What is EPIC? (Spanish, Chinese)
EPIC is a New York State prescription drug benefit for people over age 65 who meet EPIC’s income guidelines.  EPIC pays for both brand-name and generic medications.  Usually, to get EPIC you must also enroll in a Medicare Part D drug plan.  There are exceptions to this requirement; contact EPIC with any questions at 1-800-332-3742. 

When you have Medicare Part D and EPIC, your Part D drug plan pays first, and EPIC pays second.  Using the two plans together results in greater savings and drug costs that are not covered by Medicare (including deductibles, co-pays, coinsurance, and the coverage gap) can be submitted to EPIC.  EPIC will help you enroll in the Part D plan that is best for you based on your drug and pharmacy needs.

Will it cost me anything?
Yes.  Some members pay an annual fee (which is billed quarterly and depends on the plan).  Other members with higher incomes pay a yearly deductible. There is also a co-payment ranging from $3 to $20 per prescription.  Once total co-payments reach a certain dollar amount, you will have no further copays for the rest of the plan year.  Fees, deductibles, and annual co-payment maximums are determined by your income and marital status.

What is a deductible?
Yearly deductibles are the amount you must first pay before EPIC pays.  Under a deductible program, you pay the full cost of your prescription until you meet your deductible. Your deductible will range from $530 to $1,715, depending on your marital status and your annual income. If you are enrolled in a Medicare Part D drug plan, EPIC will lower the amount of your deductible to help you pay the cost of your Part D monthly premium.

What are the co-payments for prescriptions?
The costs are decided based on whether your prescription is generic or brand name.  After you pay the annual fee or reach the annual deductible, there are four levels of co-pays.  If the prescription costs:

  • Up to $15.00, your co-pay is $3.00
  • From $15.01 to $35.00, your co-pay is $7.00
  • From $35.01 to $55.00, your co-pay is $15.00
  • From $55.01 and over, your co-pay is $20.00.

To lower your prescription co-pay, talk with your doctor about getting generic prescriptions.  Since generic prescriptions are less expensive for EPIC, your co-pay may also be lower.

How do I know when I have met my deductible or fee?

  • Under a deductible plan, you may ask the plan for a statement of your total purchases to show you if you have received credit for all prescriptions purchased.
  • Under a fee plan, you can ask for a statement of your prescription costs and how much you saved with EPIC during the year you are covered.

NOTE:  It is best for you to keep receipts and records of your purchase in case there is a question about the amounts you have paid.

What is considered an Income?

  • Federal adjusted gross household income reported on your income tax return;
  • Social Security Payments
  • Railroad retirement benefits
  • Taxable amount of an IRA distributions and retirement annuities
  • Support money, including foster care
  • Supplemental Security Income
  • Tax exempt interest
  • Workers’ compensation
  • Gross amount of loss-of-time insurance
  • Cash public assistance and relief, other than medical assistance for the needy
  • Non-taxable strike benefits
  • Veterans’ disability pensions
  • Lottery winnings

What is not considered an Income?

  • Food stamps
  • Medicare premiums paid by Medicare Savings Programs
  • Medicaid
  • Scholarships
  • Grants
  • Surplus Food
  • Payments made to veterans under the Federal Veteran’s Dioxin and Radiation Exposure Compensations Standard Act (Agent Orange)
  • Payments made to individuals because of their status as victims of Nazi persecution.

What if I have other insurance?
If you have other prescription coverage (including Medicare Part D or private insurance), the amount you pay out-of-pocket under the other insurance will count toward your EPIC deductible.  For example, any co-pays or deductibles required under your other drug plan will count toward your EPIC deductible so long as the drug is covered under EPIC.

NOTE:  If you have Medicare Part D, the pharmacy must first submit a claim to your Part D plan.  However, EPIC will pay regardless of whether the Part D plan covers your drug as long as EPIC covers the drug.

How do I make certain that Medicare Part D is my primary coverage?

  • Show both your Medicare Part D and your EPIC cards to your pharmacist.  Tell the pharmacist that you have prescription coverage under both programs.
  • Tell the pharmacist that a claim must first be submitted to your Medicare or other prescription plan before it is submitted to EPIC.
  • If any prescription cost is not covered by your other coverage, the pharmacist may submit it to EPIC for coverage consideration.

What if my I have Medicare and have limited income?
If your annual income is below $16,245 for an individual or $21,855 for a married couple, you qualify for a program call “Extra Help” under Medicare Part D.  You can also get Extra Help if your Medicare Part B medical premium is paid by Medicaid through a Medicare Savings Program.  If you join a basic Medicare Part D plan, you will not be charged a premium for your Part D plan, there is no annual deductible, and the EPIC enrollment fee will be waived. Your co-payments for prescriptions covered under Medicare Part D are $2.50 for generics and $6.30 for brand-name drugs.   If the drug is not covered by Part D but is covered by EPIC, you will pay EPIC co-pays ranging from $3.00 to $20.00.

Will EPIC assist me with applying for Extra Help?
Yes.  If your income meets the standards for Extra Help from Medicare, EPIC will request additional information to determine whether you qualify for Extra Help.  In order to continue to be eligible for EPIC, you must complete the “Request for Additional Information” form that EPIC mails to you.  If you need assistance completing the form, you may contact EPIC’s toll-free Hotline at 1-800-332-3742, or call CIDNY at 646-442-4186 and ask to speak to a benefits counselor. 

