Eligibility Guidelines

Key elements to determine when developing eligibility guidelines include demographics of the population being served and any guidelines from referral sources, funders, vendors or state drug donation programs. Work with referral sources (case management, etc.) to determine how they track and determine eligibility. When possible, utilize pharmacy point of service software to check patient insurance status.

  • Develop criteria for patients to meet to receive new and refill medications. Criteria can include:
    • Household income
      • Income usually includes that of entire household, not just patient
      • Size of household: adults, children under 18
      • Program criteria may vary: Children over 18 may not be counted as part of household by some programs
      • Romantic partner may count but someone just staying may not
    • Difference in household income versus expenses
    • Where patient resides: zip code, city, state
    • Patient age
    • Provider network or referral source
    • United States residency status
    • Veteran
    • Eligibility for other assistance programs (social security, disability, state, etc.)
    • Prescription drug insurance status: uninsured, gap in insurance, donut hole, spend down, etc.
  • Do these guidelines fit the demographics of the patient population to be served?
  • Do these guidelines fit the eligibility requirements of the medication suppliers used? (Manufacturer bulk replacement, patient assistance programs, non-profit vendors, purchased distributors, state drug donation program, etc.)
  • Some vendors require all documentation to be acquired prior to dispensing of any medication, even first fill.
  • Acceptable proof of eligibility and guidelines for documentation.
    • Photo ID. Exceptions: discharge from a facility, mail order, patient not able to be present (age, illness, disability), minors
    • Types of acceptable photo ID: State/government issued, school issued, credit/debit card, other
    • Residency: USPS mail, utility bill, rent receipt, or copy of lease
    • Residency, others: homeless, shelters, rehabilitation center, facility, staying with another person: See Appendices\Eligibility\Sample Letter of Cash Income or Food & Shelter STA.docx for form letter.
    • Insurance: denial letter, lack of coverage criteria (not US resident, etc.), attestation
      • Some software programs can screen for prescription insurance status
    • Income: pay stubs (how recent, how many?), bank statement, letter from employer (notarized may be burdensome for patient), attestation, Social Security, child support, previous year tax form

Example Algorithm for acceptable income documentation:

HOPE Dispensary of Greater Bridgeport

  • Determine timeline for patient to provide documents needed for initial eligibility 
    • Prior to dispensing
    • Prior to refill, 30 days, 60 days, 90 days
    • Exceptions: emergency medication, other
  • Criteria for refill
    • All documentation provided 
    • For mail order, 10 business days prior to refill needed. This may be adjusted for shipping holidays and delays (weather, etc.)
  • Criteria for 90-day supply refill verses 30 or 60-day fill
    • Some pharmacies restrict all refills to 30-day supply to monitor adherence
    • Another option is monitoring patient 30-day refills. When 3 refills in a row are timely (+ or – 3 days of due date), the patient is congratulated for adherence, a note made in patient chart, and future refills will be for 90 days. This may require a collaborative practice agreement in some states.
    • For shipping of maintenance meds, a 90-day supply following first fill may be set as a policy for the program.