly premium of a basic plan with a premium below the benchmark (premium payment percentage is based upon income/assets) *These figures are for Figures may be adjusted annually. Beneficiaries of Extra Help will pay no more than a 15% copayment for their covered medications at any point during the year. Extra Help can also be combined with Prescription Advantage to provide additional cost savings. 56 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.

57 Patient Assistance Programs Patient assistance programs are services offered by many pharmaceutical companies for uninsured, underinsured and other individuals who cannot afford their medications. Assistance may range from reduced cost of drugs to free medicine. Each program has different eligibility and application requirements. Most applications require information both from the patient and from the prescribing physician. Once the patient is determined eligible by the company, the medication will be sent to the patient's home or the physician's office, depending on the program guidelines. Eligibility Eligibility is determined by each patient assistance program. Generally, individuals with a low income (less than 250% - 300% FPL) and no or limited prescription coverage are eligible. Some medication assistance may be available for Medicare beneficiaries who have reached their gap in coverage. How to Apply The MCPHS MedLine program can help to screen individuals and facilitate the application process for patient assistance programs. The following websites also provide information and applications: - Partnership for Prescription Assistance - RxAssist - Needy Meds Many companies offer programs to assist Medicare beneficiaries who have reached the gap in coverage or the donut hole. Programs such as AZ and Me, sponsored by Astra Zeneca, offer assistance with many commonly prescribed medications. MCPHS pharmacy outreach program

58 Copayment Assistance Foundations There are a number of private foundations that have been developed to assist individuals with insurance who are facing high prescription costs and other expenses related to chronic and life altering illnesses. Each foundation has its own eligibility requirements and funding may vary. Funding is often determined on a first come-first served basis. How to Apply Below are a few foundations that offer assistance for a number of medical conditions. Please call the numbers below for eligibility screening. The MCPHS MedLine program can help in finding potential foundation assistance. Call our toll free number, , Monday through Friday between 8:30 am and 5 pm. Chronic Disease Fund HealthWell Foundation American Kidney Fund Patient Access Network Patient Advocate Foundation 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.

59 Generic Pricing Programs Generic pricing programs allow individuals to obtain generic medications at a discount whether or not they have prescription insurance. These programs usually do not have income or insurance criteria. Many retail pharmacy chains now offer over 300 medications for $4 for a one month supply and $10 for a three month supply. Below is a partial list of some of the programs available. For more information regarding how each program works, what medications are available, pricing, and restrictions visit or contact the pharmacy directly by phone or at their web site. Local Retail Pharmacy Chains with Special Generic Programs Rite Aid Stop and Shop Hannaford Grocery Stores Price Chopper Kmart Target Wal-Mart Mail Order Programs RxOutreach Xubex To ensure that possible drug interactions are detected, it is important that an individual notifies each pharmacy they use of their full list of medications. MCPHS pharmacy outreach program

60 HIV Drug Assistance Plan (HDAP) The Massachusetts HIV Drug Assistance Program (HDAP) provides access to critical HIV-related medications for residents of the Commonwealth of Massachusetts who are otherwise unable to obtain these life-saving drugs. HDAP is administered by Community Research Initiative of New England (CRI). Eligibility Massachusetts resident HIV-positive Income below 500% FPL US Citizenship is not required How to Apply Contact the Community Research Initiative of New England / HDAP at to request an application or visit to download an application. CRI, the organization that administers HDAP, also runs the Comprehensive Health Insurance Initiative (CHII). This program provides assistance with Health Insurance Premiums. For more information contact CRI. Prescription Coverage The HIV Drug Assistance Plan provides direct coverage and copayment assistance. HDAP uses an open formulary however there are some exceptions. For medications that are covered, HDAP covers 100% of the costs, including copayments. A list of excluded medications can be found on the CRI website. 60 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.

61 Medication Appropriateness Index Geriatric Considerations Medication Appropriateness Index (MAI) takes a further look at medications, especially those medications that may be found on the Beer s List. The following points should be considered when evaluating a patient s medications: - appropriate indication - effectiveness - correct dose - correct directions - drug/drug interactions - drug disease interactions - practical directions - expense - duplication of therapy - duration of therapy appropriate Hajjar ER, Hanlon JT. Polypharmacy and other forms of suboptimal drug use in older patients. In: Hutchison LC and Sleeper RB. Fundamentals of Geriatric Pharmacology: An Evidence-based approach. Bethesda: MD. American Society of Health-System Pharmacists; p MCPHS pharmacy outreach program

