LIS – Low Income Subsidy  – Extra Help

Get help paying for your prescriptions

Here’s #MoreAassistance
Even if you have high assets & Income
Beyond Part D Rx

Assistance Programs from the Manufacturer
and Government Programs

 This tool includes Merck

CA Health Care Advocates – Resources for Rx Drug Savings

The Patient Access Network (PAN) Foundation is  dedicated to helping federally and commercially insured people living with life-threatening, chronic and rare diseases with the out-of-pocket costs for their prescribed medications. Partnering with generous donors, healthcare providers and pharmacies, PAN provides the underinsured population access to the healthcare treatments they need to best manage their conditions and focus on improving their quality of life.

search disease or medication

Pharmaceutical Assistance Program

pharmaceutical assistance program

 

Benefits Checkup.org

benefit checkup org

 

National Patient Advocate Foundation

National Organization for Rare Disorders

California Prescription Drug Discount Program
At Medi-Cal participating pharmacies, you can get prescription drugs at the Medi-Cal rate plus a $0.15 processing fee. This rate may be lower than the Part D rate. Payments may not apply toward your Part D cost-sharing. This program should not be used as a substitute for Medicare Part D. To receive benefits, show your Medicare card at Medi-Cal participating pharmacies   SB 393 2000

6 Hints to get help with Rx costs on Medicare.gov

california rx card.com

Glaxo Smith Kline Rx Assistance

pfizer rx pathways.com    Find Assistance That’s Right for You    Pfizer RxPathways connects eligible patients to a range of assistance programs that offer insurance support, co-pay help,* and medicines for free or at a savings.†  Enter the name of the medicine you’ve been prescribed. You can search one medicine at a time. Then answer a few questions to see which available program(s) may be right for you.

Humira

MS Multiple Sclerosis

Financial Assistance Programs

Manufactures Coupons 

 

  • If one has Part D Rx, the manufacturers cannot help out with coupons.  One might consider dropping Part D or if you have Medicare Advantage Plan, finding one that doesn’t include Part D.
    • We CANNOT advise you to do this. It’s beyond our pay grade and we are mandated to tell you about the penalty if you don’t purchase Part D.  I’m having trouble finding a reliable plain English citation for this.  Scroll down for hints from one of our wholesalers on using coupons and not using your Part D Rx plan.
  • The intention for coupons is to steer patients away from cheaper generic alternatives and toward the brands that they produce. That is to increase demand for their drugs. Experts estimate that brand drug manufacturers are spending between $3 billion and $6 billion annually on coupon programs. Anti-Kick Back and all. HHS Report Mfg safeguards might not prevent coupons for Part D Rx.  Legally, the use of drug co-pay cards and coupons by individuals with government funded health care and prescription drug benefits, such as Medicare and Medicaid, is prohibited by the federal anti-kickback statute.
    • (2) Whoever knowingly and willfully offers or pays any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind to any person to induce such person—
      • (A) to refer an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a Federal health care program, or SSA.gov

Resources, Links, Bibliography

Here’s some hints from our wholesaler…

 

Coupons are allowed to be used in Medicare, but it is tricky. When a client uses a coupon, or a GoodRX or even the pharmacies billing costs (which are sometimes cheaper than the plan copay) the drug doesn’t get run through Medicare, it becomes a cash pay situation and it doesn’t go against the Medicare deductibles, donut hole,  etc.   So that is the negative.

I have many clients that have purchased drugs directly from the pharmacy to get a lower cost, and some that have used Good RX or even just googled their drugs and bought them online at a cheaper cost.

There are certain things that are much cheaper online, Progesterone is a big one that my female clients find cheaper online..

So, if the pharmacy will work with the client to help them find the lowest cost, there are alternatives for our Medicare clients. Not all pharmacies will do this however, so it is good to do some research on more expensive drugs to find alternative solutions.

#Understanding Medicare Advantage Plans (PDF) #12026

Watch Steve's Video Seminar

Insurance Companies get a fee from the Federal Government, when you enroll in an MAPD plan.  MAPD Plans must cover all A & B services Medicare.Gov *

That's why the premium is very low or ZERO!

#GoodRx

goodrx.com/discount-card

We do not know who they are.  We are not endorsing them.  We’ve heard from some of our clients, who are happy with them.

 

good-rx-video

 

#Co-Pay Accumulator Programs

When Copay Assistance Backfires on Patients  

If a patient has an insurance plan with an accumulator program, all copays funded by the manufacturer copay savings program will not count towards their deductible and annual maximum out-of-pocket costs. When this patient goes to refill their prescription without the copay savings program, they will be responsible for the full cash price of the drug until they reach their deductible and out-of-pocket annual maximum.

In the absence of accumulator programs, when a patient uses a copay savings program, the portion paid by the manufacturer would contribute to the patient’s deductible. However, copay accumulator programs are designed to keep manufacturer contributions from counting towards a patient’s deductible and annual maximum out-of-pocket costs.

