EPIC helps more than 325,000 New York seniors pay what their Medicare Part D plan leaves them owing at the pharmacy. Short for Elderly Pharmaceutical Insurance Coverage, New York EPIC is open to New York State residents age 65 and older with annual income up to $75,000 if single or $100,000 if married. EPIC pays second, behind your Medicare Part D plan, so a Part D plan has to be in place before EPIC pays anything.

In This Guide

Who Qualifies for EPIC in New York?

New York's eligibility page lists four conditions, and all four have to be true at once.

  1. You are a New York State resident age 65 or older. Residency means your permanent home, not a summer or winter home, is in New York State.
  2. You are enrolled in, or eligible to be enrolled in, a Medicare Part D drug plan. New York writes this one as "no exceptions."
  3. Your annual income is up to $75,000 if single or $100,000 if married, the 2026 EPIC limits for a New York applicant.
  4. You are not receiving full Medicaid benefits.

A Medicaid spenddown is a different arrangement from full Medicaid benefits, and it appears again below as one of the routes to an EPIC fee waiver.

That list is the whole test. It names residency, age, Part D enrollment, income, and Medicaid status, and stops there. There's also no enrollment window. You can join EPIC at any time during the year, and once you do, New York gives you a Medicare special enrollment period to pick up a Part D plan if you don't already have one.

Pennsylvania's PACE and PACENET, the Pharmaceutical Assistance Contract for the Elderly and its Needs Enhancement Tier, are the closest programs to compare EPIC against, and in 2026 they cover single applicants only up to $33,500. A married New York couple with annual income up to $100,000 is still inside EPIC's income door.

Income above $75,000 single or $100,000 married puts a New York applicant outside EPIC. A New Yorker in that position can still take Medicare prescription drug coverage questions to the state's free HIICAP counselors, on the toll-free helpline at 1-800-701-0501.

Fee Plan or Deductible Plan

EPIC is one program with two tiers, and your income picks the tier for you.

Fee Plan Deductible Plan
Single income Up to $20,000 $20,001 to $75,000
Married income (combined) Up to $26,000 $26,001 to $100,000
What you pay to participate An annual EPIC fee of $8 to $300 An annual EPIC deductible of $530 to $3,215
When EPIC starts paying As soon as your Part D plan has paid, with no EPIC deductible to meet first After you meet the EPIC deductible

Both the EPIC fee and the EPIC deductible are set from your previous year's income, so where that income falls inside the range above decides the amount you owe. New York publishes the banded Fee Plan and Deductible Plan schedules behind those ranges in its 2026 EPIC Program Highlights.

What New York EPIC Costs You

At the pharmacy you show both cards, your Part D card and your EPIC card, and New York's EPIC copay in 2026 is $3, $7, $15, or $20, set by the cost of the drug. The copay tracks the price of the prescription, and $20 is the top figure in that schedule.

EPIC Deductible Plan members pay their own Part D cost-sharing until they have met their EPIC deductible for the year. After that, the same EPIC copay schedule applies.

What EPIC pays on is approved Part D and EPIC-covered drugs, plus approved Part D-excluded drugs such as prescription vitamins and cough and cold preparations. Whether a particular prescription falls inside that is a question for the EPIC Helpline, the line New York gives members for program questions, at 1-800-332-3742 (TTY 1-800-290-9138).

There's one route to a zero-fee EPIC. Members approved for federal Extra Help, a Medicare Savings Program (MSP), or a Medicaid spenddown don't pay any EPIC fees. At the top of the 2026 EPIC fee range that waiver is worth $300 a year, and at the bottom of it, $8.

How New York EPIC Works With Medicare Part D

EPIC is a wraparound, and the payment order is set by federal regulation rather than by New York. 42 CFR 423.464(b) provides that "a Part D plan is always the primary payer relative to a State Pharmaceutical Assistance Program." Your Part D plan prices and adjudicates the prescription first. EPIC then picks up part of what is left.

Two things follow from that.

First, EPIC reaches drugs Part D leaves out. After any Part D deductible is met, EPIC provides secondary coverage on approved Part D and EPIC-covered drugs, and it also covers approved Part D-excluded drugs such as prescription vitamins and cough and cold preparations.

