EPIC explained: New York's prescription help for people 65 and over
EPIC, the Elderly Pharmaceutical Insurance Coverage program, is a New York State benefit that sits behind your Medicare Part D plan and cuts what you pay at the pharmacy to a flat $3 to $20 per prescription. The income limits are far higher than most people assume, and a large share of eligible New Yorkers have never applied.
What EPIC is
EPIC is a state pharmaceutical assistance program, run by the New York State Department of Health since 1987. It doesn't replace Medicare Part D; it works behind it. Your Part D plan pays first, and EPIC picks up most of what's left, so that what reaches you at the counter is a small fixed copay. It also plugs a few holes Part D leaves open, and for lower-income members it pays the Part D premium itself.
The reason so few people use it is the name. "Elderly Pharmaceutical Insurance Coverage" sounds like a program for the poor. The income limits, $75,000 for a single person and $100,000 for a married couple, take in most retired households in Saratoga, Albany, Schenectady and Rensselaer counties.
Who qualifies
- Age 65 or over.
- A New York State resident.
- Annual household income up to $75,000 if single, $100,000 if married.
- Enrolled in, or eligible for, Medicare Part D.
- Not receiving full Medicaid benefits. (People with the Medicare Savings Program only, or with a Medicaid spend-down, can still have EPIC.)
There is no asset test: savings, home and car don't matter. Income is measured for the household, so a married couple's incomes are combined against the $100,000 limit.
The two plans: Fee and Deductible
Which plan you're in is decided by income and nothing else.
| Fee Plan | Deductible Plan | |
|---|---|---|
| Income (single) | Up to $20,000 | $20,001 to $75,000 |
| Income (married) | Up to $26,000 | $26,001 to $100,000 |
| What you pay to join | Annual fee, $8 to $300 by income, payable quarterly | Nothing |
| Before EPIC copays start | Immediately | After an annual EPIC deductible set by income |
| Part D premium | Paid by EPIC, up to the benchmark | Paid by EPIC up to $23,000 single / $29,000 married; otherwise you pay it and your EPIC deductible is reduced |
The Deductible Plan is the one most Capital Region retirees land in, and it's still worth having. The deductible is only what you'd have spent anyway on drugs and Part D cost-sharing; once you've spent it, everything for the rest of the year drops to EPIC copays. For someone on one or two brand-name drugs, that can be the difference between a $1,000 year and a $2,100 year at the pharmacy.
What you pay at the pharmacy
After your Part D plan has paid and, on the Deductible Plan, once your EPIC deductible is met, each prescription costs:
| Cost of the prescription after Part D | Your EPIC copay |
|---|---|
| Up to $15 | $3 |
| $15.01 to $35 | $7 |
| $35.01 to $55 | $15 |
| Over $55 | $20 |
So a specialty drug with a $300 Part D coinsurance costs an EPIC member $20. Fee Plan members pay these copays from the first fill of the year, including while their Part D plan's deductible would otherwise apply.
What else EPIC does
- Pays the Part D premium for members with income up to $23,000 single or $29,000 married, up to the state's benchmark amount for a basic plan. If you pick a plan that costs more than the benchmark, you pay the difference.
- Covers some drugs Part D won't, such as certain prescription vitamins and cough and cold medicines, at the same copays.
- Gives you a Part D Special Enrollment Period. EPIC members can join or change a Part D plan once a year outside the Annual Enrollment Period, which is useful if a new prescription lands in April.
- Counts as creditable coverage alongside Part D, so it doesn't create any late-enrollment penalty issue.
EPIC, Extra Help and the Medicare Savings Program are different programs
Extra Help is the federal Part D subsidy for lower incomes; the Medicare Savings Program pays the Part B premium. You can have EPIC alongside either. If your income qualifies you for Extra Help, that applies first and EPIC covers what remains. On a Part D review I screen for all three, because the combinations matter.
How to apply
- Get the application from the Department of Health's EPIC page or by calling the EPIC helpline, 1-800-332-3742 (Monday to Friday, 8:30 to 5:00).
- Send proof of age and residence and a copy of your most recent tax return or income statements. If you don't file taxes, Social Security and pension statements are enough.
- Once approved you'll receive an EPIC card. Show it at the pharmacy with your Part D card; the pharmacy bills Part D first and EPIC second, automatically.
Coverage typically starts the first of the month after approval. If you're between Part D plans, EPIC can also help you enrol in one so the two start together.
What I do
Every Part D comparison I run includes an EPIC screening, because the right Part D plan can change once EPIC is in the picture: with EPIC absorbing cost-sharing, a lower-premium plan with a bigger deductible often wins. If you qualify, I'll help you complete the application in the same sitting. No fee for any of it. Request a Part D and EPIC review.
- EPIC program (NY State Department of Health) — eligibility and how it works
- EPIC 2026 program highlights, Fee Plan and Deductible Plan schedules (NY DOH)
- EPIC Medicare Part D premium assistance (NY DOH) — $23,000 / $29,000 thresholds
- EPIC program overview (Medicare Rights Center)
I do not offer every plan available in your area. Any information I provide is limited to the plans I do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your State Health Insurance Assistance Program for information on all of your options. Not connected with or endorsed by the U.S. government, the Social Security Administration or the federal Medicare program.
Common questions
Short answers to what people ask before they call.
Who qualifies for EPIC?
New York residents aged 65 or older with annual income up to $75,000 if single or $100,000 if married, who are enrolled in or eligible for Medicare Part D and who don't receive full Medicaid benefits. There is no asset test. Income is your total household income as reported for tax purposes.
What does EPIC actually pay?
Once your Part D plan has paid its share, EPIC pays the rest except a fixed copay: $3 for a prescription costing up to $15, $7 up to $35, $15 up to $55, and $20 for anything over $55. It also pays the Part D premium for lower-income members and covers some drugs Part D excludes.
What's the difference between the Fee Plan and the Deductible Plan?
It depends only on income. Singles up to $20,000 and couples up to $26,000 are in the Fee Plan: you pay a small annual fee, from $8 to $300 by income, and get EPIC copays from your first prescription. Above that, up to the $75,000 and $100,000 limits, you're in the Deductible Plan: no fee, but you pay your Part D costs in full until you've met an annual EPIC deductible set by income, and then EPIC copays apply for the rest of the year.
Do I have to have a Part D plan to use EPIC?
Yes. EPIC is secondary coverage and requires you to be enrolled in Medicare Part D, either a standalone plan or an Advantage plan with drug coverage. Being an EPIC member also gives you a Special Enrollment Period to join or change a Part D plan once a year outside the usual windows.
Does EPIC help with the Part D premium?
For members with income up to $23,000 single or $29,000 married, EPIC pays the Part D premium up to a benchmark amount for a basic plan. Higher-income members pay their own premium, but EPIC lowers their EPIC deductible to reflect it.
How do I apply?
A short application to the New York State Department of Health, by mail or through the EPIC helpline at 1-800-332-3742. You'll need proof of age, residence and income. I help clients complete it as part of their Part D review; it takes about fifteen minutes.
Let's talk it through
A phone call or a message is all it takes. The first conversation is just a conversation.