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What concerns you the most about your health care? That is what we thought: your rising prescription drug medication! Rising drug costs hit seniors especially hard, since seniors are usually on a fixed income. In recent years, seniors, and the long-term disabled, have had to figure out a way to manage these increasing costs more than the average working family. If you are a senior or a disabled person living in Massachusetts, there may be a solution. What if I told you there is a way you can lower your prescription drug costs? Significantly in most cases. In this article, we discuss Massachusetts’ Prescription Advantage program and its eligibility rules. Don’t think you can qualify? Think again.
What Is Prescription Advantage?
Prescription Advantage is Massachusetts’ state-sponsored prescription drug assistance program. The Executive Office of Elder Affairs administers the program. Prescription Advantage is designed to help seniors and the disabled with their prescription drug costs.
This is not Medicare’s Extra Help, although we will discuss how Extra Help and Prescription Advantage work together.
Medicare beneficiaries exposed to the “donut hole” may find the program especially “advantageous”. We illustrate an example later.
Who Is Eligible For Prescription Advantage?
Likely, you are. And, yes, even if you have a high income. We will get to that more in a minute.
First, anyone who has MassHealth or CommHealth is not eligible for Prescription Advantage. Why? Because you likely receive prescription benefits and other benefits through those aforementioned programs. So, if you are on MassHealth or have CommonHealth, you are not eligible.
You are eligible for Prescription Advantage if you are:
(1) age 65 or older, or
(2) under 65 with a qualified disability
If you meet either #1 or #2 above, you still have income limits to meet. There are 5 income levels that qualify you for Prescription Advantage. Yes. 5! We discuss those further. You must provide page 1 of 1040 tax form and/or 1099 from social security to confirm your income.
It a nutshell, that it is. You still have to go through the approval process, and we will get to that, but you are eligible.
What was that? You are asking about assets? Nope, assets are not criteria for Prescription Advantage. You could have $1,000,000 in assets and still qualify as long as your income met the income limits.
Those under age 65 have additional criteria to meet. We discuss the criteria next.
Eligibility Criteria For Those Under Age 65
For those under age 65, you qualify for Prescription Advantage if you:
(1) are disabled (must meet disability guidelines of being totally disabled with no work)
(2) work no more than 40 hours per month
(3) have income less than 188% of federal poverty level (FPL), which is $22,823 annually for single people and $30,945 for a married couple
Eligibility Criteria For Those 65 And Older
If you are 65 and older, you just need to fall within 5 categories of income limits. Each category has a different level of benefits depending on Medicare eligibility.
People Over Age 65 And NOT Eligible For Medicare
You may not be eligible for Medicare because you don’t have the required working quarters. This is usually the case for people who moved to the US and have started their working careers here later.
If you are NOT eligible for coverage, Prescription Advantage becomes your primary drug coverage.
There could be deductibles and copays you must pay. The amount depends on your income. There are 6 categories of income levels for those age 65 and NOT eligible for Medicare.
You don’t pay a monthly premium to Prescription Advantage. Moreover, the plan caps your out-of-pocket spending. The amount of out-of-pocket spending depends on your income.
People Over Age 65 And Eligible For Medicare
Before Prescription Advantage benefits, you must be in a Medicare Part D plan, Medicare Advantage plan, of have creditable coverage.
There are 5 levels of income limits. Your gross annual income can’t exceed 500% of FPL ($60,700 for single or $82,300 if married).
Think you don’t qualify for anything? Think again. Moreover, as we mentioned, the plan helps people financially through the donut hole. Let’s say you are single and bring home $3,000 per month. That will qualify you for category 4 of Prescription Advantage. It means that you will have to pay your normal share up of drug costs to the donut hole. However, after the donut hole, Prescription Advantage will limit generic copay cost to $12 and brand name cost to $30. Say goodbye to 45%/35% coinsurance for donut hole drug costs.
Moreover, the plan will limit your out-of-pocket prescription drug spending.
How Do Extra Help And Prescription Advantage Work Together?
Extra Help is Medicare’s prescription drug financial assistance available to Medicare beneficiaries. Extra Help will pay for your prescription drugs and part or all of your Part D premiums and/or deductibles. It goes further than Prescription Advantage.
In order to qualify for Extra Help, you must meet income AND asset limit tests (Prescription Advantage tests only income, and those limits are more liberal, too). Here are the income and asset tests for Extra Help:
Countable assets include:
Retirement / Savings accounts
Life insurance with cash value
Stocks, bonds, etc
Countable assets do not include your home, one car, $1,500 towards burial expenses, a burial plot, household items, and furniture.
If you qualify for Extra Help, you don’t need Prescription Advantage. However, you should still apply. Why? If your income or assets increase that disqualify you for Extra Help, you will automatically be in the Prescription Advantage system. You will likely qualify for Prescription Advantage.
Prescription Advantage Formulary & Claims
If you are a Medicare beneficiary, Prescription Advantage will cover your drugs allowed in your Part D plan’s formulary.
If you are not eligible for Medicare, Prescription Advantage is primary and has its own formulary.
The claims process is rather easy. It all takes place at the pharmacy. The pharmacy will know you have Prescription Advantage. The pharmacy submits your prescription claim to your Medicare Part D plan first and then to Prescription Advantage. At the point of purchase, you just pay your required, fixed copay.
You can enroll in Prescription Advantage anytime. By doing so, you create a special enrollment period for you. At that point, you can switch Part D or Medicare Advantage plans.
Once you are in, you are in.
We hope you found this article on Prescription Advantage helpful. Do you think you qualify? You might. There is no harm in applying. Contact us or use the form below for our assistance. We can help you determine the right course of action and apply online. We always work in your best interest and will do so here as well.