Second, what EPIC pays counts toward your Medicare Part D out-of-pocket cap. That turns on EPIC's federal status, and New York states that status outright in two places: the Department of Health's own current EPIC application form, DOH-5080, says "EPIC is a qualified State Pharmaceutical Assistance Program," and the New York State Assembly's 2026 EPIC guide says the same.

Qualified-SPAP status is what triggers the federal treatment. Under the definition of incurred costs at 42 CFR 423.100, costs paid "Under State Pharmaceutical Assistance Program (as defined in § 423.464)" count among your incurred costs when Medicare decides whether you have hit the annual out-of-pocket threshold. For 2025 and later years, what insurance, a group health plan, or certain other third-party payment arrangements pay generally counts toward that threshold too, excluding only your own Part D or MA-PD plan's basic prescription drug coverage and manufacturer payments under the Manufacturer Discount Program. So EPIC's qualified-SPAP status is what puts those dollars on your tally toward the Part D out-of-pocket cap.

One warning the New York State Department of Health states plainly: EPIC isn't creditable coverage on its own. Keep the Part D plan alongside it.

What EPIC Pays Toward Your Part D Premium

One income line, $23,000 single or $29,000 married, decides which form the premium help takes.

Your annual income Who pays the Part D monthly premium What EPIC does
Up to $23,000 single, $29,000 married EPIC, up to a benchmark of $58.82 per month in 2026; you pay any amount above the benchmark Pays the premium at the plan
Above $23,000 single, $29,000 married You, each month Lowers your annual EPIC deductible by approximately $706, the annual cost of a benchmark Part D plan in 2026

The $58.82 benchmark is the average cost of a Medicare Part D drug plan in New York State, and a member whose plan premium runs higher than it is responsible for the difference each month. Above the income line, New York returns the premium money through the deductible instead of at the plan.

The two thresholds do not line up with the tier boundaries. Every EPIC Fee Plan member falls under the premium-assistance line, because the Fee Plan tops out at $20,000 single while New York's 2026 premium-assistance threshold is $23,000. EPIC Deductible Plan members with single income between $20,001 and $23,000 still get their Part D premium paid; past $23,000, EPIC reduces the annual EPIC deductible instead.

How Often EPIC Lets You Change Part D Plans

The same qualified-SPAP status carries a second benefit. Because EPIC is a qualified State Pharmaceutical Assistance Program, joining it gives you a Medicare special enrollment period, and New York describes that period two ways: a new member can enroll in a Part D drug plan during the year once enrolled in EPIC, and an existing EPIC member can change their Medicare Part D plan one time during the year.

The federal rule behind that is specific about the limit. Under 42 CFR 423.38(c)(17), someone in a qualified State Pharmaceutical Assistance Program "is eligible to make one enrollment election per year."

If you spend the election in April and find a better plan in September, this special enrollment period won't move you again that year. And if you lose EPIC eligibility, your Part D special enrollment period stays open for an additional two calendar months after either the month eligibility ends or the month you're notified, whichever is later.

Can You Have EPIC and Extra Help, a Savings Program, or Medicaid?

These three get tangled together constantly, so here is how New York stacks them.

Income-eligible EPIC seniors are required to apply for Extra Help, the federal Part D Low-Income Subsidy run through Social Security. That's a requirement of EPIC membership, not a suggestion.

Extra Help and EPIC then stack rather than compete. Approval for Extra Help, a Medicare Savings Program, or a Medicaid spenddown waives your EPIC fees entirely, and EPIC keeps wrapping around whatever your Part D plan still leaves you owing.

New York's Medicare Savings Programs are one of those routes. New York applies no asset limit to either Medicare Savings Program benefit level it runs, so financial eligibility for a New York applicant turns on income alone. That's more generous than the federal floor, and MSP approval is one of the routes to an EPIC fee waiver.

Full Medicaid is where the stacking stops: a spenddown waives your EPIC fees, but receiving full Medicaid benefits closes New York's EPIC to you outright.

How to Apply for EPIC in New York

No documentation is required with the application; EPIC verifies your information with the Social Security Administration and the New York State Department of Taxation and Finance.

  1. Apply whenever you are ready. There is no annual window. You can join EPIC at any time during the year.
  2. Apply online, or complete the application and mail or fax it in. The paper form is DOH-5080, and both routes run through the EPIC program pages at the New York State Department of Health.
  3. Call the EPIC Helpline at 1-800-332-3742 (TTY 1-800-290-9138) with questions.
  4. Line up a Part D plan. Enrolling in EPIC opens the Medicare Part D special enrollment period you need to join one, and New York pays no EPIC benefits until you're enrolled in a Part D drug plan.

