What's New?

2014 Program Highlights

The 2014 EPIC program highlights flyer is now available. The document includes the 2014 EPIC Fee Plan Schedule and the Deductible Plan schedule.

Attention Members, Prescribers and Pharmacists - July 2012

There were articles in the July 2012 Medicaid Update for EPIC members, prescribers and pharmacy providers giving information regarding the upcoming 2013 program changes to EPIC coverage.

SFY 2012-2013 Key Points and Additional FAQs

Beginning January 1, 2013, Executive Budget Changes have restored the EPIC program with additional provisions. The frequently asked questions are listed in SFY 2012-2013 Key Points and Additional FAQs.

Pharmacy Update

Attention: Providers

Please assist us in notifying EPIC members of recent program changes by printing the PDF version of this document and displaying it. Feel free to copy and distribute.

EPIC Members — Effective January 1, 2012 your EPIC coverage changed

This notice provides information regarding the recent changes to your EPIC coverage

  • EPIC is a free program, with no fees or deductibles.
  • You must be enrolled in a Medicare drug plan in order to receive benefits.
  • EPIC only provides coverage for Medicare Part D covered drugs or Part D excluded drugs purchased during the Part D coverage gap (donut hole).
  • Your EPIC copayment for drugs purchased during the Part D coverage gap (donut hole) will be $3-$20, depending on the cost of the drug.

For more information call the toll-free EPIC Helpline at (800) 332-3742, or write to:

EPIC
P.O. Box 15018
Albany, New York 12212

Frequently Asked Questions (FAQ)

Q1. How has the EPIC program changed?

Answer: Effective January 1, 2012, EPIC is a free program, with no fees or deductibles. All members must be enrolled in a Medicare Part D drug plan in order to receive EPIC benefits. EPIC only provides drug coverage in the Medicare Part D coverage gap (donut hole).

Q2. What drug coverage does the EPIC program provide?

Answer: EPIC only provides secondary drug coverage for Medicare Part D covered drugs or Part D excluded drugs purchased during the coverage gap (donut hole).

Q3.What is a Medicare Part D excluded drug?

Answer: Part D excluded drugs are medications that are not required to be covered by a Part D plan. (e.g., some anti-anxiety drugs such as benzodiazepines or some anti-seizure drugs such as barbiturates).

Q4. My Medicare Part D drug plan has a deductible. Will EPIC provide secondary coverage during this time?

Answer: No, EPIC coverage is limited to drugs purchased during the Part D coverage gap. You will need to pay any deductible required by your Part D drug plan.

Q5. Will EPIC provide secondary coverage of my drugs after I pay my Part D deductible and enter the initial coverage phase (prior to the coverage gap)?

Answer: No. EPIC drug coverage is limited to drugs purchased during the Part D coverage gap. You will need to pay the co-payment charged by your Part D plan (approximately 25 percent of the drug cost) during the initial coverage phase.

Q6. How much will I have to pay before EPIC helps me pay for drugs?

Answer: You will have to pay approximately $970 out of pocket before you reach the Medicare Part D coverage gap. Your total cost of drugs prior to the coverage gap (what you pay and what Medicare Part D pays is $2,930).

Q7. What are the EPIC co-payments for drugs purchased in the Part D coverage gap?

Answer: EPIC's co-payment structure has not changed. Members pay EPIC copayments of $3-$20 based on the cost of a covered drug.

Q8. Will EPIC provide secondary coverage during the Part D catastrophic coverage phase?

Answer: No. You will use your Part D plan for covered drugs and your co-insurance will be approximately 5 percent of the cost of the drug.

Q9. Will EPIC help pay my monthly Part D drug premium?

Answer: EPIC will pay the monthly Part D drug premium up to $39.79 in 2012 for members with income up to $23,000 if single or $29,000 if married. Those with higher incomes must pay their Part D drug premium each month.

Q10. How can I reduce my drug costs?

Answer: You should work with your doctor and pharmacist to use drugs covered by your Part D plan. You should ask your doctor if you can take a generic drug or a lower cost brand drug that is covered by your Part D plan, if appropriate for you.

Q11. I need additional help in paying for my prescriptions. What can I do?

Answer: The Patient Assistance Resources sheet (below) lists various organizations that may offer financial assistance in paying for your drugs.

Q12. Am I eligible for Extra Help from Medicare?

Answer: If your current annual income is up to $16,755 if single or $22,695 if married and your total assets are up to $13,070 if single or $26,120 if married, you may be eligible for Extra Help from Medicare. If approved in 2012, you will pay copayments as low as $2.60 for generics and $6.50 for brand drugs covered by your Part D plan. Please call the EPIC Helpline at (800) 332-3742 and ask for a Request for Additional Information form to be mailed to you. You must complete, sign and return the form to EPIC and we will apply for the benefit for you.

Q13. Am I eligible for a Medicare Savings Program?

Answer: If your current annual income is up to $15,324 if single or $20,676 if married, you may be eligible for a Medicare Savings Program. There is no asset limit to apply for the benefit. If approved in 2012, you will receive Extra Help from Medicare and you will pay copayments as low as $2.60 for generics and $6.50 for brand drugs covered by your Part D plan. Please call the EPIC Helpline at (800) 332-3742 and request a Medicare Savings Program application to be mailed to you. You must complete, sign and return the form to EPIC, along with required income documentation, and we will apply for the benefit for you.

