Navigating Medicare can feel overwhelming, especially when it comes to prescription drug coverage. If you’re a New York resident aged 65 or older, there’s a valuable program that can help reduce your out-of-pocket medication costs that many seniors don’t know about. The Elderly Pharmaceutical Insurance Coverage (EPIC) program is New York State’s answer to making prescription drugs more affordable for income-eligible seniors.

What Is the EPIC Program?

The New York State Department of Health administers the Elderly Pharmaceutical Insurance Coverage (EPIC) program for seniors. This program helps more than 325,000 income-eligible seniors aged 65 and older supplement their out-of-pocket Medicare Part D drug plan costs.

Think of EPIC as a wraparound program that works alongside your Medicare Part D prescription drug plan. When making a prescription purchase, Medicare Part D is the first payer, then this program contributes toward the costs that the Part D plan does not cover. This secondary coverage can significantly reduce what you pay at the pharmacy counter.

How EPIC Works With Medicare Part D

To participate in EPIC, you must have Medicare Part D coverage. All members must enroll in a Medicare Part D drug plan to receive EPIC benefits. EPIC requires members to enroll in a Medicare Part D drug plan or a Medicare Advantage (HMO) health plan with Part D coverage.

Here’s how the payment process works:

• Your Medicare Part D plan pays first for covered medications
• After your Part D deductible, EPIC provides secondary coverage
• EPIC maintains co-payments of $3, $7, $15 or $20 based on the cost of the drug
• EPIC covers many Part D excluded drugs that Medicare doesn’t cover, such as prescription vitamins and minerals

Two Plan Options: Fee Plan vs. Deductible Plan

EPIC offers two plan structures that correspond to your income level:

Fee Plan

The Fee Plan serves members with incomes up to $20,000 if single or $26,000 if married. Key features include:

• EPIC annual fees range from $8 – $300 based on the previous year’s income
• EPIC pays the Part D monthly drug plan premiums up to the average cost of a basic Medicare drug plan, $72.34 per month in 2025
• Immediate access to EPIC co-payments for covered drugs
• EPIC sends bills quarterly to fee plan members

Deductible Plan

The Deductible Plan serves members with incomes ranging from $20,001 to $75,000 if single or $26,001 to $100,000 if married. Key features include:

• No annual fee to join
• EPIC deductibles range from $530 – $3,215 based on the previous year’s income
• Premium assistance available for those with income up to $23,000 (single) or $29,000 (married)
• You must meet the annual deductible before you receive EPIC co-payments

Income Eligibility Requirements

To qualify for EPIC in 2025:

• Annual income for eligibility is up to $75,000 for singles and $100,000 for married couples
• Must be a New York State resident
• Must be 65 years of age or older
• Cannot be enrolled in full Medicaid benefits
• Must be enrolled in or eligible for Medicare Part D

Additional Benefits and Special Features

Extra Help Integration: Medicare’s full Extra Help program waives EPIC fees for qualifying members. This means if you qualify for Medicare’s Low Income Subsidy (Extra Help), you won’t pay EPIC fees.

Special Enrollment Opportunities: If you have EPIC, you have a once-per-year Special Enrollment Period (SEP) to switch your Part D or Medicare Advantage coverage. This gives you flexibility to change plans if your needs change.

Excluded Drug Coverage: Unlike Medicare Part D, EPIC covers many medications that Medicare excludes, providing broader prescription drug coverage.

How to Apply

Joining the program takes minimal effort. Simply complete the application and mail or fax it to EPIC, or apply online. You need no documentation upfront. EPIC verifies information with the Social Security Administration and the New York State Department of Taxation and Finance.

You can apply for EPIC at any time during the year, and the application process is straightforward with no required documentation upfront.

Why EPIC Matters for Medicare Planning

At Craig’s Smith Insurance Group, we understand that Medicare prescription drug costs can be one of the biggest concerns for seniors. The EPIC program represents significant potential savings for eligible New York residents. For example, if you’re paying $100 out-of-pocket for a prescription after your Medicare Part D coverage, with EPIC, you might only pay $20 instead.

The program’s ability to cover Medicare Part D excluded drugs also provides valuable peace of mind, ensuring you have access to medications your doctor prescribes, even if Medicare doesn’t typically cover them.

Getting Started

If you think you might be eligible for EPIC, don’t wait. With over 325,000 New Yorkers already benefiting from this program, it’s proven to provide real value. Contact the EPIC Helpline at 1-800-332-3742 for more information or to request an application.

Remember, you must have Medicare Part D coverage to participate in EPIC, so if you don’t currently have prescription drug coverage, that should be your first step. Our team at Craig’s Smith Insurance Group can help you understand your Medicare Part D options and how EPIC might fit into your overall Medicare strategy.

The bottom line: EPIC is a valuable state program that can significantly reduce prescription drug costs for eligible New York seniors. When combined with proper Medicare Part D planning, it’s one more tool in your toolkit to make healthcare more affordable in retirement.

For personalized assistance with Medicare planning and understanding how EPIC might benefit your specific situation, contact Craig’s Smith Insurance Group. We specialize in helping seniors navigate the complexities of Medicare to find the coverage that best meets their needs and budget.