What you need to know about EPIC - New York's prescription drug program for seniors - 2013 Changes

New York has a State Pharmaceutical Assistance Program (SPAP) to help low- to moderate-income older adults age 65+ pay for prescription drugs.   

The Elderly Pharmaceutical Insurance Coverage (EPIC) program is administered by the New York State Department of Health (NYSDOH).  It's easy to apply for EPIC; application forms can be obtained through the EPIC helpline at 1-800-332-3742 (TTY 1-800-290-9138) or via EPIC's website. EPIC has gone through significant changes over the past couple of years.  Benefits were severely reduced in January 2012; but much of the original EPIC benefit is restored in January 2013. 

SEE WARNING BELOW THAT PEOPLE IN EPIC FEE PLAN MUST PAY FEE BILL BY FEB. 11, 2013 TO KEEP EPIC.

Here are more details about EPIC as it currently operates  in 2013.

ELIGIBILITY

• Must be age 65 or older and a NYS resident.

• Income eligibility limit:   $35,000/year for singles; $50,000/year for married couples.     

• No asset test. 

• Must be enrolled in Medicare Part D.

EPIC HELPS IN THREE WAYS:

1)  Part D premium assistance

      Pays cost of monthly Part D premiums (up to benchmark)

     Must have annual income at/below $23,000 year (single)/$29,000 (couple).

2)  Coverage gap ("Doughnut Hole" )assistance

      Helps with cost sharing for Part D.  In 2012, this assistance was limited to the period the senior was in the "coverage gap" (donut hole).   In 2013, EPIC will subsidize the Part D co-insurance year-round, AFTER the member has met the Part D plan's deductible, if any.  With EPIC's help,.the member's Part D co-pay will be no higher than $20 per drug; EPIC will pick up the balance.    

                         EPIC cost sharing  

EPIC will also pay for Part D excluded drugs in the coverage gap.  

Additionally, EPIC will help members enroll into the Part D Low Income Subsidy ("Extra Help") and Medicare Savings Programs.

3)   "Special Enrollment Period" -- EPIC members are allowed to change Part D plans once a year just because they are in EPIC.  Otherwise, most Part D enrollees may only change once a year during the Annual Enrollment Period in the fall.   

EPIC again has two tiers of coverage  (as it used to prior to 2012).    

   1) "Fee" program.

           Income eligibiilty threshold:  $20,000 yearly/singles, $26,000/couples. 

          Members are charged an annual fee on a sliding scale basis.  Fee ranges from $8 to 300 and is waived for full "Extra Help" recipients.

SEE CHART OF Fee Scale  

2013  WARNING - Must pay Fee Bill or EPIC will be discontinued Feb. 11, 2013 -- - Bills for EPIC Fee Plan members were mailed in early December 2012. Second notice bills were mailed at the end of December. To date, approximately ten percent of these members have still not paid their EPIC fee.  A final bill is being mailed the week of January 28, 2013 with a notice explaining that EPIC coverage will end on February 11, 2013 if payment is not received. This means that EPIC will no longer pay the  Medicare Part D drug plan premium or provide secondary coverage of claims after February 11th.

EPIC memners must pay the bill to avoid disruption in their EPIC coverage.  If they don't pay the fee, they will be responsible for paying their Part D plan premium and will no longer receive any drug coverage from EPIC if they do not send in payment.  If a member misses or knows they will miss the February 11th due date for payment, they should call the EPIC Helpline at 1-800-332-3742. Coverage will not be reinstated until payment is received but notification will expedite processing of the payment

    2) "Deductible" program:

           Income eligibility threshold:  $20,001-$35,000 yearly (single); $26,001-$50,000 yearly (couples).

           No fee charged, but EPIC coverage doesn't kick in until/unless member's out of pocket Part D drug costs meet a specified limit  (their  "EPIC deductible amount").   The  amount of the deductible ranges from $530 to $1,715, based on the household income. 

See Chart of Deductibles by Income. 

Some EPIC members have plans which charge an annual Part D deductible.  EPIC cannot cover the cost of the Part D deductible. 

Transition to 2013

In August 2012, EPIC sent a letter to existing members explaining the changes for 2013.  The mailing  included an EPIC renewal form which members must complete and return, so that EPIC can enroll them into the proper category of assistance (fee or deductible) for 2013. 

Members who don't return the renewal form will get a follow-up letter and renewal form. 

Existing members who don't respond to the first or second mailing will not be able to be enrolled in EPIC for 2013 until/unless they complete an EPIC renewal or an EPIC application form.

Where to get more information

Call the EPIC helpline at 1-800-332-3742 (TTY 1-800-290-9138) or visit EPIC's website, with 2013 changes.   Copies of the EPIC statute and regulations, as well as the August 2012 letter and renewal form, are attached to this article.