What's New?

Medicare Enrollment Required

Extra Help with Medicare Prescription Drug Costs

EPIC enrollees with limited income and resources should visit the Social Security Administration's Web site for Extra Help with Medicare Prescription Drug Plan Costs.

Your Guide to New York State EPIC

Welcome to the Elderly Pharmaceutical Insurance Coverage (EPIC) Program, New York State's Senior Prescription Plan. We are happy to have you as a member, and we look forward to helping you save money on your prescription drugs. This booklet explains how to use your EPIC card and answers some of the most frequently asked questions about EPIC.

Medicare now offers prescription drug coverage through Medicare Part D and private drug plans. You are encouraged to consider joining a Medicare drug plan, and using it together with EPIC for greater coverage and savings. If you have lower income and assets, you may be eligible for extra savings from Medicare and EPIC. This booklet explains how Medicare Part D and EPIC can be used together.

Please let us know if you have any questions or if you would like an EPIC enrollment application for a friend or relative. You can call our toll-free Helpline at 1-800-332-3742 from 8:30 a.m. until 5:00 p.m., Monday through Friday. The TTY number for the hearing impaired is 1-800-290-9138. Language service lines are also available.

You can also write to us at:

Please have your EPIC ID number available when calling the Helpline. This number should also be included on any letters or written material submitted to the program.

EPIC information is also available at your city or county Office for the Aging and at most pharmacies.

¿ Necesita Ayuda? Llame al 1-800-332-3742

Contents

EPIC Enrollment Plans
Medicare Part D Drug Coverage and EPIC
If You Have Medicare Part D or Other Drug Coverage
Your EPIC Card
Participating Pharmacies
Out-of-State Travel
Co-payments
More Savings For You
Your Purchases Are Quickly Processed
Keeping Track Of Your Drug Costs
Verification Of Benefits
Using Your Medicines Safely
What Is Covered By EPIC
What Is Not Covered By EPIC
Mail-Order Pharmacies
Coverage Period
Renewing Your EPIC Coverage
Residency
Income
Problems
If You Lose Your Card
Your EPIC Records
If You Want To Cancel Your EPIC Coverage
Fraud And Abuse Hotline
Notice of EPIC Program Privacy Practices
Fee Schedule
Deductible Schedule

EPIC Enrollment Plans

Based on your income and marital status, you were eligible for enrollment as a "FEE " Plan participant or a "DEDUCTIBLE " Plan participant.

FEE Plan participants are either single seniors with an annual income of $20,000 or less, or married with a joint income of $26,000 or less.

DEDUCTIBLE Plan participants are either single seniors with an annual income between $20,001 and $35,000, or married with a joint income between $26,001 and $50,000.

Fee Plan

If you are enrolled in the FEE Plan, you must pay an annual fee to EPIC for your coverage. Your fee amount is based on your income and marital status. To find your fee amount, please check the FEE Plan table at the end of this booklet.

When you are enrolled in the FEE Plan, you will receive your first bill along with your EPIC identification card. You will receive four bills a year, one for each quarter. You may pay the quarterly amount or pay for the full year of coverage if you so choose.

However, if you are approved for Extra Help from Medicare with the full premium subsidy and join a Medicare Part D drug plan, your EPIC fee will be waived.

Your EPIC card can be used at any New York State participating pharmacy, saving you about 80 percent or more on your prescriptions.

Deductible Plan

If you are enrolled in the DEDUCTIBLE Plan, you must meet an annual deductible instead of paying a fee to EPIC. This means you pay the full cost of your prescriptions, at EPIC discount pharmacy prices, until you reach your EPIC deductible. If you have other prescription coverage, such as Medicare Part D, the amount you pay "out-of-pocket" will count toward your EPIC deductible. This means that any co-payments or deductibles required by your other drug plan, as well as the cost of drugs not covered by that plan, will count toward your EPIC deductible – as long as the drug is an EPIC covered drug.

Your deductible amount is based on your income and marital status. To find your deductible amount, please check the DEDUCTIBLE Plan table at the end of this booklet.

