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 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 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?
    • 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 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 drugs?
  • If I am eligible for Medicare, do I have to join a Part D 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 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 durgs 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?
  • Will I get help paying my Part D premium?
  • Will the SPAP help me when I am in the coverage gap (donut hole)?
  • 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?
  • 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?

Return to: Medicare Admin

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