If you are thinking about joining a State Pharmaceutical Assistance Program (SPAP), here are some questions to ask to find out if you are eligible and how your state’s program works with other drug coverage you may have.
SPAP eligibility
- Does my state have an SPAP?
- Who is eligible for the SPAP?
- Do my income and/or assets Assets are resources such as savings and checking accounts, stocks, bonds, mutual funds, retirement accounts, and real estate. have to be below a certain amount to get help? What are the limits?
- Do I have to have a certain medical condition to get help?
- Can I get help if I am in a nursing home A nursing home, also called a long-term care facility, is a residential facility for people with chronic illness or disability. Nursing home services include room and board, nursing care, personal care, and therapy services. A skilled nursing facility (SNF) is a nursing home that provides skilled care, but not all nursing homes are SNFs. Medicare does not cover the cost of nursing homes that are not SNFs. or in the hospital for an extended period?
- Can I get help if I am under 65?
- Can I get help if I do not have Medicare Medicare is the federal government health insurance program that provides health care coverage if you are 65 or older, are under 65 and receive Social Security Disability Insurance (SSDI) for 24 months, begin receiving SSDI due to ALS/Lou Gehrig’s Disease, or have End-Stage Renal Disease (ESRD) no matter your age. You can receive health coverage directly through the federal government (see Original Medicare) or through a private company (see Medicare Advantage). ?
- Can I get help if I have Medicare and Medicaid Medicaid is a federal and state program that provides health coverage for certain people with limited income and assets. ?
- Can I qualify for help from the SPAP if my income or assets are higher than the limits? For example are the eligibility rules different if if my household has more than one or two people, or if I spend a certain amount of my income on prescription A prescription is an order for a health care service or drug written by a qualified health care professional. drugs?
- If I am eligible for Medicare, do I have to join a
Part D
Part D, also known as the Medicare prescription drug benefit, is the part of Medicare that provides prescription drug coverage. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with a Medicare Advantage Plan.
plan in order to be eligible for the SPAP?
- Do I have to join a Part D plan that coordinates with the SPAP?
- Can I be in a Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Plan with drug coverage, or do I have to be in a stand-alone Part D plan (PDP)?
- Will the SPAP automatically enroll me in a Part D plan, or do I have to enroll myself? If the SPAP will automatically enroll me, what is the process like?
- Can I qualify if I have drug coverage other than Part D, such as an employer plan?
- Do I have to apply for Extra Help in order to be eligible for the SPAP? If so, do I have to qualify for a certain level, or be denied Extra Help, to get assistance from the SPAP?
SPAP benefits
- How much will I pay for my prescriptions?
- Will I pay a different amount for drugs that are not covered by my Part D plan (if I have a Part D plan)? How much?
- Will I pay a different amount for drugs that are excluded from Medicare coverage? How much?
- Will I get help paying my Part D deductible The deductible is the amount you must pay for health care expenses before your health insurance begins to pay. Deductible amounts can change every year. ?
- Will I get help paying my Part D ?
- Will the amount the SPAP pays for my Part D-covered drugs count toward my Part D out-of-pocket maximum that must be met before I reach catastrophic coverage Catastrophic coverage is a phase of coverage designed to protect you from having to pay very high out-of-pocket costs for prescription drugs. It usually begins after you have spent a pre-determined amount on your health care. For example, Part D prescription drug plans offer catastrophic coverage. After you have spent a certain amount out of pocket, you owe no cost-sharing for the cost of your covered drugs for the remainder of the year. ?
- Is there an SPAP out-of-pocket maximum? If so, how much is it, and how much do I pay for drugs after I have reached the maximum?
- Is the SPAP considered creditable coverage?
- Does the SPAP offer assistance beyond help with prescription drug costs (for example, will I receive a Special Enrollment Period)?
SPAP enrollment
- Where can I get an SPAP application?
- What documentation do I have to show when I apply?
- Do I have to apply in person?
- Do I have to pay a premium or fee?
- Is anyone automatically enrolled?
- Can I get immediate help paying for prescription drugs?
- Do I have to recertify to stay in the SPAP? If so, how often and what is the process like?
Using the SPAP to get prescriptions
- Where can I get prescriptions using the SPAP?
- Can I use my current pharmacy?
- Can I get drugs by mail order?