EPIC and Medicare Part D

How does the Medicare Part D drug plan requirement work?

EPIC members are required to be enrolled in a Medicare Part D drug plan or a Medicare Advantage (HMO) health plan with Part D (with no exceptions). Enrolling in EPIC will give a member a Special Enrollment Period (SEP) to join a Medicare Part D drug plan. Medicare Part D provides primary drug coverage for EPIC members. After a Part D deductible is met, if a member has one, EPIC provides secondary coverage for approved Part D and EPIC covered drugs. EPIC also covers approved Part D-excluded drugs such as prescription vitamins as well as cough and cold preparations after enrolling in a Part D drug plan.

The New York State EPIC program is not Creditable Coverage (primary coverage) for members. This means that EPIC benefits are not as generous as Medicare Part D. If a member is not enrolled in a Medicare Part D drug plan, the member will not have any prescription coverage from EPIC or receive any EPIC benefits.

Because EPIC is a State Pharmaceutical Assistance Program, EPIC can provide:

  • a Medicare Special Enrollment Period (SEP) so that a new member may enroll in a Part D drug plan at any time during the year;
  • a Medicare one-time plan change per calendar year for existing members;
  • Medicare Part D drug plan premium assistance;
  • co-payment assistance after the Medicare Part D deductible is met, if the member has one. EPIC also covers approved Part D-excluded drugs once a member is enrolled in a Part D drug plan.

How is EPIC used with Medicare Part D?

EPIC supplements Medicare Part D drug coverage for greater annual benefits and savings. When purchasing prescription drugs, the member shows both their EPIC and Medicare Part D drug plan cards at the pharmacy. After any Medicare Part D deductible is met, if the member has one, drug costs not covered by Part D (including co-payments/co-insurance) can be submitted to EPIC for payment. The member will pay an EPIC co-payment ranging from $3 to $20 based on the cost of the drug. For example, if the EPIC member's out-of-pocket drug cost is $100, the member will pay $20.

Please note that EPIC deductible members must first meet their EPIC deductible before they pay EPIC co-payments. This is in addition to meeting their Medicare Part D drug plan deductible should their Part D plan have one.

How does Extra Help work?

Extra Help from Medicare comes in two levels – full and partial. All levels of Extra Help provide a Low Income Subsidy (LIS) with reduced co-payments for approved drugs. Drug co-payments are as low as $11.20 for brand or $4.50 for generic drugs in 2024 when enrolled in a Part D drug plan.

How does EPIC help members apply for Extra Help ?

Income-eligible EPIC seniors are required to apply for Extra Help. This may be done at the time of completing the EPIC application to enable EPIC to apply for this federal benefit on their behalf. This can also be done after becoming an EPIC member by using the application but checking off the box "Extra Help only". The application for Extra Help will also be submitted to the New York State Medicaid program for eligibility in a Medicare Savings Program that provides additional benefits as well as LIS for approved members.

Eligibility for Extra Help :

Individuals with limited income and resources who are receiving Medicare may qualify for Extra Help to lower drug costs. In 2024, those with an annual income level of up to $22,836 (single) or $30,900 (married) may qualify for Extra Help. Resources (such as savings, CDs, IRAs, stocks, bonds – not ones's home or car) can be no more than $17,220 (single) and $34,360 (married). If assets are higher, those individuals may qualify for a Medicare Savings Program.

What are the benefits of Extra Help and EPIC?

Those approved for Extra Help, a Medicare Savings Program or a Medicaid Spenddown do not have to pay any EPIC fees. EPIC will continue to pay Medicare Part D plan premiums for LIS members, and those with LIS in enhanced plans or Medicare Advantage plans up to the basic amount ($48.72 per month in 2024) after Medicare premium subsidization.