Treating type 1 diabetes is expensive. You could even say insulin, which type 1 patients need in order to live, is worth its weight in gold.
In 1996 one vial of the most popular form of insulin cost about $20. Compare that to 2019 when paying for one vial without insurance costs $540. Most people with type 1 diabetes require two vials a month. Each vial holds about one-third of an ounce of insulin. How much is gold trading for? About $1,500 per ounce.
But it’s not just insulin that’s hitting the wallets of people with type 1 diabetes. The American Diabetes Association says the average cost of health care for a person with diabetes is $16,752 a year—more than twice the cost of health care for someone without diabetes.
Luckily, there is help available to help pay for diabetes medication.
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Medicare
The federal government’s health insurance program, known as Medicare, is a lifeline for people with diabetes 65 years and older. It generally covers the diagnosis and treatments needed to control diabetes. Enrolling in Medicare’s “Part D” option adds prescription drug coverage, including insulin for people with type 1 diabetes.
It’s possible to apply online for Medicare even if you aren’t ready to retire. Use Medicare’s online application to sign up takes less than 10 minutes. In most cases, once an application is submitted electronically, that’s all that’s required. There are no forms to sign and usually no documentation is needed. Social Security will process the application.
Determine your Medicare eligibility
For more information, call 1-800-MEDICARE (1-800-633-4227)
Medicaid
A similar program, Medicaid, offers assistance for people with low incomes and those with disabilities. Specific restrictions on who is eligible for Medicaid are set by individual states. Some states impose limits on income and some do not.
Applying for Medicaid is a little more difficult because each state is different. Eligibility depends on age, income level, family size and more. For more information, contact your state’s Medicaid agency. See here for a list of agencies and additional information.
Additional Help for Prescription Costs for Type 1 Diabetes
In addition to those federal programs, many states (but not all) provide additional assistance when it comes to paying for prescription drugs such as insulin. Many of the programs listed below require applicants to already be enrolled in Medicare while many others are not available to those who are using Medicaid assistance. Be sure to check your individual state. Per each program’s website, eligibility requirements, any recent changes and additional contact information are listed below.
Type 1 Diabetes Prescription Assistance State by State
Jump to your state by clicking a link below
Connecticut
Indiana
Massachusetts
Maine
Maryland
Montana
New Jersey
New York
Nevada
Pennsylvania
Virgin Islands
Vermont
Wisconsin
Connecticut
Connecticut Pharmaceutical Assistance Contract to the Elderly and Disabled Program (PACE)
Am I Eligible?
Applicants must meet the following requirements:
You must be a Connecticut resident for 6 months prior to applying.
You must be 65 years of age or older or be a disabled person over the age of 18.
You must pay a $45 annual enrollment fee per person.
You must not be receiving Medicaid benefits.
You must not have an insurance plan that pays for all or a portion of each prescription on a continuous basis or have a deductible insurance plan that includes prescriptions.
The current ConnPACE income eligibility limit for single people is $26,400. For married couples, the income limit is $35,600.
You must sign up for Medicare Part D if Medicare eligible.
Phone
(800) 423-5026
(860) 269-2029
Where to Apply
P.O. BOX 5011
Hartford, CT 06102
Items of Note
Due to a change in the Connecticut state budget, effective July 1, 2011, ConnPACE will no longer be available to individuals who are eligible for Medicare.
The ConnPACE program will be available to only those individuals who meet all of the current ConnPACE eligibility requirements and are NOT eligible for Medicare.
Most current ConnPACE members, therefore, will no longer qualify for ConnPACE because they are eligible for Medicare.
Medicare Part D will be the only insurance that covers their prescription drugs.
The ConnPACE program will only pay Medicare Part D Prescription Drug Plan premiums on behalf of members who are enrolled in one of the Connecticut-approved Medicare Part D ‘benchmark’ plans.
The ConnPACE program will NOT pay for Medicare Part D prescriptions that are not covered by your Part D plan. These are drugs that are not on your Part D Plan’s formulary (which means approved drug list).
If your doctor prescribes a drug for you that is not on your Medicare Part D Plan’s formulary, the pharmacist should contact your physician to discuss other drugs that are covered by your Medicare Part D Plan. Your doctor may either change your prescription to a drug that is covered by your Medicare Part D Plan, or may ask your Medicare Part D Plan to grant an exception or authorization for that drug to be covered. If the specific drug is medically necessary for you to receive and is not covered by your Part D plan, your doctor must ask the Part D Plan for this exception or authorization.