Your EPIC identification card was mailed to you when your application was approved. It is important to show this card at the pharmacy whenever you buy prescriptions, even when the prescription is being covered by another drug plan, so that your purchases can be automatically tracked by the EPIC system. That way, you will immediately receive credit for your deductible purchase without having to mail your prescription receipts to EPIC. Once the deductible is reached, your pharmacist will be notified to only collect a co-payment, and you will save about 80 percent of the cost of your prescriptions for the rest of your coverage year.

Medicare Part D Drug Coverage and EPIC

Medicare now offers prescription drug coverage for Medicare beneficiaries through Medicare Part D drug plans. You can join a Medicare Part D drug plan and use it together with EPIC for greater coverage and savings. If you have Medicare Part D coverage, it is primary coverage and should be used first at the pharmacy. Any prescription drug costs that are not covered by your Medicare drug plan including deductibles, co-payments, coinsurance, non-covered drugs, or any gap in coverage can be submitted to EPIC for payment. In many instances you will pay lower EPIC co-payments using Medicare Part D and EPIC together.

EPIC is encouraging all enrollees to consider joining a Medicare drug plan. If you have lower income, you may be eligible for Extra Help from Medicare and save even more, as explained below. If you are in the EPIC DEDUCTIBLE Plan, you will start saving sooner with Medicare Part D because Medicare has much lower deductibles than EPIC; some Part D plans have no deductibles. Any out-of-pocket drug costs that are not covered by your Medicare Part D drug plan will count towards your EPIC deductible if EPIC covers the drug.

Extra Help For Lower Income Enrollees

If you are eligible for Extra Help from Medicare with the full premium subsidy and you join a basic Medicare Part D drug plan, you do not have to pay any Medicare drug premium and your EPIC enrollment fee will be waived. You will pay low co-payments ($2 for generics and $5 for brands) for drugs covered by your Part D plan. If a drug is not covered by your Medicare drug plan, you will pay the EPIC co-payment of $3 - $20 if it is an EPIC covered drug.

EPIC Request For Additional Information Form

If your income indicates you may be eligible for Extra Help from Medicare, you will be required to provide EPIC with additional information to determine if you qualify for this federal benefit. We will send you a Request for Additional Information form, which you will need to complete and return to EPIC in order to keep your EPIC coverage. The information on the form will be used to apply for Extra Help on your behalf. The toll-free Helpline at 1-800-332-3742 can provide assistance in completing the form, or can make arrangements with your County Office for the Aging for any special assistance needed.

Enrollment In A Medicare Drug Plan

If you are approved for Extra Help with the full premium subsidy, EPIC will select and enroll you in a basic Medicare Part D drug plan that covers all or most of your prescriptions at a pharmacy you use. You will have an opportunity to decline or "opt-out" of Medicare Part D drug coverage by contacting the EPIC Helpline, or you can select a different Part D plan. If you decide not to join Part D, you can continue to use your EPIC coverage, but we will not be able to waive your EPIC enrollment fee.

If you are approved for Extra Help with the full premium subsidy and a Medicare Advantage plan (HMO or PPO) member, you can only enroll in Medicare Part D drug coverage offered by your Medicare Advantage plan. If you have union or retiree coverage, you should not enroll in a Medicare drug plan because it may affect your health care coverage.

EPIC AND EXTRA HELP "PARTIAL " PREMIUM SUBSIDY

If you are approved for Extra Help from Medicare with a partial (25%, 50%, or 75%) premium subsidy you may want to consider joining a Medicare drug plan. If you do join a plan, you will usually pay lower EPIC co-payments when using Medicare Part D and EPIC together. EPIC will cover most prescription drugs that are not covered by Medicare. You will have to pay a partial Medicare Part D premium (which varies by plan) every month and also pay your quarterly EPIC enrollment fee. Using both a Medicare Part D drug plan and EPIC together may help you save more on your prescription drugs.

If You Have Medicare Part D or Other Drug Coverage

You can join EPIC even if you have Medicare Part D or other prescription coverage. However, State law requires that you use your other coverage before you use EPIC. This means that EPIC may be used to cover prescription costs not covered by your other insurance. We understand that it may be confusing coordinating your other prescription coverage and your EPIC coverage, so we recommend that you follow the steps shown below:

  • Show both your Medicare Part D drug plan (or other insurance plan) and EPIC cards to your pharmacist. Tell your pharmacist that you have prescription coverage through both plans.
  • Tell your pharmacist that your Medicare Part D drug plan (or other insurance plan) is your primary prescription coverage, and all claims for prescription medications must be submitted to that plan first.
  • Any prescription medication costs not covered by your other coverage may be submitted by your pharmacy to EPIC for coverage.

