NY STATE MEDICARE INSURANCE PLANS 
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EPIC PROGRAM

Elderly Pharmaceutical Insurance Coverage (EPIC) Program

EPIC

 

Eligibility Requirements

To join EPIC, a senior must:

  • be a New York State resident age 65 or older
  • have an annual income below $35,000 if single or $50,000 if married
  • be enrolled or eligible to be enolled in a Medicare Part D plan (no exceptions), and
  • not be receiving full Medicaid benefits.

Note:

  1. You can join EPIC at any time during the year. Once enrolled, you will receive a 'Special Enrollment Period' to join a Medicare Part D drug plan. You are not eligible to receive EPIC benefits until you are enrolled in a Part D drug plan.
  2. Seniors who are not eligible to join a Medicare Part D drug plan cannot join EPIC (e.g. seniors with a retiree drug subsidy program, seniors that do not have Medicare Part A, Medicare Part B or Medicare Advantage (HMO) health insurance without drug coverage, etc.).

Residency

To enroll in EPIC, you must be a resident of New York State. This means that your permanent home (not just a summer or winter home) is located in New York State. It also means you live in the State on a regular, on-going basis, and your New York State address is listed as your home address on official and legal documents. You need to notify EPIC whenever you change your address.

Income

For purposes of your EPIC enrollment, household gross income is the 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;
  • 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 Veteran's Dioxin and Radiation Exposure Compensations Standards Act (Agent Orange);
  • Payments made to individuals because of their status as victims of Nazi persecution.

Eligibility for Extra Help:

Individuals with limited income and resources who are receiving Medicare may qualify for Extra Help to lower drug costs if your annual income level is not over $16,335 (in 2011, 2012 dollar limits not yet set) for a single person or $22,065 (in 2011, 2012 dollar limits not yet set) for a married couple. Your resources (such as savings, CDs, IRAs, stocks, bonds – not your home or car) can be no more than $12,640 (in 2011, 2012 dollar limits not yet set) if single and $25,260 (in 2011, 2012 dollar limits not yet set) if married. If your assets are higher, you may qualify for partial Extra Help.

EPIC seniors who are income eligible for Extra Help from Medicare are required to complete a Request for Additional Information (RFAI) form (PDF, 231KB, 4pg.) to enable EPIC to apply for this federal benefit on their behalf. The application for Extra Help will also be submitted to the New York State Medicaid program for eligibility in a Medicare Savings Program that provides additional benefits.

To enroll in EPIC, you must be a resident of New York State. This means that your permanent home (not just a summer or winter home) is located in New York State. It also means you live in the State on a regular, on-going basis, and your New York State address is listed as your home address on official and legal documents. You need to notify EPIC whenever you change your address.

below $35,000 if single or $50,000 if married

  • be enrolled or eligible to be enolled in a Medicare Part D plan (no exceptions), and
  • not be receiving full Medicaid benefits.

Note:

  1. You can join EPIC at any time during the year. Once enrolled, you will receive a 'Special Enrollment Period' to join a Medicare Part D drug plan. You are not eligible to receive EPIC benefits until you are enrolled in a Part D drug plan.
  2. Seniors who are not eligible to join a Medicare Part D drug plan cannot join EPIC (e.g. seniors with a retiree drug subsidy program, seniors that do not have Medicare Part A, Medicare Part B or Medicare Advantage (HMO) health insurance without drug coverage, etc.).

Residency

To enroll in EPIC, you must be a resident of New York State. This means that your permanent home (not just a summer or winter home) is located in New York State. It also means you live in the State on a regular, on-going basis, and your New York State address is listed as your home address on official and legal documents. You need to notify EPIC whenever you change your address.

New York State EPIC Program Application

For more detailed information you can visit our links page and go to the official NY State EPIC website.

EPIC Drug Coverage

Coverage Period

While a member is in the Medicare Part D coverage gap, EPIC provides supplemental coverage for Medicare Part D covered drugs and Part D excluded drugs such as benzodiazepines (anti-anxiety) or barbiturates (anti-seizure) drugs. Your EPIC coverage ordinarily runs from January 1st to December 31st of each year you are enrolled. If you enroll after January 1st, your coverage will still end on December 31st.

You must maintain EPIC coverage and be enrolled in a Medicare Part D drug plan in order to receive benefits. If you disenroll from your Medicare Part D drug plan either by request or due to failure to pay, you must re-enroll in a Medicard Part D plan or you will not receive EPIC benefits for the remainder of the year.

How to use EPIC:

  • Show both your Medicare Part D drug plan and EPIC cards to your pharmacist. Tell your pharmacist that you have prescription coverage through both plans.
  • Tell your pharmacist that your Medicare Part D drug plan is your primary prescription coverage, and all claims for prescription medications must be submitted to Medicare Part D first and then to EPIC.
  • While you are in the Medicare Part D drug coverage gap, EPIC will cover Medicare Part D covered drugs and Medicare Part D excluded drugs.

