Prescriber Bulletin 10-01 July 2010
- Prescriber Bulletin No. 10-01 is also available in Portable Document Format (PDF, 93 KB, 3 pg.)
Prescriber BulletinNew York State EPIC - Prescription Protection for Seniors
P.O. BOX 15018
ALBANY, NY 12212-5018
Bulletin No. 10-01
Subject: EPIC Program Changes
As the result of recent statutory amendments to Title III of the NYS Elder Law, effective October 1, 2010, EPIC members with Medicare Part D will be required to maximize the use of their Part D coverage. This change will result in lower program costs and reduced out-of-pocket expense for members.
EPIC will continue to provide members with:
- Primary coverage for claims denied by the Part D plan only after the members, with assistance from their prescribers, have exhausted two levels of appeal available under Medicare Part D and documentation of the denial at appeal level 2 (Reconsideration) has been received by EPIC.
- Coverage of up to a 90-day temporary supply may be obtained from EPIC after the pharmacist notifies the prescriber that the member's Part D plan and EPIC have denied payment for the prescribed medication and the prescriber does not choose to change the prescription but instead, informs the pharmacist that a Medicare Part D appeal will be pursued.
- To obtain the 90-day temporary supply from EPIC while the appeal is being processed, the prescriber will need to call the EPIC Temporary Coverage Request (TCR) Helpline at 1-800-634-1340. If the pharmacist cannot reach the prescriber to find out if an appeal is being pursued, he/she may call the TCR Helpline to request authorization to dispense a 3-day emergency supply.
- Primary coverage for drugs that are excluded from Medicare Part D coverage:
- Prescription vitamins and minerals
- Drugs for anorexia, weight loss or gain
- Drugs for cosmetic purposes
- Drugs to relieve cough and cold symptoms
- Secondary (supplemental) coverage for drugs that are first covered by the Part D plan as primary payer. This allows EPIC to help members pay their Part D deductibles, co-payments/coinsurance and coverage gap (donut hole) claims for drugs that are covered by the Part D plan.
Approximately 36,000 EPIC members enrolled in a Part D plan, who in the last 100 days received at least one drug for which EPIC has paid as the primary payer, will receive a customized letter (sample attached). Members will be advised to work with their pharmacies to determine why their drug(s) were denied by Part D. The pharmacist will be instructed to try to resolve the denial with the Part D plan. If unsuccessful, the pharmacist or your patient will contact you to suggest that you change the medication to one that is on your patient's Medicare Part D plan formulary or to contact the Medicare Part D plan to request a coverage determination. A coverage determination may be necessary if the drug is not on the Medicare Part D plan formulary, or requires a prior authorization to address dosage, quantity or step therapy.
- Before your patient leaves your office, please review his or her Medicare Part D formulary to determine if the drug you have prescribed is covered. NOTE: Some prescribed medications may be covered and billed by you under your patient's Medicare Part B benefit (e.g. medications in the chemotherapy drug class).
- If you have been contacted by the pharmacy or your patient because the drug prescribed is not covered by the Medicare Part D plan, please consider substituting a therapeutic alternative that is covered.
- If you determine that there is no suitable clinical alternative available, refer to the steps below:
- Please contact the member's Medicare Part D plan, either by phone, or by faxing or mailing a completed Medicare Coverage Determination Request Form to pursue coverage of the needed medication. Please provide a statement of medical necessity that includes any information as to why the medication is needed (e.g. trial and failure of previously used medications, lab values, etc).
- As a result of initiating this formal appeal process you may be required to provide additional pertinent clinical information as requested by the Medicare Part D plan. Refer to http://www.cms.gov/partnerships/downloads/11112.pdf for complete instructions on how to file a Medicare Part D appeal.
- While your request for coverage of your patient's medication is being reviewed and processed by the Medicare Part D plan, you may request temporary coverage of the drug from EPIC.
EPIC's Temporary Coverage Request (TCR) Helpline
Available October 1, 2010
If you determine there is no suitable alternative drug, you or your authorized agent must call EPIC's Temporary Coverage Request (TCR) Helpline and respond to several questions, which will create a "temporary override" in EPIC's claims system that will allow for up to a 90-day supply to be dispensed, depending on how the prescription is written.
- TCR Helpline questions will require the prescriber, or the prescriber's authorized agent, to register his/her intent to initiate an appeal for Medicare Part D coverage.
- In order to accelerate any request for temporary coverage, you should be prepared to provide:
- Member's Name
- Member's Date of Birth
- Member's EPIC ID Number (if available)
- Member's Address
- Your Name and Phone Number
- Your Address and Fax Number
- Your NPI Number
- Name of the drug and its strength
- Once you have contacted EPIC's TCR Helpline, and registered your intent to pursue Medicare Part D coverage of the denied drug, the prescription can be processed at the pharmacy for up to a 90-day supply. There will be no need for a tracking or authorization number from EPIC to process the claim at the pharmacy.
- If the Part D plan still denies coverage of the drug after the first two levels of the Medicare appeal process have been exhausted, EPIC will cover the drug as the primary payer. The member, pharmacist or prescriber must submit to EPIC a copy of the reconsideration denial letter from the Independent Review Entity (Maximus Federal Services) before EPIC can approve coverage of the drug. You may be contacted for additional information. This letter should be faxed to 1-800-562-1126.
- Once the denial documentation is received, and EPIC has confirmed that the first two levels of the Medicare appeals process have been exhausted, a long-term override will be granted.
3-Day Emergency Supply
If your patient's pharmacist is unable to reach you to ascertain whether an appeal will be pursued and your patient needs the medication immediately, the pharmacist can obtain approval for a 3-day (72 hour) emergency supply by calling the TCR Helpline. If you have questions regarding these program changes, please call the EPIC toll-free Provider Helpline at 1-800-634-1340.