FILLING THE GAPS IN MEDICARE PART D:
A Survey of Drug Store Discount cards, Pharmaceutical company programs,
and state programs to provide Prescription drug assistance
On January 1, 2006, the Medicare Part D prescription drug benefit went into
effect. As a result, the availability of discount drug card programs and
related assistance has changed, as has the way in which beneficiaries may use
these programs to achieve maximum drug coverage. The resources listed
below include programs that can act as a supplement to Part D, and some that
operate independent of Part D. The monetary value of assistance provided
by programs that operate independently of the Part D drug benefit cannot count
toward out-of-pocket costs for Part D; in other words, assistance from
independent programs will not count toward meeting the deductible, the initial
coverage limit, or catastrophic coverage.
The Center for Medicare
Advocacy does not endorse the use of any particular assistance program, and
encourages beneficiaries to research all their options carefully.
I. Pharmacy and Retailer Prescription Drug Discount Programs
Discount drug cards offered through
chain pharmacies for a small monthly premium provide discounts on a number of
services, including prescription drugs.
Those with a Part D plan may use a discount card, but the two drug
programs operate independently of one another.
That is, drug card discounts cannot be applied to Part D prices or to
Part D copayments, nor can the cost of drugs
purchased using a discount card be applied toward Part D out-of-pocket
costs. Discount cards may be useful for
those whose drugs are excluded by Part D, or for those who have reached the
donut hole but will not have enough drug costs to reach catastrophic
coverage. Discount cards also provide
discounts on services not covered by Medicare, such as vision and dental. The utility of these cards depends on each
individual’s situation and will likely require detailed calculations of costs
and savings.
This list is not exhaustive. Some chains such as Walgreens
(www.walgreens.com)
and Rite Aid (www.riteaid.com)
have links to discount cards
sponsored by pharmaceutical companies or to discount websites, and therefore
have not been included in this list.
1. Eckerd HealthCare
Discount Plan
The Eckerd HealthCare Discount Plan is a low-cost discount membership
program offering savings on health services such as prescription drugs, vision,
hearing, podiatric, and chiropractic care. A description of this plan can be
found at
www.eckerddiscountplan.com.
Eligibility
One membership covers an entire family. The membership also covers any
dependents of the member living away from home.
Discounts
-
Dental: Eckerd offers discounts on many dental care procedures including 15-50% off
the national average price for preventative and diagnostic care and a minimum
of 15% off providers’ regular fees for all other procedures.
-
Pharmacy: Eckerd offers up to 30% off regular retail prices for most prescription
drugs. Mail order services also can be discounted.
-
Vision:
Discounts off eye examinations, eyeglasses, even sunglasses
are available from JCPenney Optical Centers on a fee
schedule. Other providers offer discounts of up to 20% off exams, lenses,
frames and contacts.
-
Hearing: Eckerd offers discounts of up to 20% through a network of audiologists
throughout the
U.S.
-
Podiatric: Eckerd offers discounts of up to 50% through a network of podiatric specialists.
-
Chiropractic: Eckerd offers discounts of up to 50% through a network of licensed
chiropractors.
2. CVS Pharmacy Health
Savings Pass Program
The CVS Pharmacy Health Savings Pass Program is a discount membership
program that provides 5-50% savings on prescriptions, dental, hearing, and
vision products. A description of this plan can be found at
www.cvshealthpass.com.
Eligibility
To become a member of the CVS Plan, one must be 50
years of age or older. An established membership fee must be paid when signing
up for the program. A membership is not transferable and can be used only by
the original member and one household member age 50 or older. A member must
present a membership card at the time a purchase is made.
Discounts
-
Pharmacy: CVS offers a 5-50% discount on every prescription filled. There are no
limits on quantities or brand names.
-
Dental: CVS offers savings of up to 60% on many dental procedures, including
routine oral exams, cleanings and major work such as crowns, root canals, and
dentures. The CVS Plan partners with a network of 20,000 dentists and
specialists. This plan does not require claim forms, deductibles or maximums.
-
Hearing: The CVS Plan provides access to over 1500 audiologists nationwide. Savings
for hearing services range from 20% off a provider’s usual charge for
conventional hearing aids to 10% off programmable/digital hearing aids. CVS
does not charge for annual follow-up cleaning and check of hearing aids
purchased through the plan.
-
Vision: CVS offers access to a national network of over 19,000 vision providers
including the LensCrafters chain. A member receives
savings on eye exams, contact lenses and accessories, LASIK and PRK laser
vision procedures.