Patient Assistance Resources for Members who Need Help with Prescription Costs

  • Contact the manufacturer of the drug needed to see if they can help with the cost
  • Many counties have discount cards available (e.g. BigAppleRx NYC http://www.bigapplerx.com)
  • Contact your local County Office for the Aging
ResourceProgram SummaryContact
Cancer Care Foundation
www.cancercarecopay.org
  • Specifically for covering the cost of breast, lung, pancreatic, or colon cancer medications
  • Medication must be covered by foundation
  • Individual must be covered by private insurance OR have Medicare Part B, Medicare Part D, Medicare Advantage (MA), or Medigap plan
  • Assistance for Individual or family with income of up to 4 times federal poverty level
(866) 55-COPAY
Chronic Disease Fund
www.cdfund.org
  • Income levels by geographic area, number of household dependents and current out-of-pocket medical expenses are considered
  • Individual must have one of the fund listed diseases. There are separate 'Disease Trusts' with separate funds
  • Pulmonary Arterial Hypertension (PAH), Psoriasis, Rheumatoid Arthritis (RA) and Asthma are examples on the list
(877) 968-7233
Healthwell Foundation
www.healthwellfoundation.org
  • Household Adjusted Gross Income (AGI) must be below 400% of poverty level with cost of living also taken into account
  • Psoriasis, Rheumatoid Arthritis (RA) and Asthma are examples of diseases on the list
  • Foundation suggests contacting manufacturer first since assistance level from manufacturer may be greater than foundation assistance
(800) 675-8416
Leukemia and Lymphoma Society
www.leukemia-lymphoma.org
  • Household income at/within 500% above US poverty guidelines
  • Must have prescription insurance
  • Must have a blood cancer (Chronic Lymphocytic Leukemia - CLL, Hodgkin Lymphoma, non-Hodgkin Lymphoma, Myelodysplastic Syndromes, Myeloma, or Waldenstrom Macroglobulinemia) diagnosis confirmed by MD
(877) 557-2672
National Organization for Rare Disorders
www.rarediseases.org/patients-and-families/patient-assistance
  • Web site contains a list of medication-specific assistance programs, disorder-specific programs and clinical trial programs
  • Assistance level varies depending upon the program
  • Upon receipt of a completed application, National Organization for Rare Disorders (NORD) reviews and responds with an award decision within 2 business days
(800) 999-6673
Needy Meds – Discount Card
www.needymeds.org
  • Needy Meds drug discount card can only be used by those without insurance or as an alternative to their insurance
  • Web site also has a list of brand names for individual to click on drug to see if manufacturer assistance program/coupon is available http://www.needymeds.org/drug_list.taf
Refer to Website
Patient Access Network Foundation
www.panfoundation.org
  • Individual should be insured
  • Individual's insurance must cover the medication
  • Medication must fight the disease directly
  • Income must be below a designated percentage of federal poverty level depending upon individual fund requirements
  • Specific disease funds; including Crohn's, Diabetic Foot Ulcers, Macular diseases, Multiple Sclerosis (MS), Kidney Transplant Immunosuppression, Rheumatoid Arthritis (RA)
(866) 316-7263
Patient Advocate Foundation
www.copays.org
  • Assists insured patients who are financially and medically qualified
  • Breast, Lung, Lymphoma and Cutaneous T-Cell Lymphoma, Prostate, Kidney, Colon, Pancreatic, Head/Neck Cancers, Malignant Brain Tumor, Sarcoma, Diabetes, Multiple Myeloma, Myelodysplastic Syndrome (and other Pre-Leukemia diseases), Osteoporosis, Pain, Hepatitis C, Rheumatoid Arthritis, selected Autoimmune Disorders and Chemo Induced Anemia (CIA)/Chemo Induced Neutropenia (CIN)
(866) 512-3861
PatientAssistance.com
www.patientassistance.com
  • This is a resource for finding various assistance programs
  • Contains a searchable database of thousands of patient assistance programs
Refer to Website
Patient Services Incorporated
www.patientservicesinc.org
  • Based on financial need
  • Disease must be on list - Acromegaly, Advanced Idiopathic Parkinson's Disease, Alpha1 Antitrypsin Deficiency, Bone Metastases, Breast Cancer Screening, Chronic Myelogenous Leukemia, Chronic Inflammatory Demyelinating Polyneuropathy (CIPD), Complement Mediated Diseases (CMD), Clostridium Difficile, Cutaneous T-Cell Lymphoma (CTCL), Cystic Fibrosis (with Pseudomonas), Fabry Disease, Gastrointestinal Stromal Tumors (GIST), Hemophilia, Hereditary Angioedema (C1 Inhibitor Deficiencies), Inhibitors in Hemophilia, Insulin like Growth Factor 1 Deficiency (IGF1), Malignant Ascites, Mucopolysaccharidosis Type I (MPS 1 – Hurlers Syndrome), Patient Services Items Program (PSIp), Pleural Effusion, Pompe Disease, Primary Immune Deficiency, Severe Congenital Protein C Deficiency), von Willebrand Disease
(800) 366-7741
Partnership for Prescription Assistance
www.pparx.org
  • Different funds offering co-payment assistance are listed
(888) 477-2669
RxAssist
www.rxassist.org
  • Database search by drug name to locate various assistance programs. Click on patients to get to the search window
Refer to Website