Senior Life Matters

Question; I got a letter from EPIC requesting new information & I sent it to them. Now they have sent a letter cancelling my benefit, what should I do?

Question; I got a letter from EPIC requesting new information & I sent it to them. Now they have sent a letter cancelling my benefit, what should I do?


Answer; EPIC has been busy mailing forms and information to New Yorkers who have EPIC. I know because I get an EPIC related question every day!!

First, not everyone knows what EPIC is, so let me explain it. EPIC is an acronym for the Elderly Pharmaceutical Insurance Coverage, (EPIC). This New York State benefit is available to those individuals who live in New York State (legal residence), are 65 years or older, and have an annual income of up to $75,000 if single or $100,000 if married.

What you get for having an EPIC card in your wallet andshowing it to your pharmacists, is secondary prescription drug coverage for your medications purchased at a New York State pharmacy. EPIC requires that members have a Medicare Part D plan, or creditable drug coverage from an employee or retiree plan.

EPIC has two levels of benefit; Fee or Deductible Plan. 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. If you qualify for the EPIC Fee Plan, your EPIC membership requires you pay an annual fee. This fee is paid quarterly or annually by you to EPIC. Once your fee is paid, EPIC will immediately reduce the cost of your medications purchased at the pharmacy (AFTER you have met your primaryprescription 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 payEPIC anything, but as your pay your medication co-pays at the pharmacy, you are accumulating expenses towards your EPIC Deductible. If you ever meet your EPIC deductible, your medication co-pays will be reduced.

Those individuals who make less than $23,000 or married couples who make less than $29,000, have an additional benefit from EPIC. In these situations, EPIC pays up to $39.33 per month towards their prescription drug coverage premium. This extra benefit under EPIC helps to keep expenses down for many individuals 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, but spend part of their year elsewhere, or buy medications while traveling, please note that EPIC does not count those medication costs towards your deductible, or help pay for medications in outside New York State.

It is also very important that your pharmacy have your EPIC membership card on file. If your pharmacy doesn’t know you have EPIC you can’t receive any of the benefits we just talked about.

Now let’s finally get to your questions. EPIC reviews membership in the program every two years for their members. They no longer evaluate everyone, every year the way they used to. Their membership is much higher than it used to be. EPIC has more than 325,000 members across the state. Typically, EPIC sends members who are up for renewal a letter requesting updated income information. This requires the member to complete a form writing down their sources of income, then attaching proof of that income to the document and returning it back to EPIC via the mail. Once that is verified by EPIC as valid, EPIC renews your membership if you meet their income standards.

Sometimes individuals decide to mail EPIC updated income information for a variety of reasons, such as; you have retired and no longer work, making your income lower; your spouse dies or moves into a Nursing Home, so your income is different; or you are now collecting on a pension, or from an IRA, making your income higher. Just like when EPIC requests the information, this sending new information to EPIC prompts an adjustment to your EPIC benefit.

Each year EPIC sends you a letter indicating your level of coverage. If you send updated information during the year, EPIC sends a letter indicating the adjustment to the benefit. This letter indicates your level of benefit (Fee or Deductible) and what those levels mean. This is an important letter to keep track of. You will use this information throughout the year and as you fill medications.

Sometimes, like in your situation, your income verification process indicated you are now over income and therefore no longer eligible for EPIC. That isn’t all bad. That means your income is higher than most in your age group. That is something to celebrate.

The loss of EPIC may impact your spending on medications. Loss of EPIC benefits also prompts a Special Enrollment Period (SEP)! That is good news! This SEP allows you to make a different choice for your Prescription Drug Coverage. This SEP is only open to you for 60 days. In your situation, going forward you will only have your primary Medicare Part D Prescription Drug plan, so we want to use this opportunity to make sure you have the best plan you possibly can have for the rest of the year. You want to compare what you have with the other plans on the market. The best way to do that is with the www.medicare.govwebsite’s Plan Finder Tool. This Plan Finder Tool takes your location, your pharmacy and your medications, throws all those variables into the plans you have in your region and puts them in financial order for you! That is very useful and amazing information. After using this Plan Finder Tool you may find that your current coverage is the best coverage for you. You may also find a plan that covers your current medications better than your current coverage. This SEP allows you to change to that better plan.

If you feel the information EPIC used to make their decision is incorrect, or you feel it was misinterpreted, I would strongly recommend you call EPIC (1-800-332-2742). Their customer service representatives will work through the information they have, versus the information you feel is correct and help you resolve/correct the situation. When you call, be ready with all your paperwork in front of you to review your situation and concerns with them while on the phone. You will get a recorded message, saying you will have a wait time, don’t worry it is worth the wait to get the help you need. Get a cup of tea/coffee, glass of water, and maybe a magazine or good book to help you pass the wait time.

If after calling EPIC, you find you are not eligible for EPIC this year, it is best to evaluate the coverage you have. My advice to you when considering how to handle EPIC cancelling your coverage, is to evaluate your medications and the plan you have. Decide if you have the best you can get for 2019. Once this SEP 60 day window to change your drug plan ends, you may be locked into your coverage for the remainder of the year. You also may have something happen which qualifies you for a different SEP, but we will cover those in a different article.

Also it is VERY important to remember that individuals and couples can apply for EPIC anytime. So if your income means you are NOT EPIC eligible now, you could become EPIC eligible later. You can apply later and get EPIC at that time.

You have lost EPIC now, but that doesn’t mean you can’t reapply at a later date if you feel you are eligible. Simply fill out a new EPIC application, complete it, and mail it with the supporting documents and information. EPIC will make a new decision at that time.

EPIC applications can be obtained by calling EPIC at 1-800-332-3742, or at their website at most pharmacies in NY state.

To contact Janell Sluga, GCMC with questions or concerns, please call 716-720-9797 or e-mail her at