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New York State Pharmacy Assistance Programs (SPAP)

New York State Elderly Pharmaceutical Insurance Coverage (EPIC)



:: Eligiblity Requirements
:: Important Note
:: Income (What to Include/Exclude)
:: Contact Information

Eligiblity Requirements

You must meet the following requirements:
  • You must be a New York State resident (permanent home address),
  • at least 65 years of age, and not receiving full Medicaid benefits.
  • You must have an annual income below $75,000 if single, or a combined annual income below $100,000 if married.
  • You must be enrolled or eligible to be enrolled in a Medicare Part D plan (no exceptions). Seniors enrolled in a Medicare Advantage (HMO) plan can only join EPIC if their HMO includes Medicare Part D coverage.

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Important Note

EPIC provides secondary coverage for Medicare Part D and EPIC-covered drugs purchased after any Medicare Part D deductible is met. EPIC also covers approved Part D-excluded drugs once a member is enrolled in Part D.

EPIC helps pay the Medicare Part D drug plan premiums (up to the state LIS benchmark of $36.94 in 2015) for members with income up to $23,000 if single or $29,000 if married. Higher income members are required to pay their own Part D premiums but EPIC provides premium assistance by lowering their EPIC deductible.

EPIC has two plans based on income. The Fee Plan is for members with income up to $20,000 if single or $26,000 if married. The Deductible Plan is for members with incomes ranging from $20,001 to $75,000 if single or $26,001 to $100,000 if married.
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Income (What to Include/Exclude)

For purposes of your EPIC enrollment, household gross income is the previous year's total annual income of the senior or married spouses. It includes, but is not limited to:

  • Federal adjusted gross household income as reported on your income tax return;
  • Social Security payments (less Medicare premiums);
  • Railroad retirement benefits;
  • The taxable amount of IRA distributions and retirement annuities;
  • Support money, including foster care support payments;
  • Supplemental Security income;
  • Tax-exempt interest;
  • Worker's 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.

It does not include:

  • Food stamps;
  • Medicare premiums;
  • Medicaid;
  • Scholarships;
  • Grants;
  • Surplus food;
  • Payments made to veterans under the federal Veterans' Dioxin and Radiation Exposure Compensations Standards Act (Agent Orange);
  • Payments made to individuals because of their status as victims of Nazi persecution.

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Contact Information

Phone: (800) 332-3742
Email: epic@health.state.ny.us

Address
EPIC,
P.O. Box 15018
Albany, NY 12212-5018

:: New York State Elderly Pharmaceutical Insurance Coverage (EPIC)
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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.


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