p s pb commonwealth of pennsylvania department of public welfare special pharmaceutical benefits...
TRANSCRIPT
PS P B
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARESPECIAL
PHARMACEUTICALBENEFITS PROGRAM
What is the SPBP?
A state and federally funded drug assistance program for low and moderate income individuals and families that pays for
specific drug therapies for the treatment of persons living with HIV/AIDS or a DSM
IV diagnosis for schizophrenia.
SPECIAL PHARMACEUTICAL
BENEFITS PROGRAMS P B P
SPBP/ADAP ADAP/SPBP • REMEMBER IN MOST OTHER STATES THIS
PROGRAM IS CALLEDAIDS DRUG ASSISTANCE PROGRAM
ADAP• IN PENNSYLVANIA IT IS CALLED THE SPECIAL PHARMACEUTICAL BENEFITS
PROGRAM SPBP
COVERS DRUGS FOR HIV/AIDS AND SCHIZOPHRENIA
Recent Developments
• Annual Re-Certification
• Current vs New Process
• Medicare Part D Pennsylvania Participating Plans
WHAT ARE THE CRITERIA FOR RE-CERTIFICATION TO SPBP?
• •
RESIDENCEAPPLICANTS MUST BE A
RESIDENT OF THE COMMONWEALTH
NOT INSTITUTIONALIZED
INCOMETHE CURRENT
CEILING IS
$30k WITH A
FAMILY ALLOWANCE
SOCIAL SECURITY NUMBERCLIENT INFO
ALREADY ON FILE
NOT NECESSARY
MEDICAL NEED
APPLICANTS DIAGNOSIS CONFIRMED
IN PAST
SUPPORTING DOCUMENTATION
• EACH APPLICATION MUST INCLUDE SUPPORTING DOCUMENTATION.
• CLIENTS ARE RESPONSIBLE FOR PROVIDING CLEAR and LEGIBLE PHOTOCOPIES OF SUPPORTING DOCUMENTS FOR THE CRITERIA
RESIDENCE
APPLICANTS MUST PROVIDE DOCUMENTATION
SHOWING PROOF OF RESIDENCY IN
PENNSYLVANIA
EXAMPLES OF SUPPORTING DOCUMENTATION:
UTILITY BILLS
CABLE TV BILLS
DRIVER’S LICENSE
BANK STATEMENT
SOCIAL SECURITY OR UNEMPLOYMENT
AWARD LETTERS
WRITTEN VERIFICATION FROM FAMILY MEMBERS,
PARTNERS, HOMELESS SHELTERS, ETC.
THE ADDRESS ON SUPPORTING DOCUMENTATION MUST MATCH THE ADDRESS ON THE APPLICATION
INCOME
APPLICANTS MUST PROVIDE DOCUMENTATION SHOWING PROOF OF INCOME. INCOME CRITERIA IS BASED ON GROSS AMOUNT. CURRENTLY, THE CEILING IS $30,000 FOR INDIVIDUALS AND AN ALLOWANCE OF $2,480 FOR APPLICABLE FAMILY MEMBERS. FAMILY is defined on the application.
EXAMPLES OF SUPPORTING DOCUMENTATIONCURRENT PAY STUBS
A LETTER FROM EMPLOYER(S)
SOCIAL SECURITY OR UMEMPLOYMENT
AWARD LETTER
LEDGER SHEETS FROM AN ACCOUNTANT
IN SOME CASES, INCOME TAX RECORDS
SELF EMPLOYEED INDIVIDUALS MUST PROVIDE FINANCIAL INFORMATION THAT INCLUDES INCOME RECORDS 90 DAYS PRIOR TO THE DATE OF APPLICATION TO THE SPBP
WHAT IF THERE IS $0 INCOME ?
The application will be determined pending and the applicant will be sent a letter to provide
SPBP staff with a letter detailing how daily needs are being met.
For example, if a client’s friends, family, partner or homeless shelter is providing support, that information should be indicated in a letter sent
with the application.
STATUS APPROVED: CLIENT IS SENT A LETTER WITH AN ELEGIBILITY CARD
ATTACHED
PENDING: CLIENT IS SENT A LETTER WITH INSTRUCTIONS TO
SUBMIT MISSING DOCUMENTATION
DENIED: CLIENT IS SENT A LETTER EXPLAINING WHY THE
APPLICATION IS DENIED AND INSTRUCTED TO REAPPLY IF CIRCUMSTANCES CHANGE
NOTE: CASE MANAGERS, SOCIAL WORKERS, ET AL. DO NOT RECEIVE COPIES OF THIS INFORMATION (PLEASE ASK YOUR CLIENT)
ABILIFY
CLOZARIL
GEODON
RISPERDAL
SEROQUEL
ZYPREXA
SPBP MH Covered Drugs
Client Name and SPBP ID Number
Medicare PART D Plans
12 Plans
1. AmeriHealth Advantage2. First Health Premier3. Humana Standard4. Humana Enhanced
5. Highmark BlueRX Plus 6. Memberhealth Comm Care RX
Basic7. Ovations United Health RX
Basic8. Ovations AARP Medicare RX
Saver9. Ovations AARP Medicare RX
10. Elder Health Bravo RX II11. Geisinger Gold RX12. UPMC for Life PDP
Participating Plans are those that have made special agreements with the state of PA to accept payment of premiums for clients that are enrolled in PA servicing programs, i.e. SPBP and PACE clients
Partnering Plans are also referred to as PA Participating Plans
Why 12 Specific Plans???• Cost Effectiveness
• Monitoring is More Manageable
• Controlled # of Plans Ensures Seamless Coordination of Benefits
for Clients
Premium Payments• SPBP Notification from Clients
– Clients need to notify SPBP of what Part D plan they have chosen
– SPBP contacts claim processor and claim processor contacts plan
– Premium payments paid by SPBP
CONTACT US !SPBP: TOLL FREE IN STATE 1.800.922.9384
SPBP ADDRESS: P.O. BOX 8021 HARRISBURG, PA. 17105-8021
www.dpw.state.pa.us/omap: • Click on HIV/AIDS Information click Special Pharmaceutical Benefits Program (SPBP) HIV Drugs or Clozaril Program• Click SPBP Program Application with bolded area Atypical Antipsychotic Medication and printout
SPBP Email: [email protected]
John Folby, Admin Daneen Williams/Santos Osario, CoordinatorsBrenda Mitchell, SPBP Assistant
Any Office of Medical Assistance Pgm inquiries [email protected] Medicare Questions: 1-800-633-4227 www.medicare.gov