Location:
DRUGS- PHARMACEUTICAL ASSISTANCE PROGRAMS;
Scope:
Other States laws/regulations;

OLR Research Report


April 23, 2012

 

2012-R-0171

STATE PHARMACEUTICAL ASSISTANCE PROGRAMS

By: Hendrik DeBoer, Research Fellow

Mark Randall, Research Fellow

You asked whether other states have pharmaceutical assistance programs similar to ConnPACE.

SUMMARY

ConnPACE is a state-funded pharmaceutical assistance program that helps eligible senior citizens and people with disabilities afford the cost of most prescription medicines, as well as insulin and insulin syringes. Eligibility for the program requires Connecticut residents to (1) be age 65 or older, or younger and have a permanent disability; (2) be ineligible for Medicare; and (3) have income under $26,000 if single and $35,000 if married.

Prior to 2011, ConnPACE was a “wraparound” program for individuals receiving Medicare Part D (pharmacy) benefits. Currently, ConnPACE eligibility is limited to those individuals who are ineligible for Medicare, thus the program provides benefits to a much smaller number of individuals. The state's Medicare beneficiaries now get “extra help” paying for prescriptions from the federal government. For a recent history of ConnPACE and changes related to Medicare Part D, see OLR Report 2011-R-0299.

When Medicare Part D was implemented in 2006, many states converted their pharmaceutical assistance programs to wraparound programs, which further limit the out-of-pocket expenses for Part D participants. In order to qualify for these wraparound programs, those eligible for Medicare must enroll in a Part D plan. Some states discontinued their pharmaceutical assistance programs altogether when the federal government began providing the extra help.

According to the National Conference of State Legislatures, 17 other states currently have pharmaceutical assistance programs for seniors or people with disabilities. State programs vary with respect to eligibility, benefits, and co-payments or premium costs. Some states require enrollment in Medicare Part D and others require an application for the federal extra help (i.e., Low Income Subsidy (LIS)). Income limits for eligibility are typically tied to some percentage of the federal poverty level (FPL) (100% of the FPL for one person in 2012 is $11,170).

Table 1 provides a brief summary of the 17 states' programs. More detailed explanations may be obtained through the hyperlinks within the table and those at the end of the report.

Table 1: State Pharmaceutical Assistance Programs

State

Program Name

Eligibility Requirements

Benefit

Co-payment/

Premium

Delaware

Delaware Prescription Assistance Program (DPAP)

- Must be at least 65 or qualified for Social Security Disability benefits

- Income must be at or below 200% of the FPL or prescription costs must exceed 40% of annual income

- Must have no prescription insurance other than Medicare Part D

Provides each eligible individual with up to $3,000 per year toward medically necessary prescription drugs

Beneficiaries must make a co-payment of 25% of the cost of the prescription, or a minimum of $5

Illinois

Illinois Cares Rx

- Must be at least 65 or at least 16 and disabled

- Income limit for single household is $22,340 and $30,260 for two person household

- Medicare recipients must have applied for LIS

- For Medicare Part D participants, pays the premiums and helps lower co-payments. - - For those not eligible for Medicare, provides direct prescription drug coverage

Co-payment depends on type of drug, whether the person is covered by Medicare, and whether the person is in the Part D coverage gap (“donut hole”) (between $5 and $20)

Indiana

HoosierRx

- Must be at least 65 and enrolled in Medicare Part D

- Income must be at or below $16,485 for a single person and $22,095 for a married couple

- Must have applied for LIS and been awarded partial extra help or been denied LIS for having resources above the legal limit

Pays up to $70 per month of the monthly Part D premium

N/A

Iowa

Iowa Medication Voucher Program

- Income must be at or below 200% of the FPL

Provides vouchers for 90-day supplies of prescribed medications

Beneficiaries must pay a $3.00 co-payment per voucher

Maine

Low Cost Drugs for the Elderly and Disabled Program

- Must be at least 62 or at least 19 and qualified for Social Security Disability benefits

- Income must be at or below 185% of the FPL or prescription costs must exceed 40% of annual income

- For Medicare Part D participants, helps pay premiums and lowers co-payments

- For those not eligible for Medicare, pays 80% of qualifying drugs

Beneficiaries must pay a $2.00 co-payment per prescription

Maryland

Senior Prescription Drug

Assistance Program (SPDAP)

- Must be enrolled in a Medicare Part D plan

- Income must be at or below 300% of the FPL

- Pays up to $35 per month of the monthly Part D premium

- Pays for drug costs of members in the Part D “donut hole” phase

Beneficiaries must pay a 5% co-payment per prescription

Massachusetts

Prescription Advantage

- Must be at least 65 and not enrolled in Medicaid or meet state disability guidelines, work 40 hours or fewer per month, and have income at or below 188% of the FPL

- Participants eligible for Medicare must be enrolled in Medicare Part D or a plan offering equal or greater coverage and must not have income exceeding 500% of the FPL

