Effective October 1, 2010, if members present a prescription for a drug not covered by their Part D plan, the pharmacy will receive a message that the drug cannot be covered by EPIC until coverage is pursued through Medicare.
• The pharmacist will be required to notify the prescriber that Medicare has denied payment for the drug and that if the prescriber does not change the prescription, a Medicare Part D appeal must be pursued.
• All members (36,000) enrolled in a Part D plan who in the last 100 days received at least one drug that EPIC paid as the primary payer will receive a member specific letter that will list the drug(s) in question. The letter advises members to contact their pharmacists and prescriber(s) to determine if the drug(s) listed can be switched to drug(s) on their Part D plan formularies.
• A general legislation change letter will be mailed to all other EPIC members (226,000) enrolled in Medicare Part D plans to advise them of the program changes.
If you receive a letter from EPIC regarding a drug not being covered by your Part D plan it will contain the steps you would need to appeal. There will be a specific form included that your provider would need to complete.