For Example:

If a drug costs $100, and the Medicare Part D drug plan pays $75, the remaining $25 can be submitted to EPIC. You will only have to pay the EPIC co-payment of $7 and EPIC will pay $18. Without the Medicare Part D drug coverage, your EPIC co-payment would have been $20.

By following these steps, you will be using your other insurance and your EPIC coverage correctly, and getting the maximum benefits from both prescription plans. You will often save money by paying a lower EPIC co-payment, as shown in the above example. You need to notify EPIC if you have a change in your other prescription coverage, so we can help you coordinate your drug benefits for maximum savings. Some other things to keep in mind when coordinating your drug benefits to maximize your savings:

Quantity Limits: The quantities you may purchase at one time are determined by your Medicare Part D or other drug plan, not by EPIC.

  • In some cases, the quantity allowed by the other plan is less than what EPIC would usually cover, for example, a 30-day supply rather than 100 tablets taken once daily (100-day supply). Many Part D plans will offer a three-month supply through special arrangements with the pharmacy, or at certain pharmacies. You should check with your pharmacy and/or your other plan to see how you can obtain the larger quantity to avoid higher co-payments.
  • In other cases, the quantity allowed by the other plan will be greater than what EPIC usually covers, for example, a 90-day supply rather than a 30-day supply for non-tablets. You will save more by paying one co-payment for a larger supply.

Pharmacy: In order to use your other coverage and EPIC together for greater savings, please make sure the pharmacy you use participates in your Medicare Part D plan (or other insurance plan) as well as EPIC. Nearly all pharmacies in New York State participate in EPIC. Also, you will not be able to coordinate your other drug benefits with EPIC if you use a mail-order pharmacy that is located outside of New York State, which is often offered by other drug plans.

Prior Authorization: If your Medicare Part D or other drug plan requires an exception or prior authorization before covering a specific drug, EPIC will cover that prescription to ensure you receive the medication you need right away. However, in the meantime, your pharmacist or you should contact your physician to ask that they request an exception from your other drug plan. If approved by your plan, when you refill your prescription your other plan will automatically cover the drug and EPIC will cover any out-of-pocket cost, which will usually lower your co-payments.

Medicaid: If you receive full Medicaid (not Medicare) benefits, you are not eligible for EPIC. You will have full drug coverage through a Medicare Part D drug plan.

If you have a Medicaid spend-down or buy-in plan you are eligible to join EPIC. EPIC benefits will be applied towards your spend-down amount. Once you are enrolled in a Medicare Part D drug plan, you may only use EPIC to pay for prescription drugs that are not covered by your Medicare Part D drug plan. If you meet your spend-down during the month, you can use EPIC or Medicaid (not both) to pay for non-covered drugs. You need to notify EPIC if you become eligible for full Medicaid benefits.

For more information on how to use EPIC with other prescription coverage, call the EPIC toll-free Helpline at 1-800-332-3742.

Your EPIC Card

Each enrollee will receive their own identification card. If you are married, and both you and your spouse join, you will each receive your own card. If you are also enrolled in a Medicare Part D drug plan, you will receive an EPIC identification card that shows you are enrolled in Medicare drug coverage and EPIC. e card is effective for one year and shows the beginning and end dates of your coverage year. You will receive a new EPIC card about one week before the old card expires.

Each time you purchase prescriptions, you should present your EPIC card to the pharmacist to receive EPIC benefits. If you are enrolled in a Medicare Part D or other drug plan, you must also show that card to the pharmacist so they know to bill your other prescription plan first. Any drug cost not covered by your other prescription plan will then be submitted by your pharmacy to EPIC for payment.

Participating Pharmacies

You must use a participating pharmacy in New York State to receive EPIC benefits. EPIC cannot be used at pharmacies located outside New York. To maximize the coordination of benefits with your Medicare Part D drug plan (or other prescription insurance plan), you should choose a pharmacy that participates in both EPIC and the Medicare Part D drug plan or other insurance plan. You will not be able to coordinate benefits with EPIC if you use your Medicare Part D drug coverage or other prescription insurance to purchase drugs at an out-of-state mail-order pharmacy.

