Pharmaceutical Assistance Contract for the Elderly (PACE) Program began July 1, 1984 PACE Needs Enhancement Tier (PACENET) Program began January 1, 1997.

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Presentation transcript:

Pharmaceutical Assistance Contract for the Elderly (PACE) Program began July 1, 1984 PACE Needs Enhancement Tier (PACENET) Program began January 1, 1997 State Prescription Assistance Program Funded by the Pennsylvania Lottery $216.2 million spent annually on prescriptions (2011) PACE / PACENET Program What is PACE / PACENET?

1.5 million are eligible for the program Current Enrollment (Aug. 2012): PACE 111,000 PACENET 178,000 Total 289,000 Average PACE cardholder Female, 79 years old, widowed, 4-5 disease states 83% are enrolled in Medicare Part D Who is Eligible for PACE / PACENET? Of the 1.9 million older Pennsylvanians…

Pennsylvania resident Age 65 or older Can apply 30 days before 65 th birthday – benefit effective on 65 th birthday Income – based on previous calendar year PACE: less than $14,500 for single person less than $17,700 for married couple PACENET: less than $23,500 for single person less than $31,500 for married couple Assets are not counted Program Eligibility Requirements Who Qualifies for PACE / PACENET?

Prescription drugs, including insulin, insulin syringes & needles Generic medications: $6 copay (30-day supply) Brand name medications: $9 copay (30-day supply) Can get 90-day supply with PACE & Part D PACENET Prescription drugs covered including insulin, insulin syringes & needles Generic medications: $8 copay (30-day supply) Brand name medications: $15 copay (30-day supply) Can get 90-day supply with Part D Pay PACENET deductible or Part D monthly premium Program Benefit PACE

PACE/PACENET coordinates benefits with Part D No coverage gap Lower copayments Program pays Part D premium for most PACE cardholders Part D deductible coverage for members with Part D PACE/PACENET is creditable coverage Extra Help / Low Income Subsidy Enrollees with low income and few assets Provides for no or reduced Part D premium and deductible No coverage gap Low copayments Contact APPRISE Program for help in applying Part D and Low Income Subsidy Medicare Part D

STANDARD MEDICARE PART D PRESCRIPTION DRUG BENEFIT, 2012 $320 $2,930 $6,730 Catastrophic Coverage 5% Coverage Gap 50% After Brand Discount 86% After Generic Discount Initial Coverage Phase 25% BENEFICIARY PAYS $ BENEFICIARY PAYS $320 BENEFICIARY PAYS $3, TOTAL BENEFICIARY OUT-OF-POCKET (OOP) COSTS EQUALS $4,700 PRIOR TO CATASTROPHIC COVERAGE. Deductible 100% Total Drug Costs:Beneficiary OOP Costs:

PACE PLUS MEDICARE PART D PRESCRIPTION DRUG BENEFIT, 2012 $320 $2,930 $6,730 Catastrophic Coverage 5% Initial Coverage Gap 12% After Brand and Generic Discounts Coverage Phase 12% BENEFICIARY PAYS $313 BENEFICIARY PAYS $38 BENEFICIARY PAYS $456 TOTAL BENEFICIARY OUT-OF-POCKET (OOP) COSTS EQUAL $807 PRIOR TO CATASTROPHIC COVERAGE. Deductible 12% Total Drug Costs:Beneficiary OOP Costs:

Comprehensive and aggressive drug utilization review with prescription payment stopped at pharmacy counter Developed by physicians and pharmacists Tailored for older patients Goals are safety and effectiveness Dose Duration Concurrent Usage Safe and Effective Rx Utilization Program History

Physician focused medical exception process Step therapy for selected therapeutic classes Sulfonylurea, insulin or metformin before pioglitazone (Actos) Calcium acetate (Phoslo) before sevelamer (Renagel) A-rated generic substitution Drug utilization review coordinated with Part D drug plans Supplemented by academic detailing since 2005 Safe and Effective Rx Utilization Prospective Drug Review (since 1992)

Enrollment Phone PACE Portal How Do You Reach the Program?