What Is Covered By EPIC

For Part D covered drugs and Part D excluded drugs purchased in the Medicare Part D coverage gap:

  • New prescriptions and refills;
  • Insulin, insulin syringes and needles;
  • Brand name and generic prescription drugs;
  • Quantities up to your Part D plan's limits.

What Is Not Covered By EPIC

  • Any purchases made outside the Medicare Part D coverage gap or before enrollment in EPIC;
  • Drugs that are neither Part D covered drugs nor Part D excluded drugs;
  • Medicines that do not require a prescription (such as aspirin or vitamins);
  • A small number of drugs, known as DESI drugs (ask your pharmacist for more information on these particular drugs);
  • The purchase of medical devices (for example: diabetes supplies, test strips, glucometers, walkers, wheel chairs), medical supplies (cotton balls, band aids, eyeglasses and oxygen) NOTE: Check with your Medicare carrier to see if any of these items are covered by your Medicare benefits;
  • Prescriptions purchased, while in the coverage gap, at a pharmacy not participating in EPIC or located outside of New York State. (Please refer to Out-of-State Travel below).

Participating Pharmacies

You must use a participating pharmacy in New York State to receive EPIC benefits. You should choose a pharmacy that participates in both EPIC and your Medicare Part D drug plan to maximize benefits. Check with your local pharmacy to be sure they are participating before making your purchase.

Mail-Order Pharmacies

Medications may be purchased from an EPIC participating mail-order pharmacy located in New York State or an approved Medicare Part D drug plan mail order pharmacy. Check with the mail-order pharmacy for any special requirements. The Helpline can answer any questions you have or provide you with a list of EPIC participating mail-order pharmacies.

Out-of-State Travel

When traveling outside of New York State, you should make sure to bring ample supplies of all medications you will need with you. You should contact your Part D drug plan before you leave to find out their policy on refilling prescriptions while you are out of the state. Please note that EPIC only pays for Part D covered drugs and Part D excluded drugs while in the coverage gap from an EPIC participating pharmacy.

Keeping Track of Your Drug Costs

It will be helpful to you to know if you are in or are approaching the Medicare Part D drug coverage gap. You should keep your receipts and a running total of your purchases. You will need to contact your Medicare Part D drug plan to ensure they have knowledge of all your purchases and to tell you where you stand with regards to the coverage gap.

Renewing Your EPIC Coverage

Every two years, we will request that you provide EPIC updated enrollment information to renew your coverage. You may be required to provide updated income documentation to EPIC.

How can I find out more about EPIC?

  • EPIC operates a toll-free Helpline which is available from 8:30AM to 5:00PM, Monday through Friday. Call 1-800-332-3742 (TTY 1-800-290-9138) for more information or to request an application.
  • You can also write to us at:
    EPIC
    P.O. Box 15018
    Albany, NY 12212-5018
  • Or email us at: epic@health.state.ny.us.

Other Issues

Problems

If at any time you disagree with any decision affecting your enrollment in the program, you have the right to request that the issue be reviewed. This process is called a reconsideration. Some examples of decisions that you may question are:
  • The disapproval of your application or renewal form;
  • The amount of your income that we record to determine your eligibility or premium assistance;
  • Cancellation of your EPIC coverage because you have not completed, signed and returned the Request for Additional Information form to EPIC.

You will always receive a written response to your inquiry. If you still disagree with our action, you have the right to a formal administrative hearing conducted by an independent hearing judge. This process is meant to protect your rights. You are encouraged to use it if you do not agree with a decision.

To ask for a reconsideration, you can write to the address above or call our toll-free Helpline at 1-800-332-3742. Please include your name and EPIC identification number on all letters sent to the EPIC program. This will help us respond quickly to your request.

If You Lose Your Card

If you lose your card, just call our toll-free Helpline at 1-800-332-3742 to report the loss, and we will mail you a new card.

Your EPIC Records

All EPIC records are kept strictly confidential and are maintained by EPIC in Albany. You may obtain copies of your records by writing to:

EPIC
Records Access Officer
P.O. Box 15091
Albany, NY 12212-5091

If You Want To Cancel Your EPIC Coverage

To cancel your coverage you can call our toll-free Helpline at 1-800-332-3742.

Fraud And Abuse Hotline

If you think that an EPIC participant or a pharmacy is misusing or abusing the program, you can call the Fraud and Abuse Hotline by dialing toll-free 1-800-542-0424. You will not be asked for your name or any other personal data. All calls are strictly confidential.

This website is a private website and is not, associated, endorsed or authorized by the Social Security Administration, the Department of Health and Human Services or the Center for Medicare and Medicaid Services. This site contains basic information about Medicare, services related to Medicare and services for people with Medicare. If you would like to find more information about the Government Medicare program please visit the Official US Government Site for People with Medicare located at medicare.gov
Copyright 2009  Century Benefits Group Inc. All rights reserved.