For those enrolled in Medicare Part D drug plans or other insurance plans, the quantity allowed for the drug purchased is determined by the Medicare Part D drug plan or other prescription insurance plan. Some plans will cover larger quantities (e.g. 90-day supply rather than 30-day supply) at certain retail pharmacies. Check with your plan to see if you can purchase larger quantities at your pharmacy.

Almost all pharmacies in New York State participate in EPIC; check with your local pharmacy to be sure they are participating before making your purchase. If you want to know which pharmacies in your area have joined EPIC, please call our toll-free Helpline at 1-800-332-3742. If you purchase your prescriptions from a mail-order pharmacy, make sure that the pharmacy is located in New York State and is participating in EPIC. The EPIC Helpline can also provide you with a list of mail-order pharmacies enrolled in EPIC.

Remember, prescriptions purchased at a pharmacy that does not participate in the program, or is located outside of New York State, are not covered by the EPIC program. EPIC cannot reimburse you for the cost of any prescriptions purchased at these pharmacies.

Out-of-State Travel

When traveling outside of New York State, you should make sure to bring ample supplies of all medications you will need with you, because out-of-state prescription drug purchases are not covered by EPIC. If you think that you will need a refill before returning to the state, you should make arrangements with family, friends or your pharmacist in New York State to have your prescription mailed to you. If you have an emergency while out-of-state, you will be responsible for the cost of any prescriptions purchased out-of-state. There are no exceptions. In that situation, you may want to limit your prescription purchase to a small supply of medication until you return to New York State or receive a supply by mail from a New York State EPIC participating pharmacy. Most pharmacies will mail prescriptions under these circumstances.

Co-payments

Participants who pay a fee and participants who have reached their annual deductible amount will pay one of four co-payments listed below. EPIC saves you the difference between the full cost of your medications and the amount you pay at the pharmacy.

Talk to your doctor about prescribing generic drugs whenever available. Their lower cost may mean a lower co-payment and more savings for you.

If your prescription costs: You pay only:

  • Up to $15.00 $3.00
  • $15.01-$35.00 $7.00
  • $35.01-$55.00 $15.00
  • $55.01 and over $20.00

You may also pay lower co-payments when you coordinate your Medicare Part D or other prescription drug coverage with your EPIC benefits.

For Example:

If a drug costs $100, and the Medicare Part D drug plan pays $75. The remaining balance of $25 can be submitted to EPIC. You only have to pay the EPIC co-payment of $7 and EPIC will pay $18. Without Medicare Part D drug coverage, your EPIC co-payment would have been $20.

More Savings For You

If you have very high drug costs, EPIC can save you even more money. If the total amount that you pay for your co-payments during your coverage year is over a specific amount, EPIC will pay all of your prescription costs for the remainder of your coverage year. When your expenses reach this amount, we will send you a letter and you will get your prescriptions free for the rest of your coverage year. This is an important benefit if you have high prescription bills. If you want to know what your maximum co-payment expense will be, check the tables at the end of this booklet.

Your Purchases Are Quickly Processed

When you get a prescription filled, your pharmacist immediately sends an electronic record of your purchase to EPIC through the computer system. Using the system, we then send a message right back to tell your pharmacist that you are eligible for EPIC, and how much you should pay for each prescription you purchase. If you are in the DEDUCTIBLE Plan, the system tracks your purchases and lets your pharmacist know when you have reached the deductible. Then you begin saving right away on your prescriptions, without having to mail receipts to EPIC for processing. If you want to know how much you have spent towards your deductible, you can call the toll-free Helpline at 1-800-332-3742.

If you are in a Medicare drug plan or have other prescription insurance, the pharmacist will bill your other insurance first electronically and then immediately bill any remaining balance to the EPIC system. You will only pay the EPIC co-payment on the amount not covered by your Medicare drug plan or other insurance. Coordinating benefits at the pharmacy may save you even more on most purchases.

Keeping Track Of Your Drug Costs

If you are in the FEE Plan, you may request a statement showing your total drug costs and how much you saved with EPIC during your coverage year.

