Prescription Advantage is Massachusetts’ State Pharmaceutical Assistance Program (SPAP), which is overseen by the Commonwealth of Massachusetts Executive Office of Elder Affairs. It is one of the most comprehensive SPAPs in that the program provides financial assistance to both qualified Medicare and non-Medicare individuals.
Individuals who are eligible for Medicare must enroll or be enrolled in a Medicare Part D plan or a Medicare Advantage plan that has prescription coverage. When filling a prescription, Medicare is the first payer, and costs not covered by Medicare are then eligible to be paid for by the Prescription Advantage program.
For persons ineligible for Medicare, the program serves as the individual’s primary coverage for prescription drugs. However, if the individual has primary prescription coverage from another insurer, Prescription Advantage works as secondary coverage. It helps with prescription costs directly, requiring only small deductibles or co-payments until an annual out-of-pocket limit is reached. Once that limit is reached, Prescription Advantage covers the co-payments for the remainder of the plan year. Depending on the individual’s membership category, a deductible may be required.
There is an annual maximum out-of-pocket spending amount set for all individuals enrolled in this program, regardless of whether they are Medicare eligible or not.
To be eligible for this program, the state of Massachusetts considers the following factors. Note that there are interdependencies between some of these requirements.
The Prescription Advantage program provides different benefits depending on if the enrolled individual is or is not eligible for Medicare.
Medicare Eligible Individuals
For individuals on Medicare, Prescription Advantage helps with the cost of medications covered by Medicare Part D or another approved drug coverage plan. Individuals are assigned a membership level based on their annual income, and that membership level determines their copay amount and annual out-of-pocket spending limit.
Currently, for 2023, copays for generic drugs range from no more than $4.15-$12, and no more than $10.35-$30 for brand name drugs. The range for spending limits is $1,835-$4,080. The lower an individual’s income, the lower the copay and spending limit. (Specifics on membership levels and annual income can be found here.) Individuals are responsible for copays until their annual out-of-pocket spending limit is reached. Once the spending limit is reached, the program covers the cost of copays.
Individuals NOT Eligible for Medicare
For those individuals who are not enrolled in Medicare, the program acts as the individual’s prescription drug insurance plan, provided they do not have primary prescription coverage from another insurer. There is no monthly premium, and participants pay a copay determined by their annual income level. For 2023, copays for generic drugs range from $7-$50, and $14-$100 for brand name.
Like Medicare eligible individuals, an out-of-pocket limit also exists for individuals not receiving Medicare. Once this limit is reached, the plan covers copays until the end of the plan year. Out-of-pocket limits are also based on annual income. Currently, yearly out-of-pocket limits range from $920-$6,795. Specifics on income levels for non-Medicare members can be found here
The Prescription Advantage program does not have application or enrollment fees.