The Maine Low Cost Drug Program for the Elderly and Disabled and Maine Rx Plus
(programs for people who cannot get
full benefits from MaineCare)
Important Warning
This information is up to date as of April 2009.
Please contact us for information about any program changes.
| Drug Benefit |
Maine Low Cost Drug Program
for the Elderly and Disabled
For an application, contact the Maine Department of Human Services prescription drug information
line: 1-866-796-2463. |
Maine Rx Plus
For an application, contact the Maine Department of Health and Human Services prescription drug
information line:
1-866-796-2463. |
| Who Is Covered? |
Maine residents who:
1) Are aged 62 and older; or at least 19 and disabled;
2) Do not have MaineCare (formerly Medicaid)--you can be receiving Medicare
[most Medicare participants will need to enroll in Part D];
AND
3) Meet the income guidelines. |
Maine residents who do not qualify for full Maine Care Benefits.
No age or disability restrictions. |
| Income Limits |
185% of the Federal Poverty Levels
OR
If you spend at least 40% of your yearly income on prescription drugs, your income limit will be 25%
higher. |
Individuals and families with income up to
350% of the Federal Poverty Levels are eligible for Maine Rx Plus. People over 350% of poverty will be eligible if they have out of pocket prescription
drug expenses exceeding 5% of the family's income or out of pocket medical expenses exceeding 15% of the the family's
income. |
| What Drugs Are Covered At What Cost? |
- 80% of the cost of generic drugs. You will pay 20% of the cost. In addition, there is a $2.00 co-payment per
prescription.
- 80% of the cost of drugs needed for the treatment of diabetes, heart disease and high blood pressure, arthritis,
chronic lung disease (including emphysema and asthma), anticoagulation, glaucoma, high cholesterol, osteoporosis,
thyroid diseases, incontinence, Parkinson's disease, multiple sclerosis, and Lou Gehrig's disease. You will pay 20% of
the cost. In addition, there is a $2.00 co-payment per prescription.
A much smaller discount is available on most other medications.
If you pay more than $1,000 out-of-pocket for prescription drugs in a year, the program will cover 80% of the cost of
additional drugs for that year. You will pay 20% of the cost. When you buy drugs with your
prescription drug card, your costs will automatically count toward the $1,000 out-of-pocket expenses, so be sure to always
use your card!
Some drugs require prior authorization (PA)see below.
The Preferred Drug List (PDL) shows which drugs are
"preferred" (don't need PA) and which are "non-preferred" (need PA).
|
Drugs listed as "preferred" on the MaineCare
Preferred Drug List are covered. Savings will be
approximately 15% on covered brand name drugs and 60% on generic drugs. |
Some Other Important Facts
About Prescription Drug Coverage
- Eligibility for the Low Cost Drug Program is based on income. Any assets you have will not affect your
eligibility.
- The so-called "Estate Recovery Law" does not
apply to the Low Cost Drug Program or Maine Rx Plus.
- If you meet the income and asset guidelines, full benefit MaineCare (formerly Medicaid and Cub Care) provides full
prescription drug coverage. Some people need to pay a small co-payment of $3.00 per prescription (with a cap of $30 per month, per
person. If you are also enrolled in Medicare, you will get most of your drugs through Medicare Part D and the co-pays will be
different. Read more on Medicare Part D
To get an application for full benefit MaineCare, call the Maine Department of Health and Human Services
at 1-866-796-2463 or your local DHHS office. You can also call the Consumers for Affordable Health Care HelpLine at 1-800-965-7476 for
information and assistance. Seniors (age 60 and older) and people with disabilities can call the
Maine Legal Services for the Elderly HelpLine at 1-800-750-5353.
Prior Approval Of Prescription Drugs
Some prescription drugs you get through the Low Cost Drug Program must be "prior approved" by DHHS in order to
be covered. DHHS has a list of
expensive drugs for which they think there is a cheaper alternative that can treat you just as well. You can only get coverage
for the more expensive drug with DHHS's "prior approval." If you and your doctor think the more expensive drug is best
for you, your doctor must request approval from DHHS (by fax) and provide information supporting that request. If DHHS approves, you
will be able to get that drug under the Low Cost Drug Program with no further delay.
Q. How long does DHHS have to make a decision on my doctor's request for "prior approval" of a drug?
A. DHHS must grant or deny your doctor's request for prior authorization within 24 hours of the time it receives
the
doctor's completed request for "prior approval" of a particular drug.
Q. What happens if I get to the pharmacy and can't get my prescription?
A. If you can't get your prescription at the pharmacy, ask the pharmacist why you can't get your medicine.
If you can't get your medicine because your doctor did not file paperwork for prior authorization, contact your doctor right
away to discuss your options. If you cannot reach your doctor, you may be given a 96-hour (4-day) supply of
most drugs without prior authorization. Whether or not you get this supply is up to the pharmacist. If the pharmacist does not know
why your prescription was denied, you can call the MaineCare pharmacy Help Desk at 1-866-796-2463.
Q. How long does the prior approval last?
A. Up to one year. After a year, your doctor will have to ask for prior approval again.
Q. What if I am denied prior approval?
A. You can first try to resolve the dispute by contacting DHHS at 1-866-RxMaine (1-866-796-2463). If you
still disagree, you may request a fair hearing. If you are deaf and have a TYY machine, call the same number.
You Have A Right To A Fair Hearing. If you disagree with a decision of DHHS regarding drugs, you have a right to
request a "fair hearing" to have that decision reviewed by an impartial person. You have a right to be represented at that
hearing by a person of your choice. Call or write the Office of Administrative Hearings, DHHS, 11 State House Station, Augusta, Maine
04333-0011; phone: (207) 287-3610. To keep your medicine during an appeal, you must appeal within 10 days of the denial.
Who To Call For Help. If you have questions about the Low Cost Drug Program call the Consumers for Affordable Health Care
HelpLine at 1-800-965-7476, or for:
To find out which drugs require prior authorization, go to the
Preferred Drug Lists.
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Disclaimer
Maine Equal Justice Partners
April 2009
We are providing this information as a public service. We try to make it accurate as of the date
indicated for each client education page. Sometimes the law changes. We cannot guarantee or promise that this information is
always up-to-date and correct. Feel free to contact us to find out if there have been any changes since the date of the
information provided.
We do not intend this information to be legal advice. We do not intend it as advertising or
solicitation. By providing this information, we are not acting as your lawyer. It is best to consult a competent lawyer before
taking legal action.
Because it is important that information be shared, we encourage reproduction and distribution of our
work so long as appropriate acknowledgement is made. Please check
with us for updates on information before distributing any dated material.
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