EPIC Spells Trouble for Many Seniors

By: Ebey P. Soman

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New York State’s Elderly Pharmaceutical Insurance Coverage Program (EPIC) is a secondary prescription insurance program for over 280,000 income-eligible seniors aged 65 and older.  The program supplements members’ out-of-pocket Medicare Part D drug plan costs.  To be eligible, the senior must be a state resident with an annual income of less than $50,000 (if married) or less than $35,000 (if single). Up until December 31, 2011, these patients receive subsidized low-cost medication.  The copayments ranged from $3.00 to $20, depending on the cost of the medication and the income category.

On January 1, 2012, many seniors who were accustomed to the traditional EPIC coverage received an unexpected new year’s “gift.”  Many patients found that the cost of their medications had increased.  This was primarily due to the huge budget cuts and program changes that went into effect the beginning of this year.

EPIC currently covers medication copayments when the member is in the “donut hole” or the Medicare coverage gap.  The program also pays for medications excluded from Medicare Part D coverage, such as benzodiazepines and barbiturates.  During this coverage gap period, the seniors will see their familiar $3, $7, $15, or $20 copayment amounts for their medications.  To obtain EPIC’s benefits, patients must pay a deductible (up to $320) and exceed the Part D limit of $2,930 to fall into the coverage gap.

Some patients had EPIC listed as their primary insurance, and pharmacies billed EPIC as a primary plan.  This has also changed, as these members are now required to obtain Medicare Part D insurance.  Senior citizens who do not enroll in a Part D plan by the end of February (63 days after December 21, 2011) will receive a penalty in the form of an increased monthly premium.  On average, the monthly premium can increase by >1% for each month that the patient does not enroll in a Medicare Part D plan.  Additionally, patients will need to pay the increased premium rate after they obtain Part D coverage.

EPIC members have a Special Enrollment Period (SEP) to sign up for Medicare Part D.  To avoid any penalties, they may contact EPIC and receive assistance in selecting the most appropriate plan.  EPIC members who wish to switch their Part D plans may do so only once during the 2012 year, with the exception of Medicare Advantage members (who must contact their plan to exercise this option).  Patients can obtain more information on this opportunity by calling the toll-free EPIC service number 1-800-332-3742 (TTY 1-800-290-9138) or the Spanish language service line by calling 1-800-332-3742.

SOURCES:

1. New York State Department of Health. Elderly Pharmaceutical Insurance Coverage (EPIC) Program. Available online at: http://www.health.ny.gov/health_care/epic/ . Last accessed 1 Feb 2012.