Seniors enrolled in New York’s popular EPIC prescription program, including more than 15,000 in Central New York, will have to jump through extra hoops to get their drugs covered under changes that took effect Oct. 1. EPIC — short for Elderly Pharmaceutical Insurance Coverage Program — is no longer automatically covering a drug when an EPIC member’s Medicare Part...
Wegmans pharmacy technician Leanne Maracle (left) gives a prescription to customer Patine Ryu, of Fayetteville, at the DeWitt grocery store. At the end of the counter is another pharmacy technician, Loretta Miller. New rules will require senior citizens, pharmacists and doctors to jump through more hoops to fill prescriptions rejected by Medicare Part D plans.
Seniors enrolled in New York’s popular EPIC prescription program, including more than 15,000 in Central New York, will have to jump through extra hoops to get their drugs covered under changes that took effect Oct. 1.
EPIC — short for Elderly Pharmaceutical Insurance Coverage Program — is no longer automatically covering a drug when an EPIC member’s Medicare Part D prescription plan denies coverage. EPIC will only cover the prescription if the EPIC member and his or her doctor appeal the Part D plan’s denial.
The change, approved by state lawmakers, is designed to save the state money. There are more than 320,000 state residents enrolled in EPIC.
“We don’t like the Legislature and the governor tinkering with EPIC,” said Bill Ferris, a state lobbyist with AARP. “But we are satisfied that with these changes, under no circumstances should an EPIC enrollee leave the pharmacy counter without their drugs.”
Since 2007 the state has required most seniors with EPIC to join a Medicare Part D prescription drug plan. Under the arrangement, Part D provided the primary coverage and EPIC paid for prescriptions when Part D denied coverage.
Here’s how it works under the new procedure:
If a Part D plan denies coverage, the pharmacist must call the doctor to ask if an alternate drug covered by the Part D plan can be prescribed. If there is no alternative, the doctor must contact EPIC to tell the program he or she will help the member appeal.
The doctor will then get authorization for a temporary 90-day supply. If the doctor cannot be reached, the pharmacist can call EPIC and get approval for a three-day emergency supply.
If the appeal is successful, the Part D plan will pay first and EPIC and the member will pay the remaining cost. If the appeal is unsuccessful, EPIC will cover the drug as the primary payer.
If the appeal takes more than 90 days, the EPIC enrollee will get another 90-day supply. “At no time during the appeals process will the senior be without the drug,” Ferris said.
Joe Baker, president of the Medicare Rights Center, a national consumer group, said his organization has not heard any consumer complaints about the change yet. “We will monitor it to see that it does not lead to a lack of access to drug coverage over the long term,” Baker said.
EPIC will continue to cover drugs categorically excluded from Part D coverage, such as benzodiazepines and barbiturates. It also will continue to provide coverage for members during the Part D coverage gap known as the “doughnut hole.”
The changes in EPIC make it more important than ever for seniors to be careful when choosing a Part D plan, Baker said. The enrollment period begins Nov. 15. People need to make sure the plans they choose cover the drugs they take and don’t impose restrictions that could trigger a denial, he said.
James T. Mulder can be reached at 470-2245 or jmulder@syracuse.com.