For free help comparing Part D plans before you spend your one annual election, New York runs the Health Insurance Information Counseling and Assistance Program (HIICAP), its State Health Insurance Assistance Program, through the New York State Office for the Aging. More than 700 trained HIICAP counselors work out of local offices for the aging across New York, and the HIICAP toll-free helpline is 1-800-701-0501, Monday to Friday, 8:30 a.m. to 5:00 p.m. The counseling is free and personalized.

Trying to work out which EPIC tier you land in, or which Part D plan to spend your one election on? Chat with Brevy's care navigator at brevy.com.

Frequently Asked Questions

What does EPIC cost a New York member each year?

Your previous year's income sets the amount. A New York EPIC Fee Plan member pays an annual fee of $8 to $300 in 2026; an EPIC Deductible Plan member clears an annual deductible of $530 to $3,215 before EPIC starts paying. Either way the counter price is the same EPIC copay of $3, $7, $15, or $20 per prescription, and approval for Extra Help, a Medicare Savings Program, or a Medicaid spenddown drops the EPIC fee to zero.

Can I switch Part D plans anytime because I have EPIC?

No. Because EPIC is a qualified State Pharmaceutical Assistance Program, membership gives a New York member a Medicare special enrollment period. But it's one Part D plan election per calendar year, plus a short window if you lose EPIC eligibility.

My income went up. What happens to my EPIC tier?

EPIC sets both the annual fee and the annual deductible from your previous year's income, so a change in this year's income does not change the fee or deductible amount you owe EPIC today. Crossing $20,000 single or $26,000 married moves a New York member from the EPIC Fee Plan to the EPIC Deductible Plan; crossing $75,000 single or $100,000 married puts you outside EPIC eligibility altogether. If you do lose EPIC, your Part D special enrollment period stays open for two more calendar months.

I sent in my EPIC application. What happens next?

No documentation goes in with the application. EPIC verifies your information with the Social Security Administration and the New York State Department of Taxation and Finance. EPIC pays nothing until you are enrolled in a Medicare Part D drug plan, so for an applicant who is not in one yet, the Part D special enrollment period that EPIC membership opens is the step between joining EPIC and the first EPIC copay at the pharmacy. Questions on an application in progress go to the EPIC Helpline at 1-800-332-3742 (TTY 1-800-290-9138).

I already have Extra Help. Is EPIC still worth joining?

EPIC still adds a layer, and New York requires income-eligible EPIC seniors to apply for Extra Help in the first place. Extra Help approval waives your EPIC fees entirely, and EPIC keeps paying second on what your Part D plan leaves you owing, including approved Part D-excluded drugs such as prescription vitamins and cough and cold preparations.

Learn More

MedicareState Pharmaceutical Assistance Programs and Your Medicare Drug CostsThirteen states run a State Pharmaceutical Assistance Program (SPAP) that helps pay Medicare Part D drug costs. See which states, and how a SPAP works. MedicareMedicare Plans and Coverage in New YorkMedicare in New York for 2026: Part A, Part B, Medicare Advantage, Part D, and the year-round Medigap rule, plus programs that help pay your costs. MedicarePennsylvania PACE and PACENET: How the State Helps Pay Your Medicare Drug CostsPennsylvania's PACE and PACENET help residents 65 and older pay Medicare Part D drug costs. See the 2026 income limits, no asset test, and how to apply. MedicareMedicare Extra Help: The Part D Low-Income SubsidyMedicare Extra Help can cut Part D drug costs to a few dollars a prescription. See 2026 income and resource limits, what it pays, and how to apply. MedicareHow Medicare Part D WorksMedicare Part D in 2026: a $2,100 out-of-pocket cap, no donut hole, three benefit phases, the $615 deductible, premiums, the late penalty, and Extra Help. MedicareThe Medicare Part D Out-of-Pocket Cap, ExplainedYes, there's now a Medicare Part D out-of-pocket cap on covered drugs. It was $2,000 in 2025 and $2,100 in 2026. Here's how the limit works and when you hit it.

Talk through your EPIC tier and your New York Part D plan choice with Brevy's care navigator at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.

BC

Brevy Care Team

Expert eldercare guidance from Brevy's team of healthcare professionals and researchers.