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EPIC - New York's prescription drug program for seniors age 65+

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Posted: 03 Jun, 2009
by Cathy Roberts (Empire Justice Center)
Updated: 01 May, 2020
by Valerie Bogart (New York Legal Assistance Group)

New York has a State Pharmaceutical Assistance Program (SPAP) to help low- to moderate-income older adults age 65+ pay for prescription drugs.   

The Elderly Pharmaceutical Insurance Coverage (EPIC) program is administered by the New York State Department of Health (NYSDOH).   EPIC has gone through significant changes over the past couple of years.  Benefits were severely reduced in January 2012; but much of the original EPIC benefit is restored in January 2013.   Effective April 1, 2014, income limits increased dramatically -  for singles  from $35,000 to $75,000 a year and for couples from $50,000 to $100,000/year, subject to deductibles.  

APPLICATIONS

In 2020, EPIC released a  more complicated application that had  questions about ASSETS even though there is no asset limit for EPIC.  They wanted the information so they could screen applicants to refer them to enroll in Extra Help.  (Partial Extra Help has an income limit up to 150% FPL, which would qualify some people who are over income for any NYS Medicare Savings program for which highest income limit is 135% FPL.) But the added confusion of the new form and asking about assets would deter people from applying.  With NYStatewide Senior Action Council advocacy, DOH agreed to continue accepting the old application form at least for now during COVID.

However,  EPIC's website has only the new a  application.   Here is the OLD application (fill-able version) that you can still use at least during the COVID emergency.

 In an April 29, 2020 letter signed by Donna Frescatore, of the NYS Dept of Health Office of Health Insurance Programs:

"We understand your concerns regarding COVID-19 and ensuring that seniors get access to needed medications. As such, we will continue to accept the prior version of the EPIC application until after the emergency period and will also work closely with seniors to obtain the information needed so the EPIC program staff can facilitate their applications for the Extra Help program."

ELIGIBILITY

  • Must be age 65 or older and a NYS resident.

  • Income eligibility limit:    Singles  $75,000; Married couples  $100,000/year  (since 4/1/2014)

  • No asset test. 

  • Must be enrolled in Medicare Part D.

EPIC HELPS IN THREE WAYS:

1)  Part D premium assistance

      Pays cost of monthly Part D premiums (up to benchmark)

     Must have annual income at/below $23,000 year (single)/$29,000 (couple).

2)  Coverage gap ("Doughnut Hole" )assistance

      Helps with cost sharing for Part D.    Since 2013, EPIC will subsidize the Part D co-insurance year-round, AFTER the member has met the Part D plan's deductible, if any.  With EPIC's help,.the member's Part D co-pay will be no higher than $20 per drug; EPIC will pick up the balance.    

                         EPIC cost sharing  

If Part D co-pay for a drug without EPIC is...
EPIC member pays this amount
$0-$15
$0-3
$15.01 – $35
$7
$35.01 – $55
$15
> $55
$20

EPIC will also pay for Part D excluded drugs in the coverage gap.  

Additionally, EPIC will help members enroll into the Part D Low Income Subsidy ("Extra Help") and Medicare Savings Programs.

3)   "Special Enrollment Period" -- EPIC members are allowed to change Part D plans once a year just because they are in EPIC.  Otherwise, most Part D enrollees may only change once a year during the Annual Enrollment Period in the fall.   

EPIC  has two tiers of coverage    

   1) "Fee" program.

           Income eligibiilty threshold:  $20,000 yearly/singles, $26,000/couples. 

          Members are charged an annual fee on a sliding scale basis.  Fee ranges from $8 to 300 and is waived for full "Extra Help" recipients.

SEE CHART OF Fee Scale  

    2) "Deductible" program:

           Income eligibility threshold:  $20,001-$35,000 yearly (single); $26,001-$50,000 yearly (couples).

           No fee charged, but EPIC coverage doesn't kick in until/unless member's out of pocket Part D drug costs meet a specified limit  (their  "EPIC deductible amount").   The  amount of the deductible ranges from $530 to $1,715, based on the household income. 

See Chart of Deductibles by Income. 

Some EPIC members have plans which charge an annual Part D deductible.  EPIC cannot cover the cost of the Part D deductible. 

Where to get more information

Call the EPIC helpline at 1-800-332-3742 (TTY 1-800-290-9138) or visit EPIC's website.   Copies of the EPIC statute and regulations, are attached to this article.  

Click HERE to access application and more information on EPIC.

Attached files
item EPIC Statute and Regulations.pdf (309 kb) Download
item EPIC Application 2015-05 fill-able.pdf (173 kb) Download

Also read
item Medicare Part D - Overview (2019)
item AIDS Drug Assistance Program (ADAP) and other AIDS/HIV Subsidy Programs

Also listed in
folder Medicare Part D -> Overview

External links
http://www.wnylc.com/health/client/images/icons/article_out.svg http://www.health.state.ny.us/health_care/epic/

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