New York Has One of the Best State Pharmaceutical Assistance Plan In The Country
New York State EPIC Program (Elderly Pharmaceutical Insurance Coverage (EPIC) Program)
What is a State pharmaceutical plan
A state pharmaceutical assistance plan (SPAP) is a program designed to provide additional prescription drug coverage to individuals who are eligible for Medicare. This plan helps alleviate the financial burden of purchasing necessary medications for those who may have limited income or resources. SPAPs vary from state to state, offering different levels of coverage and assistance. They often work alongside Medicare Part D, which is the prescription drug coverage part of Medicare, to provide further support. Eligibility requirements and benefits offered by SPAPs can differ, so it is important for individuals on Medicare to research and understand the specific details of their state’s program.
What is Epic
The NYS EPIC program is a government initiative in the state of New York. EPIC, which stands for Elderly Pharmaceutical Insurance Coverage, is a program that helps eligible seniors with their prescription drug costs. It provides financial assistance for Medicare Part D premiums, as well as co-pays and drug costs not covered by Medicare. The program is designed to make medications more affordable for elderly individuals on fixed incomes. Eligibility requirements, including income thresholds and age restrictions, apply to participate in the NYS EPIC program.
Who Qualifies EPIC for
To qualify for the program, individuals must be aged 65 or older, be New York State residents, and have an annual income of $75,000 or less for individuals or $100,000 or less for married couples. Applicants should also be enrolled in a Medicare Part D drug plan or a Medicare Advantage plan with prescription drug coverage. Additionally, applicants cannot be receiving full Medicaid benefits. Overall, the NYS EPIC Program aims to provide affordable access to necessary medications for eligible seniors in New York State. Medicare part D can be tough to navigate at times and the New York State Epic program helps thousands of Medicare recipients in NY every year. The income requirements for Epic are only based on income and not savings or assets like the extra help program through the federal government. As of 2023 the NYS EPIC program was helping 325,000 Medicare recipients across New York State.
What Does Epic Do
The New York State EPIC program, an acronym for Elderly Pharmaceutical Insurance Coverage, provides vital assistance to consumers by offering comprehensive prescription drug coverage. This program is specifically tailored to meet the healthcare needs of elderly individuals and ensures they have access to affordable medications. By helping to lower the cost of prescription drugs, the EPIC program helps consumers manage their healthcare expenses and ensures they can consistently access the medications they require. This initiative is a valuable resource that aims to enhance the overall well-being and quality of life for consumers in New York State. Epic has two ways to receive coverage depending on your income. They have a fee plan,
The EPIC Fee Plan is available for individuals with an income up to $20,000 if single or $26,000 if married. A yearly fee is paid to EPIC, ranging from $8 to $300, based on the previous year’s income. This fee can be paid either quarterly or annually. After meeting any Part D deductible, if applicable, Fee Plan members are only required to pay the EPIC co-payment for their medications. The co-payments range from $3 to $20, depending on the drug cost not covered by Part D. Upon successful enrollment, members receive an EPIC identification card, which should be retained and used for subsequent years. The coverage year goes until December 31st annually. EPIC also pays the Medicare Part D plan premiums, up to $48.72 per month, for members in the Fee plan. When visiting a pharmacy, both the Medicare Part D drug plan and the EPIC ID cards should be shown. The Medicare Part D drug plan serves as the primary drug coverage, and maintaining enrollment in it is necessary to receive EPIC benefits. EPIC provides secondary coverage for Medicare Part D and EPIC-covered drugs after meeting the Medicare Part D deductible, if applicable. Additionally, EPIC covers approved Medicare Part D-excluded drugs, such as prescription vitamins and cough/cold preparations. The member only pays the EPIC co-payments based on the drug cost, ranging from $3 to $20. If the member has the full Extra Help Low-Income Subsidy (LIS) from Medicare, they are exempt from paying EPIC fees and enjoy lower co-payments.
