Elderly Pharmaceutical Insurance Coverage (EPIC)

EPIC (Elderly Pharmaceutical Insurance Coverage) is a program provided by the New York State Department of Health to assist seniors with income below a specified level cover their out-of-pocket Part D drug costs.

Elderly Pharmaceutical Insurance Coverage

EPIC provides secondary coverage for certain drugs after any Part D deductible is met, and covers certain approved drugs excluded from Part D. Part D excluded drugs covered by EPIC include prescription vitamins and cold medicines.

In order to be eligible for EPIC you must be enrolled in a Part D plan.

A Medicare Advantage health plan with Part D will satisfy the Part D requirement. You also must be a full time resident of New York State. This means that you must live in the state on a regular, ongoing basis, listing your New York State home address on official and legal documents.

You can apply for EPIC year-round; there is no need to wait for a special enrollment period, even if you do not have a Part D plan. As a State Pharmaceutical Assistance Program, EPIC can provide individuals with a Medicare Special Enrollment Period, allowing a new member to enroll in a Part D plan at any time during the year.

There are two Elderly Pharmaceutical Insurance Coverage plans: the fee plan and the deductible plan.

Both plans help bring the benefits of a Part D plan within the financial reach of New York seniors by reducing out of pocket drug costs.

The Deductible Plan

In order to be eligible for the deductible plan, you must have income of $75,000 per year or less as an individual, or $100,000 per year or less for a married couple.

As a secondary plan, you will need to present both your Part D plan card and your EPIC card at the pharmacy. Once you meet your Plan D deductible, if any, out-of-pocket drug costs for covered medications will then be applied to your EPIC deductible. All drug costs for approved Part D excluded drugs are applied to your EPIC deductible, even before your Part D deductible is met. Once your EPIC deductible is met, you will only pay EPIC co-payments, which range from $3 to $20 depending on the cost of each drug. There are no EPIC co-payments before you meet the deductible.

The Fee Plan

In order to be eligible for a fee plan, you must have income of $20,000 per year or less as an individual, or $26,000 per year or less for a married couple. New York state residents who qualify for the fee plan can get assistance with their Part D premiums and all the benefits of the Deductible Plan without an EPIC deductible. Members of the fee plan pay an annual fee of between $8 and $300 based on their income in the prior year. EPIC covers the monthly Part D premiums of Fee Plan members up to $39.33 per month. Fee Plan members are responsible for co-payments of $3 to $20 based on the costs of each drug.