EPIC program overview

EPIC (Elderly Pharmaceutical Insurance Coverage) is the New York State Pharmaceutical Assistance Program (SPAP) State Pharmaceutical Assistance Program (SPAP) State Pharmaceutical Assistance Programs (SPAPs) are state-subsidized programs that provide assistance in paying for prescription drug costs. SPAPs vary by state, but they generally help pay for the Part D premium and any cost-sharing. 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 if single or $100,000 if married
• Do not receive full Medicaid Medicaid Medicaid is a federal and state program that provides health coverage for certain people with limited income and assets.  benefits
• And, are enrolled, or eligible to be enrolled, in a Medicare Part D Part D Part D, also known as the Medicare prescription drug benefit, is the part of Medicare that provides prescription drug coverage. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with a Medicare Advantage Plan. drug plan or Medicare Advantage Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Plan that provides drug coverage

Your EPIC benefits are determined by whether you are eligible for the Fee plan or Deductible plan:

EPIC Fee plan

• To qualify for the EPIC Fee plan, your income must be less than $20,000/year if single or less than $26,000/year if 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 to $300). EPIC will mail you bills to pay this annual fee in quarterly installments (every three months). This fee is waived if you have Extra Help Extra Help Extra Help, also known as the Part D Low-Income Subsidy (LIS), is a federal program administered by Social Security that helps pay for some to most of the out-of-pocket costs of Medicare prescription drug coverage, including coinsurances, deductibles, and premiums. People with Medicare who have income and assets below specified limits are eligible for Extra Help, which has different levels. Depending on your income and assets, you may qualify for either full Extra Help or partial Extra Help. People may also be automatically enrolled in Extra Help if they have certain other types of coverage, even if their income and assets are above the set levels. .
  • EPIC will pay your Part D premium premium A premium is an individual’s monthly payment to a Medicare or other health insurance plan for coverage. up to the state benchmark benchmark The Extra Help benchmark amount, also known as the Extra Help Premium Amount, is the amount of money that full Extra Help will pay for the monthly premium of a Part D plan that offers basic benefits. Benchmarks vary by state, and if you enroll in a Part D plan with a monthly premium above your state’s benchmark amount, you will have to pay the difference. ($72.34/month in New York in 2025). You will be responsible for any excess premium cost. If Extra Help is also paying your Part D premium, EPIC and Extra Help will both pay $72.34 towards your Part D premium. In other words, EPIC and Extra Help will pay up to $144.68 toward your Part D premium.
  • You must pay your Part D plan’s deductible, if it has one. EPIC will not pay for this cost. After you meet your Part D deductible, your EPIC copayments will range from $3 to $20. EPIC members will also pay copays for Part D-excluded drugs.

EPIC Deductible plan

• To qualify for the EPIC Deductible plan, your income must range from $20,001-$75,000/year if single and $26,001-$100,000/year if married.
  • If your income is between $20,001-$23,000 and you are single, or $26,001-$29,000 and you are married:
    • You will not have to pay an annual fee to have EPIC.
    • EPIC will pay your Part D premium up to the state benchmark ($72.34/month in New York in 2025). You will be responsible for any excess premium cost. If Extra Help is also paying your Part D premium, EPIC and Extra Help will both pay $72.34 towards your Part D premium. In other words, EPIC and Extra Help will pay up to $144.68 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 toward your Part D deductible will not count toward your EPIC deductible. However, the out-of-pocket amounts you pay for covered drugs (copays, coinsurance coinsurance The coinsurance is the portion of the cost of care you are required to pay after your health insurance pays. Usually, it is a percentage of the approved amount or negotiated amount. In Original Medicare, the coinsurance is usually 20% of Medicare’s assignment. ) after you meet your Part D plan’s deductible will count toward your EPIC deductible. After you have met both your Part D and your EPIC deductibles, you will pay EPIC copays (ranging from $3 to $20) for your drugs.
  • If your income is over $23,001 and you are single, or over $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 amounts you pay toward your Part D deductible will not count toward your EPIC deductible. However, the out-of-pocket amounts you pay for covered drugs (copays, coinsurance) will count toward your EPIC deductible. After you have met both your Part D and your EPIC deductibles, you will pay EPIC copays (ranging from $3 to $20) for your drugs.
    • Your EPIC deductible will be lowered by the annual premium cost of a benchmark Part D plan ($868.08 in 2025).

Note: The EPIC deductible ranges from $530 to $3,215/year. The EPIC deductible is determined based on your income last year.

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

If you have EPIC, you have a once-per-year Special Enrollment Period (SEP) to switch your Part D or Medicare Advantage coverage. If you have additional questions about EPIC, contact the toll-free EPIC helpline at 800-332-3742.