Fee Plan Schedule:
The cost to join the Fee Plan is based on your previous year’s income. You can pay your Annual Fee in total or pay a bill every three months. EPIC fees are waived for those with full Extra Help from Medicare.
| Who Pays Premium | Annual Income | Annual Fee |
|---|---|---|
| EPIC pays Part D Premium | Up to $6,000 | $8 |
| $ 6,001 – $ 7,000 | $16 | |
| $ 7,001 – $ 8,000 | $22 | |
| $ 8,001 – $ 9,000 | $28 | |
| $ 9,001 – $10,000 | $36 | |
| $10,001 – $11,000 | $40 | |
| $11,001 – $12,000 | $46 | |
| $12,001 – $13,000 | $54 | |
| $13,001 – $14,000 | $60 | |
| $14,001 – $15,000 | $80 | |
| $15,001 – $16,000 | $110 | |
| $16,001 – $17,000 | $140 | |
| $17,001 – $18,000 | $170 | |
| $18,001 – $19,000 | $200 | |
| $19,001 – $20,000 | $230 | |
| See Deductible Plan | Over $20,000 | See Deductible Plan |
| Who Pays Premium | Joint Annual Income | Annual Fee (Each Person) |
|---|---|---|
| EPIC pays Part D Premium | Up to $ 6,000 | $ 8 |
| $ 6,001 – $ 7,000 | $12 | |
| $ 7,001 – $ 8,000 | $16 | |
| $ 8,001 – $ 9,000 | $20 | |
| $ 9,001 – $10,000 | $24 | |
| $10,001 – $11,000 | $28 | |
| $11,001 – $12,000 | $32 | |
| $12,001 – $13,000 | $36 | |
| $13,001 – $14,000 | $40 | |
| $14,001 – $15,000 | $40 | |
| $15,001 – $16,000 | $84 | |
| $16,001 – $17,000 | $106 | |
| $17,001 – $18,000 | $126 | |
| $18,001 – $19,000 | $150 | |
| $19,001 – $20,000 | $172 | |
| $20,001 – $21,000 | $194 | |
| $21,001 – $22,000 | $216 | |
| $22,001 – $23,000 | $238 | |
| $23,001 – $24,000 | $260 | |
| $24,001 – $25,000 | $275 | |
| $25,001 – $26,000 | $300 | |
| See Deductible Plan | Over $26,000 | See Deductible Plan |
Epic Deductible Plan
| Who Pays Premium | Annual Income | Annual Deductible |
|---|---|---|
| EPIC pays Part D Premium | Under $20,000 | See Fee Plan |
| $20,001 – $21,000 | $530 | |
| $21,001 – $22,000 | $550 | |
| $22,001 – $23,000 | $580 | |
| Member pays their Part D premium (shaded incomes). EPIC Deductible shown is lowered by approximately $585 to help them pay. |
$23,001 – $24,000 | $720 |
| $24,001 – $25,000 | $750 | |
| $25,001 – $26,000 | $780 | |
| $26,001 – $27,000 | $810 | |
| $27,001 – $28,000 | $840 | |
| $28,001 – $29,000 | $870 | |
| $29,001 – $30,000 | $900 | |
| $30,001 – $31,000 | $930 | |
| $31,001 – $32,000 | $960 | |
| $32,001 – $33,000 | $1,160 | |
| $33,001 – $34,000 | $1,190 | |
| $34,001 – $35,000 | $1,230 | |
| $35,001 – $36,000 | $1,260 | |
| $36,001 – $37,000 | $1,290 | |
| $37,001 – $38,000 | $1,320 | |
| $38,001 – $39,000 | $1,350 | |
| $39,001 – $40,000 | $1,380 | |
| $40,001 – $41,000 | $1,410 | |
| $41,001 – $42,000 | $1,440 | |
| $42,001 – $43,000 | $1,470 | |
| $43,001 – $44,000 | $1,500 | |
| $44,001 – $45,000 | $1,530 | |
| $45,001 – $46,000 | $1,560 | |
| $46,001 – $47,000 | $1,590 | |
| $47,001 – $48,000 | $1,620 | |
| $48,001 – $49,000 | $1,650 | |
| $49,001 – $50,000 | $1,680 | |
| $50,001 – $51,000 | $1,710 | |
| $51,001 – $52,000 | $1,740 | |
| $52,001 – $53,000 | $1,770 | |
| $53,001 – $54,000 | $1,800 | |
| $54,001 – $55,000 | $1,830 | |
| $55,001 – $56,000 | $1,860 | |
| $56,001 – $57,000 | $1,890 | |
| $57,001 – $58,000 | $1,920 | |
| $58,001 – $59,000 | $1,950 | |
| $59,001 – $60,000 | $1,980 | |
| $60,001 – $61,000 | $2,010 | |
| $61,001 – $62,000 | $2,040 | |
| $62,001 – $63,000 | $2,070 | |
| $63,001 – $64,000 | $2,100 | |
| $64,001 – $65,000 | $2,130 | |
| $65,001 – $66,000 | $2,160 | |
| $66,001 – $67,000 | $2,190 | |
| $67,001 – $68,000 | $2,220 | |