It is important to remember that this only applies to drugs that are non-formulary or require prior authorization under your Medicare Part D Plan. Medicare Part D excluded drugs will continue to be covered by the Department as they have in the past (i.e. Benzodiazepines, Barbiturates).
There is an annual ConnPACE open enrollment period from November 15 to December 31 of each year with eligibility beginning January 1. The ConnPACE open enrollment period coincides with the annual open enrollment period for the Medicare Part D Program and is for NEW applicants only.
New ConnPACE applications will NOT be accepted outside of the open enrollment period unless the applicant is within 31 days of his/her 65th birthday or becoming eligible for Social Security Disability or Supplemental Security Income.
Again, the ConnPACE open enrollment period does NOT apply to current ConnPACE members. Individuals who are currently eligible for ConnPACE will continue to renew their benefits in the month their renewals are due. However, we wanted to remind you about the open enrollment period in case you let your ConnPACE enrollment expire for some reason and want to re-enroll. If you do let your ConnPACE benefits expire, you will have to wait for the next open enrollment period.
Indiana
Am I Eligible?
Must be an Indiana resident, 65 or older.
Annual income at or below $18,060 (if single) or $24,276 (if married).
All members must be enrolled in Medicare Part D plan working with HoosierRx and have applied for “Medicare Extra Help”. State will provide assistance to those who are eligible for reduced Medicare Extra Help or are denied Medicare Extra Help due to higher assets. No HoosierRx membership cards required.
Have applied for the “Medicare Extra Help” through Social Security to pay for your Medicare Part D plan, and received either a “Notice of Award” or “Notice of Denial” from Social Security.
Your Social Security “Notice of Denial” must be because your resources are above the limit established by law.
Your Social Security “Notice of Award” must state that you are receiving partial extra help subsidy to help pay for your Medicare Part D premium.
Phone
(866) 267-4679
(317) 234-1381
Where to Apply
HoosierRx 402 W. Washington Street
Room W374, MS07
Indianapolis, IN 46204
Items of Note
Premium assistance up to $70 per month. State program will pay the premium directly to the ten participating Medicare Rx plans. Includes a $20/per month/per family income disregard.
New applications may take up to 4 weeks to process.
Massachusetts
Massachusetts Prescription Advantage
Am I Eligible?
Mass. residency required. Age 65 and over: with Medicare, income up to 500% FPL; without Medicare, no income limit.
Under age 65: individuals with disabilities who work 40 hours or fewer per month and have incomes up to 188% FPL. No asset limits.
Members/applicants with Medicare must be in Part D plan or have creditable coverage to receive assistance, but may be enrolled in Prescription Advantage before enrolling in a Part D plan.
Members/applicants with incomes below 150% FPL must apply for LIS.
Phone
(800) 243-4636 EXT: 2
Where to Apply
P.O. Box 15153
Worcester, MA 01615
Items of Note
Individuals receiving assistance from MassHealth to pay for Medicare Part A and/or Part B premiums, deductibles and co-payments may still be eligible for Prescription Advantage.
If there are more than two people in your household, please call Prescription Advantage for more information regarding income eligibility requirements.
For Members with Medicare:
Important Note: Reductions to the current fiscal year budget for Prescription Advantage require that benefits be changed effective January 1, 2010. Prescription Advantage will no longer pay any part of the Medicare Part D plan premium for members in categories S1, S2 and S3. Members in these categories will be responsible for paying the premium invoices from their Medicare Part D plans to ensure that their Medicare Part D coverage continues. Co-payment assistance from Prescription Advantage is only available to members enrolled in a Medicare Part D drug plan or creditable coverage plan.
Medicare Prescription Drug Plan Co-payments
Prescription Advantage will provide supplemental coverage for members enrolled in Medicare prescription drug plans. Assistance with co-payments is based on annual household income. There is no separate monthly premium for Prescription Advantage membership, but members are required to pay the Part D premium amounts that their Medicare Drug Plan bills them for.
Annual Out-of-Pocket Spending Limit
Prescription Advantage provides an annual out-of-pocket spending limit. Once this limit is reached, Prescription Advantage will cover prescription drug co-payments for the remainder of the plan year.
Formulary
Prescription Advantage will provide assistance only for drugs covered by a member’s Medicare prescription drug plan. However, Prescription Advantage will cover benzodiazepines for members, but will not cover other drugs excluded from Medicare coverage, such as barbiturates and over the counter drugs.
Plan Year
The Prescription Advantage plan year runs from January 1 – December 31 of each year.
For members who reach their annual out-of-pocket spending limit, Prescription Advantage covers drug co-payments for the rest of the plan year.
