Press Release             

Contact: Akiko Takano
Deputy Director of Communications

September 30, 2010

Changes Coming to New York State’s Elderly Pharmaceutical Insurance Coverage (EPIC) Program

-- Beginning October 1, EPIC Members and Their Doctors Must Appeal Denials
of Drugs Not Covered by Medicare Part D Prescription Drug Plans
Before EPIC Provides Coverage --

New York, NY—On Friday, October 1, there will be important changes to New York’s Elderly Pharmaceutical Insurance Coverage (EPIC) program. EPIC is New York’s state pharmaceutical assistance program that helps low- and middle-income New Yorkers who are 65 and over pay for their prescription drugs.

Most EPIC members are required to enroll in a Medicare Part D plan.

Beginning October 1, EPIC will no longer automatically cover a drug when an EPIC member’s Part D plan denies coverage because the drug is not covered or subject to plan restrictions. It will pay for the drug only after the EPIC member has asked the Part D plan for a coverage determination and then an appeal to reverse that determination if it contains a denial of coverage. EPIC will provide a 3-day supply of the noncovered drug while the member is requesting an appeal. It will provide a 90-day supply of the noncovered drug, but only if the doctor agrees to assist with the appeal process.

EPIC will continue to cover drugs that are categorically excluded from Medicare Part D coverage, such as benzodiazepines and barbiturates. And it will also continue to provide coverage for members in the deductible period or the coverage gap (also known as the “doughnut hole”) for drugs that are on their Part D plan’s formulary.

“EPIC members need to be extra careful when choosing their Medicare prescription drug plan this year to make sure their drugs are covered by the plan and have no restrictions on use, since EPIC will no longer serve automatically as a fail-safe when their Part D plan does not cover, or places restrictions on, their drugs,” said Joe Baker, president of the Medicare Rights Center, a consumer service organization. “But if drug coverage is denied by a plan, members should not hesitate to appeal. Our experience shows that when people work with their doctors through the appeals process, many are successful. For those who are in the midst of the appeals process, EPIC will supply emergency or temporary supplies of the drug. And for those who are not successful in their appeal, EPIC will cover the drug. No one should walk away from the pharmacy without their medicine.

Below is an outline of how this will work:

  • Doctor prescribes a drug to an EPIC member. The drug is not covered by the member’s Medicare Part D prescription drug plan or is subject to restrictions.

  • The EPIC member takes the prescription to the pharmacy. The pharmacist attempts to fill the prescription, but cannot do so because the plan denies coverage. The pharmacist should receive a message that the member’s drug plan does not cover or has restrictions on the drug, and that EPIC cannot pay for it until the member has appealed the denial. (It is important that the pharmacist determine why EPIC denied payment, since some denials are a result of billing issues and not due to these changes in the law.)

  • Pharmacist calls the doctor to ask if an alternate drug that is covered by the member’s Part D plan can be prescribed.

  • The member and doctor ask the Part D plan for an exception, also known as a coverage determination, for the drug in question. They can use this form to do so.

  • If the exception request is denied, the member and doctor must appeal up to the second level, which is known as “reconsideration” or the “Independent Review Entity (IRE)” or the “Maximus” level. Maximus Federal Services is currently the private contractor that handles Medicare prescription drug appeals when your plan has denied your request for coverage. Maximus is independent and is not affiliated with any Medicare private drug plan. Members should also be aware that there are time limits at each stage of the appeals process.
  • If the member’s appeal is successful
    The Part D plan will pay first, and EPIC and the member will pay as usual.

    If the member’s appeal is unsuccessful
    The member must fax a copy of the denial from Maximus to EPIC at 1-800-562-1126. EPIC will then cover the drug as the primary payer, and the member will pay the appropriate EPIC copay.

    For more information about EPIC and these new changes, go to the Medicare Rights Center’s free online resource, Medicare Interactive. There is also information in this article by Selfhelp Community Services, Inc., Legal Aid Society and the Empire Justice Center.

    For more information about the appeals process, including time limits, go to this Medicare Interactive page.

    Medicare consumers, doctors and pharmacists who have questions about the changes should contact EPIC at 1-800-332-3742.

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    Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through counseling and advocacy, educational programs, and public policy initiatives.


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