New PACE/PACENET Coverage

~ Stacy Maksin, BSW, Care Coordinator

I’m pleased to share with you a little about PACE/NET and the benefits of this important program. PACE stands for “pharmaceutical assistance contract for the elderly”. PACENET is PACE “needs enhancement tier”. PACE/NET, a Pennsylvania based program that is funded by the lottery, assists with the cost of medications covered under an eligible person’s medical or prescription benefit plan. In order to benefit from PACE/NET assistance, the patient’s medication claim must first be sent to the primary insurer (and this can be Medicare, commercial, private, veterans insurance, etc.). For those eligible for PACE or PACE NET, when the insurance does not cover the cost of the medication in full, PACE or PACE NET will cover the remaining expense with the exception of a small copay for which the patient is responsible.

Many Medicare advantage plans are set up that the patient is often responsible for a percentage of the medication/chemotherapy until they reach a certain dollar amount (often a patient may owe 20% up to a maximum of $6,700 a year). This maximum dollar amount is called an out of pocket. It is the maximum amount a person must pay in a given year (either a calendar or rolling year). Once the out of pocket is met, the insurance typically covers the bill in full.

For instance, Mr. Jones needs the medication Rituxan. The total cost of one Rituxan treatment is $10,000. Mr. Jones financial responsibility would be 20% of the $10,000. The is would mean he would owe $2000 each Rituxan treatment until he paid his maximum out of pocket of $6,7000. Now, if Mr. Jones has PACE/NET, that program would step in and pay $1985 of that bill, and Mr. Jones is simply responsible to pay a $15 copay. Thus, Mr. Jones saves $1985 each Rituxan treatment. PACE/NET allows patients to reach their insurance company’s out of pocket while minimizing the patient’s financial responsibility. It also eliminates the “donut hole/coverage gap” often associated with Medicare Part D prescription plans.

I would especially like to thank the Pennsylvania-based Genentech representatives. They listened as I explained how many Pennsylvanians were not able to access needed medications because Genentech products were not covered under the PACE plan. He was instrumental in assisting me in my goal to advocate to Genentech management to apply for and eventually become part of the PACE network.

While I am based in the Camp Hill location, my counterpart, Mary Buss is located in the Harrisburg location. As social workers, we are well positioned to assist with any financial or social needs that may arise. Please feel free to contact either of us at any time. We look forward to meeting you!

CLICK HERE for more information about PACE, PACENET and PACE plus Medicare. This web page also provides a hyperlink directly to the PACE/NET application.