Can I be eligible for EPIC if my Extra Help only pays a portion of my Part D premium?
Some people with income slightly above the limits for Full Extra Help can still qualify for partial Extra Help.  The Part D plan has a $63 annual deductible, and then you pay up to 15% of the cost of your drug.  If you are approved for partial Extra Help under Medicare, you will still usually pay lower EPIC co-pays when using Medicare Part D and EPIC together.  EPIC covers most prescriptions that are not covered under Medicare Part D.

NOTE:  You will have to pay the partial Medicare Part D premium every month as well as your annual EPIC enrollment fee.  But using both Medicare Part D and EPIC may help you save more on prescriptions overall.

Are there quantity limits and, if so, who decides on the limits?
Sometimes, your Part D plan will limit the quantity or number of pills you can receive with each fill of a prescription.  If your doctor writes your prescription for a greater quantity than your plan allows, EPIC will cover the balance not covered by your Part D plan.

Can I use any drug store?
No, in order to use your other coverage and EPIC together for greater savings, you must use pharmacies that participate in your Medicare Part D or other insurance plan as well as EPIC. Although most pharmacies in New York State participate with EPIC, check with the pharmacy to be sure they are participating.

NOTE:  You will not be able to receive coverage from EPIC if you use a mail-order pharmacy that is located outside of New York State.  Always make sure that the pharmacy you use accepts all of your drug coverage.  If your plan does not offer mail-order pharmacies that EPIC accepts, then it would be best to purchase your prescription monthly through a participating retail pharmacy.

What do I do if prior authorization or an exception is required under my other prescription plans?
Sometimes your Medicare or other drug plan will require prior approval before it will cover a drug.  In that case EPIC will cover the prescription to ensure you receive the medication right away.  In the meantime, however, your pharmacist or you should contact your doctor to request the appropriate prior authorization form from Medicare Part D or your other plan.  In some cases EPIC may file an appeal for you if the Part D plan denies coverage.

Are there things to consider if I receive Medicaid?
If you receive full Medicaid benefits, you are not eligible for EPIC.  You will have full prescription coverage through Medicare Part D.

If you are eligible for Medicaid spend-down, you are eligible for EPIC.  Any amounts paid by you and by EPIC will be applied towards your monthly Medicaid spend-down amount.  Once you enroll into Medicare Part D, you may only use EPIC to pay for prescriptions or quantities that are not covered by Medicare Part D. If you meet your spend-down during the month, you can use EPIC or Medicaid, but not both, to pay for prescriptions that are not covered by Medicare Part D.

What is covered by EPIC?

  • New prescriptions and refills
  • Insulin, insulin syringes and needles
  • Brand name and generic prescriptions
  • Up to 100 tablets or capsules, or 30-day supply, whichever is greater
  • Up to a 30-day supply for any product other than tablet or a capsule (such as liquids, patches, inhalers, creams, and prescriptions that must be injected).

What is not covered by EPIC?

  • Non-prescription medicines (such as aspirin or vitamins)
  • A small number of prescriptions know as DESI drugs – ask your pharmacist for more information on these specific drugs
  • Medical devices (such as diabetes supplies, test strips, glucometers, walkers, wheelchairs)
  • Medical supplies (such as cotton balls, band aids, eyeglasses and oxygen)
  • Drugs manufactured by a small number of companies that do not participate in the Manufacturers’ Rebate Program
  • Any purchase made before or after the coverage dates listed on your EPIC card
  • Prescriptions purchased at a pharmacy not participating in EPIC or located outside New York State.

How long does EPIC last?
You are covered for one year from the effective date of your enrollment.

Can my EPIC coverage be cancelled?
If you are in a fee payment program and do not pay your quarterly bill on time, your EPIC coverage will be cancelled. Remember that if you are enrolled in Medicare Part D and receive Extra Help through Medicare with a full premium subsidy your EPIC fee is waived.

How often do I have to renew my EPIC coverage?
You have to renew your coverage every two years.  EPIC will request updated enrollment information to renew your coverage.  EPIC will send the renewal form three months before your coverage is ending.  It is important to return the renewal form as soon as possible, or your EPIC coverage may end before your renewal is approved.  If you report income that shows you may be eligible for Extra Help, you will be sent a Request for Additional Information form so EPIC can apply for the Extra Help benefit from Medicare on your behalf.  You must complete EPIC’s requests for information in order to keep your EPIC coverage.

NOTE:  It is important to notify EPIC whenever you have a change of address.

Do I have to be a resident of New York State?
Yes, you must have a permanent home (not just for the summer or winter) in New York State.  Permanent home means you live in New York State on a regular, ongoing basis, and your New York State address is listed as your home address on official and legal documents.

What is “Reconsideration”?
You can ask for a reconsideration if you disagree with any decision made by EPIC. 
For example:

  • Disapproval of your application or renewal form
  • The amount of your premium or deductible
  • The amount of your income that was recorded that determined your deductible or fee
  • Cancellation of your EPIC coverage because you have not completed, signed and returned the Request for Additional Information form to EPIC.

How do I request Reconsideration?
You can write to:
P.O. Box 15018
Albany, NY  12212-5018

Getting Help
You can call EPIC’s toll free hotline 1-800-332-3742. Or you can call CIDNY at 646-442-4186 and ask to speak to a benefits counselor.