Changes to EPIC in 2012
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Last Update: August 11, 2011
EPIC (Elderly Pharmaceutical Insurance Coverage) is the New York State Pharmaceutical Assistance Program (SPAP). EPIC is available to New York state residents who are 65 or older and have annual incomes below $35,000 for an individual and $50,000 for a couple.
EPIC is changing on January 1, 2012. Starting in 2012:
- EPIC will be free
- There will be no fees or deductibles.
- EPIC income limits will stay the same
- Individuals with annual incomes below $35,000 and couples with annual incomes below $50,000 can join the EPIC program.
- There will still be premium assistance
- EPIC will keep paying Part D premiums for individuals with yearly incomes below $23,000 (or $29,000 for couples).
- EPIC will help members apply for other programs
- Members eligible for Extra Help and Medicare Savings Programs must fill out forms to let EPIC apply for these programs for them. These are programs that can help people with low incomes pay for drugs and health care.
- Members must have Medicare Part D
- In 2011, most EPIC members had to have a Part D plan, but there were some exceptions and it wasn’t always required.
- Starting in January 1, 2012, all EPIC members must have a Part D plan. This can be a Part D plan that only covers drugs or a Medicare Advantage plan that covers health care and drugs.
- EPIC will only provide doughnut hole coverage.
- Starting in 2012, EPIC will only help pay for drugs when you’re in the Part D coverage gap, also called the doughnut hole. It will no longer help pay your drug copays when you’re not in the doughnut hole.
- The doughnut hole is when your Part D plan stops covering your drugs for a period of time.
- When you’re in the doughnut hole, EPIC will help pay for drugs on your Part D plan’s formulary (its list of covered drugs) and drugs that are excluded from Medicare coverage by law (such as barbiturates and benzodiazepines).
- Copays stay the same.
- When EPIC covers your drugs in the doughnut hole, the copays will range from $3 to $20.
- No more temporary EPIC coverage.
- EPIC will no longer provide temporary coverage for drugs your Part D plan doesn’t cover because the drug is not on your plans formulary or it is covered with restrictions such as prior authorization, step therapy or quantity limits.
- If your Part D plan won’t pay for a drug because of the above reasons, you can submit a formal request (called an appeal) to your Part D plan asking it to pay for your drug.