First, for those that don’t know what EPIC (Elderly Pharmaceutical Insurance Coverage) is. This benefit is available to residents of New York State, over age 65 and make less than $75,000 for an individual and $100,000 for a married couple. Individuals and Couples can apply for EPIC anytime of the year they meet the criteria. Once a member, EPIC will automatically recertify your eligibility using your New York State tax returns.
When EPIC is verifying your income and finds significant differences, EPIC will mail you a letter requesting that you list all sources of income and mail back.
If EPIC finds your income had no significant change, they mail you a letter dated December 1, stating the EPIC benefits you will receive in 2022.
EPIC offers two different types of coverage based on your household income; Fee or Deductible. As we age our income sometimes changes. This may change due to retirement plans beginning to pay benefits, adjustments to Social Security, IRA and 401K Disbursements, etc.
To be in the EPIC Fee Plan, your annual income can be up to $20,000 for an individual or $26,000 for a married couple. The EPIC Fee Plan requires you pay an annual fee. either quarterly or annually. Once your fee is paid, EPIC will immediately reduce the cost of your medications purchased at the pharmacy to $3, $7, $15 or $20 per refill (30, 60 or 90 day refill). Remember this is AFTER you have met your Part D prescription drug coverage deductible.
Individuals with incomes between $20,000 & $75,000 and married couples between $26,000 and $100,000 qualify for the EPIC Deductible Plan. In this case, you don’t pay EPIC anything, but your medication co-pays at the pharmacy, you are accumulating as expenses towards your EPIC Deductible. If you meet your EPIC deductible during the year, your medication co-pays will be reduced to $3, $7, $15 or $20 per refill (30, 60 or 90 day refill).
Those individuals who make less than $23,000 or married couples who make less than $29,000, have an additional benefit from EPIC. For these members, EPIC pays up to $43.42 per month towards their prescription drug coverage premium. This extra benefit helps to keep expenses down for many in two different ways, lower Part D premiums & lower co-pays at the pharmacy!
It is also important to remember that EPIC will only help to cover the cost of medications purchased in New York State. If you use mail order, EPIC may not help as much because the medications are coming from outside New York. For those who have EPIC, and buy medications while traveling, please note that EPIC does not count those medication costs towards your deductible, or help pay for medications purchased outside New York State.
EPIC will NOT help reduce the cost of your medications during your Part D deductible, if you have one. During the Part D plan deductible you will pay the full cost of the medication at the pharmacy. Most deductibles are $480. There are a few plans that have lower deductibles than that, but never more than $480 in 2022.
If you don’t have EPIC and think you are eligible call 1-800-332-3742 to talk to an EPIC representative and get a copy of the EPIC application. There is also a useful website where you can print off an application and learn more about the program, https://www.health.ny.gov/health_care/epic/. If you have questions when you get the form, call EPIC for help.
If you are already a member of EPIC, watch for that benefit letter in the coming weeks if you have not already received it.