Important Notice: Attention Supervising Pharmacist
October 2011
EPIC Will Only Cover Medicare Part D Coverage Gap Claims
Beginning on January 1, 2012, the Elderly Pharmaceutical Insurance Coverage (EPIC) program will only cover Medicare Part D covered drugs purchased while in the Medicare coverage gap (donut hole) and Medicare Part D excluded drugs such as benzodiazepines and barbiturates, purchased during the coverage gap. During this period, EPIC co-payments will be the same ($3, $7, $15, or $20) depending upon the cost of the drug. Before reaching the coverage gap, members will need to pay the price charged by their Part D plan including any Part D deductible, co-payment or coinsurance. EPIC will not provide secondary coverage for any claims covered by insurers other than Medicare Part D drug plans.
Pharmacy Software Upgrade to National Council of Prescription Drug Programs (NCPDP) Version D.0
EPIC will transition from NCPDP version 5.1 to NCPDP version D.0 on January 1, 2012. This change brings EPIC in compliance with the latest NCPDP standards. All claims must be submitted to EPIC using D.0 beginning January 1, 2012. For more information regarding version D.0 visit the Centers for Medicare and Medicaid Services (CMS) - Educational Resources.
If you need a paper copy of the payer specifications please contact the EPIC Provider Helpline at 1-800-634-1340 and one will be faxed to your pharmacy.
How to Bill EPIC Claims After January 1st
EPIC will only reimburse pharmacies for Medicare Part D coverage gap claims, however claims submitted during other Part D phases should be billed and will be accepted. EPIC continues to require that each participating pharmacy submit all members' claims to EPIC. This will ensure that accumulations and patient records are up to date and accurate. A letter amendment to your provider agreement was sent to your pharmacy that explains this change in detail.
EPIC will return a 100% participant co-payment for Medicare Part D covered drugs in non-coverage gap Part D phases. In order to receive a paid response the claim must be paid by the primary Part D plan and submitted with an Other Coverage Code (OCC) of 8 (Field 308-C8). The OCC values of Blank, 0, 1, 2, and 4 will no longer be accepted by EPIC, and will reject for 13 – M/I Other Coverage Code. In addition to the OCC, the following fields must be submitted to EPIC:
| Field | Field Name |
|---|---|
| 353-NR | OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT COUNT |
| 351-NP | OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT QUALIFIER |
| 352-NQ | OTHER PAYER-PATIENT RESPONSIBILITY AMOUNT |
| 392-MU | BENEFIT STAGE COUNT |
| 393-MV | BENEFIT STAGE QUALIFIER |
| 394-MW | BENEFIT STAGE AMOUNT |
The fields above should be returned to your system from the primary Medicare Part D insurance once a paid response is received. Based on the values in these fields EPIC can determine whether the member is in the coverage gap. The claim will be priced accordingly with the co-payment that the participant is responsible to pay.
Medicare Part D excluded drugs that are not covered by Part D can be submitted to EPIC with OCC of 3 (Other Coverage Billed – Claim Not Covered) and Other Payer Reject Code of 70 (Product/Service Not Covered - Field 472-6E). Medicare excluded drugs will only be reimbursed during the Part D coverage gap.
If you have any questions or require further assistance please contact the EPIC Provider Helpline at 1-800-634-1340.
