Massachusetts State Pharmacy Assistance Programs

Important Note For Members with Medicare

Individuals receiving assistance from MassHealth to pay for Medicare Part A and/or Part B premiums, deductibles and copayments 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.

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. Copayment 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 Copayments
Prescription Advantage will provide supplemental coverage for members enrolled in Medicare prescription drug plans. Assistance with copayments 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 copayments 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 copayments for the rest of the plan year.

Important Note For Members Not Eligible for Medicare

Individuals receiving assistance from MassHealth to pay for Medicare Part A and/or Part B premiums, deductibles and copayments 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.

Deductible and Copayments
Deductible and copayments 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 copayment. 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 copayments reaches your annual out-of-pocket spending limit, Prescription Advantage will cover prescription drug copayments 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 copayment, while additional brand-name drugs have the highest copayment. 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.