-
NurseLine:
CVS offers health information and education 24 hours a day via telephone,
the Internet, or informational recorded messages at no cost. A member can call
NurseLine toll free to speak with an experienced registered
nurse that can help with everything from self-care tips to preparation for an
upcoming doctor visit. NurseLine also provides
recorded messages from the Health Information Library on a variety of health
and well being issues. CVS also provides Healthforums.com which is an
interactive Internet application that gives instant access to reliable health
and well-being information.
II. Pharmaceutical Company Prescription Drug Discount Programs (Patient
Assistance Programs, or PAPs)
PAPs operating outside of Medicare Part D, that offer free or
reduced-cost prescription drugs - mostly to persons with low incomes and no
insurance - may still be able to offer assistance to Medicare Part D
enrollees. Assistance from PAPs does not count toward Medicare Part D out-of-pocket
costs (i.e. toward meeting the deductible, initial coverage limit, and
catastrophic coverage). PAPs usually require patients to apply for and be rejected
by all other available public assistance as a condition of eligibility,
including the Part D low-income subsidy.
For more on how PAPs interact with Medicare
Part D, read our Weekly Alert (AlertPDFs\2006\06_05.04.PAPs.pdf).
This
is not an exhaustive list. Many PAPs are deciding whether to open their programs to
Medicare Part D enrollees, or are developing new programs for Part D
enrollees. We will update the site as
new information becomes available.
1.
Schering-Plough
Schering-Plough offers two
patient assistance programs that are available to Part D enrollees:
Commitment to Care, which offers free outpatient
prescription drugs for cancer and hepatitis, and SP-Cares, which offers
allergy, asthma, dermatology and cardiovascular prescription drugs.
Eligibility
-
Commitment to Care:
Provides assistance to
U.S.
residents with cancer or hepatitis with incomes below 325% of Federal poverty
(or 340% in some areas). Medicare beneficiaries must meet an additional test
requiring that their prescription drug expenses exceed 3% of their annual
household income. Applicants may be enrolled in a Part D plan. Those who do not must prove that they are
unable to find an affordable plan. Beneficiaries are also required to apply to,
and be rejected by, the low-income subsidy.
-
SP-Cares: Provides
assistance with allergy, asthma, dermatology and cardiovascular prescription
drugs to
U.S.
residents with incomes below of 250% of Federal poverty. Medicare beneficiaries must meet an
additional test requiring that their prescription drug expenses exceed 3% of
their annual household income.
Applicants may be enrolled in a Part D plan. Those who do not must prove that they are
unable to find an affordable plan. Beneficiaries are also required to apply to,
and be rejected by, the low-income subsidy.
Discount
-
Commitment to Care:
Free
Schering-Plough medication for remainder of year after recipients meets 3%
out-of-pocket requirement. Confirmation
by phone of eligibility after 6 months.
Full reevaluation of eligibility every year.
-
SP-Cares: Free 3-month supply of medication, sent to
the ordering physician. Physician must
renew request for a new 3-month supply.
Full reevaluation of eligibility every year.
More information on Schering-Plough’s patient
assistance programs can be found at
http://www.schering-plough.com/schering_plough/pc/patient_programs.jsp. Information about how Medicare beneficiaries
can obtain drug assistance through these patients assistance programs, see
http://www.schering-plough.com/schering_plough/news/release.jsp?releaseID=844149.
2. Merck
Merck provides 26 of its drugs for free to qualifying individuals, through
several different assistance programs.
Eligibility
Assistance is available to
U.S. residents with incomes of $19,600 or less
for individuals, $26,400 or less for couples, or $40,000 or less for a family
of four in the continental
United
States.
For certain exceptions, the income limit is $39,200 for individuals,
$52,800 for couples, $80,000 for a family of four in the continental
United States. Medicare beneficiaries who elect not to
enroll in a Part D plan are eligible.
Beneficiaries enrolled in a Part D plan who have extraordinary financial
and medical circumstances may also qualify.
Discount
Free 90-day supply of up to 3 Merck medications (of those offered through their
programs), with a maximum of 3 refills.
Full reapplication is required every 12 months.
More
information on Merck’s patient assistance programs can be found at
http://www.merckhelps.com/patientassistance/. For information about how Medicare
beneficiaries can obtain drug assistance through these patients
assistance programs, see
http://www.merck.com/newsroom/press_releases/corporate/2006_0302.html.
3.
