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What you need to know about EPIC - New York's prescription drug program for seniors - 2014 Changes

Views: 16178
Posted: 03 Jun, 2009
by Cathy Roberts (Empire Justice Center)
Updated: 06 Apr, 2014
by Valerie Bogart (New York Legal Assistance Group)

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.   Effective April 1, 2014, income limits will increase dramatically, as enacted in the State budget April 1, 2014.  These changes are still being studied - see press release of Sen. Valesky, Chair of Senate Aging Committee.  Income limits for singles are increasing from $35,000 to $75,000 a year and for couples from $50,000 to $100,000/year, subject to deductibles.  

Here are more details about EPIC as it currently operates since  2013.  Details on the 2014 changes are not yet known. Check back in this article.

ELIGIBILITY

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

  • Income eligibility limit:   Until April 1, 2014  $35,000/year for singles (increasing to $75,000 after 4/1/14); $50,000/year for married couples. (increasing to $100,000/year)   

  • 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).   Since 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  

If Part D co-pay for a drug without EPIC is...
EPIC member pays this amount
$0-$15
$0-3
$15 – $35
$7
$36 – $55
$15
> $55
$20

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  

    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. 

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, are attached to this article.  

Attached files
file EPIC Renewal Form 2013 FINAL.docx (22 kb)
file General Participant Ltr - G13R With Renewal Form Aug 2012 FINAL.doc (36 kb)
file EPIC Statute and Regulations.pdf (309 kb)

Also read
document Medicare Part D - Overview
document AIDS Drug Assistance Program (ADAP) and other AIDS/HIV Subsidy Programs

External links
http://www.health.state.ny.us/health_care/epic/

Also listed in
folder Medicare Part D -> Overview

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