STATE—The New Jersey Department of Health and Senior Services today began mailing PAAD and Senior Gold participants a letter describing prescription benefit changes that will take effect Aug. 1, Health and Senior Services Commissioner Heather Howard announced.
New Jersey’s Fiscal Year 2010 budget makes important changes to these benefit programs as of Aug. 1.
1. Certain drugs that are not covered under the Medicare Part D program will no longer be covered by PAAD and Senior Gold. PAAD and Senior Gold will no longer cover the following medications that are excluded from coverage under Medicare Part D prescription drug regulations:
• drugs to treat impotency
• cosmetic drugs (including but not limited to drugs used to treat skin conditions, weight gain, weight loss, or hair loss)
• cough and cold products, and
Currently, Medicare Part D also does not cover two other types of drugs—benzodiazepines and barbiturates, which are used to treat epilepsy, anxiety and chronic mental health disorders. However, PAAD will continue paying for these drugs because of their clinical importance and because Medicare Part D will cover benzodiazepines and barbiturates in the future.
2. PAAD and Senior Gold will only provide coverage as secondary payer for those medications that are also covered by your Medicare Part D prescription drug plan.
Drugs Covered by Your Medicare Part D Plan — If you are taking a medication that is covered under your Medicare Part D plan (it’s listed in the plan’s formulary and Medicare pays first for the drug), then PAAD or Senior Gold will provide secondary coverage for any drug eligible under the PAAD/Senior Gold programs. This means that Medicare Part D and PAAD/Senior Gold will pick up most of the drug’s cost and you will only have to pay your regular PAAD or Senior Gold copayment. In some cases, you may even pay less because Part D co-pays for certain drugs are lower than the PAAD/Senior Gold co-pays.
Drugs Not Covered by Your Medicare Part D Plan – If you are taking a medication that is not covered under your Medicare Part D plan (it’s not listed in the plan’s formulary and Medicare does NOT pay for the medication) then PAAD and Senior Gold will not pay for the drug either, you must:
• switch to a drug that is on your Part D plan’s formulary, OR
• ask your doctor to request an exception due to medical necessity directly to your Part D plan.
If you do not switch to a formulary drug or your doctor does not request an exception, you may file an appeal directly with your Part D plan. Contact your Part D plan for information on its appeal process.
However, you will be responsible for handling your own appeal, and you must pay the entire cost of the drug you are taking during the appeal period.
About 154,000 people are currently enrolled in the PAAD program for low-income seniors and disabled people. About 22,000 people are enrolled in the Senior Gold prescription discount program for people with moderate incomes.
PAAD and Senior Gold program members should call the PAAD/Senior Gold hotline at 1-800-792-9745 if they have any questions.
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