Elderly Pharmaceutical Insurance Coverage (EPIC) is a New York State program* for seniors that helps with out-of-pocket Medicare Part D drug plan costs. It works together with Medicare Advantage plans, and over 320,000 New Yorkers have already joined EPIC to save on their prescription drug coverage. EPIC helps pay Medicare Part D drug plan premiums or provides assistance by lowering the EPIC deductible. There are two plans based on income:
- The Fee Plan is for members with incomes up to $20,000 if single or $26,000 if married.
- The Deductible Plan is for members with incomes ranging from $20,001 to $75,000 if single or $26,001 to $100,000 if married.
How to Join the Program
Joining the program is easy and you can apply at any time of the year. Just complete the application and mail or fax it to EPIC. EPIC verifies information with the Social Security Administration and the New York State Department of Taxation and Finance.
* You must be a New York State resident 65 years of age or older and be enrolled or eligible to be enrolled in a Medicare Part D drug plan to receive EPIC benefits and maintain coverage. EPIC provides secondary coverage for Medicare Part D- and EPIC-covered drugs after any Part D deductible is met. EPIC also covers approved Part D-excluded drugs such prescription vitamins as well as prescription cough and cold preparations once a member is enrolled in a Part D drug plan. Learn more at the New York State Department of Health website.
Do you believe you have qualified for extra help and that you are paying an incorrect copayment amount?
If you believe you are paying an incorrect copayment amount when you get your prescription at the pharmacy, we can help you confirm your eligibility. We follow Medicare's Best Available Evidence Policy and if you have the appropriate documentation, we can help you sort out your eligibility issues. Call Customer Care toll-free at 1-877-883-9577 (TTY 711) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Mar. 31, representatives also are available weekends from 8 a.m. to 8 p.m.
What is Best Available Evidence?
Medicare's Best Available Evidence Policy is used to determine eligibility for extra help with prescription drug costs when information is not readily available to us through other standard sources. This policy allows a member, member's pharmacist, advocate, representative, family member or other individual acting on behalf of the member to submit certain documentation that we will use to update a member's eligibility when appropriate
Examples of Acceptable Documentation
Permissible documents are as follows:
- A copy of the beneficiary’s Medicaid card that includes the beneficiary’s name and an eligibility date during a month after June of the previous calendar year;
- A copy of a state document that confirms active Medicaid status during a month after June of the previous calendar year;
- A print out from the State electronic enrollment file showing Medicaid status during a month after June of the previous calendar year;
- A screen print from the State’s Medicaid systems showing Medicaid status during a month after June of the previous calendar year;
- Other documentation provided by the State showing Medicaid status during a month after June of the previous calendar year;
- A letter from SSA showing that the individual receives SSI; or,
- An Application Filed by Deemed Eligible confirming that the beneficiary is “…automatically eligible for extra help…” SSA publication HI 03094.605
If You are Dual Eligible
To establish that you are a full benefit dual eligible individual, institutionalized and qualify for a zero cost-sharing level, we will accept any one of the following forms of proof:
- A remittance from the facility showing Medicaid payment for a full calendar month for that individual during a month after June of the previous calendar year;
- A copy of a state document that confirms Medicaid payment on behalf of the individual to the facility for a full calendar month after June of the previous calendar year;
- A screen print from the State’s Medicaid systems showing that individual’s institutional status based on at least a full calendar month stay for Medicaid payment purposes during a month after June of the previous calendar year.
- Effective as of a date specified by the Secretary, but no earlier than January 1, 2012, a copy of:
- A State-issued Notice of Action, Notice of Determination, or Notice of Enrollment that includes the beneficiary’s name and home and community based services (HCBS) eligibility date during a month after June of the previous calendar year;
- A State-approved HCBS Service Plan that includes the beneficiary’s name and effective date beginning during a month after June of the previous calendar year;
- A State-issued prior authorization approval letter for HCBS that includes the beneficiary’s name and effective date beginning during a month after June of the previous calendar year;
- Other documentation provided by the State showing HCBS eligibility status during a month after June of the previous calendar year; or,
- A state-issued document, such as a remittance advice, confirming payment for HCBS, including the beneficiary’s name and the dates of HCBS.
For additional assistance on where to send your documents, please call Customer Care toll-free at 1-877-883-9577 (TTY 711) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Mar. 31, representatives also are available weekends from 8 a.m. to 8 p.m.
Follow this link to View Medicare's Best Available Evidence Policy. You will be taken to the Centers for Medicare and Medicaid Services (CMS) Website.
When you go to a network pharmacy, we provide a temporary or transition supply of at least a month's supply (unless the enrollee presents with a prescription written for less) of a drug that isn't on our formulary, or that has coverage restrictions or limits (but is otherwise considered a "Part D drug"). We provide this temporary supply in the following situations:
New Member or Current Member - We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you are a new member or during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication.
Current member and a resident of a LTC Facility - For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away, we will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above temporary supply situation.
Current member with a level of care change - For members who are being admitted to or discharged from a LTC facility, the Plan will not utilize early refill edits and this will allow appropriate and necessary access to your Part D benefit. Members will be allowed to access a refill upon admission or discharge.
We will provide you and your provider with a written notice after we cover your temporary supply. This notice will explain the next steps, such as requesting a formulary exception for the drug or talking to your doctor about switching to an appropriate drug we cover. See Chapter 9 of the Evidence of Coverage under "What is an exception?" to learn more about how to request an exception. Please contact our Customer Care for any additional questions about our transition policy.
GDPR Notification Content