Appendix_D-Sample_Eligibility.pdf

Appendix D – RFP #HHS-ASPR-16-100-SOL-00006 EPAP Long Term Requirement

Sample Eligibility Sheet For

Emergency Prescription Assistance Program Event

Customer Service:

Call Center Telephone Number:

Event Identifier: [Event descriptive identifier from the Activation Task Order]

Benefit Plan ID: [Added by ACS when EPAP Event activated]

Covered Region: EPAP Event Region includes:

[Insert Zip codes from the EPAP Activation or Change Task Order]

Emergency Prescription Assistance Program (EPAP) processes claims for prescription drugs and limited durable medical equipment (DME) for individuals who are affected by a disaster of national significance and have no other health insurance.

• Recipient(s) must demonstrate residence within the covered region. Identification can be a driver’s license, state issued identification card, current lease, utility bill, or other credible attestation of residence.

• Recipient enrollment is performed during the real-time RX POS claim transaction. As such, recipient information required on the POS transaction includes recipient name, full USPS address, city, state and zip code. Failure to include this information on the POS transaction may cause the enrollment verification to be rejected and the claim denied.

• Recipient is eligible for a one time fill of up to a 30-day supply for medication to treat an acute condition and chronic illnesses, with standard limitations for controlled substances.

• Replacement of maintenance prescription drugs or medical equipment lost or damaged as a direct result of the declared emergency.

• Formulary excludes the following:

o Cosmetic Agents o Contraceptives o Fertility Agents o Erectile Dysfunction o Weight Loss Medications o Over-the-Counter (OTC) Medications

• Mandatory Fill for the lowest price alternative between brand and generic, unless prescribed Dispense as Written (DAW).

• EPAP coverage is only available to individuals who do not have other drug and/or DME coverage; POS claims submitted will check for possible other payer coverage. If other payer coverage is known, claims are not eligible for payment under EPAP.