EPIC Drug Coverage
EPIC provides secondary coverage for Medicare Part D- and EPIC-covered drugs after any Part D deductible is met. EPIC also covers approved Part D-excluded drugs such prescription vitamins as well as prescription cough and cold preparations once a member is enrolled in a Part D drug plan. EPIC coverage runs from January 1st to December 31st of each year. If enrolled after January 1st, coverage will still end on December 31st.
Members must maintain EPIC coverage and be enrolled in a Medicare Part D drug plan in order to receive benefits. If you disenroll from your Part D drug plan either by request or due to failure to pay, you must re-enroll in a Part D plan or you will not receive EPIC benefits for the remainder of the year.
How to use EPIC:
- Show both your Medicare Part D drug plan and EPIC cards to your pharmacist. Tell your pharmacist that you have prescription coverage through both plans.
- Tell your pharmacist that your Medicare Part D drug plan is your primary prescription coverage, and all claims for prescription medications must be submitted to Medicare Part D first and then to EPIC.
- EPIC will cover Medicare Part D- and EPIC-covered drugs after any Medicare Part D deductible is met. EPIC will also cover approved Part-D excluded drugs once a member is enrolled in a Part D plan.
What Is Covered By EPIC
For Part D- and EPIC-covered drugs after any Medicare Part D deductible is met or approved Part D-excluded drugs, EPIC will cover:
- New prescriptions and refills;
- Insulin, insulin syringes and needles;
- Brand name and generic prescription drugs;
- Quantities up to your Part D plan's limits.
What Is Not Covered By EPIC
- Any drug purchases before a member joins EPIC;
- Any drug purchases before an EPIC member joins Part D;
- Any drug purchases made in the Medicare Part D deductible;
- Drugs not covered by Part D unless it is an approved Part D-excluded drug;
- Medicines that do not require a prescription (such as aspirin or vitamins);
- A small number of drugs, known as DESI drugs (ask your pharmacist for more information on these particular drugs);
- The purchase of medical devices (for example: diabetes supplies, test strips, glucometers, walkers, wheel chairs), medical supplies (cotton balls, Band-Aids®, eyeglasses and oxygen) NOTE: Check with your Medicare carrier to see if any of these items are covered by your Medicare benefits;
- Prescriptions purchased at a pharmacy not participating in EPIC or located outside of New York State. (Please refer to Out-of-State Travel below);
- Drugs sold by manufacturers that do not participate in EPIC's Manufacturer's Rebate Program.
You must use a participating pharmacy in New York State to receive EPIC benefits. You should choose a pharmacy that participates in both EPIC and your Medicare Part D drug plan to maximize benefits. Check with your local pharmacy to be sure they are participating before making your purchase.
There are some mail-order pharmacies that participate with the New York State EPIC program. The mail-order pharmacy must participate with your Medicare Part D plan first. You need to do the following to determine if a mail-order pharmacy participates with your Medicare Part D plan and EPIC:
- Contact your Part D plan and ask if they use a mail-order pharmacy.
- Ask your Part D plan to provide you with the mail-order pharmacy NPI (National Provider Identifier). Note: The name of the mail-order pharmacy alone is not enough to confirm participation.
- Contact the EPIC Helpline at 1-800-332-3742 to check if the mail-order pharmacy participates with the EPIC program.
When traveling outside of New York State, you should make sure to bring ample supplies of all medications you will need with you. You should contact your Part D drug plan before you leave to find out their policy on refilling prescriptions while you are out of the state. Please note that EPIC only pays for Part D- and EPIC-covered drugs after any Medicare deductible is met or approved Part D-excluded drugs purchased from an EPIC participating pharmacy.
Keeping Track of Your Drug Costs
It is helpful for you to keep your receipts and a running total of your purchases. You will need to contact your Medicare Part D drug plan to ensure they have knowledge of all your purchases and to tell you where you stand with regards to your Medicare Part D drug coverage.
Renewing Your EPIC Coverage
Every two years, we will request that you provide EPIC updated enrollment information to renew your coverage. You may be required to provide updated income documentation to EPIC.