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EPIC in New York: How the State’s Senior Drug Program Works With Medicare Part D

Boldt Castle on Heart Island in the Thousand Islands, New York, a large gray stone castle with steep red roofs and towers rising above thick green trees under a soft blue sky, above hook text: EPIC in New York. Help With Part D Costs?

EPIC (Elderly Pharmaceutical Insurance Coverage) is a New York State program that helps income-eligible seniors 65 and older with their out-of-pocket Medicare Part D drug costs. It is run by the New York State Department of Health and works alongside your Part D plan, not instead of it. Whether you live in Buffalo, Rochester, Syracuse, Albany, the Hudson Valley, Long Island, or New York City, the rules are the same statewide.

This article is educational. Instant Health Help is a licensed health insurance agency, and our agent, Lobsang Rivas, is licensed in New York and certified as a broker with NY State of Health. We are not EPIC, the New York State Department of Health, Medicare, NY State of Health, or an insurance company, and EPIC decides who qualifies. We do not quote prices or name plans here. See the official EPIC program page.

The short answer

  1. EPIC is secondary drug coverage. Your Medicare Part D plan pays first. After any Part D deductible, EPIC can help with what is left.
  2. You must have Part D. EPIC says members must be enrolled in a Part D plan, or a Medicare Advantage Plan with Part D, with no exceptions.
  3. You can apply any time of the year, and joining EPIC gives you a special chance to join or change a Part D plan.

Who qualifies

According to the EPIC eligibility page, to join EPIC you must:

  1. Be a New York State resident. Your permanent home, not a summer or winter home, must be in New York.
  2. Be 65 or older.
  3. Have income under the EPIC limit. EPIC uses your previous calendar year’s income. The limits are posted on the EPIC eligibility page.
  4. Be enrolled, or eligible to enroll, in a Medicare Part D plan.
  5. Not be getting full Medicaid benefits.

EPIC also notes that people with a Medicare Advantage Plan can only join if their plan includes Part D drug coverage, and seniors who cannot join a Part D plan, such as some people with a union or retiree drug program that is not Part D, cannot join EPIC.

How EPIC works at the pharmacy

  1. Show both cards, your Part D plan card and your EPIC card, every time you fill a prescription.
  2. Part D pays first. EPIC pays after you meet any Part D deductible.
  3. EPIC copays. You pay an EPIC copay based on the cost of the drug instead of your full Part D share.
  4. Some drugs Part D leaves out. Once you are in a Part D plan, EPIC also covers approved Part D excluded drugs, such as prescription vitamins and prescription cough and cold medicines.

The two EPIC plans

EPIC places members in one of two plans based on prior year income:

  1. Fee Plan for lower incomes. You pay an annual EPIC fee, billed quarterly or once a year, then pay EPIC copays. EPIC can also help pay Part D plan premiums, up to a set amount, for Fee Plan members.
  2. Deductible Plan for higher incomes. You meet an annual EPIC deductible first, then pay EPIC copays. Some members at the lower end of this plan also get help with Part D premiums.

EPIC also says that members who get Extra Help from Medicare do not have to pay any EPIC fees, and their copays are lower. If your income might qualify you for Extra Help, EPIC may ask for extra information on pages 2 and 3 of the application, or for your Extra Help letter from Social Security. Learn more about Extra Help on Medicare.gov.

The enrollment window EPIC gives you

Because EPIC is a State Pharmaceutical Assistance Program, it can give you:

  1. A Special Enrollment Period to join a Part D plan when you first join EPIC, at any time of the year.
  2. One plan change per calendar year for existing members.

Medicare.gov lists the same rule for anyone in a State Pharmaceutical Assistance Program: you can join a Medicare drug plan or a Medicare Advantage Plan with drug coverage once during the calendar year. See Medicare.gov’s Special Enrollment Periods page.

One important warning

EPIC says it is not creditable coverage. That means EPIC by itself does not protect you from the Part D late enrollment penalty, and if you are not in a Part D plan, you get no EPIC benefits at all. Keep your Part D coverage in place.

How to apply

  1. Online through EPIC’s online application.
  2. By mail or fax with the paper application, in English, Spanish, and many other languages. Mail to EPIC, P.O. Box 15018, Albany, NY 12212-5018, or fax (518) 452-3576.
  3. By phone. Call the EPIC Helpline at 1-800-332-3742 (TTY 1-800-290-9138), 8:00 AM to 5:00 PM, Monday through Friday, for questions or a paper application.

See EPIC application and contact information and how EPIC works with Medicare.

Unbiased counseling

New York’s Health Insurance Information, Counseling and Assistance Program (HIICAP) offers Medicare counseling. Visit the HIICAP page. Our New York Medicare annual enrollment guide explains what to review each fall, and our Medigap guaranteed issue guide covers New York’s Medigap rules.

Someone in your house under 65?

Our agent is certified as a broker with NY State of Health, so for a spouse or adult child under 65, we can go through the application with you, compare plans, and help you enroll, at no extra cost to you for our help. We are not NY State of Health, and NY State of Health decides what you qualify for. Read our New York open enrollment guide.

How we help

We are licensed in New York and help by phone and online, in English or Spanish. Learn more on our New York health insurance help page. We can explain how EPIC fits with your Part D plan, check that your drugs are on the plans you are considering, compare Medicare Advantage Plans, Medigap policies, and drug plans with you, and help you enroll if you decide to. The choice is always yours. EPIC decides EPIC eligibility.

Want to talk it through?

Have your Medicare card, your Part D plan card, and your list of medicines, and we will go over your options step by step.

Call (321) 315-0054 | agent@inshh.com

We do not offer every plan available in your area. Currently we represent 10 organizations which offer 489 products in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048, is available 24 hours a day, 7 days a week, except some federal holidays. Instant Health Help is not connected with or endorsed by the U.S. government or the federal Medicare program.

Featured photo: Boldt Castle, Heart Island, Thousand Islands by Fhard555, CC BY-SA 4.0, cropped with text added.