Prescriber Packet September 2008


On October 1, 2008, EPIC will implement the following program changes in order to increase the use of Medicare Part D coverage and generic drugs. These changes are designed to improve the cost effectiveness of the program without compromising seniors' access to needed drugs, and will also result in lower co-payments that will increase senior savings.

  • Follow Part D Plan Formulary
    • When a Part D plan or other primary drug plan denies coverage of a drug for EPIC enrollees, before billing EPIC, pharmacists are required to consult with the prescriber to consider an alternative drug covered by the Part D plan.
    • When an alternative cannot be substituted, EPIC will provide immediate coverage and subsequently submit an appeal to the Part D plan on behalf of the EPIC member when cost effective. The assistance of prescribers will be requested as needed to complete the formulary exception and prior authorization requests.
  • Mandatory Generic Drug Program - EPIC will require substitution of brand multi-source drugs with “A” rated generic equivalents, unless the brand is being covered by other coverage and EPIC is secondary. The prescriber will need to request an EPIC prior authorization if the brand is necessary, by calling the EPIC PA Call Line at 1-800-256-8082.

Follow Part D Plan Formulary

EPIC provides wraparound coverage to eligible seniors with Medicare Part D or other primary coverage. EPIC helps seniors pay for their monthly Part D premiums, deductible, co-payments/co-insurance, and purchases during the coverage gap (“donut hole”). To ensure immediate access to needed medications, EPIC will also cover drugs not covered by the Part D plan. However, the substitution of a drug on the primary plan formulary should be considered by the prescriber and pharmacist first.

To maximize the use of drugs covered by the primary Part D plans, EPIC will be implementing the following changes effective October 1, 2008:

  1. Pharmacists are required to consult with the prescriber to determine if an alternative drug covered by the Part D plan can appropriately be substituted, before billing EPIC for a drug that is not being covered by the senior's Medicare Part D plan.
    • If the prescriber determines there is no acceptable alternative, or if the pharmacist was unable to reach the prescriber before the senior needed the medication, EPIC can be billed and will cover the drug.
    • If the pharmacist was unable to reach the prescriber before filling the prescription, he/she will need to contact the prescriber before the next refill.
    • The pharmacist must certify, when billing EPIC, that he/she consulted (or attempted to consult) with the prescriber.
    • The prescriber needs to be consulted the first time a prescription (not covered by another plan) is dispensed on or after October 1, 2008, and with each new prescription thereafter.
    • The following categories of drugs excluded from Medicare Part D coverage will not be subjected to this new requirement:
      • Benzodiazepines
      • Barbiturates
      • Prescription vitamins and minerals
      • Drugs for anorexia, weight loss or gain
      • Drugs for cosmetic purposes
      • Drugs to relieve cough and cold symptoms
  2. EPIC will submit an “appeal” on behalf of enrollees for drugs not covered by their Medicare Part D plan.
    • Many Part D plans require the completion of a prior authorization or formulary exception form (i.e. Coverage Determination Form) before certain medications can be dispensed. These forms typically require diagnosis and clinical information from the prescriber.
    • Prescribers will be asked to complete a portion of the required form, before EPIC forwards it to the Part D plan. EPIC will assist prescribers with this process by faxing the applicable form to the prescriber's office that includes available information. In some cases, only the prescriber signature will be required.
    • Prescribers are requested to expeditiously fax the completed form back to EPIC. Instructions on how to complete the initial Coverage Determination form, and where to send it, will be included with the form. EPIC will then forward the completed form to the Part D plan for further processing. The Part D plan will contact the prescriber directly when it issues the final determination.
    • When a coverage determination is denied by a Part D plan, EPIC may decide to elevate the request to the first level of the Part D Appeals Process called Plan Redetermination. Additional levels of appeals may be pursued if cost effective.
    • For questions about the processing of appeals, call the EPIC Provider Helpline at 1-800-634-1340 and ask for the EPIC Appeals Unit.

Prescriber: Your assistance with the coordination of EPIC benefits with Medicare Part D, and submission of requests for formulary exceptions or prior authorizations, will help your patients receive the medications that you feel are necessary while assuring that they are being provided in the most cost-effective manner. EPIC appreciates your cooperation, as these initiatives are important measures in helping enable New York State to continue to help EPIC seniors afford the medications they need.

Mandatory Generic Drug Program

Beginning October 1, 2008, brand name drugs that have an “A” rated generic equivalent available will be subject to prior authorization (PA) when EPIC is the only payer. Prescriptions being covered by Medicare Part D or other drug plan, where EPIC is covering the senior out-of-pocket cost, will not require an EPIC prior authorization.

Prescriber Process to Obtain EPIC PA

To obtain a PA, prescribers or their agents need to call the EPIC Prior Authorization Call Line, which will be available 24/7 beginning October 1st. (Fax requests will not be accepted.) The Call Line is an interactive voice response (IVR) system that will prompt the caller to provide needed information via voice or phone keypad, as follows:

  • Call the EPIC Prior Authorization Call Line: 1-800-256-8082.
  • Select option for “Prescriber.”
  • Prescriber or agent must provide the prescriber's ten-digit NPI number or six to eight digit license number.
  • Prescriber or agent must provide:
    • the EPIC participant's nine to twelve-digit EPIC identification number or
    • the EPIC participant's complete last and first name plus date of birth or
    • the last four digits of the EPIC participant's social security number plus date of birth.

The IVR system will verify the prescriber and participant information. If verification is not successful, the call will be forwarded to a call center helpline representative.

  • Once the participant identification is established, the prescriber or agent will be prompted for the name of the brand drug.
  • After system verification of the drug name, the prescriber or agent will be asked to select one or more of the following questions that best describe the reason for requesting the multi-source brand name drug.
    • Does the participant have a history of an allergy to any of the generic drug inactive ingredient(s)?
    • Does the participant have a history of adverse reaction to any of the generic drug inactive ingredient(s)?
    • Is there a documented history of successful therapeutic control with the brand-name drug?
  • If the prior authorization is approved, the PA will be activated immediately. A PA reference number will be provided for tracking purposes only.

As soon as the PA is obtained, the pharmacy can submit the claim for the brand name drug, assuming the prescription was written as “dispense as written” (DAW). The EPIC claim system will automatically approve the claim if a PA is on file for that EPIC enrollee and drug.


Consistent with the NYS Medicaid Program, the following drugs are exempt from the EPIC Mandatory Generic Program and do not require prior authorization:

  • Clozaril®
  • Coumadin®
  • Dilantin®
  • Gengraf®
  • Lanoxin®
  • Levoxyl®
  • Neoral®
  • Sandimmune®
  • Synthroid®
  • Tegretol®
  • Unithroid™
  • Zarontin®

Emergency Supply

If an EPIC member presents a prescription to the pharmacy for a brand name drug that requires generic substitution or PA and the pharmacist is unable to reach the prescriber, the pharmacist may request a PA for a 72-hour emergency supply using the same toll-free number. However, once the pharmacist obtains the PA for a 72-hour emergency supply, the prescription will then become invalid for any refills. When contacted by the pharmacy for a new prescription, the prescriber will either need to call to obtain a PA or change the order to the generic equivalent.

Generic Unavailable in the Market

In the event an “A” rated generic equivalent is not available in the marketplace, the pharmacist may call the EPIC Prior Authorization Call Line and obtain authorization to dispense the multi-source brand name drug. This authorization will be effective for up to six months. The pharmacist is expected to dispense the generic for any subsequent refills within that timeframe in the event it becomes available.

For questions about the EPIC Mandatory Generic Program, please call the EPIC Provider Helpline at 1-800-634-1340.