- Medicare recipients must have applied for LIS

- For Medicare Part D participants, helps pay premiums for certain member categories and lowers co-payments

- For those enrolled in plans offering greater or equal coverage to Medicare Part D, may provide assistance with plan co-payments

- For those not eligible for Medicare, prescription drug expenses are covered after deductible and there is an annual out-of-pocket spending limit

Beneficiaries ineligible for Medicare must pay a co-payment up to spending limit

Missouri

Missouri Rx

- Must be enrolled in a Medicare Part D plan

- Income must be $21,66 or less if single, and below $29,140 if married

Pays for 50% of members' out of pocket costs remaining after their Medicare Prescription Drug Plan pays

N/A

Montana

Big Sky Rx

- Must be enrolled in Medicare Part D

- Income must be at or below $22,340 if single, and $30,260 if married

Pays up to $36.02 per month of the monthly Part D premium

N/A

Nevada

Nevada Senior Rx and Disability Rx

- Must be at least 62 or at least 18 with a verifiable disability

- Income must be at or below $26,054 if single, and $34,731 if married

- For Medicare Part D participants, helps pay premiums and prescription costs after reaching Part D coverage limit

- For those not eligible for Medicare, provides annual coverage up to $5,100 for prescription costs

Beneficiaries without Medicare must pay co-payments based on drug type ($10 for generics, $25 for brand names)

New Jersey

Pharmaceutical Assistance to the Aged and Disabled and Senior Gold

- Must be at least 65 or at least 18 and receiving Social Security Disability benefits

- Income must be at or below a certain level (differs between two programs)

- Those enrolled in Medicare Part D must apply for LIS

- Helps pay premiums, co-payments, and other costs for Medicare Part D

- Beneficiaries must pay co-payments depending on drug type ($5 for generics, $7 for brand names)

New York

Elderly Pharmaceutical Insurance Coverage (EPIC)

- Must be at least 65 and enrolled in a Medicare Part D plan

- Income must be below $35,000 if single, and $50,000 if married

- Must not be receiving full Medicaid benefits

Participants receive partial donut hole coverage and co-payment assistance

Beneficiaries pay co-payments based on drug price (between $3 and $20)

Pennsylvania

Pharmaceutical Assistant Contract for the Elderly (PACE), PACE Needs Enhancement Tier (PACENET), and PACE Plus Medicare

- Must be at least 65

- Income must be at or below a certain level (differs between programs)

- Cannot be enrolled in state's Medicaid prescription benefit

- For Medicare Part D participants, helps pay premiums and lowers co-payments

- For those not enrolled in Medicare Part D, helps pay for prescription drugs

- Beneficiaries pay co-payments based on which program they are enrolled in and the drug type (between $6 and $15)

- Those not enrolled in Medicare Part D pay a monthly premium

Rhode Island

Rhode Island Pharmaceutical Assistance To The Elderly (RIPAE)

- Must be at least 65 or between 55 and 64 and receiving Social Security Disability benefits

- Must be enrolled in a Medicare Part D plan

- Income must be at or below a certain level

State pays a percentage of the cost of certain prescription drugs depending on beneficiary's income level

Beneficiaries pay the percentage of the cost not covered by the program or Medicare

Vermont

VPharm, VHAP-Pharmacy, and VScript

- Must be at least 65 or disabled

- Income must be at or below approximately $3,600 per month for one person

- For those enrolled in Medicare Part D, helps lower co-payments

- For those not enrolled in Medicare Part D, helps pay for prescription drugs

- Beneficiaries must pay a premium based on income levels

Wisconsin

SeniorCare Rx

- Must be at least 65

- Must not be enrolled in Medicaid

- Pays prescription drug expenses over the cost of deductible (depends on income level)

- Beneficiaries must pay a co-payment depending on the drug type ($5 for generics, $15 for brand names)

Wyoming

Prescription Drug Assistance Program (PDAP)

- Income must be at or below 100% of FPL

- Must not be eligible for Medicare

- Pays the cost of up to three prescriptions a month

- Beneficiaries must pay a co-payment depending on the drug type ($10 for generics, $25 for brand names)

Source: State pharmacy assistance program websites

HYPERLINKS:

NCSL State Pharmaceutical Assistance Programs:

http://www.ncsl.org/issues-research/health/state-pharmaceutical-assistance-programs-2011.aspx#AK

Medicare Rights Center: State Pharmaceutical Assistance Programs

http://www.medicareinteractive.org/uploadedDocuments/mi_extra/SPAP-Chart.pdf

Q1Medicare.com: State Pharmacy Assistance Programs: http://www.q1medicare.com/PartD-State-PharmacyAssistancePrograms.php

Medicare.Gov: State Pharmaceutical Assistance Programs: https://www.medicare.gov/pharmaceutical-assistance-program/state-programs.aspx?AspxAutoDetectCookieSupport=1

HD/MR:ro