Special Pharmaceutical Benefits Program Fact Sheet

What is the Special Pharmaceutical Benefits Program (SPBP)?

The SPBP is a program for low and moderate income individuals and families that helps pay for specific drug therapies used for the treatment of persons with HIV/AIDS or a DSM IV diagnosis for schizophrenia. Please note that the HIV/AIDS side of the SPBP is usually called: AIDS Drug Assistance Program (ADAP) in other states.

Who administers and funds the program?

The SPBP is administered by the Department of Public Welfare (DPW), Office of Medical Assistance Programs. The HIV/AIDS portion of the program is funded through a combination of Ryan White Emergency Care Act Title II funds and state funds. The mental health drug component is funded exclusively through state funds. The SPBP is not an entitlement program.

How can I apply to the program?

Clients can obtain an SPBP application from their local County Assistance Office, community based AIDS service organizations, Department of Health clinics, hemophilia centers, some doctors' offices and pharmacies, and local mental health providers. You can also download application:

Special Pharmaceutical Benefits Application (PDF download)

El Programa Especial de Beneficios Farmacéuticos (SPBP) (version espanola)

Clients may also call or write to the SPBP staff for an application at:

SPBP P.O. Box 8021 Harrisburg, PA 17105-8021 Or call 1-800-922-9384 (in state only) 1-717-772-6228 (local number)

Eligibility determination is processed at a centralized office in Harrisburg. Eligible clients are issued an SPBP identification card, which may be used at enrolled Pennsylvania Medicaid providers who are also contracted with SPBP’s online claims processing contractor, First Health Services Corporation.

What are the eligibility criteria?

Eligibility for the SPBP is determined by the following criteria:

Income Limits:

Individuals - $35,000 gross income per year;

Families - $35,000 gross income per year, plus an allowance of $2,893 for each additional family member. (Example: family of two $37,893 combined gross; family of three $40,786 combined gross; etc.)

Applicants must provide proof of income.

Residence:

Must be a Pennsylvania resident living in Pennsylvania (not institutionalized).

Applicants must provide proof of residence.

Medical Need:

Must have a diagnosis of HIV/AIDS.

Applicants must submit a copy of at least one HIV/AIDS specific antiretroviral medication.

Applicants must submit photocopies of documentation which supports the eligibility criteria along with a completed Special Pharmaceutical Benefits Application.

For HIV/AIDS Applicants: A diagnosis of HIV/AIDS should be written on the physician’s prescription and/or copies of HIV/AIDS specific drug(s) prescriptions provided.

For Mental Health applicants: Prescription with the DSM diagnosis for schizophrenia, including ICD-9-CM code, plus the signed physician’s attestation found on the application.

All information received is kept strictly confidential and is only used for the purpose of program administration.

To participate in the SPBP HIV/AIDS program, clients are required to recertify. In certain situations, some clients may have to reapply. For example: clients who have not utilized benefits for one year or longer or clients who might have been living in the community and moved out of state for an extended period of time, would have to reapply. Clients must advise program staff of any changes regarding residence, income, third party insurance coverage and drug therapies on an ongoing basis.

What does the SPBP cover?

The SPBP covers the cost(s) for drugs on the SPBP’s HIV/AIDS Baseline Formulary Tiers Formulary or Mental Health Drugs Formulary; outpatient aerosolized pentamidine treatments; 12 piece IV administration package used with Ganciclovir therapy; and Clozaril support services, if applicable.

Providers should not submit claims for drugs not covered on the specific formularies. It is suggested that clients/patients be referred to drug manufacturer’s patient assistance programs, drug trials, local AIDS service organizations, or mental health agencies for drugs not covered on the SPBP’s formularies.

The Department of Health provides free CD4 T-Cell and viral load testing for eligible SPBP clients at various Department of Health clinics. Eligible SPBP clients should call the Department of Health’s s AIDS Factline at 1-800-662-6080 for information on how to access a viral load or CD4 T-Cell test site in their area.

What are the SPBP participant's responsibilities?

Eligible SPBP participants must present their eligibility card to enrolled Pennsylvania Medical Assistance/Medicaid providers who are also contracted with First Health Services Corporation only.

Clients must advise SPBP staff of any changes regarding residence, income, third party insurance coverage and drug therapies on an ongoing basis.

Clients must use all third party resources first, if applicable. Clients who become eligible for drug coverage through Medical Assistance/Medicaid must inform their pharmacist and use their ACCESS card. The SPBP card becomes invalid.

What are the provider's responsibilities?

The provider must be enrolled in the Medical Assistance/Medicaid Program to receive payment for services provided under the SPBP and have a signed contract with First Health Services Corporation. First Health Services is the SPBP’s online claims processing contractor. Clozaril support services are only compensable for SPBP clients on Clozaril therapy and only for three specific provider types: (31) physician/physician groups (08) outpatient psychiatric clinics and (11) psychiatric partial hospitalization clinics.

All claims must be submitted online through First Health Services. The SPBP does not accept or process paper claims. Providers should only submit claims for drugs on the SPBP formularies. Call 1-800-835-4080 for questions regarding provider enrollment and billing.

If third party coverage exists, the third party must be billed before billing the Department. Providers must bill Medical Assistance/Medicaid for SPBP clients who convert to drug coverage through an ACCESS card. Providers must accept reimbursement from the SPBP as payment in full. Dispensing limits parallel Medical Assistance: 100 units or a 34 day supply.

For additional SPBP information or applications, please contact:

SPBP P.O. Box 8021 Harrisburg, PA 17105-8021 Or call 1-800-922-9384 (in state only) 1-717-772-6228 (local number)

SPECIAL NOTE FOR MEDICAL ASSISTANCE RECIPIENTS - Persons who are eligible for pharmaceutical coverage under Medical Assistance/Medicaid or through a Medical Assistance/Medicaid managed care provider are not eligible for SPBP coverage.