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					                                Medicare Prescription Drug Benefit and Coordination with New Jersey's
                    Medicaid, Pharmaceutical Assistance to the Aged and Disabled (PAAD) and Senior Gold Programs

                                                                                  Medicaid                                                      PAAD                                                              Senior Gold
Administered by                                                      Department of Human Services                               Department of Health and Senior Services                              Department of Health and Senior Services

                                                          Division of Medical Assistance and Health Services              Division of Senior Benefits & Utilization Management                  Division of Senior Benefits & Utilization Management
Toll-Free Hotline                                                                 1-800-356-1561                                              1-800-792-9745                                                         1-800-792-9745
Web site                                                              www.state.nj.us/humanservices/                                          www.njpaad.gov                                                        www.njsrgold.gov
Eligibility                                                  Dual Eligibles: Medicaid clients with Medicare                                A New Jersey resident;                                                A New Jersey resident;
                                                       Dual eligible clients are age 65 or older and/or are blind or
                                                      disabled with income less than 100% of poverty or $9,570 a        65 years of age or older or 18 years of age or older receiving     65 years of age or older or 18 years of age or older receiving Social
                                                       year for a family size of one. (Waiver programs allow for              Social Security Title II Disability benefits; and                          Security Title II Disability benefits; and
                                                                              higher income.)

                                                                                                                        Annual income for 2009 of less than $24,432 if single or less      Annual income for 2009 is between $24,432 and $34,432 if you are
                                                                                                                                        than $29,956 if married.                              single or between $29,956 and $39,956 if you are married.
Current Enrollment                                                                   140,000                                                      167,000                                                                 21,000
Medicare Prescription Drug Benefit “Part
D” Effective Date                                                                 January 1, 2006                                             January 1, 2006                                                        January 1, 2006

Is Medicaid/PAAD/Senior Gold going away? No. However, Medicaid will no longer provide                                  No. However, PAAD will become secondary payor to Part D           No. However, Senior Gold will become secondary payor to Part D for
                                         prescription drug coverage for dual eligible clients after                    for those beneficiaries who also are Medicare beneficiaries.      those beneficiaries who also are Medicare beneficiaries. Effective
                                         December 31, 2005.                                                                                                                              August 1, 2008, Medicare-eligible, Senior Gold beneficiaries must
                                                                                                                                                                                         enroll in a Medicare Part D Prescription Drug Plan unless prohibited
                                                                                                                                                                                         from doing so.

What will I have to pay?                              Nothing. Whereas the Part D rules require the payment of You will pay no more than your PAAD co-payment of $6 per                  When you join a Medicare Part D plan, you must pay the Medicare
                                                      copays up to $5 per prescription for dual eligibles, the   covered generic drug or $7 per covered brand name drug.                 prescription drug plan the monthly premiums. Senior Gold will help you
                                                      Medicaid agency will pay the in-network pharmacist the co-                                                                         pay for any other out-of-pocket costs.
                                                      payment for dual eligibles.


Can I get my prescription filled at any               The federal Medicare prescription drug program that you          As a Medicare-eligible PAAD beneficiary, you have to enroll in    As a Medicare-eligible Senior Gold beneficiary, you have to enroll in
pharmacy in the community?                            join will advise you of the pharmacies that are in their         the Medicare prescription drug coverage to use your PAAD          the Medicare prescription drug coverage to use Senior Gold benefits
                                                      network. You should use the pharmacies that are "in-             benefits. New Jersey's Department of Health and Senior            effective August 1, 2008. You must pay the premiums to join a
                                                      network." In the event of an emergency, you may be able to       Services (DHSS) will assist you, if needed, in selecting an       Medicare drug plan and any late enrollment imposed by Medicare for
                                                      fill your prescription at a pharmacy that is not a part of the   appropriate Part D prescription plan. You should use              each month that you were eligible to enroll in Medicare Part D but did
                                                      plan's network or "out-of-network." If you use an "out-of-       pharmacies that are "in-network." PAAD will only pay your         not enroll. You should use pharmacies that are "in-network." Senior
                                                      network" pharmacy and it is not an emergency, you will be        premiums, deductibles and any other out-of-pocket costs--         Gold will only cover your out-of-pocket costs-- except for premiums,
                                                      responsible for 100% of the cost of the drug and any co-         beyond your PAAD co-payment-- when you use a pharmacy             which you must pay-- when you use a pharmacy that is in your plans'
                                                      payments. New Jersey's Medicaid agency will only cover           that is in your plan's network. In addition, some plans may       network. In addition, some plans may designate "preferred
                                                      the cost of copays when you use a pharmacy that is in your       designate "preferred pharmacies." You may use a preferred or      pharmacies." You may use a preferred or non-preferred pharmacy--
                                                      plan's network. In addition, some plans may designate            non-preferred pharmacy-- there will be no difference for a        there will be no difference for a Senior Gold client.
                                                      "preferred pharmacies." You may use a preferred or non-          PAAD client.
                                                      preferred pharmacy. There will be no difference for a dual-
                                                      eligible client.


