New York's New EPIC + Program

(8/14/12)- The following is an extract from a Special Message for Senior Citizens sent by New York State Assemblyman Micah Kellner in early August:

"Note: Beginning January 1, 2013, EPIC will have two plans again. The Fee plan will be for members with incomes up to $20,000 single or $26,000 married. The annual fee will be based on income. The Deductible plan will be for members with incomes from $20,001 to $35,000 single or $26,001 to $50,000 married. The annual deductible will be based on income.

As of January 1, 2012, EPIC has no fees or deductibles and pays for Part D premiums for those who meet income standards.

During 2012 EPIC provides secondary coverage for prescription drugs when an enrollee reaches the Medicare Part D coverage gap("donut hole") (Under the above changes for 2013 EPIC will cover all eligible prescriptions.)"

(8/23/10)- The New York State Senate passed legislation (s1839) that would increase income eligibility levels in the EPIC program from $35,000 to $50,000 for unmarried residents, and from $50,000 to $75,000 for married residents. The House has yet to act on the bill.

(10/3/05)- There are now over 350,000 New York State residents who are enrolled in the state's Elderly Pharmaceutical Insurance Coverage Program (EPIC). If you are a New York State resident over the age of 65 with an annual income of less than $35,000 if single and $50,000 for couples, and not receiving full Medicaid benefits, you are eligible for EPIC.

Even though Medicare will be covering prescription drugs beginning January 1, 2006, EPIC can be used to supplement the new Medicare coverage. For more information about EPIC, or how EPIC and Medicare can be used together you can call the EPIC Helpline at 800-332-3742 or by writing to:

P.O.Box 15018
Albany, N.Y. 12212-5018

Applications for Extra Help are available from the Social Security Administration also.

(1/11/05)-EPIC is a New York State sponsored prescription drug plan for senior citizens who need help in paying for their prescriptions. According to data on the site for the plan, "Over 340,000 seniors already belong and are saving on average, over 80% of the costs of their medicines." Seniors who receive full Medicaid benefits or have other prescription plans that are better than EPIC are not eligible for EPIC benefits.

Almost all medications are covered as well as insulin, and insulin syringes and needles. Enrollees can buy up to100 tablets or a 30-day supply at a time. For more information or an application call 800 332 3742.

(1/03)-Even though Governor George Pataki had called for a 10% increase in fees and deductibles in the new EPIC + program in his budget, the state legislature passed and upheld a budget that held the line on the program. That same budget preserved Medicaid funding for nursing homes, hospitals and other health programs even though the governor's budget called for a cut of $2 billion in these programs.

According to Republican Governor George Pataki of New York, a preferred drug formulary program could save the state about $1.2 billion in Medicaid costs, and also could save the state's Elderly Pharmaceutical Insurance Coverage (EPIC) program about $38 million in the coming fiscal year. Because the state is experiencing serious budget shortfalls, this would be the only way to prevent extremely serious cutbacks from occurring.

The programs would cover only medicines that have been deemed clinically effective and less costly by outside medical experts. A physician could still prescribe a drug not on the approved list but the patient would need to get prior approval for the drug to be covered under either of the programs. The state is seeking a pharmacy management contractor to start the program later this year.

Effective January 1, 2001 new income eligibility guidelines were established for the New EPIC program. There are 2 types of plans available under the New Epic. You can join the fee plan if you are single and have an annual income no higher than $20,000, or if you are married with a joint income no higher than $26,000. You can join the deductible plan if you are single with an annual income of $20,000 to $35,000, or if you are married with a joint income from $26,001 to $50,000. You must be 65 years of age or older and you must be a resident of New York State to be eligible to join the plan. There are no fees under the deductible plan, you pay the full price of your prescriptions until you meet your annual deductible. For further information on this topic call the EPIC Hotline at 800-332-3742.

You are not eligible if you receive Medicaid benefits or have other coverage that is better than EPIC. Prescriptions must be filled at EPIC participating pharmacies, and most pharmacies participate in the plan. You can buy up to 100 tablets or capsules or a 30-day supply at a time. Insulin and insulin syringes are included in the plan. Almost all prescription medicines are covered, as well as insulin and insulin syringes. Both brand name and less expensive generic drugs are included.

There are 2 type EPIC plans that are available. The choices are as follows:

The New Fee Plan: Under this plan you pay an annual fee in one payment, or in smaller amounts every 3 months. The fee varies for a single person with income up to $6,000, it is an annual fee of $8; for annual income of $10,001-$11,000 the annual fee is $40; from $17,001-$18,000 of annual income the annual fee is $170. If annual income is from $19,001 to $20,000 the annual fee is $230. For married couples the top income limit to be eligible for the plan is $26,000 for which the annual fee per person is $300. See a copy of the plan to get the detailed breakdown. Under the fee plan you will pay the following for each prescription:

For Each Prescription costing:

You Pay
Up to $15 $3
$15.01 to $35 $7
$35.01 to $55 $15
Over $55 $20


The annual fee schedule is as low as $8 for a single person with income of $6,000 to as high as a fee for a single person of $230 with income up to $20,000. For married couples the fee is as low as $8 for each person with the couples annual income of up to $6,000. The annual fee for a couple with joint annual income of $21,000 is $194.

The Deductible Plan: Under the deductible plan single seniors are eligible as long as income does not exceed $35,000 and for married seniors with joint incomes the limit is $50,000. With this plan, you pay full price for your prescriptions until you spend a deductible that will range from $530 if you are single and have an income of under $20,001 to $1,230 if you have income of $34,001 to $35,000. For married couples with annual joint income of $26,001 to $27,000 the annual deductible is $650 maxing out at $1,715 for those with joint income of $49,001 to $50,000.

For More Information Call the Free EPIC Help Line at -1-800-332-3742, or send inquiries to: EPIC-P.O. Box 15018-Albany, N.Y. 12212-5018



By Allan Rubin
updated August 14, 2012

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