Elderly Pharmaceutical Insurance Coverage (EPIC) Program: Provider Bulletin January 2018

Attention Pharmacy Providers: Benefit Stage Qualifier Change for NYS EPIC Program

The purpose of this bulletin is to provide updated guidance regarding submission of Benefit Stage Qualifier. Effective 3/1/2018, EPIC will no longer pay claims that indicate a Benefit Stage Qualifier = "61" since it has been determined that these claims are not for Medicare Part D drugs but instead Medicare Part B drugs. This is consistent with program coverage policy and statute per NYS Elder Law Title 3, whereby EPIC provides secondary coverage for Medicare Part D, EPIC covered drugs and approved Medicare Part D excluded drugs.

Once the above change has been implemented, prescription drug claims paid by a Medicare Part D plan with benefit stage qualifier of "61" will be denied in National Council for Prescription Drug Programs (NCPDP) field 511-FB, with reject code MV-M/I Benefit Stage Qualifier in the response segment. Therefore, pharmacies should contact the member's Part D plan directly, to obtain billing instructions for these denied claims.

NCPDP Field 393-MV - BENEFIT STAGE QUALIFIER

The following Qualifiers are covered by EPIC in field 393-MV are:

  • 01 = Deductible
  • 02 = Initial Benefit
  • 03 = Coverage Gap
  • 04 = Catastrophic Coverage

In addition to paying secondary for Medicare Part D covered claims, EPIC also covers approved Part D-excluded drugs. The Benefit Stage Qualifiers listed below are to be used for Medicare Excluded drugs.

Benefit Stage QualifierDescriptionAdditional Explanation
62Non-Part D/non-qualified drug not paid by Part D plan benefit. Paid as or under a co-administered benefit only.Non-qualified drugs are defined as not meeting the definition of a Part D drug.
80Non-Part D/non-qualified drug not paid by Part D plan benefit, hospice benefit, or any other component of Medicare; paid by the beneficiary under plan-sponsored negotiated pricing.This qualifier applies to a plan sponsor that offers negotiated pricing to the beneficiary when drug is not covered under Part D law (i.e. excluded drugs).
90Enhanced or over the counter drug (Prescription Drug Event value of 'E' or 'O') not applicable to the Part D drug spend, but is covered by the Part D plan.NCPDP does not provide any explanation for this field, but claims submitted to EPIC using this stage show that all claims using this stage are excluded drugs and therefore justifies EPIC's decision to accept this stage.

The following qualifiers are not allowed by EPIC and are not considered covered by EPIC since Medicare Part D has not paid and the drug is not Medicare Excluded:

Benefit Stage QualifierDescriptionAdditional Explanation
50Not paid under Part D, paid under Part C benefit (for Medicare Advantage prescription drug plan).None
61Part D drug not paid by Part D plan benefit, paid as or under a co-administered insured benefit only.None
63Non-Part D/non-qualified drug not paid by Part D plan benefit. Paid under Medicaid benefit only of the Medicare/Medicaid plan.None
70Part D drug not paid by Part D plan benefit, paid by the beneficiary under plan-sponsored negotiated pricing.This qualifier applies to a plan sponsor that offers negotiated pricing to the beneficiary when the Part D drug is not covered by the plan (e.g. non-formulary, quantity limit, etc.).

The EPIC program seeks to ensure the maximum drug benefit for all members, therefore, below are some resources that may further assist your pharmacy and the member with Medicare coverage pursuant to this change.

Pharmacies who have questions regarding what Medicare Part D covers, please contact the member's plan directly. Should you have any additional questions or concerns, please contact the EPIC Provider Helpline at 1-800-634-1340.

NYS Elderly Pharmaceutical Insurance Coverage Program
P.O. Box 15018
Albany, NY 12212-5018