Can I still use my Medco Discount Card?               Dual eligible clients are not eligible for the Medco or          No.                                                               No.
                                                      Medicare Prescription Drug Discount Card.
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Do I need to complete the Social Security            No, dual eligibles are “deemed” eligible for this extra help.   You may complete the Social Security Administration's Low-          In all likelihood, Senior Gold beneficiaries’ income exceeds the low-
Administration’s Low-Income Subsidy?                 As a result, they will be enrolled in a Medicare prescription   Income Subsidy application. However, if PAAD believes you           income subsidy threshold.
                                                     drug plan with no deductible, premium, or gaps in               may be eligible, we will send a similar application for you to
                                                     coverage.                                                       complete.
What action do I need to take to join a              The federal Medicare prescription drug program will         PAAD will assist you in selecting and enrolling in a Part D             Senior Gold beneficiaries may enroll in any Medicare Part D
Medicare prescription drug plan?                     automatically pre-assign dual eligibles to a plan in random plan.                                                                   prescription drug plan of their choice. For assistance, please contact
                                                     order in October. A dual eligible beneficiary may choose a                                                                          Medicare at 1-800-633-4227 or go to http://www.medicare.gov.
                                                     different plan beginning November 15, 2005.




How often can I switch plans?                        Once a month. If a dual eligible client elects to switch        Once a year during the annual election period November 15           Once a year during the annual election period November 15 through
                                                     plans, we strongly encourage the client to select the new       through December 31 of each year. (However, PAAD                    December 31 of each year. NOTE: Senior Gold beneficiaries are
                                                     plan. The selection of a new plan will automatically trigger    beneficiaries who have their Medicare Part B benefits paid          members of a qualified state pharmaceutical assistance program. That
                                                     disenrollment from the previous plan. This will prevent any     through the SLMB or QI-1 programs will be able to change            means they are entitled to one Special Enrollment Period each calendar
                                                     possible gap in coverage.                                       plans monthly.) NOTE: PAAD beneficiaries are members of a           year for Medicare Part D beyond the annual enrollment period.
                                                                                                                     qualified state pharmaceutical assistance program. That means
                                                                                                                     they are entitled to one Special Enrollment Period each
                                                                                                                     calendar year for Medicare Part D beyond the annual
                                                                                                                     enrollment period.

Will I be able to get a Part D excluded drug? Yes, Medicaid will continue to cover benzodiazepines,       Yes, PAAD will continue to cover benzodiazepines,                Yes, Senior Gold will continue to cover benzodiazepines, barbiturates
                                              barbiturates and over-the-counter medications to the extent barbiturates and over-the-counter medications to the extent that and over-the-counter medications to the extent that the current policy
                                              that the current policy covers them.                        the current policy covers them.                                  covers them.


What happens if a medication is not covered First, if the physician can switch to a medication that is on            If the physician can switch to a medication that is on the          If the physician can switch to a medication that is on the formulary, we
by my Medicare drug plan?                   the formulary, we encourage the physician to do so. If the               formulary, we encourage the physician to do so. If the              encourage the physician to do so. If the physician does not switch, the
                                            physician does not switch, the plan or the Medicaid agency               physician does not switch, the plan or PAAD will provide an         plan or Senior Gold will provide an emergency supply until the
                                            will provide an emergency supply until the physician                     emergency supply until the physician requests an exception.         physician requests an exception. Medicare prescription drug plans
                                            requests an exception. If the plan still doesn’t cover the               Medicare prescription drug plans must cover all medically           must cover all medically necessary drugs for clients. As such, Senior
                                            prescription, Medicaid will cover it if it is medically                  necessary drugs for clients. As such, PAAD will seriously           Gold will challenge any determination by a plan that is denied for a
                                            necessary.                                                               challenge any determination by a plan that is denied for a          medically necessary drug. We will cover the cost of our beneficiaries'
                                                                                                                     medically necessary drug. We will cover the cost of our             drugs at the regular Senior Gold level, during an appeals process. If
                                                                                                                     beneficiaries' drugs during an appeals process. If after we have    after we have completely challenged an appeal or denial and it still
                                                                                                                     completely challenged an appeal or denial and it still stands, we   stands, we will cover a medically necessary drug, at the Senior Gold
                                                                                                                     will cover a medically necessary drug.                              coverage level.




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