COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE SPECIAL

COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE SPECIAL PHARMACEUTICAL BENEFITS PROGRAM S P B P

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 PROGRAM SPBP/ADAP/SPBP • REMEMBER IN MOST OTHER STATES THIS PROGRAM IS CALLED AIDS 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? • RESIDENCE INCOME APPLICANTS MUST BE A RESIDENT OF THE COMMONWEALTH THE CURRENT CEILING IS NOT INSTITUTIONALIZED FAMILY ALLOWANCE SOCIAL SECURITY NUMBER CLIENT INFO ALREADY ON FILE NOT NECESSARY $30 k WITH A • 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 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 DOCUMENTATION CURRENT 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)

SPBP MH Covered Drugs ABILIFY CLOZARIL GEODON RISPERDAL SEROQUEL ZYPREXA

Client Name and SPBP ID Number

Medicare PART D Plans 12 Plans 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 1. Ameri. Health Advantage 2. First Health Premier 3. Humana Standard 4. Humana Enhanced 5. Highmark Blue. RX Plus 6. Memberhealth Comm Care RX Basic 7. Ovations United Health RX Basic 8. Ovations AARP Medicare RX Saver 9. Ovations AARP Medicare RX 10. Elder Health Bravo RX II 11. Geisinger Gold RX 12. UPMC for Life PDP

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 SPBP ADDRESS: 1. 800. 922. 9384 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: spbp@state. pa. us John Folby, Admin Daneen Williams/Santos Osario, Coordinators Brenda Mitchell, SPBP Assistant Any Office of Medical Assistance Pgm inquiries pamedicaid@state. pa. us Medicare Questions: 1 -800 -633 -4227 www. medicare. gov