  • CMS allows all Insurance Plans to do this.   Good Rx.com * Actuary Magazine.orgPolicy Med.comThomsonReuters *
  • Los Angeles Times explanation April 2018
  • Court Ruling in favor of Rx companies:  The dispute centers on programs in which drug companies help patients cover their share of the prescription drug costs that they otherwise could not afford.

    In recent years, some insurers have established so-called accumulator adjustment programs, in which they do not count assistance toward patients’ deductibles and out-of-pocket maximums. Such programs effectively capture some of the assistance for insurers instead of patients.  Read More Reuters.com

 

Response from Anthem Blue Cross CA…

Our company does use Rx Co Pay Accumulator Programs. Depending on the policy/plan, some Anthem policies do not allow the amounts you save with using a Mfg Rx coupon to count toward your deductible or out of pocket accumulations. Only your true out of pocket expense will be accumulated. If you have any additional questions feel free to contact our Pharmacy Ingenio RX team at 833-419-0530. 

Blue Shield of CA

This confirms member’s who use manufacturer coupons for prescriptions, will be credited the amounts paid towards their deductible/out-of-pocket.

Oscar

At this time, the only amount that will contribute towards the members deductible and/or out of pocket maximums will be the amount that the member pays.

Pamphlets, Brochures & Websites to help prevent Fraud

 

 

 

YouTube VIDEO's

you tube videos

LIS Low Income xSubsidy  Extra Help

Low Income Subsidy – Extra Help

The Low-Income Subsidy (LIS) program/extra helps pay for a portion of Part D prescription drug plan costs, including Part D premiums, deductibles and copayments.

Depending on your income and assets, you may qualify for the full subsidy or a partial subsidy. All beneficiaries who qualify for the LIS program are permitted to change Part D plans once a month at anytime during the year. CA Health Care Advocates     The full Low-Income Subsidy (LIS) program covers the premium and deductible of benchmark plans, that meet the minimum standards.  This means you do not pay a premium or deductible if you receive the full LIS benefit and enroll in a benchmark plan. You are, however, still responsible for copayments of $3.70 to $9.20  for each covered prescription. CA Health Care Advocates

SSA.Gov  LIS/Extra Help

What help can I receive?

The Social Security Extra Help is estimated to be worth about $5,000 per year.  To qualify for the Extra Help, a person must be receiving Medicare, have limited resources and income  (scroll down to view) and reside in one of the 50 States or the District of Columbia.

Medicare beneficiaries can qualify for Extra Help with their Medicare prescription drug plan costs. The Extra Help is estimated to be worth about $4,000 per year. To qualify for the Extra Help, a person must be receiving Medicare, have limited resources and income, and reside in one of the 50 States or the District of Columbia.

I feel that the brochure on Medicare Rx Coverage, their extra help section really explains it IMHO the best, simplest and easiest way to understand.

Prescription Drug Coverage Guide # 11109

get extra help table of contents

  • See if you qualify for Extra Help and apply SSA.gov
  • Qualifications to get Extra Help

    • You have Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance); and
    • You live in one of the 50 States or the District of Columbia; and
    • Your combined savings, investments, and real estate are not worth more than $29,160, if you are married and living with your spouse, or $14,610 if you are not currently married or not living with your spouse.
      • (Do NOT count your home, vehicles, personal possessions, life insurance, burial plots, irrevocable burial contracts or back payments from Social Security or SSI.)
    • Your annual income must be limited to $19,140 for an individual or $25,860 for a married couple living together. Even if your annual income is higher, you may still be able to get some help.
      • Some examples where your income may be higher and you can still get Extra Help include if you or your spouse:
        • Support other family members who live with you.
        • Have earnings from work.
        • Live in Alaska or Hawaii.
    • EXCEPTION:  If you have Medicare and Supplemental Security Income (SSI) or Medicare and Medicaid [Medi-Cal] you automatically will get the extra help.   Publication 10525 * Social Security ONLINE Application for Extra Help  *  Publication 10508 Understand 

Prescription Drug 2022 #RxGuide
PDF # 11109

part d video explanation

 

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Coverage Gap - Donut Hole $2,000 Cap

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#Understanding Medicare Advantage Plans (PDF) #12026

Watch Steve's Video Seminar

Insurance Companies get a fee from the Federal Government, when you enroll in an MAPD plan.  MAPD Plans must cover all A & B services Medicare.Gov *

That's why the premium is very low or ZERO!

#Medicare10050 and You  2024
Everything you want to know 

Steve's video on Medicare & You

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your medicare benefits # 101116

 

Links  &  Resources

#My Medi-Cal 
How to get the Health Care
You Need

24 pages

Smart Phones - try turning sideways to view pdf better
My medi cal explanation of medi cal