For Members Not Eligible for Medicare:
Deductible and Co-payments
Deductible and co-payments are based on annual household income. There is no monthly premium for Prescription Advantage membership. When you purchase prescription drugs, you first satisfy your deductible, then you pay a modest co-payment. Some members may qualify to have part or all of their deductibles waived, depending on their annual household income.
Annual Out-of-Pocket Spending Limit
Prescription Advantage provides an annual out-of-pocket spending limit. Once the amount you have paid in deductible and co-payments reaches your annual out-of-pocket spending limit, Prescription Advantage will cover prescription drug co-payments for drugs that are on the plan formulary for the remainder of the plan year.
Formulary
The Prescription Advantage formulary, for members not eligible for Medicare, includes most prescription drugs. Please visit the Prescription Advantage Non- Medicare Formulary Prescription Drug Web Tool for more information about the formulary for non-Medicare members.
The formulary for non-Medicare members in Prescription Advantage categorizes prescription drugs into three categories: generic drugs, brand-name drugs, and additional brand-name drugs. Generic drugs have the lowest co-payment, while additional brand-name drugs have the highest co-payment. The Plan’s formulary covers most outpatient oral prescription drugs, including insulin and disposable insulin syringes with needles.
Plan Year
The Prescription Advantage plan year runs from January 1 – December 31 of each year. For members who reach their annual out-of-pocket spending limit, Prescription Advantage pays the full cost of their covered prescription drugs through the end of the plan year.
Please read Prescription Advantage Rate Schedule Guide for Members Not Eligible for Medicare (PDF) for more information.
Maine
Am I Eligible?
Applies to Maine residents.
Income limit is 175% of the federal poverty level.
Must be 62 years old or 19 years old or older and medically qualified for Social Security Disability Income (SDDI).
If you spend 40% or more of household income on prescription drugs, the income limits increases.
Phone
(866) 796-2463
Where to Apply
Office of MaineCare Services
242 State Street
Augusta, ME 04333
Items of Note
Basic Benefits:
80% minus $2.00 of the cost of all generic prescription drugs on the Preferred Drug List.
80% minus $2.00 of the cost of brand-name medications on the Preferred Drug List for the treatment of diabetes, heart disease, high blood pressure, chronic lung disease (emphysema and asthma), arthritis, anticoagulation, Hyperlipidemia (high cholesterol), incontinence, thyroid disease, osteoporosis, (bone density loss,), Parkinson’s Disease, glaucoma, Multiple Sclerosis, and ALS (Lou Gehrig’s Disease).
Supplemental Benefits:
The Supplemental Benefit includes other drugs not covered in he basic Benefit. The drugs must be medically necessary and supplied from participating manufacturers. Actual savings vary from drug to drug. DEL Members pay the State’s negotiated MaineCare rate minus $2.00.
Catastrophic Spending Limit:
After a Member spends $1,000 on eligible prescription drugs, the State pays 80% of the cost of all eligible prescription drugs, regardless of any disease or condition. The drugs must be medically necessary and supplied from companies with agreements with the State. Eligible prescription drugs are only those drugs that were covered by DEL on May 31, 2001. The Catastrophic Spending Limit is tracked from August 1st each year to July 31st of the following year.
Some drugs require ‘prior approval’ for coverage.
Coverage through DEL is funding of last resort. Members with other prescription drug coverage must use those benefits first.
Members with Medicare Part D coverage are eligible for DEL Wrap benefits only.
Maryland
Maryland Senior Prescription Drug Assistance Program (SPDAP)
Am I Eligible?
Maryland residents enrolled in MedicareRx may be eligible for prescription drug subsidies under the Maryland Senior Prescription Drug Assistance Program (SPDAP).
You may be eligible for SPDAP if you are enrolled in a MedicareRx plan or Medicare Advantage Prescription Drug plan.
Reside in Maryland for at least 6 months.
Have income up to 300% FPL, have no other prescription drug benefits, and are not eligible for full federal extra help with MedicareRx coverage (Low Income Subsidy).
Phone
(800) 551-5995
Where to Apply
Maryland SPDAP
c/o Pool Administrators
628 Hebron Avenue
Suite 100
Glastonbury, CT 06033
Items of Note
SPDAP will pay up to $40.00 per month for a member’s Medicare Rx prescription drug plan premium, as long as the individual is enrolled in an approved Medicare prescription drug plan or a Medicare Advantage prescription drug plan. There are 56 different prescription benefit plans and Medicare Advantage drug plan options from which to choose. A complete list of Stand Alone Plans may be found here. Follow this link for a complete list of Medicare Advantage Plans.