AstraZeneca
AstraZeneca
provides 20 of its drugs for free to qualifying individuals through the
AstraZeneca Foundation Patient Assistance Program.
Eligibility
Assistance is available to
U.S.
residents with incomes below $24,500 per individual or $33,000 for
couples, or $50,000 for a family of four. For Medicare beneficiaries enrolled in Part
D, they must apply for and be rejected by the low-income subsidy (LIS). Those who have applied for LIS may temporarily
qualify for assistance while their LIS eligibility is being determined. All Medicare beneficiaries who choose not to
enroll in a Part D plan are eligible if they meet the income requirements of
the PAP.
Discount
Free medications for those who qualify. Eligibility and the number of month’s supply each
patient may receive are determined on a case-by-case basis.
More information on AstraZeneca’s
patient assistance program can be found at
http://www.astrazeneca-us.com/content/drugAssistance/patientAssistanceProgram/default.asp. Information about coverage for Medicare
beneficiaries is at
http://www.astrazeneca-us.com/modules/PRMS/display.asp?id=221548.
4. GlaxoSmithKline
Eligibility
Medicare beneficiaries enrolled in Part D
with incomes below 200% of federal poverty for Bridges to Access, and below
350% of federal poverty for Commitment to Access (oncology medications), who do
not qualify for the Low-Income Subsidy, and who were enrolled in a GSK patient
assistance program Jan. 1, 2006; Part D beneficiaries may then qualify for
transitional assistance through the end of the year. Those who have applied for the low-income
subsidy (LIS) may temporarily qualify for assistance while their LIS
eligibility is being determined. All
Medicare beneficiaries who choose not to enroll in a Part D plan are eligible
if they meet the income requirements of the PAP.
Discount
-
Bridges to Access provides a 60-day supply of
outpatient drugs for a $10 copayment at the
pharmacy. Refills are delivered via
mail-order. Patients can receive a maximum of two 90-day refills via mail. Eligibility can be extended for an additional
6 months after the two 90-day supplies have been used. Full reapplication is required every 12
months.
-
Commitment to Access provides a free 30-day supply to
the prescriber.
The patient is initially eligible for 60-days, and can have eligibility
extended to six months, and then an additional six months, for a total of 14
months. Each 30-day supply must be
requested. Full reapplication is
required at the end of the initial 14-month enrollment, and then every 12
months thereafter.
More information on GlaxoSmithKline’s patient
assistance programs can be found at
http://bridgestoaccess.gsk.com/
and
http://commitmenttoaccess.gsk.com/.
5.
Other programs
Several other programs are available for those choose not to enroll in a
Part D plan. Many programs require
patients to apply for, and be rejected by, the low-income subsidy in order to
be eligible; however a beneficiary might be eligible while in the process of
having their eligibility for the low-income subsidy determined. For a complete list of programs available and
whether Medicare beneficiaries may qualify, see
www.rxassist.org/docs/medicare-and-paps.cfm.
III. Insurance Company Prescription Drug Discount Program
BlueCross/BlueShield
The BlueCross
BlueShield Service Benefit Plan for Federal employees
offers a Discount Prescription Drug Program to members for specific drugs not
covered under the regular prescription drug benefit. It provides discounts on
prescription drugs at most retail pharmacies. Information on this program can
be found at
www.fepblue.org/openseason.
Eligibility
The Blue Cross Blue Shield Service Benefit Plan is offered to all members of
Blue Cross Blue Shield. The cost of these benefits is not included in a Service
Benefit Plan premium and charges for these medications do not count toward the
out-of-pocket maximum.
Discount
Participants can expect to save an average of 20% off certain prescription
drugs. Discounts apply to commonly used prescription drugs at participating
retail pharmacies.
IV. State Pharmaceutical Assistance Programs (SPAPs)
SPAPs are state-funded programs that provide
low-income and medically needy senior citizens and individuals with
disabilities financial assistance for prescription drugs. Twenty-three states and one territory offer
these programs to Part D enrollees.
Assistance from qualified SPAPs counts toward
out-of-pocket costs. CMS has published a
list of qualified SPAPs available at
www.cms.hhs.gov/States/Downloads/QualifiedSPAP4.15.08.pdf. The National Conference of State Legislatures
keeps a list of SPAPs and other state programs, and
closely follows new developments in state drug coverage at
http://www.ncsl.org/programs/health/SPAPCoordination.htm.
