Member Letter July 2010
- Member Letter July 2010 is also available in Portable Document Format (PDF, 25 KB, 2 pg.)
State of New York Elderly Pharmaceutical Insurance Coverage Program
New York State Senior Prescription Plan
P.O. Box 15018
Albany, New York 12212-5018
As a result of a change in NYS Law, beginning October 1, 2010, EPIC may no longer cover your drug(s) listed below:
- List of member's medications for which EPIC was the primary payer.
Our records indicate that EPIC was the primary payer for the above drug(s) because your Medicare Part D plan does not cover the drug(s) or the Part D plan denied the claim(s) for other reasons. Effective October 1, 2010, EPIC will no longer be the primary payer of the drug(s) unless your doctor calls to request temporary coverage. See back of letter for more information.
As soon as possible, show this letter to your pharmacist to find out why your Medicare Part D plan denied your claim(s) for the above drug(s). Please ask your pharmacist to:
- Contact your Part D plan to find out why your claim(s) was denied and resolve the issue, if possible, so that Medicare will cover your claim(s) as the primary payer and EPIC will be the secondary payer; or
- Contact your doctor to inquire if another drug can be prescribed that is covered by your Part D plan if non-coverage is the issue. If your doctor wants you to continue to take the drug(s) listed above, you or your pharmacist will have to request that your doctor fill out a Medicare Part D Coverage Determination Request Form (enclosed) and send it to your Part D plan. This will begin a formal process of requesting your Part D plan to cover the drug.
- If the request is approved, your Part D plan will be the primary payer and EPIC will provide secondary coverage.
- If the request is denied, you will need to work closely with your doctor to pursue an appeal. EPIC will only cover the drug after you have exhausted the first two levels of appeals available under your Part D plan.
See the back of this letter for more information about how the change in law will affect your EPIC coverage and for more details about the Medicare Part D appeals process.
Please don't wait! Contact your pharmacist and doctor so that they can review the drug(s) listed above to ensure you receive the drugs you need. Call the EPIC Helpline at 1-800-332-3742 if you have questions about these important program changes.
¿Necesita ayuda? Llame al 1-800-332-3742
EPIC Program Changes Effective October 1, 2010
NYS Law has been changed to require EPIC members to maximize their Medicare Part D plan as their primary drug coverage. Beginning October 1, 2010, EPIC will only provide secondary coverage for drug claims that are approved by members' Part D drug plans. EPIC will allow an exception and pay drug claims denied by members' Part D plans if a coverage determination and two levels of Medicare appeals have been submitted and denied by their Part D plan. After October 1, 2010, members' doctors or health care providers can contact EPIC to request temporary coverage (up to a 90-day supply of the drug) to allow access to drugs while the appeals are processed and evaluated by Part D plans.
EPIC will continue to:
- Help members pay their Medicare Part D deductibles, co-payments and coverage gap (donut hole) claims for drugs that are on their Part D plan drug list (formulary).
- Provide immediate primary coverage for drugs in categories that are excluded from Medicare Part D coverage (e.g. benzodiazepines, barbiturates, etc).
Upon receipt of this letter members should:
- Show this letter to your pharmacist to find out why your Medicare Part D plan denied your claim(s) for your drug(s) listed on the front of this letter.
- Show your Medicare Part D plan enrollment card to your pharmacist, doctors and health care providers so that they know what Medicare Part D plan you are enrolled in. Make sure they know your Medicare Part D plan is your primary drug coverage and EPIC is secondary coverage for drugs that are covered first by Part D.
- Show your doctor any Part D plan covered drug list (formulary) information that you receive from your plan to help them select drugs for you that are covered by your Part D plan.
- Make sure you know whether drugs prescribed for you are covered by your Part D plan before you leave your doctor's office.
If your doctor prescribes a drug that is NOT covered by your Medicare Part D plan:
- Ask your doctor to complete a Medicare Part D Coverage Determination Request Form and submit it to your Part D plan. This form requires diagnosis and medical information and must be signed by your doctor.
- Advise your doctor that if your coverage determination request is denied by your Part D plan, two additional levels of appeals (redetermination and reconsideration) must be submitted and denied before EPIC can cover the drug as the primary payer.
- Ask your doctor to call EPIC to submit a Temporary Coverage Request (available after October 1, 2010) that will allow you to receive up to a 90-day supply of the drug from EPIC while the appeals process is underway.
Call the EPIC Helpline at 1-800-332-3742 (TTY 1-800-290-9138) if you have questions, or contact your local Office for the Aging to talk to a counselor about the changes.
Letter Number: M1