If the plan you have elected to enroll in is one of the plans that is administering the SPDAP Coverage Gap subsidy your prescription costs during the coverage gap or “doughnut hole” will be 5% co-insurance on the total prescription cost plus the non-formulary drug cost. The remaining cost of your prescription will be covered by, any supplemental covrage offered by your plan, any applicable Federal Drug Discount, with the remainder being paid by SPDAP.
Not all plans will provide this subsidy. To take advantage of the doughnut hole subsidy, you must be enrolled in one of the Medicare Rx prescription drug plans or Medicare Advantage Plans that has agreed to participate.
If you are approved in SPDAP, we will notify Medicare of your membership in the program. Medicare will then advise us of the Medicare Rx prescription drug plan or Medicare Advantage Plan in which you are enrolled. This process may take 60 to 90 days. If you wait to enroll in a drug plan, the process will take longer.
Once Medicare informs us of the Medicare Rx prescription drug plan or Medicare Advantage Plan in which you are enrolled, we will pay up to $40 for each month after your effective date with SPDAP.
Montana
Am I Eligible?
Montana is your primary state of residence
Must be a Medicare recipient
Income less than $23,760 (single person) Or $32,040 (two person household).
Assets (your nest egg – for example; IRAs, Bonds, Stocks, Savings Accounts) are NOT income.
Phone
(866) 369-1233
(406) 444-1233
Where to Apply
P.O. Box 202915
Helena, MT 59620
Items of Note
Enrollment in BSRx is on-going. Clients may enroll ANYTIME of the year.
NOTE: Due to the fact that we are a State Pharmaceutical Assistance Program (SPAP), clients may enroll in a Prescription Drug Plan (PDP) at any time of the year, or change plans once a year. Clients do not need to wait until the end of the year for the open enrollment period.
To Enroll: You must be qualified. Be enrolled in a Medicare Part D Plan. And if you meet Social Security Extra Help requirements: Have applied for and received a determination from Social Security Extra Help (SSEH).
NOTE: If your SSEH award amount is 100% assistance Big Sky Rx cannot assist you.
Big Sky Rx helps with Medicare Part D premiums only.
New Jersey
New Jersey Senior Gold Prescription Discount Program
Am I Eligible?
You must be a New Jersey resident, age 65 year of age or older 18 years of age or older and receiving Social Security Title II Disability benefits; and
Annual income for 2016 is between $26,575 and $36,575 if you are single or between $32,582 and $42,582 if you are married.
All Medicare-eligible Senior Gold beneficiaries are also required to enroll in a Medicare Part D Prescription Drug Plan of their choice. They will be responsible for paying the monthly premium directly to the Medicare Part D plan. They also will be responsible for paying any late enrollment penalty imposed by Medicare for each month they were eligible to enroll in Medicare Part D but did not enroll.
Phone
(800) 792-9745
Where to Apply
New Jersey Department of Health and Senior Services
Senior Gold Prescription Discount Program
P.O. Box 715
Trenton, NJ 08625
Items of Note
The state will not cover premiums for SPAP members, but it will offer assistance with deductibles, copayments, and the coverage gap. The state is not auto-assigning the Senior Gold members into PDPs. Instead, the state applied their criteria for auto-assignment to these members and sent them a letter recommending the plans that best meet their needs, and encouraging them to enroll.
Senior Gold does not pay for diabetic testing supplies (e.g., test strips and lancets) and Medicare Part D excluded drugs except benzodiazepines and barbiturates. If Senior Gold beneficiaries have health insurance coverage, such as Medicare Part B that pays for diabetic testing supplies, a pharmacy must bill that insurance plan. Senior Gold will not pay for them.
The PAAD and Senior Gold programs are required by law to provide generic substitution on brand name drugs that have approved generics available. Generic drugs are less costly substitutes with the same active ingredients as drugs sold under a brand name. In order for a PAAD or Senior Gold cardholder to receive the brand name version instead of the approved generic when PAAD or Senior Gold is the primary payer for a prescription, the prescribing physician must request Prior Authorization. However, certain brand name drugs with a narrow therapeutic index or a lower cost per unit than the generic may be excluded from the Prior Authorization process.
Initial prescriptions are limited to a 34-day supply when Senior Gold is the primary payer. Subsequent refills may be dispensed up to a 34-day supply or 100 unit doses, whichever is greater. This regulation prevents the waste of medication should the initial prescription prove to be inappropriate to the beneficiary and allows person on maintenance drugs to receive up to 100 unit doses for subsequent refills.