V. National Prescription Drug Assistance Programs
1. AIDS Drug Assistance Program (ADAP)
www.atdn.org/access/states/
ADAPs provide crucial prescription drug coverage to HIV/AIDS patients as a
payer of last resort. Assistance from
ADAPs does count toward out-of-pocket costs as they are partially funded with
federal dollars.
Who qualifies?
Low-income, uninsured or underinsured with
HIV/AIDS.
Income restrictions?
Vary from state to state
2.
National Organization for Rare Disorders (NORD)
www.rarediseases.org
Who qualifies?
NORD’S Medication Assistance Programs help people
obtain Rx they could not otherwise afford or that are not yet on the market.
Income restrictions?
Provides prescriptions on a sliding scale
based on income.
3.
TRICARE 1-877-363-6337
TRICARE is a health care plan, available to more than 6 million military
personnel and their families, which is administered by private contractors who
are selected for participation through a competitive procurement process.
Medicare considers TRICARE coverage to be
“creditable.” Those who keep TRICARE and do not enroll in a Part D plan with
NOT be assessed a penalty if they decide to enroll in Part D during a future
enrollment period.
Who qualifies?
Military retirees who have served at least 20 years
are eligible for the prescription drug assistance program. Eligibles must be
registered with Defense Enrollment Eligibility Reporting System (DEERS).
Income restrictions?
None.
VI. Mail Order Discount Pharmacies
1.
OMC
www.advantagerx.com
1-800-809-1389
Specializes in diabetic and respiratory supplies.
No fee. Discount depends on item.
2.
APP Pharmacy
www.accentrx.com 1-800-677-4323
Specializes in long-term and chronic medications.
No fee. Discount depends on Rx.
3. DrugPlace.com
www.drugplace.com 1-800-881-6325
Discounts on generic Rx only. Shipping and handling
fees apply. Discount depends on manufacturers’ current prices.
4. Express Script
www.express-script.com
1-800-854-4469
Discounts on Rx, dental, hearing, and eye care.
Discount depends on quantity and manufacturer’s current price.
5.
Liberty
Health Supply
www.libertymedical.com 1-866-691-9277
(Diabetes) 1-866-486-2383 (Respiratory) 1-888-800-8824 (General Rx)
Specializes in diabetic and ostomy supplies.
Discount depends on item.
VII. Internet Based Discount Programs
1.
www.canadadrugs.com
1-800-226-3784
pharmacists@canadadrugs.com
More than 2,300 Rx available from Manitoba Pharmacy
Association. Discount depends on Rx.
2.
www.canadapharmacy.com
1-800-891-0844
customerservice@canadapharmacy.com
Discounts on Rx. Discount depends on RX. $10
shipping and handling fee per order.
3.
www.canadameds.com
1-877-542-3330
pharmacists@canadameds.com
Discounts on Rx, diabetic supplies, vitamins/nutrition,
and home health care items. $9.95 shipping and handling
fee per Rx package, plus $40 CDN in addition for international destinations.
30-70% discount.
4.
www.canadarx.net
Specializes in chronic and acute
Rx, and HIV/AIDS treatment. Limit
3-month supply. You can mail order Rx from
U.S. or make an appointment to
purchase Rx at participating Canadian pharmacies. $7.50 handling fee per item,
plus $18.50 per parcel for shipping. Discount depends on Rx.
VIII. Paying for Drugs with the Incurred Medical Expense
Deduction: Help for Some Medicaid Beneficiaries
Medicaid beneficiaries who live in nursing homes or in assisted living
facilities under a home and community-based waiver are ordinarily required to
pay most of their income to the facility as their “share of cost.” Nonetheless,
a provision in the Medicaid law allows Medicaid beneficiaries to deduct the
costs of certain medical expenses from the amount they must pay for their
nursing home or assisted living facility stay. When a beneficiary uses this
“incurred medical expense deduction,” the state Medicaid agency makes up the
lost amount in its own payment to the nursing home or assisted living facility.
The provider gets the same Medicaid rate that it would have gotten if the
beneficiary had not used the deduction, but more of the rate is paid by the
state, and less by the beneficiary.
In calculating a Medicaid beneficiary’s share of cost for a nursing home or
assisted living stay, the Medicaid law requires states to allow a beneficiary to
pay for health insurance premiums, deductibles, and coinsurance, without any
limitations on those payments. It also allows a beneficiary to deduct the costs
of medical services that are recognized by state law but not covered by the
state’s Medicaid plan. The deduction has most often been used by beneficiaries
to pay for prescription drugs, eyeglasses, hearing aids, and dentures that their
state has not included in its Medicaid program or that exceed the state’s
coverage. The deduction – called the “incurred medical expense deduction” – is
also useful for getting prescription drugs that are not covered by, or are
excluded from, a resident’s Part D drug plan.