If you are in the DEDUCTIBLE Plan, you may also request a statement of your total purchases. This will allow you to see if you received credit for all of your prescription purchases. If you bought prescriptions that are not listed, you should ask your pharmacist to send a record of your purchases to EPIC.

But remember, it is always a good idea to keep receipts and records of your purchases.

Verification Of Benefits

During your coverage year, you may receive a letter from EPIC asking you to verify that you received certain prescriptions. On the back of the letter will be a list of prescription drugs billed to EPIC on your behalf. The letter requests that you confirm that you have received or did not receive each prescription listed. Please sign and return the letter to us. This is one way EPIC confirms that you received the prescriptions paid for by EPIC. It is very important that you take the time to review the list very carefully and quickly return it to EPIC. If you have any questions, please call the toll-free Helpline at 1-800-332-3742.

Using Your Medicines Safely

Sometimes health problems result from taking certain medicines at the same time, or by using too much of one medicine. If it appears that you could have a serious health problem with your medicines, we may send your pharmacist a message while you are still at the store. Your pharmacist may then talk with you about the problem, or may talk with your doctor before the prescription is filled. If necessary, we may also send information to your physician. These services are provided by EPIC to help you use your medicines safely and stay healthy.

What Is Covered By EPIC

  • New prescriptions and refills;
  • Insulin, insulin syringes and needles;
  • Brand name and generic prescription drugs;

    (Remember, you can save even more on your prescriptions by asking your doctor to prescribe generic drugs.)

  • Up to 100 tablets or capsules, or a 30-day supply, whichever is greater;
  • Up to a 30-day supply for any product other than a tablet or a capsule (such as liquids, patches, inhalers, creams, injectables).

What Is Not Covered By EPIC

  • Medicines that do not require a prescription (such as aspirin or vitamins);
  • A small number of drugs, known as DESI drugs (ask your pharmacist for more information on these particular drugs);
  • The purchase of medical devices (for example: diabetes supplies, test strips, glucometers, walkers, wheel chairs), medical supplies (cotton balls, band aids, eyeglasses and oxygen) NOTE: Check with your Medicare carrier to see if any of these items are covered by your Medicare benefits;
  • Drugs manufactured by a small number of companies that do not participate in the Manufacturers' Rebate Program;
  • Any purchases made before or after the coverage dates listed on your EPIC card;
  • Prescriptions purchased at a pharmacy not participating in EPIC or located outside of New York State. (Please refer to Out-of-State Travel on page 11).

Mail-Order Pharmacies

Medications may be purchased from an EPIC participating mail-order pharmacy located in New York State. Check with the mail-order pharmacy for any special requirements. e Helpline can answer any questions you have or provide you with a list of EPIC participating mail-order pharmacies. If you are enrolled in a Medicare Part D drug plan or have other prescription insurance, you cannot coordinate benefits with EPIC if you purchase your medication at an out-of-state mail-order pharmacy.

Coverage Period

You are approved for one year of coverage from the effective date of your enrollment. Remember, if you are in the FEE Plan and you do not pay your quarterly bill on time, your EPIC coverage will be cancelled. However, if you are approved for the Extra Help full premium subsidy and join a Medicare drug plan, your EPIC fee will be waived.

Renewing Your EPIC Coverage

Every two years, we will request that you provide EPIC updated enrollment information to renew your coverage. However, some enrollees may be required to update their enrollment information on a yearly basis.

About three months before your coverage ends, EPIC will send you a renewal form to provide the program with updated enrollment information. Just enter your income for the previous calendar year, note any other information changes, sign the form and return it to EPIC as soon as possible. It is important that you quickly return your renewal form, or your EPIC coverage will end on the last day of your coverage year. If the income reported on your renewal form indicates that you may be eligible for Extra Help from Medicare, you will be required to complete, sign and return a Request for Additional Information form to EPIC that will be used to apply for the Extra Help benefit from Medicare on your behalf. Enrollees must complete this form in order to keep their EPIC coverage.

If you do not receive a renewal form, your coverage will automatically be renewed for another year. During the coverage year, if there is a change in your marital status or other enrollment information that may affect your EPIC coverage, please call the toll-free Helpline at 1-800-332-3742 to inquire how this information should be reported to EPIC.