Senior Gold participants can receive their prescription drugs at the pharmacy of their choice. The total cost of the prescription to the Senior Gold Beneficiary will be a $15 co-pay plus 50% of the remaining cost of the drug. Senior Gold participants with prescription costs exceeding $2,000 a year (if single) or $3,000 a year (if married) will have 100% of their prescription costs paid after paying the $15 co-pay per prescription during the annual 12 month eligibility period. This period is based on the initial date of enrollment. Applications are available at local pharmacies, senior citizen centers, county Offices on Aging, visiting the Senior Gold Website, or by writing to the address listed above.
NOTE: PAAD and Senior Gold only cover drugs approved by the Food and Drug Administration. Drugs purchased outside the State of New Jersey are not covered, nor are any pharmaceutical products whose manufacturer has not signed a rebate agreement with the State of New Jersey.
New York
New York State Elderly Pharmaceutical Insurance Coverage (EPIC)
Am I Eligible?
To join EPIC, a senior must:
Be a New York State resident age 65 or older
Have an annual income below $75,000 if single or $100,000 if married
Be enrolled or eligible to be enolled in a Medicare Part D plan (no exceptions)
Not be receiving full Medicaid benefits
Phone
(800) 332-3742
Where to Apply
EPIC
P.O. Box 15018
Albany, NY 12212
Items of Note
EPIC Medicare Part D Premium Assistance
EPIC will pay the Medicare Part D premiums up to the benchmark amount $39.73 in 2016 for members with incomes up to $23,000 if single and $29,000 if married. The benchmark amount is equivalent to the average cost of a Medicare Part D plan in New York State. It changes each year. If your Part D plan premium is higher than this amount, you are responsible to pay the difference each month.
If EPIC is paying your Part D premium and you currently have your premium deducted from your Social Security check, you must contact your Part D drug plan to stop the deduction.
If a member’s income is above $23,000 if single and $29,000 if married then the member is required to pay their Part D premium each month. To help them pay, their EPIC deductible on the Deductible Plan schedule is further reduced by $477, the annual cost of a benchmark Part D plan in 2016.
If you are approved for the full Medicare Low Income Subsidy (LIS) because you were approved for Extra Help, the Medicare Savings Program, or a Medicaid Spenddown, EPIC will provide additional premium assistance up to the benchmark amount $39.73 in 2016 every month if Medicare does not cover the entire premium.
If you are approved for Extra Help from Medicare with a partial (25%, 50%, or 75%) LIS, EPIC will provide additional premium assistance towards the member’s Medicare part D plan drug premium up to the benchmark amount of $39.73 per month in 2016.
EPIC Fee Plan
The Fee Plan is for members with income up to $20,000 if single or $26,000 if married. Members pay an annual fee to EPIC ranging from $8 to $300 based on their prior year’s income (see Fee Plan schedule). This fee is billed in quarterly installments or can be paid annually. After any Part D deductible is met, if the member has one, Fee Plan members only pay the EPIC co-payment for drugs. Co-payments range from $3 to $20 based on the drug cost not covered by Part D. An EPIC identification card is mailed to the member upon successful enrollment. This card is issued once and should be kept and used for subsequent years. The coverage year runs through December 31st each year.
EPIC pays the Medicare Part D plan premiums up to $39.73 per month in 2016 for members in the Fee plan.
This is how EPIC works for Fee Plan members:
Show both your Medicare Part D drug plan and EPIC ID cards when you go to the pharmacy to purchase your drugs.
Your Medicare Part D drug plan is your primary drug coverage and you must maintain enrollment in a Part D drug plan to receive EPIC benefits.
EPIC provides secondary coverage for Medicare Part D- and EPIC-covered drugs after you meet your Medicare Part D-deductible if you have one.
Once enrolled in a Medicare Part D drug plan, EPIC also covers approved Medicare Part D-excluded drugs such as prescription vitamins and prescription cough and cold preparations.
You will only pay the EPIC co-payments ranging from $3 to $20 based on the cost of your drug.
If you have the full Extra Help Low-Income Subsidy (LIS) from Medicare, you will not be required to pay any EPIC fees and your co-payments will be lower.
EPIC Deductible Plan
The Deductible Plan is for members with income ranging from $20,0001 to $75,000 if single or $26,001 to $100,000 if married. Members must meet an annual EPIC deductible based on their prior year’s income before they pay EPIC co-payments for drugs (see Deductible Plan schedule). An EPIC identification card is mailed to the member upon successful enrollment. This card is issued once and should be kept and used for subsequent years. The coverage year runs through December 31st each year.