Use of the Incurred Medical Expense Deduction
Non-Formulary Drugs
Each Part D plan identifies in its formulary the drugs that it will cover for
plan members. If a physician determines that the nursing facility or long-term
care beneficiary needs a particular drug that is not included in the formulary
of the beneficiary’s plan, the resident may file for an exception so that the
Plan will pay for that drug for that beneficiary. If the beneficiary does not
persuade the Plan that the non-formulary drug is “medically necessary,” the
beneficiary may file an appeal. The beneficiary can use the medical expense
deduction while using both the exceptions and appeals processes.
In addition, if the beneficiary loses both the exception and the appeal, and the
physician continues to believe that the non-covered drug is medically necessary
and to prescribe it, the beneficiary can use the medical expense deduction to
purchase the drug.
Excluded Drugs
The Medicare Prescription Drug, Improvement, and Modernization Act (MMA)
excludes certain drugs from coverage by Part D plans. Medicaid programs can
cover these excluded drugs, but are not required to cover them. A beneficiary
who is prescribed an excluded drug that the state Medicaid program does not
cover may use the incurred medical expense deduction to purchase the drug.
Paying Premiums for a More Comprehensive Part D Plan
The incurred medical expense deduction may also be used to pay premiums for a
more comprehensive Part D plan. Beneficiaries who are dually eligible for
Medicare and Medicaid are randomly and automatically assigned to low-cost Part D
plans called benchmark plans. Beneficiaries can use some of their income to pay
premiums for a more comprehensive Part D plan – for example, a prescription drug
plan providing enhanced alternative coverage – that covers drugs that are
otherwise excluded from the standard benchmark plans.
Paying Co-Payments During the First Month in the Nursing Home as a Medicaid
Beneficiary
Although nursing home residents (but not beneficiaries receiving services in the
community) do not have to pay co-payments for their prescription drugs, the
exemption from co-payments does not begin until the beneficiary has been
institutionalized in a nursing facility for a full calendar month as a
Medicaid beneficiary. The delayed exemption means that a beneficiary who is
admitted to a nursing facility as a Medicaid beneficiary on June 3, for example,
will be charged co-payments until August 1. If the beneficiary is admitted on
June 3 as a Medicare beneficiary and Medicare pays for his or her care until
July 3, when Medicaid begins to pay for the stay, the beneficiary will be
charged co-payments from July 3 until September 1. The Centers for Medicare &
Medicaid Services (CMS) recognizes that such beneficiaries can use their
incurred medical expense deduction to pay the co-payments. Question ID 7042
(Apr. 20, 2006).
Eligibility For The Incurred Medical Expense Deduction
The incurred medical expense deduction is available only to Medicaid
beneficiaries who have income such as Social Security or a private pension that
they use to contribute to the cost of their long-term care in the nursing home
or assisted living facility. If their only income is SSI, they have no income
to protect for non-covered medical care expenses and cannot use this deduction.
Most nursing home residents are medically needy Medicaid beneficiaries and have
income to use for the incurred medical expense deduction.
How Beneficiaries Can Use This Deduction
After determining that an individual is financially eligible for Medicaid, a
state makes a second “post-eligibility” determination to calculate the amount of
money the person must contribute to the cost of care. The Medicaid law
establishes a mandatory deduction for “incurred expenses for medical or remedial
care,” including health insurance premiums and expenses for services recognized
by state law but not covered by the state plan.
States may use either the actual expenses incurred by a beneficiary or expenses
that are projected for a period of no more than six months. While a state may
set reasonable limits on these medical expenses, it may not set overall dollar
limits (such as $50 per month) nor may it impose a limit on the number of
services or items that the beneficiary could deduct each month (such as a
maximum of three drugs). States may not set any limits on the health insurance
premiums, deductibles, or coinsurance charges.
If a state has failed to implement, or has improperly implemented, the incurred
medical expense deduction, advocates may negotiate with the state about the
deduction or, if negotiations fail, may consider litigation to ensure that the
deduction is available .
_______________________________
Law
42 U.S.C.§§1396a(a)(17), 1396a(r)(1)(A)(i), (ii)
Frequently Asked Question ID 7042
(information regarding copays in the first
month of nursing home stay)
© Copyright,
Center for Medicare Advocacy, Inc.
06/04/2008