Residency

To enroll in EPIC, you must be a resident of New York State. This means that your permanent home (not just a summer or winter home) is located in New York State. It also means you live in the State on a regular, on-going basis, and your New York State address is listed as your home address on official and legal documents. You need to notify EPIC whenever you change your address.

Income

For purposes of your EPIC enrollment, household gross income is the total annual income of the senior or married spouses. It includes, but is not limited to:

  • Federal adjusted gross household income as reported on your income tax return;
  • Social Security payments;
  • Railroad retirement benefits;
  • The taxable amount of IRA distributions and retirement annuities;
  • Support money, including foster care support payments;
  • Supplemental Security income;
  • Tax exempt interest;
  • Worker's compensation;
  • Gross amount of loss-of-time insurance;
  • Cash public assistance and relief, other than medical assistance for the needy;
  • Non-taxable strike benefits;
  • Veterans' disability pensions;
  • Lottery winnings.
It does not include:
  • Food stamps;
  • Medicare premiums;
  • Medicaid;
  • Scholarships;
  • Grants;
  • Surplus Food;
  • Payments made to veterans under the Federal Veteran's Dioxin and Radiation Exposure Compensations Standards Act (Agent Orange);
  • Payments made to individuals because of their status as victims of Nazi persecution.

Problems

If at any time you disagree with any decision affecting your enrollment in the program, you have the right to request that the issue be reviewed. This process is called a reconsideration. Some examples of decisions that you may question are:
  • The disapproval of your application or renewal form;
  • The amount of your premium or your deductible;
  • The amount of your income that we record to determine your fee or deductible;
  • Cancellation of your EPIC coverage because you have not completed, signed and returned the Request for Additional Information form to EPIC.

You will always receive a written response to your inquiry. If you still disagree with our action, you have the right to a formal administrative hearing conducted by an independent hearing judge. This process is meant to protect your rights. You are encouraged to use it if you do not agree with a decision.

To ask for a reconsideration, you can write to:

EPIC
P.O. Box 15018
Albany, NY 12212-5018

or call our toll-free Helpline at 1-800-332-3742

Please include your name and EPIC identification number on all letters sent to the EPIC program. This will help us respond quickly to your request.

If You Lose Your Card

If you lose your card, just call our toll-free Helpline at 1-800-332-3742 to report the loss, and we will mail you a new card.

Your EPIC Records

All EPIC records are kept strictly confidential and are maintained by EPIC in Albany. You may obtain copies of your records by writing to:

EPIC
Records Access Officer
P.O. Box 15091
Albany, NY 12212-5091

If You Want To Cancel Your EPIC Coverage

To cancel your coverage you can call our toll-free Helpline at 1-800-332-3742. You will receive a refund for all fees paid for coverage after the date of your cancellation.

Fraud And Abuse Hotline

If you think that an EPIC participant or a pharmacy is misusing or abusing the program, you can call the Fraud and Abuse Hotline by dialing toll-free 1-800-542-0424. You will not be asked for your name or any other personal data. All calls are strictly confidential.

Notice of EPIC Program Privacy Practices

(Effective April 14, 2006)

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

By law, the New York State Elderly Pharmaceutical Insurance Coverage (EPIC) Program is required to protect the privacy of your personal health related information. EPIC is also required to give you a notice to tell you how the program may use and disclose (give out) your personal health related information held by EPIC.

EPIC must use and disclose your personal health related information:

  • To you or someone who has the legal right to act for you (your personal representative or caregiver),
  • To the Secretary of the federal Department of Health and Human Services, if necessary, to make sure your privacy is protected, and
  • Where required by law (for example, government oversight and audit).