EPIC pays the Medicare Part D drug plan premiums up to $39.73 in 2016 for members in the Deductible Plan with incomes ranging from $20,001 to $23,000 if single or $26,001 to $29,000 if married.
Deductible Plan members with income between $23,001 to $75,000 if single or $29,001 to $100,000 if married are required to pay their Medicare Part D plan premium each month. To provide Part D premium assistance, the EPIC deductible shown on the Deductible Plan schedule is further reduced by $477 per year, the annual cost of a basic benchmark Part D drug plan.
This is how EPIC works for Deductible Plan members:
Show both your Medicare Part D drug plan and EPIC ID cards when you go to the pharmacy to purchase your drugs.
Your Part D drug plan is your primary drug coverage and you must maintain enrollment in a Part D drug plan in order to receive EPIC benefits.
EPIC provides secondary coverage for Medicare Part D- and EPIC-covered drugs after you meet your Medicare Part D deductible if you have one.
Once enrolled in a Part D drug plan, EPIC also covers approved Part D-excluded drugs such as prescription vitamins and prescription cough and cold preparations.
After you meet any Part D deductible if you have one, out-of-pocket drug costs for covered Part D and EPIC medications will be applied to your EPIC deductible.
Once you are enrolled in a Part D drug plan, drug costs for approved Part D-excluded drugs will be applied to your EPIC deductible.
After you meet your EPIC deductible, you will only pay the EPIC co-payments ranging from $3 to $20 based on the cost of your drug.
NOTE:
- You can join EPIC at any time during the year. Once enrolled, you will receive a ‘Special Enrollment Period’ to join a Medicare Part D drug plan. You are not eligible to receive EPIC benefits until you are enrolled in a Part D drug plan.
- Seniors who are not eligible to join a Medicare Part D drug plan cannot join EPIC (e.g. seniors with a union/retiree drug subsidy program that is not a Part D plan, seniors without Medicare Part A or Medicare Part B).
- Seniors with Medicare Advantage (HMO) health insurance can only join EPIC if they have Part D drug coverage with their HMO.
EPIC Drug Coverage
EPIC provides secondary coverage for Medicare Part D- and EPIC-covered drugs after any Part D deductible is met. EPIC also covers approved Part D-excluded drugs such prescription vitamins as well as prescription cough and cold preparations once a member is enrolled in a Part D drug plan. EPIC coverage runs from January 1st to December 31st of each year. If enrolled after January 1st, coverage will still end on December 31st.
Members must maintain EPIC coverage and be enrolled in a Medicare Part D drug plan in order to receive benefits. If you disenroll from your Medicare Part D drug plan either by request or due to failure to pay, you must re-enroll in a Medicard Part D plan or you will not receive EPIC benefits for the remainder of the year.
Nevada
Am I Eligible?
Eligible for Medicare: Applicants who are eligible for Medicare Part D must enroll in Medicare Prescription Drug Plan and use that program as the first source of help with prescriptions. In addition, Part C beneficiaries who qualify for Extra Help with Part D costs (such as premiums, deductibles and co-payments) must apply for and, if approved, use that help.
Age: Applicant and spouse (if spouse is also applying) must be 62 years or older at time of application.
Income:Includes income from all sources for both applicant and spouse. Effective July 1, 2016, the maximum annual household income for singles is $28,119, and the maximum annual household income for married couples is $37,483.
Residency: Applicants must have lived continuously in Nevada for at least 12 consecutive months (one year) prior to the date of application.
Phone
(866) 303-6323
(775) 687-4210
Where to Apply
Nevada Senior Rx
Department of Health and Human Services
3416 Goni Road, Suite D-132
Carson City, NV 89706
Items of Note
Senior Rx, Nevada’s plan to provide Nevada seniors relief from the high cost of prescription medicine while in the coverage gap (donut hole). Senior Rx provides assistance to seniors who are eligible for Part D with Medicare Part D expenses.
Senior Rx is funded with a portion of Nevada’s share of tobacco settlement funds and was passed into law during the 1999 legislative session. Many of the program’s benefits are administered through a contracted pharmacy benefit manager (OptumRx). Other benefits are coordinated directly with the Medicare Part D plans that serve as the first prescription drug resource for enrolled members.
Am I Eligible?
Eligible for Medicare:
Applicants who are eligible for Medicare Part D must enroll in Medicare Prescription Drug Plan and use that program as the first source of help with prescriptions. In addition, Part C beneficiaries who qualify for Extra Help with Part D costs (such as premiums, deductibles and co-payments) must apply for and, if approved, use that help.
