No More Automatic EPIC "Wrap Around" Coverage for Medicare Part D Enrollees

August 19, 2010

Author: Cathy Roberts

As part of the state budget process, changes are coming to the EPIC program (the Elderly Pharmaceutical Insurance Coverage program, New York State’s prescription drug program for older adults).  The changes affect people who have EPIC and Medicare Part D.  You can find the new statutory language in the Article VII legislation which was part of Governor Paterson’s Program Bill #280R (available at http://www.ny.gov/governor/bills/pdf/GPB_280R_BILL.pdf), amending Section 242(3)(c) of the New York State Elder Law.

Beginning October 1, 2010, EPIC will no longer act as primary insurer for Part D covered drugs if the Part D plan denies payment.  After that date, if a member submits a prescription for a drug that is not covered by their Part D plan, EPIC will deny the claim.  EPIC is instructing pharmacists to contact the member’s doctor in these instances.  If the pharmacist cannot reach the doctor, EPIC will allow the pharmacist to dispense an emergency 3-day supply of the drug.  Once the pharmacist reaches the doctor, if the doctor agrees that there is an alternative drug available that is covered by the member’s Part D plan, EPIC will provide secondary coverage to the alternative drug.  However, if the doctor indicates that the member cannot take an alternative drug, EPIC can provide temporary coverage if (1) the doctor contacts EPIC to request temporary coverage and (2) the doctor or EPIC member agrees to pursue an appeal.

While appeals are underway, EPIC will provide up to a 90-day supply of the drug.  According to the new statutory language, the 90 day temporary supply can be extended if needed “to ensure coverage of the prescribed medication during the pendency of the Medicare Part D appeal.”  If two levels of appeals have been denied, EPIC can make an exception and pick up the drug as primary payor. EPIC members should tell their doctor that they have Medicare Part D and EPIC coverage and ask before they leave the office whether a particular drug being prescribed is covered by their Part D plan. If it is not, they should explore with their doctor whether there is an alternative drug they can take that is covered by their Part D plan. This will help avoid delays at the pharmacy counter.   

EPIC will continue to provide immediate primary coverage for drugs in categories that are excluded from Medicare Part D (such as benzodiazepines and barbiturates).  Additionally, EPIC will continue to act as secondary payor for drug claims that are approved by members’ Part D drug plans… meaning that EPIC will help members pay their Medicare Part D deductibles, co-payments and coverage gap (donut hole) claims for drugs that are on their Part D plan drug list (formulary).  
 
EPIC is sending out letters this summer to affected members explaining the changes and the steps they may need to take to comply with the new requirements and continue to receive their drugs. The letter includes a coverage determination request.  EPIC is also alerting pharmacies, doctors, and local office for the aging staff about the changes.  EPIC members can call the EPIC Helpline at 1-800-332-3742 with any questions. 

This change may be confusing to many EPIC members and we anticipate that there will be an increased need for Part D advocacy on behalf of EPIC members.  The change in the law also makes it more important than ever for EPIC members to choose the best Part D plan possible during the open enrollment period, since beneficiaries can no longer rely on EPIC to automatically “wrap” coverage if the Part D plan denies payment. 

A copy of this article, along with a sample letter being sent to EPIC members, will be posted on the nyhealthaccess.org website.  If you have any questions about the EPIC changes, or other questions about EPIC, Medicare Part D or health care access issues affecting dual eligibles (people with Medicare and Medicaid), please contact Cathy Roberts at 518-462-6831, croberts@empirejustice.org.