62 Falls/Vitamin D/Calcium In the United States, greater than one-third of adults 65 years and older fall each year. According to the Centers for Disease Control and Prevention (CDC), in 2007, 18,000 adults 65 years and older died from unintentional falls. In 2009, 2.2 million adults 65 and older were treated in an emergency department and more than 581,000 of these patients were hospitalized due to unintentional falls. Falls among older adults: an overview. [database on Internet]. Atlanta (GA):[cited 2011Mar 31]. Updated December 8, Available from: Vitamin D insufficiency has been linked to cardiovascular disease, cancer, hypertension, muscle weakness, and falls. Several trials have been performed to assess the effects of vitamin D on these disease states. Unfortunately, those trials have yet to show a correlation between vitamin D and the various health conditions except for falls. In a short-term randomized controlled trial, elderly people in a nursing home were randomized to receive 200 IU, 400 IU, 600 IU, or 800 IU of vitamin D or placebo. These doses were given daily along with calcium for 5 months. The primary objective was to record the number of fallers and falls within those months. The nursing home residents taking 800 IU of vitamin D had the lowest number of fallers and falls compared to residents taking other doses. The Institute of Medicine (IOM) currently recommends that people under the age of 71 take a total of 600 international units (IU) of vitamin D every day. For people 71 years and older, the recommendation is 800 IU of vitamin D every day. 62 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.

63 Broe KE, Chen TC, Weinberg J, Bischoff-Ferrari HA, Holick MF, Kiel DP. A higher dose of vitamin D reduces the risk of falls in nursing home residents: a randomized, multiple-dose study. J Am Geriatr Soc. 2007;55: Zhang R, Naughton D. Vitamin D in health and disease: current perspectives. Nutr J. 2010;9: Institute of Medicine (IOM) updates vitamin D recommendations. [database on Internet]. Washington DC:[cited 2011Mar 31]. Updated November 30, A meta-analysis claims that people 40 years and older that take 500 mg of supplemental calcium or greater per day are at a higher risk for myocardial infarction and cardiovascular events. The proposed mechanism of these events is vascular calcification. Unfortunately, these people were taking calcium without vitamin D and dietary calcium was not taken into consideration. It has been established that too much calcium from supplements increases a person s risk for kidneys stones and other health issues. Therefore, food should be the first choice for calcium intake. Calcium supplements should only be taken if a person does not get adequate calcium from their diet. According to the National Osteoporosis Foundation (NOF), adults 50 years and older should be taking a total of 1,200 mg of calcium every day along with the recommended amount of vitamin D. Bolland MJ, Avenell A, Baron JA, et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ 2010;341:c3691. Calcium and cardiovascular risk. Pharmacist's Letter/Prescriber's Letter. 2010;26(9): Following is a statement by the national osteoporosis foundation on calcium recommendations. [database on Internet]. Washington DC:[cited 2011Mar 31]. Updated August 2, MCPHS pharmacy outreach program

64 Vaccination updates Medicare Part D now covers both the Zostavax and Tdap vaccination. On March 24, 2011, the FDA approved the Zostavax vaccine in people 50 years and older to prevent shingles. Medicare Part B will cover the annual flu vaccine; pneumococcal vaccine; and Hepatitis B for those at medium to high risk for Hepatitis B. Vaccination parameters The CDC currently recommends that people 60 years and older should receive the Zostavax vaccination. This recommendation will most likely be updated since the FDA has approved Zostavax for people 50 years and older. The CDC recommends that people 65 years and older should receive the Td booster every 10 years. People 65 years and older who have not previously received Tdap may be vaccinated with Tdap and then continue with Td boosters every 10 years. The CDC recommends that all adults receive the influenza vaccination yearly. Flu season begins in September when vaccines are typically available. The CDC recommends that people 65 years and older receive one dose of the pneumococcal polysaccharide (PPSV) vaccination. If people 65 years and older were vaccinated 5 or more years previously and were less than 65, a one-time revaccination is recommended. FDA approves Zostavax vaccine to prevent shingles in individuals 50 to 59 years of age. [database on Internet]. Silver Spring MD:[cited 2011Mar 31]. Updated March 24, Recommended Adult Immunization Schedule. [database on Internet]. Washington DC:[cited 2011Mar 31]. Updated February 4, 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.