EPIC has the right, based on your authorization (permission) during enrollment, to use and disclose your personal health related information to pay for your medications and to operate the EPIC Program. For example:

  • EPIC may share your personal health related information with EPIC pharmacists to make sure that they are paid for the services they provide to you.
  • EPIC may use and disclose your personal health related information to your prescribing physician in the event that your drug regimen is potentially dangerous to your health. For example, if you are taking a combination of drugs that may result in a serious drug interaction or therapeutic duplication, the doctor may change your medication based on this information.
  • EPIC may use your personal health related information to make sure you and other EPIC enrollees receive quality health care, to provide customer service to you, or to resolve any complaints you may have.
  • EPIC may disclose your personal health related information to other insurance companies to identify any prescriptions billed to the EPIC Program that appear to be the responsibility of the other insurer.
  • EPIC may disclose your personal health related information to any other governmental agencies, including Medicare as well as Medicare drug plans that have been authorized as agents by Medicare, that act as a co-payer.
  • EPIC may disclose your personal health related information to business partners to operate the EPIC Program. This includes entities that provide assistance and education to EPIC seniors regarding the Medicare Part D drug benefit.

EPIC may use or disclose your personal health related information for the following purposes under limited circumstances:

  • For research studies that meet all privacy law requirements.
  • To avoid a serious and imminent threat to health or safety, as permitted by law.
  • To act as an authorized representative in accordance with the Elder Law, Title 3, Program for Elderly Pharmaceutical Insurance Coverage, Section 242, in pursuing prescription drug coverage under Medicare Part D.
  • To contact you about new or changed benefits under EPIC or notify you about other state or federal government benefits that you may be eligible for including but not limited to food stamps, Medicare Savings Program or Energy Assistance Programs.
  • To persons involved in your healthcare for the purpose of EPIC's routine program operations, unless you object by contacting us.

By law, EPIC must have your written authorization to use or disclose your personal health related information for any purpose that is not set out in this notice. You may revoke (take back) your written authorization at any time, except if EPIC has already acted based on your authorization.

By law, you have the right to:

  • See and obtain a copy of your personal health related information held by EPIC.
  • Have your personal health related information amended if you believe that it is wrong or if information is missing and EPIC agrees. If EPIC disagrees, you may have a statement of your disagreement added to your personal health related information.
  • Obtain a listing of those persons or organizations who receive your personal health related information from EPIC. The listing will not cover health related information that was disclosed to you, information used to pay for your medications, and information used to conduct EPIC routine operations.
  • Ask EPIC to communicate with you in a different manner or at a different place (for example, by sending materials to a P.O. Box instead of your home address).
  • Ask EPIC to limit how your health related information is used. Please note that EPIC may not be able to agree to your request.

For additional information, forms, to report a problem or file a complaint (if you believe your privacy rights have been violated), you can contact the EPIC Program by calling toll-free at 1-800-332-3742, or by writing to the following address:

NYS EPIC Program
PO Box 15018
Albany, NY 12212-5018
Attn: EPIC Privacy Officer

You may also file a complaint with the Office for Civil Rights, US Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza, Suite 3312, New York, New York 10278, telephone number (212) 264-3313, fax number (212) 264-3039, TDD (212) 264-2355. You will not be penalized for filing a complaint or assisting an investigation.

By law, EPIC is required to follow the terms in this notice. EPIC has the right to change the way your personal health related information is used and disclosed. If EPIC makes any changes, you will receive a new notice by mail within 60 days of the change.

¿Necesita Ayuda? Llame al 1-800-332-3742

Fee Schedule

If you are SINGLE
If your income is: Your annual fee is: When your co-payments total:
$ 5,000 or LESS $ 8 $ 340
$ 5,001-$ 6,000 $ 8 $ 408
$ 6,001-$ 7,000 $ 16 $ 476
$ 6,001-$ 7,000 $ 16 $ 476
$ 7,001-$ 8,000 $ 22 $ 544
$ 8,001-$ 9,000 $ 28 $ 612
$ 9,001-$ 10,000 $ 36 $ 700
$10,001-$11,000 $ 40 $ 720
$11,001-$12,000 $ 46 $ 827
$12,001-$13,000 $ 54 $ 896
$13,001-$14,000 $ 60 $ 964
$14,001-$15,000 $ 80 $ 1,016
$15,001-$16,000 $ 110 $ 1,034
$16,001-$17,000 $ 140 $ 1,052
$17,001-$18,000 $ 170 $ 1,070
$18,001-$19,000 $ 200 $ 1,088
$19,001-$20,000 $ 230 $ 1,160
Then you pay only a co-payment of $3 - $20. EPIC pays the full cost of your prescriptions for the rest of your coverage year.

