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: spbp@state.pa.us

John Folby, Admin Daneen Williams/Santos Osario, CoordinatorsBrenda Mitchell, SPBP Assistant

Any Office of Medical Assistance Pgm inquiries pamedicaid@state.pa.us Medicare Questions: 1-800-633-4227 www.medicare.gov