Age:
Applicant and spouse (if spouse is also applying) must be 18-61 years old at time of application collecting long-term Social Security Disability and Medicare-eligible.
Income:
Includes income from all sources for both applicant and spouse. Effective July 1, 2016, the maximum annual household income for singles is $28,119, and the maximum annual household income for married couples is $37,483.
Residency:
Applicants must have lived continuously in Nevada for at least 12 consecutive months (one year) prior to the date of application.
Phone
(866) 303-6323
(775) 687-4210
Where to Apply
Nevada Disability Rx
Department of Health and Human Services
3416 Goni Road
Building D, Suite 132
Carson City, NV 89706
Items of Note
Program Benefits:
Assistance with prescription costs when in the Medicare Part D coverage gap (donut hole).
Assistance towards monthly premiums with participating Medicare Part D Prescription Drug Plan (if not qualified for maximum Extra Help from Medicare with that expense)
For both programs:
Applicant must not be receiving full Medicaid assistance or 100% Extra Help from Medicare (Full LIS).
Pennsylvania
Pharmaceutical Assistance Contract for the Elderly (PACE)
Am I Eligible?
You must be a Pennsylvania resident for at least 90 days prior to the date of application and over the age of 65 years.
You cannot be enrolled in the Department of Public Welfare’s Medicaid prescription benefit.
You must not be eligible for pharmaceutical benefits under medical assistance.
Your income for the year preceding your application must be less than $14,500 a year for a single person and less than $17,700 per year for a married person. Note that the income requirements for applying are based on your previous year’s income.
Phone
(800) 225-7223
(717) 651-3600
Where to Apply
PACE/PACENET Program
P.O. Box 8806
Harrisburg, PA 17105
Items of Note
If you are eligible for the PACE program, you must pay a $6 co-payment for generic drugs and $9 for each single-source brand name drug. These copayments are based on a 30-day supply.
PACE/PACENET benefits are considered “creditable coverage” which means that the benefits offered through this program are as good as or better than the prescription benefits offered through Medicare Part D. However, individuals are encouraged to be enrolled in PACE/PACENET and Part D together. By doing so, cardholders can potentially save even more money when buying their prescription medications.
Virgin Islands
Pharmaceutical Assistance Program
Am I Eligible?
Senior citizens 60 years of age or older.
A resident of the U.S. Virgin Islands for at least 6 months.
Proof of age, residency, medical status and income are required with the application.
Income up to $18,000 for a single person and $30,000 for couples.
Program provides: 100% of deductible, co-payment, coverage gap, and premium assistance.
Phone
(340) 774-0930
Where to Apply
1303 Hospital Ground Knud Hansen Complex
Building A
St. Thomas, VI 00802
Items of Note
Will cover the monthly premium, co-pays and the annual deductible expected to be associated with the Medicare Prescription Drug Plan. Individuals with Medicare with chronic or catastrophic illness can receive extra financial help in paying the premium, co-pay, deductible and other required out-of-pocket expenses. In order to get the “extra help,” you must first enroll into a Medicare Prescription Drug Plan.
SPAP participants are required to pay an enrollment/identification card fee of $5.00; renewable every five years.
A co-pay is required for each prescription at time of purchase.
If you are a Medicare recipient, you must be enrolled in Medicare Part A, Part B, or both. SPAP requires you to enroll in an approved VI Medicare Part D Prescription Drug Plan. Additionally, you cannot be currently covered by a private insurance plan that pays for all or part of your prescription costs on a continuous basis – this does not include Medicare Part D. Medicaid beneficiaries are not eligible to participate in SPAP.
Vermont
Am I Eligible?
To be eligible for these programs, seniors must meet the following criteria:
You must be a Vermont state resident and U.S. citizen or resident alien who is lawfully admitted.
You must be 65 years of age or receiving disability benefits from Social Security.
Must have Medicare Part D, but cannot have other prescription drug insurance
Have an income less than 150% -VPharm 1, 175%-VPharm 2 and 225%-VPharm 3.
Phone
(800) 250-8427
Where to Apply
312 Hurricane Lane, Suite 201
Williston, VT 05495
Items of Note
VPharm 1 – Members on VPharm 1 pay a monthly premium. In return, VPharm 1 pays for:
The amount of your PDP premium that LIS does not pay for, up to a maximum amount.
PDP copays, deductibles, co-insurance and coverage gaps not covered by LIS, for shortterm and long-term drugs covered by the PDP.
Specific types of drugs that are not covered by the PDP, but are covered by Vermont (drugs for anorexia, weight gain, or weight loss; certain vitamins; some over-the- counter medicine, barbiturates; or benzodiazepines), and
One comprehensive eye exam and one interim exam every two years by an optometrist or an ophthalmologist.
