EPIC and Medicare
How does the Medicare Part D drug plan requirement work?
EPIC members are required to be enrolled in a Medicare Part D drug plan or a Medicare Advantage (HMO) health plan with Part D (with no exceptions). If a senior is not already enrolled in a Medicare Part D drug plan, EPIC can help the senior select and enroll in one. Medicare provides primary drug coverage; EPIC is supplemental while in the Medicare Part D coverage gap.
Beginning January 1, 2012, the New York State EPIC program will no longer be Creditable Coverage (primary coverage) for members. This means that EPIC benefits are not as generous as Medicare Part D. If you are not enrolled in a Medicare Part D drug plan or other prescription insurance after December 31, 2011, you will not have any prescription coverage from EPIC or receive any EPIC benefit.
Because EPIC is a State Pharmaceutical Assistance Program, EPIC can provide:
- a Medicare Special Enrollment Period (SEP) so that a new member may enroll in a Part D drug plan at any time during the year
- a Medicare one-time plan change per calendar year for existing members
- Medicare Part D drug plan premium assistance
- co-payment assistance in the Medicare Part D coverage gap
- benefits during the Medicare Part D coverage gap for Part D-covered drugs and for Part D-excluded drugs (e.g. benzodiazepines (anti-anxiety) or barbiturates (anti-seizure), etc.)
How is EPIC used with Medicare Part D?
EPIC supplements Medicare Part D drug coverage while in the coverage gap for greater annual benefits and savings. When purchasing prescription drugs, the enrollee shows both EPIC and Medicare Part D drug plan card at the pharmacy. While the member is in the Medicare Part D coverage gap, prescriptions and co-insurance/co-payments can be submitted to EPIC for payment. The member will pay an EPIC co-payment ranging from $3 to $20 based on the cost of the drug. For example, should the drug cost $100, the member will pay $20.
How does Extra Help work?
Extra Help comes in two levels – full and partial. If approved for full Extra Help, Medicare Part D provides all coverage with co-payments of up to $6.50 for brand name drugs and up to $2.60 for generic drugs for 2012. Members who receive Low Income Subsidy (LIS) are those who are approved for full or partial Extra Help from Medicare, a Medicare Saving program or a Medicaid Spendown. EPIC members with LIS do not have a coverage gap and will not receive assistance from EPIC to pay any claims. EPIC will continue to pay Part D premiums for LIS members, those with Full LIS in enhanced plans or Medicare Advantage plans up to the basic amount ($39.79 per month in 2012) after Medicare premium subsidization.
Information for EPIC Enrollees
- Update: EPIC has changed - March 2012
- EPIC No Longer Creditable Coverage - January 2012
- Important News About Coverage Changes - January 2012
- 2011-2012 Program Changes - September 2011
- SFY 2011-2012 Key Points and Additinal FAQ - September 2011