65 Examples of Potentially Inappropriate Medications in the Elderly Inappropriate Medication Propoxyphene (now off the market) Indomethacin (most CNS side effects of NSAIDs) Meperidine (not as effective in elderly, confusion) Amitriptyline (confusion and sedation) Chlordiazepoxide, diazepam, flurazepam (longacting benzodiazepines) Digoxin (watch dose for decreased renal clearance) Amiodarone Diphenhydramine (potent anticholinergic) Alternative Acetaminophen Acetaminophen or low dose NSAIDs Acetaminophen, tramadol, other narcotics SSRI Lorazepam, oxazepam, alprazolam, temazepam Should not exceed >0.125mg/d except for treating atrial arrhythmias Caution- associated with QT interval problems and risk of provoking torsades de pointes Caution- confusion/sedation; other hypnotics, loratadine Other SSRI Fluoxetine ( long half life, sleep disturbances, agitation) Bupropion (may lower seizure threshold) Caution use Ferrous Sulfate >325mg/d Caution use, increased incidence of constipation Fick DM, Cooper JW, Wade WE. Updating the Beers Criteria for potentially inappropriate medication use in older adults. Arch Int Med 2003;163: MCPHS pharmacy outreach program

66 Appendices Appendix A Referrals and Resources Appendix B 2011 Medicare Advantage Plans Appendix C 2011 Medicare Part D Plans, Prior Authorization Info, Websites Appendix D 2011 No Premium Part D Plans for MassHealth Beneficiaries Appendix E Limited Newly Eligible Transition Program (LiNet) 66 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.

67 Appendix A Referrals and Resources MCPHS MedLine Program SHINE Prescription Advantage /option 2 MassHealth Customer Service Health Safety Net Medicare Social Security Health Care For All Medicare Advocacy Project MCPHS pharmacy outreach program

68 Appendix B 2011 Medicare Advantage Plans Plan Name Contact Number for Members Contact Number for Non- Members AARP MedicareComplete Choice Regional PPO Fallon Senior Plan Plus Enhanced Rx (HMO) Fallon Senior Plan Saver Basic Rx (HMO) Fallon Senior Plan Saver Enhanced Rx (HMO) Fallon Senior Plan Standard Rx (HMO) HNE Medicare Basic HMO HNE Medicare Plus HMO Medicare HMO Blue PlusRx 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.

69 Medicare PPO Blue PlusRx Tufts Medicare Preferred HMO Basic Rx Tufts Medicare Preferred HMO Prime Rx Plus Tufts Medicare Preferred HMO Value Rx Special Needs Plans Evercare Senior Care Options) NaviCare HMO (Worcester County) Commonwealth Care Alliance Senior Whole Health Contact Number MCPHS pharmacy outreach program

70 Appendix C 2011 Medicare Part D Plans NOTE: BOLDED plans denote $0 premium for extra help or dual eligible beneficiaries Medicare Drug Benefit Plan Name Member Contact Number Non Member Contact Number Prior Authorization Contact Numbers Websites Aetna Medicare Rx Essentials Aetna Medicare Rx Plus Aetna Medicare Rx Premier AARP MedicareRx Preferred AARP MedicareRx Enhanced Advantage Star Plan Rx America Blue Medicare Rx Value Plus Blue Medicare Rx Premier Bravo Rx CIGNA Medicare Rx Plan One CIGNA Medicare Rx Plan Two Community CCRx Basic Community CCRx Choice CVS Caremark Value CVS Caremark Plus Envision Rx Plus Silver Envision Rx Plus Gold First Health Part D-Secure 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.

71 First Health Part D-Premier Health Net Orange Option Health Net Orange Option HealthSpring Pres Drug Plan Reg X Humana Walmart Preferred Rx Humana Enhanced Humana Complete MedcoMedicare Pres Plan Value MedcoMedicare Pres Plan Choice Medicare Rx Rewards Standard Sterling Rx Tufts Standard org Tufts Health Enhanced org UA Medicare Part D Rx Covg WellCare Classic Wellcare Signature MCPHS pharmacy outreach program

72 Appendix D 2011 No Premium Part D Plans for MassHealth Beneficiaries MassHealth/Full LIS beneficiaries AARP MedicareRx Preferred BravoRx CVS Caremark Value Health Net Orange Option Humana Walmart Preferred RX Advantage Star Plan by RxAmerica Community CCRX Basic First Health Part D Premier Health Spring Prescription Drug Plan MedicareRx Rewards Standard Wellcare Classic 72 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.

73 Appendix E Limited Newly Eligible Transition Program (LiNet) On January 1, 2010, the Medicare Limited Income Newly Eligible Transition (Limited Income NET) Program replaced the Point-of-Sale Facilitated Enrollment. The Humana Company administers the Limited Income NET Program. The Limited Income NET Program ensures that individuals with Medicare s Low-Income Subsidy (LIS), or extra help, who are not yet enrolled in a Part D prescription drug plan are still able to obtain immediate prescription drug coverage. Following is the necessary billing information: The BIN is The PCN is The Cardholder ID = the Medicare Claim Number with alpha character The Group ID may be left blank The Patient ID = Medicaid ID or Social Security # or Medicare # - no alpha character MCPHS pharmacy outreach program

74 Proudly sponsored by Astra Zeneca 74 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.

75 MCPHS pharmacy outreach program