| $68,001 – $69,000 | $2,250 | |
| $69,001 – $70,000 | $2,280 | |
| $70,001 – $71,000 | $2,310 | |
| $71,001 – $72,000 | $2,340 | |
| $72,001 – $73,000 | $2,370 | |
| $73,001 – $74,000 | $2,400 | |
| $74,001 – $75,000 | $2,430 | |
| Not Eligible | Over $75,000 | Not Eligible |
| Who Pays Premium | Joint Annual Income | Annual Deductible (Each Person) |
|---|---|---|
| EPIC pays Part D Premium | Under $26,000 | See Fee Plan |
| $26,001 – $27,000 | $650 | |
| $27,001 – $28,000 | $675 | |
| $28,001 – $29,000 | $700 | |
| Member pays their Part D premium (shaded incomes). EPIC Deductible shown is lowered by approximately $585 to help them pay. |
$29,001 – $30,000 | $725 |
| $30,001 – $31,000 | $900 | |
| $31,001 – $32,000 | $930 | |
| $32,001 – $33,000 | $960 | |
| $33,001 – $34,000 | $990 | |
| $34,001 – $35,000 | $1,020 | |
| $35,001 – $36,000 | $1,050 | |
| $36,001 – $37,000 | $1,080 | |
| $37,001 – $38,000 | $1,110 | |
| $38,001 – $39,000 | $1,140 | |
| $39,001 – $40,000 | $1,170 | |
| $40,001 – $41,000 | $1,200 | |
| $41,001 – $42,000 | $1,230 | |
| $42,001 – $43,000 | $1,260 | |
| $43,001 – $44,000 | $1,290 | |
| $44,001 – $45,000 | $1,320 | |
| $45,001 – $46,000 | $1,575 | |
| $46,001 – $47,000 | $1,610 | |
| $47,001 – $48,000 | $1,645 | |
| $48,001 – $49,000 | $1,680 | |
| $49,001 – $50,000 | $1,715 | |
| $50,001 – $51,000 | $1,745 | |
| $51,001 – $52,000 | $1,775 | |
| $52,001 – $53,000 | $1,805 | |
| $53,001 – $54,000 | $1,835 | |
| $54,001 – $55,000 | $1,865 | |
| $55,001 – $56,000 | $1,895 | |
| $56,001 – $57,000 | $1,925 | |
| $57,001 – $58,000 | $1,955 | |
| $58,001 – $59,000 | $1,985 | |
| $59,001 – $60,000 | $2,015 | |
| $60,001 – $61,000 | $2,045 | |
| $61,001 – $62,000 | $2,075 | |
| $62,001 – $63,000 | $2,105 | |
| $63,001 – $64,000 | $2,135 | |
| $64,001 – $65,000 | $2,165 | |
| $65,001 – $66,000 | $2,195 | |
| $66,001 – $67,000 | $2,225 | |
| $67,001 – $68,000 | $2,255 | |
| $68,001 – $69,000 | $2,285 | |
| $69,001 – $70,000 | $2,315 | |
| $70,001 – $71,000 | $2,345 | |
| $71,001 – $72,000 | $2,375 | |
| $72,001 – $73,000 | $2,405 | |
| $73,001 – $74,000 | $2,435 | |
| $74,001 – $75,000 | $2,465 | |
| $75,001 – $76,000 | $2,495 | |
| $76,001 – $77,000 | $2,525 | |
| $77,001 – $78,000 | $2,555 | |
| $78,001 – $79,000 | $2,585 | |
| $79,001 – $80,000 | $2,615 | |
| $80,001 – $81,000 | $2,645 | |
| $81,001 – $82,000 | $2,675 | |
| $82,001 – $83,000 | $2,705 | |
| $83,001 – $84,000 | $2,735 | |
| $84,001 – $85,000 | $2,765 | |
| $85,001 – $86,000 | $2,795 | |
| $86,001 – $87,000 | $2,825 | |
| $87,001 – $88,000 | $2,855 | |
| $88,001 – $89,000 | $2,885 | |
| $89,001 – $90,000 | $2,915 | |
| $90,001 – $91,000 | $2,945 | |
| $91,001 – $92,000 | $2,975 | |
| $92,001 – $93,000 | $3,005 | |
| $93,001 – $94,000 | $3,035 | |
| $94,001 – $95,000 | $3,065 | |
| $95,001 – $96,000 | $3,095 | |
| $96,001 – $97,000 | $3,125 | |
| $97,001 – $98,000 | $3,155 | |
| $98,001 – $99,000 | $3,185 | |
| $99,001 – $100,000 | $3,215 | |
| Not Eligible | Over $100,000 | Not Eligible |
The EPIC Deductible Plan is a healthcare option available to individuals and families with certain income levels. This plan requires members to meet an annual deductible based on their prior year’s income before they are eligible for EPIC copayments for prescription drugs. Upon enrollment, members receive an EPIC identification card that can be used for subsequent years. The coverage period for this plan runs through December 31st each year.