VPharm 2 – Members on VPharm 2 pay a monthly premium. In return, VPharm 2 pays for:
The amount of your PDP premium that LIS does not pay for, up to a maximum amount.
PDP copays, deductibles, co-insurance and coverage gaps not covered by LIS for drugs covered by the PDP that are used to treat long-term medical problems, and
Specific types of drugs used to treat long-term medical problems that are not covered by the PDP, but are covered by Vermont (drugs for anorexia, weight gain, or weight loss; certain vitamins; some over-the-counter medicine, barbiturates; or benzodiazepines). The Healthy Vermonters Program may also give you a discount on some of the drugs not covered by VPharm 2 that are used to treat short-term medical problems. As a VPharm 2 member you do not need to apply for the Healthy Vermonters Program, you will receive the discount automatically.
VPharm 3 – Members on VPharm 3 pay a monthly premium. In return, VPharm 3 pays for:
The amount of your PDP premium that LIS does not pay for, up to a maximum amount.
PDP copays, deductibles, co-insurance and coverage gaps not covered by LIS for drugs covered by the PDP and Vermont that are used to treat long-term medical problems, and have a rebate agreement with the state of Vermont.
Specific types of drugs used to treat long-term medical problems that are not covered by the PDP but are covered by Vermont (drugs for anorexia, weight gain, or weight loss; certain vitamins; some over-the-counter medicine, barbiturates; or benzodiazepines).
Co-Pays – If you are on VPharm 1, 2, or 3, you will have a co-pay of $1 or $2.
If the cost to the state for your prescription is $29.99 or less, your co-pay will be $1.00.
If the state’s cost is $30.00 or more, your co-pay will be $2.00.
Premiums – VPharm 1, 2, and 3 monthly premiums are $15, $20 or $50 depending on income.
Wisconsin
Am I Eligible?
You must meet the following requirements:
You must be a Wisconsin resident.
You must be a U.S. citizen or qualifying immigrant.
You must be 65 years of age or older.
You must pay a $30 annual enrollment fee per person.
Only income is measured. Assets, such as bank accounts, insurance policies, home property, etc., are not counted.
If you are receiving prescription drug coverage from Medicaid you are not eligible.
Phone
(800) 657-2038
Where to Apply
P.O. Box 6710
Madison, WI 53716
Items of Note
New Prescription Policy for SeniorCare Members:
As of July 15, 2013, the Department of Health Services has implemented a new policy due to the Affordable Care Act for SeniorCare members who get prescriptions. In order for SeniorCare to reimburse pharmacies for prescriptions, the prescription must be written by a physician enrolled with Wisconsin Medicaid. If your physician is not enrolled with Medicaid and you are unable to get your prescription filled, you can take the following action:
Encourage your physician to enroll in Wisconsin Medicaid as a Prescribing/Referring/Ordering Only Provider. Your physician can call Provider Services at (800) 947-9627 for more information.
Ask your provider to refer you to another physician who is Medicaid-enrolled. You may also call Member Services to find a provider who is Medicaid-enrolled at (800) 362-3002.
Level 1 – At or below $19,008 per individual or $25,632 per couple annually.
No deductible or spenddown.
$5 co-pay for each covered generic prescription drug.
$15 co-pay for each covered brand name prescription drug.
Level 2a – $19,009 to $23,760 per individual and $25,633 to $32,040 per couple annually.
$500 deductible per person.
Pay the SeniorCare rate for drugs until the $500 deductible is met.
After $500 deductible is met, pay a $5 co-pay for each covered generic prescription drug and a $15 co-pay for each covered brand name prescription drug.
Level 2b – $23,761 to $28,512 per individual and $32,041 to $38,448 per couple annually
$850 deductible per person.
Pay the SeniorCare rate for most covered drugs until the $850 deductible is met.
After $850 deductible is met, pay a $5 co-pay for each covered generic prescription drug and a $15 co-pay for each covered brand name prescription drug.
Level 3 – $28,513 or higher per individual and $38,449 or higher per couple annually.
Pay retail price for covered drugs during spenddown.
Covered drug costs for spenddown will be tracked automatically. During the spenddown, there is no discount on drug costs.
After spenddown is met, meet an $850 deductible per person.
Pay SeniorCare rate for most covered drugs until the $850 deductible is met.
After the $850 deductible is met, pay a $5 co-pay for each covered generic prescription drug and a $15 co-pay for each covered brand name prescription drug.
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