Fee Schedule

If you are MARRIED
If your joint income is: Your annual fee is:
(each individual)		 When your co-payments total:
(each individual)
$ 5,000 or LESS $ 8 $ 291
$ 5,001-$ 6,000 $ 8 $ 342
$ 6,001-$ 7,000 $ 12 $ 399
$ 7,001-$ 8,000 $ 16 $ 456
$ 8,001-$ 9,000 $ 20 $ 513
$ 9,001-$10,000 $ 24 $ 570
$10,001-$11,000 $ 28 $ 622
$11,001-$12,000 $ 32 $ 641
$12,001-$13,000 $ 36 $ 660
$13,001-$14,00 $ 40 $ 684
$14,001-$15,000 $ 40 $ 710
$15,001-$16,000 $ 84 $ 826
$16,001-$17,000 $ 106 $ 877
$17,001-$18,000 $ 126 $ 928
$18,001-$19,000 $ 150 $ 980
$19,001-$20,000 $ 172 $ 990
$20,001-$21,000 $ 194 $ 1,008
$21,001-$22,000 $ 216 $ 1,026
$22,001-$23,000 $ 238 $ 1,044
$23,001-$24,000 $ 260 $ 1,062
$24,001-$25,000 $ 275 $ 1,080
$25,001-$26,000 $ 300 $ 1,150
Then you pay only a co-payment of $3 - $20. EPIC pays the full cost of your prescriptions for the rest of your coverage year.

Deductible Schedule

If you are SINGLE
If your income is: Your annual deductible is: When your co-payments total:
$20,001-$21,000 $ 530 $1,050
$21,001-$22,000 $ 550 $1,100
$22,001-$23,000 $ 580 $1,150
$23,001-$24,000 $ 720 $1,200
$24,001-$25,000 $ 750 $1,250
$25,001-$26,000 $ 780 $1,300
$26,001-$27,000 $ 810 $1,350
$27,001-$28,000 $ 840 $1,400
$28,001-$29,000 $ 870 $1,450
$29,001-$30,000 $ 900 $1,500
$30,001-$31,000 $ 930 $1,550
$31,001-$32,000 $ 960 $1,600
$32,001-$33,000 $ 1,160 $1,650
$33,001-$34,000 $ 1,190 $1,700
$34,001-$35,000 $ 1,230 $1,750
After you have reached your annual deductible, then you pay only a co-payment of $3 - $20. EPIC pays the full cost of your prescriptions for the rest of your coverage year.

Deductible Schedule

If you are MARRIED
If your joint income is: Your annual deductible is:
(each individual)		 When your co-payments total:
(each individual)
$26,001-$27,000 $ 650 $1,080
$27,001-$28,000 $ 675 $1,120
$28,001-$29,000 $ 700 $1,160
$29,001-$30,000 $ 725 $1,200
$30,001-$31,000 $ 900 $1,2400
$31,001-$32,000 $ 930 $1,280
$32,001-$33,000 $ 960 $1,320
$33,001-$34,000 $ 990 $1,360
$34,001-$35,000 $ 1,020 $1,400
$35,001-$36,000 $ 1,050 $1,440
$36,001-$37,000 $ 1,080 $1,480
$37,001-$38,000 $ 1,110 $1,520
$38,001-$39,000 $ 1,140 $1,560
$39,001-$40,000 $ 1,170 $1,600
$40,001-$41,000 $ 1,200 $1,640
$41,001-$42,000 $ 1,230 $1,680
$42,001-$43,000 $ 1,260 $1,720
$43,001-$44,000 $ 1,290 $1,760
$44,001-$45,000 $ 1,320 $1,800
$45,001-$46,000 $ 1,575 $1,840
$46,001-$47,000 $ 1,610 $1,880
$47,001-$48,000 $ 1,645 $1,920
$48,001-$49,000 $ 1,680 $1,960
$49,001-$50,000 $ 1,715 $2,000
After you have reached your annual deductible, then you pay only a co-payment of $3 - $20. EPIC pays the full cost of your prescriptions for the rest of your coverage year.

Call today for more information 1-800-332-3742

Para obtener más informaciones, llame a la línea de Ayuda EPIC: 1-800-332-3742

若需瞭解詳情，請即日致電EPIC求助熱線: 1-800-332-3742

August 2006