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 whether your state’s program works with other drug coverage you may have.

Eligibility

  • Who is eligible for the SPAP?
    • Do my income and/or assets have to be below certain amounts 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 or in the hospital for an extended time period?
    • Can I get help if I am under 65?
    • Can I get help if I do not have Medicare?
    • Can I get help if I have Medicare and Medicaid?
  • Can I qualify for help from the SPAP if my income or assets are higher than the limits, for example, if my household has more than one or two people or if I spend a certain amount of my income on prescription drugs?
  • Do I have to join a Medicare private drug (Part D) plan if I am eligible for Medicare?
    • Do I have to join a Part D plan that coordinates with the SPAP?
    • Can I be in a Medicare private health plan (Medicare Advantage) 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, the federal program that helps pay for Part D drug costs? 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 get help paying my Part D deductible?
  • Will I get help paying my Part D premium?
  • How much will I pay for drugs that are covered by my Part D plan?
  • How much will I pay for drugs that are not covered by my Part D plan?
  • How much will I pay for drugs that are excluded from Medicare coverage?
  • Will the SPAP help me when I am in the Part D coverage gap (donut hole)?
  • Will what 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?
  • Is there an out-of-pocket maximum (after my total prescription costs reach a certain amount will my individual prescription costs go down)? 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 help with medical care)?

Enrollment

  • Where can I get an application?
  • What documentation do I have to show when I apply?
  • Do I have to go in person to apply?
  • Do I have to pay a premium or fee?
  • Is anyone automatically enrolled?
  • Can I get immediate help paying for prescription drugs?
  • Once I am receiving assistance, do I have to recertify to stay in the program? 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 pharmacy?
  • Can I get drugs by mail order?

 State Pharmaceutical Assistance Programs (SPAPs)