33.8 Countable Costs

33.8.1 SeniorCare Countable Costs Introduction

In order for the prescription drug purchase to count towards meeting a spenddown or deductible, it must be:

Prescribed for the eligible SeniorCare participant,
Purchased during the benefit period, and
Covered by the SeniorCare program (33.6 SeniorCare Financial Requirements).

All covered prescription drug costs the participant incurs will be tracked, and the SeniorCare Program will coordinate coverage with insurance companies. If the prescription is covered by insurance, only the portion not paid by insurance is applied toward the spenddown or deductible.

When a participant’s out-of-pocket expense requirements are met for a deductible or spenddown, participating pharmacies will be informed.

33.8.2 Carryover

There is no carryover of prescription costs from one benefit period to the next. There are two instances, within a benefit period, when carryover covered prescription amounts are applied.

1. When the covered prescription cost exceeds the remaining deductible amount, SeniorCare pays the difference.

Example 1: Jeff earns between 160% and 200% of the FPL for a FTG size of one (39.11 SeniorCare Income Limits and Participation Levels). He is eligible for SeniorCare and has a $500 deductible. In three months, Jeff has a remaining deductible amount of $30.

During the fourth month of his benefit period, with a $30 remaining deductible, Jeff purchases a covered prescription drug that costs $100. The pharmacist informs him that he owes $30 of the $100 prescription drug cost. He has met his deductible. The remaining $70 will be paid by SeniorCare.

For the next prescriptions that Jeff has filled during his benefit period, he will pay only co-payment amounts.

2. When the cost of a covered prescription drug is applied toward meeting the spenddown and the amount exceeds the remaining spenddown amount, the excess will be applied toward the deductible.

Example 2: Rachel's income is $1,800 more than 240% of the FPL for a FTG of one (see Section 39.11 SeniorCare Income Limits and Participation Levels). Her spenddown amount for the 12-month benefit period is $1,800. In four months, Rachel has incurred all but $50 of her spenddown amount by purchasing covered prescription drugs at retail price.

During the fifth month of her benefit period when she has $50 of her spenddown left, Rachel purchases a covered prescription drug that costs $100. Rachel pays the full $100. Of the $100, $50 is applied to her spenddown, and $50 is applied to her deductible. She now has satisfied the spenddown, and the remaining deductible amount is $800.

33.8.3 Date of Purchase

A prescription is considered purchased on the date the prescription is filled. For the drug purchase to count toward either the spenddown or the deductible, the prescription must have been purchased during the benefit period.

This page last updated in Release Number: 18-01

Release Date: 04/13/2018

Effective Date: 04/13/2018