One of the benefits of the EPIC Deductible Plan is that it covers the Medicare Part D drug plan premiums. For individuals with incomes between $20,001 to $23,000 if single or $26,001 to $29,000 if married, EPIC pays up to $48.72 in 2024 towards these premiums. However, for members with incomes between $23,001 to $75,000 if single or $29,001 to $100,000 if married, they are required to pay their Medicare Part D plan premium each month.
To assist with the Part D premium, EPIC reduces the deductible shown on the Deductible Plan schedule by approximately $585 per year. This reduction is equivalent to the annual cost of a basic benchmark Part D drug plan. Therefore, Deductible Plan members can benefit from this premium assistance.
When using the EPIC Deductible Plan, it is important to have both the Medicare Part D drug plan and EPIC ID cards on hand when purchasing prescription drugs at the pharmacy. The Part D drug plan serves as the primary drug coverage, and to receive EPIC benefits, enrollment in a Part D drug plan is required. EPIC acts as secondary coverage for drugs covered by both Medicare Part D and EPIC, after the member has met their Part D deductible if applicable.
Additionally, once enrolled in a Part D drug plan, EPIC also covers approved Part D-excluded drugs such as prescription vitamins and cough and cold preparations. After meeting any applicable deductibles, out-of-pocket costs for covered drugs will be applied towards the EPIC deductible. This includes both Part D-covered drugs and EPIC-covered drugs. Once the EPIC deductible has been met, members are only responsible for paying co-payments ranging from $3 to $20, depending on the cost of the drug.
How Does Epic Work With Part D
EPIC, serves as a supplement to Medicare Part D and provides enhanced benefits and cost savings for prescription drugs. When individuals with EPIC coverage purchase prescription medications, they are required to present both their EPIC and Medicare Part D drug plan cards at the pharmacy.
Once the member has met any deductible associated with their Medicare Part D plan, if applicable, they can submit the expenses not covered by Part D, including copayments or coinsurance, to EPIC for payment. It should be noted that EPIC members are responsible for paying a co-payment to EPIC, which ranges from $3 to $20 depending on the cost of the drug.
For instance, if the out-of-pocket drug cost for a member is $100, they would be required to pay $20 as their EPIC co-payment. It is important to highlight that EPIC members with a deductible must fulfill their EPIC deductible prior to paying any EPIC co-payments. Moreover, they must also meet the deductible of their Medicare Part D drug plan, if one is applicable.
In conclusion, EPIC serves to supplement Medicare Part D drug coverage by providing additional benefits and savings to its members. By introducing EPIC as a secondary insurance and incorporating co-payments based on the cost of the drugs, individuals can potentially increase their annual benefits while decreasing out-of-pocket expenses.
In conclusion
The New York State Epic program is truly a great program here in New York that exceeds any other state pharmaceutical coverage across the country. The Key to understanding first qualifying is all income based and absolutely has nothing to do with any savings or assets. You must be 65 before you apply, if you apply before 65th birthday you will be declined. Yes I have had eager clients who have not followed this rule and have been declined, not because of income but because they are not yet 65. Another thing many agents don’t share with their clients is that if you enroll in the New York State Epic program you will qualify for a (SEP) Special election period which gives you the ability to change your part D plan or Medicare Advantage plan one time during the year no matter what month it is. Having that special election in your back pocket is always a good thing. If you have any questions about the NYS EPIC program feel free to comment, or email me medicare@paulbinsurance.com