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  • June 1, 2013 - May 31, 2014

    Special Pharmaceutical Benefits Program Mental Health Questions and Answers
     
    The following are the most frequently asked questions regarding supporting documentation and situations for eligibility consideration for the Special Pharmaceutical Benefits Program (SPBP).
     
    RESIDENCE

    Criteria - Proof of Residence (Note: The address on supporting documentation must match the address on the application!)

    How do I show where I live?

    • Provide a copy of client's Pennsylvania Driver's License.
    • Provide a copy of a utility bill, bank statement, or any miscellaneous mail label with the client's address on it.
    • Provide a copy of a lease or purchase agreement.

    I am being released from prison and do not have my own place. What do I do? 

    The client should provide a note from a family member, friend, shelter manager or caseworker that verifies the address.

    I use a P.O. Box because I do not want the SPBP staff sending mail to my home address. What should I do?

    SPBP staff will have mail sent to a P.O. box; however, a P.O. box is NOT a place of residence and the client must still provide proof of residency in Pennsylvania. In some rural areas of the state a P.O. Box number may be accepted as proof of residence.

    I am living with my parent(s)/other relative(s)/friends(s)/partner. Everything is in their name. What should I do?

    Provide a note from a responsible adult within the residence that verifies your living arrangement.

    I am homeless and living in a shelter or living in a personal care home or CLA. What should I do?

    Have the shelter manager/caseworker provide a note to verify residency.

    SOCIAL SECURITY CARD

    Criteria - Provide a Copy of Your Social Security Card - SS Number

    I do not have a Social Security Card to copy. What should I do?

    Provide a copy of something that has your social security number mechanically imprinted on it, such as:

    • Copy of pay stub showing the SS number;
    • Copy of income tax forms;
    • Copy of unemployment or social security award letters; or
    • A computer print out from the local Social Security Office showing your name and number. (While you are there, ask them for a replacement social security card!)

    MEDICAL NEED - PRESCRIPTIONS 

    Criteria - Medical Need Through Copies of Prescriptions

    I do not have prescriptions. My doctor has not prescribed anything yet. What should I do?

    Do NOT apply for SPBP benefits until the doctor has written prescriptions.

    I do not have prescriptions. The pharmacy kept my originals. What should I do?

    Ask the physician or the pharmacist to please provide copies of your prescriptions so you can apply for SPBP coverage. Note: Prescriptions for atypical antipsychotic medications must include the DSM IV Diagnostic code written on the prescription. The only acceptable DSM IV codes are: 295.10, 295.20, 295.30, 295.60, and 295.90. DO NOT submit applications or prescriptions for any other diagnostic code.

    INCOME

    Criteria - Proof of Gross Annual Income (Before Taxes)

    What do I use for proof?

    Copies of pay stubs, Social Security or unemployment award letters, bank statements, or other appropriate documentation that shows income BEFORE taxes.

    I am self-employed and do not have pay stubs. What should I do?

    Individuals who are self employed must provide verification of income 90 days prior to application. It is the client's responsibility to provide documentation from an accountant, fiscal agent or copies of the previous year's income tax return.

    I only make a few or a couple of hundred dollars more than the current SPBP income ceiling. What can I do?

    The current ceiling is $35,000, with an allowance of $2,893 for additional applicable family members. DO NOT APPLY if you are over the current income ceiling.

    I do not have any income. What can I do?

    Provide a note from your care giver or other person that explains that they are helping cover your day-to-day needs. Applications indicating ZERO income are not processed until the applicant provides information regarding their zero income.

    NOTE: Clients with no or ZERO income are encouraged to apply for Medical Assistance/Medicaid benefits.

    OTHER QUESTIONS

    Criteria - Provide a Copy of Your Social Security Card - SS Number

    How long does it take to get my card?

    Usually a week to 10 days. However, clients should not wait to apply for benefits until two days before a current prescription runs out. Applications with missing documentation take much longer to process.

    Where does the client go for drugs?

    There are over 1,400 pharmacies statewide that accept SPBP cards. The pharmacy must have a contract with the SPBP's claim processing contractor, First Health Services Corporation.

    What about third party insurance?

    Per Ryan White legislation and Medical Assistance/Medicaid, the SPBP is the payer of last resort. Clients with third party insurance with drug coverage MUST inform their pharmacy and bill the third party carrier FIRST! The SPBP may not be available for some clients with other insurance. Clients should know how their policy covers or provides drug benefits.

    My client paid for drugs out of pocket, can they have their money back? The SPBP does not reimburse clients or third party insurance carriers, in these situations.

    My client got a bill from their doctor for a viral load test. Are you going to pay for it? SPBP clients may use their SPBP control card to have CD4 and viral load tests covered through THE DEPARTMENT OF HEALTH. The SPBP does NOT pay for these or any other kind of tests, medical services etc. SPBP clients should call 1-800-662-6080 for testing sites and information.

    My client got a bill for Clozaril support services, are you (DPW) going to pay it?

    The SPBP covers the cost of Clozaril support services through provider types: (01) physicians (29) outpatient psychiatric clinics or (33) psychiatric partial hospitalization facilities. The SPBP does not reimburse any other provider type nor does it reimburse clients.

    What is my client's SPBP control number? ASK YOUR CLIENT. SPBP eligibility cards and control numbers are issued and mailed to the client.

    BEFORE YOU CALL US…..

    Plan ahead --- submit applications before a client is down to a one-day supply of drugs. Eligible clients receive their SPBP cards in the mail in a plain white envelope. It looks like it could be junk mail, but it isn't !

    It takes a week to ten days from the day the SPBP receives an application to the time a client is notified of their status.

    It takes a week to ten days from the day the SPBP receives an application to the time a client is notified of their status.

    If you have questions regarding the status of a client's application, wait for at least ten days after you have submitted the application to call the SPBP. Conversely, do not wait for two months to call if the client tells you they have not received a card. The SPBP is NOT an entitlement program. The HIV/AIDS piece of the program is funded through the Ryan White Emergency Care Act and state funds. The mental health drug component is funded with state funds only.

    Clients 65 years old or older and within the income guidelines for the PACE program, should apply to the PACE program. They may not have PACE and SPBP coverage. Keep in mind that the SPBP has a very limited formulary. Clients who are eligible for PACE or Medical Assistance/Medicaid drug coverage have access to a greater variety of drugs.

    Have the client's Social Security number handy if you call SPBP staff regarding a client. Please call SPBP staff if you know of any deceased client who might have been participating in the SPBP. We usually do not know when a client dies, unless someone contacts us.