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Changes limit EPIC drug coverage for seniors; Will cover only co-pays on Part D 'doughnut hole'

New York State's supplemental prescription drug plan for the elderly is changing. Its coverage will be significantly more limited, but it will be free upfront.

Originally designed to help low- and moderate-income seniors pay for prescription drugs, the Elderly Pharmaceutical Insurance Coverage (EPIC) program is shifting toward a much narrower focus in response to the state's ongoing budget crisis.

Where it used to cover a range of drug costs for seniors, regardless of insurance plan, EPIC will now be limited to covering Medicare Part D co-payments in the so-called "doughnut hole" -- the gap when participants must pay all of their prescription costs after they have exhausted the coverage limit and before reaching the catastrophic coverage threshold.

The EPIC coverage will now be mostly free for its 250,000 members, with no fees to participate and no deductibles of its own, although members will have co-pays.

But where it previously covered all out-of-pocket costs for Part D coverage, now it will pay only for Part D co-payments, and only after the members have met the Part D deductible, if they have one.

And it will no longer provide secondary drug coverage to help seniors pay deductibles and co-payments for other government or private drug plans.

The changes, which were imposed as part of the state budget that was passed on March 31, will take effect on Jan. 1.

The result is much less expense for the state but potentially higher costs for individual consumers, such as Shirley Beyer of Orchard Park.

The 75-year-old diabetic spends thousands of dollars a year on prescription drugs and has relied on her insurance and EPIC for more than two years.

If it weren't for EPIC, she said, she would struggle to afford her prescriptions with an income of less than $25,000. So she was dismayed to learn of the "big-time" changes, which she said were "snuck through" when most people weren't aware of them.

"I appreciate my EPIC," she said. "It helped out, and it's going to be changing very dramatically."

She has done well on her medications and said she will "sure try hard" to keep using them, despite what she says is a temptation to cut back to save money. She did receive additional cash after selling her home, but now she pays "big rent" for an apartment, and she is worried that the new costs will cut into whatever money she has.

"I'm not poverty-stricken, but I don't have much of a life. I'm not looking for anything," she said. "I will do as best as I can for as long as I can."

EPIC is a program administered by the state Health Department.

Most enrollees currently have either Medicare Part D or some other primary drug coverage and use EPIC to cut their costs even more by helping them cover the deductibles or co-pays the other plans require them to pay. EPIC also helps more than 92,000 members in its fee plan pay their Part D premiums, up to the average monthly cost of a basic drug plan.

To participate, members must live in New York, be at least age 65 and have annual incomes of less than $35,000 for singles or $50,000 for married couples. They also must not be receiving full Medicaid benefits.

Currently, there are two plans, based on a person's income: a fee plan with a low quarterly fee totaling up to $300 a year for seniors with moderate incomes, and a plan with an annual deductible ranging from $530 to $1,715 for those with higher incomes. The latter is what Beyer is on, with a $550 deductible.

Those on the fee plan or those who have met their deductible also pay a co-pay at the pharmacy when buying their drugs.

By using both EPIC and Medicare or other coverage, members have been able to save more than they would using only one or the other.

The new rules will eliminate any deductible that must be met as of Jan. 1, 2012. After that, there will be only one plan, with no deductible or fees. But members will still have EPIC co-pays ranging from $3 to $20, depending on the drug.


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