Question: I have EPIC, but how do I know when EPIC will help pay for my medications?

Answer: First, for those that don’t know what EPIC (Elderly Pharmaceutical Insurance Coverage) is, this benefit is available to residents of New York state, over age 65 and with an income of less than $75,000 for an individual and $100,000 for a married couple. Individuals and couples can apply for EPIC anytime of the year they meet the stated criteria. Once a member, EPIC will automatically recertify your eligibility using your New York State tax returns.

When EPIC is verifying your income and finds significant differences, EPIC will mail you a letter requesting that you complete the enclosed form, listing all sources of income and mail back to EPIC for review.

When EPIC is verifying your income and finds you have had no significant change, they mail you a letter during December, stating the EPIC benefits you will receive in the coming year.

EPIC offers two different types of coverage based on your household income; Fee or Deductible. As we age our income sometimes changes. This may change due to retirement plans beginning to pay benefits, adjustments to Social Security, IRA and 401K Disbursements, etc.

To be in the EPIC Fee Plan, your annual income can be up to $20,000 for an individual or $26,000 for a married couple. The EPIC Fee Plan requires you pay an annual fee. either quarterly or annually. Once your fee is paid, EPIC will immediately reduce the cost of your medications purchased at the pharmacy to $3, $7, $15 or $20 per refill (30, 60 or 90 day refill). Remember this is AFTER you have met your Part D prescription drug coverage deductible.

Individuals with incomes between $20,000 & $75,000 and married couples between $26,000 and $100,000 qualify for the EPIC Deductible Plan. In this case, you don’t pay EPIC anything, instead your medication co-pays at the pharmacy are accumulating as expenses towards your EPIC Deductible. If you meet your EPIC deductible during the year, your medication co-pays will be reduced to $3, $7, $15 or $20 per refill (30, 60 or 90 day refill).

Those individuals who make less than $23,000 or married couples who make less than $29,000, have an additional benefit from EPIC. For these members, EPIC pays up to $58.80 per month towards their prescription drug coverage premium. This extra benefit helps to keep expenses down for many in two different ways, lower Part D premiums & lower co-pays at the pharmacy!

It is also important to remember that EPIC will only help to cover the cost of medications purchased in New York State. If you use mail order, EPIC may not help as much because the medications are coming from outside New York. For those who have EPIC, and buy medications while traveling, please note that EPIC does not count those medication costs towards your deductible, or help pay for medications purchased outside New York State.

EPIC will NOT help reduce the cost of your medications during your Part D deductible, if you have one. During the Part D plan deductible you will pay the full cost of the medication at the pharmacy. Most deductibles this year are $615. There are a few plans that have lower deductibles than that, but never more than $615 in 2026.

If you don’t have EPIC and think you are eligible call 1-800-332-3742 to talk to an EPIC representative and get a copy of the EPIC application. There is also a useful website where learn more about the program, https://www.health.ny.gov/health_care/epic/. The website also now has an online application tool, so you can fill out the application online and get an immediate answer about your eligibility. If you have questions, you can call EPIC for help.

For those of you that are already a member of EPIC, watch for that benefit letter in the coming weeks. You can also call the EPIC helpline anytime you have questions about the program or your benefits. Again that number is 1-800-332-3742.

Janell Sluga is a Geriatric Care Manager helping seniors in our community access services and insurance. To reach her, please email editorial@post-journal.com.