EPIC (Elderly Pharmaceutical Insurance Coverage) is the New York State Pharmaceutical Assistance Program (SPAP) that helps older adults with Medicare pay for prescription drug costs. EPIC is available to New York State residents who:

  • Are 65 years or older;
  • Have annual incomes below $75,000 for an individual or $100,000 for a couple;
  • Do not receive full Medicaid benefits; and
  • Are enrolled, or eligible to be enrolled, in a Medicare Part D drug plan or Medicare Advantage Plan that provides drug coverage.

In 2018, EPIC will have a Fee plan and Deductible plan:

    • To qualify for the EPIC Fee plan, your income must be less than $20,000/year single or less than $26,000/year married. If you qualify for the EPIC Fee plan:
      • You must pay an annual fee based on your income last year (fees range from $8-300).  EPIC will mail you bills to pay this annual fee every three months. This fee is waived if you have Extra Help.
      • EPIC will pay your Part D plan premium up to a certain amount ($38.98/month in New York in 2018). You will be responsible for any excess premium amount. If Extra Help is also paying your Part D premium, EPIC and Extra Help will both pay $38.98 towards your Part D premium. In other words, EPIC and Extra Help will pay up to $77.96 towards your Part D premium.
      • After you pay your Part D plan’s deductible, your EPIC copays will range from $3 to $20. EPIC members will also pay copays for Part D excluded drugs.
      • If your Part D plan requires you to meet a deductible, you must pay for it yourself. EPIC will not pay it for you.

 

    • To qualify for the EPIC Deductible plan, your income must range from $20,001-$75,000/year if you are single and $26,001-$100,000/year if you are married.
        • If your income is between $20,001-$23,000 and you are single or $26,001-$29,000 are you are married:
          • You will not have to pay an annual fee to have EPIC.
          • EPIC will pay your Part D plan premium up to a certain amount ($38.98/month in New York in 2018). You will be responsible for any excess premium amount. If Extra Help is also paying your Part D premium, EPIC and Extra Help will both pay $38.98 towards your Part D premium. In other words, EPIC and Extra Help will pay up to $77.96 towards your Part D premium.
          • If your Part D plan requires you to meet a deductible, you must pay for it yourself. EPIC will not pay it for you.
          • In addition to paying your Part D plan’s deductible (if you have one), you must also pay an EPIC deductible, which is separate from your Part D plan’s deductible. The amount you pay towards your Part D deductible will not count towards your EPIC deductible. However, the out-of-pocket drug costs you pay for covered drugs (i.e. copays, coinsurance) after you meet your Part D plan’s deductible will be applied towards your EPIC deductible. You will pay EPIC copays (ranges from $3-20) for your drugs after you meet your EPIC deductible.
      • If your income is over $23,001 and you are single or $29,001 and you are married:
        • You will not have to pay an annual fee to have EPIC.
        • EPIC will not pay your part D premium.
        • If your Part D plan requires you to meet a deductible, you must pay for it yourself. EPIC will not pay it for you.
        • You will have to meet an EPIC deductible, which is separate from your Part D plan’s deductible. The costs you pay towards your Part D deductible will not count towards your EPIC deductible. However, the out-of-pocket drug costs you pay for covered drugs (i.e. copays, coinsurance) will be applied towards your EPIC deductible. You will pay EPIC copays (ranges from $3-20) for your drugs after you meet your EPIC deductible.
        • Since EPIC is not paying your Part D premium, your EPIC deductible will be lowered by the annual Part D premium for a basic Medicare Part D plan.

Note: The EPIC deductible ranges from $530-$3,215/year. The EPIC deductible is determined based on your income last year. The copays and coinsurances you pay for covered drugs will help you meet your EPIC deductible.

Remember, EPIC works with your Part D plan to help you pay for your prescription drugs. You must have a Part D plan in order to have EPIC. EPIC will act as secondary (supplementary) coverage for EPIC and Medicare Part D covered drugs, after your Part D and/or EPIC deductible is met. In other words, your Part D plan must pay first on your drugs and EPIC will pay second. EPIC may cover medications that Medicare Part D doesn’t cover (excluded drugs), such as prescription vitamins and minerals.

If you have EPIC, you can change your Part D or Medicare Advantage coverage once a year during a Special Enrollment Period (SEP). This SEP can help you enroll into Part D if you failed to do so when you were first eligible. If you have any further questions about EPIC, you may contact the toll-free EPIC helpline at 800-332-3742.