EPIC plan offers prescription coverage for seniors

The New York State Department of Health offers a prescription protection plan for seniors that covers prescriptions at a low cost called EPIC (Elderly Pharmaceutical Insurance Coverage). Legislation increased the income limits, lowered co-pays and introduced a new deductible plan for higher income seniors in January 2001.

Seniors who are 65 or older and have an annual income of $20,000 or less if single and $26,000 or less if married are eligible for the fee plan. Single seniors with an income of $20,0001 to $35,000 and married seniors with an income level of $26,001 to $50,000 are eligible for the deductible plan. Seniors who have full Medicaid benefits are not eligible, however persons can apply if they have other prescription coverage from another insurance company.

The application process is very simple. Most pharmacies have the application and brochure at their counter. It is written in large print and asks for income from Social Security, pensions, dividends and other income. Proof of age is required. Many seniors do not realize that they are eligible for this prescription plan.

EPIC offers two plans - the fee plan and the deductible plan. The fee plan is for seniors with moderate income. Single seniors with an income of $20,000 or less or marred seniors with an income up to $26,000 may apply. They pay a quarterly fee based on their income and pay moderate co-pays for their prescriptions.

Under the fee plan, a single senior with an income of $10,000 pays an annual fee of $40 to join; an annual income of $20,000 is $230 per year, making quarterly payments of $57.50. This fee allows them to get prescriptions with co-pays starting at $3 for prescriptions that normally cost $15 or less. The highest co-payment would be $20 for prescriptions over $55.

Married seniors pay an annual fee of $28 if their income is $10,000 or less. The maximum income of $26,000 pays $300 per year. You can opt to pay in quarterly installments. The annual income brackets and the amount of the annual fee are included in the brochure.

The deductible plan is for single seniors with an income level between $20,001 to $35,000 and married seniors with an income of $26,001 to $50,000. There is no fee to join, but they must pay out a certain dollar amount for prescriptions before the co-payments apply. Co-payments are the same as the fee plan - ranging from a minimum of $3 for prescriptions costing $15 or less to a maximum of $20 for prescriptions costing over $55.

A single senior with an income of $20,001 or less must meet a deductible of $530 paid out for prescriptions before the co-pays apply. At the other end of the scale, single seniors with an income between $34,001 to $35,000 must pay out $1,230 before the co-pays take effect. Again, the full scale of annual income levels versus the amount that must be paid out is explained in full in the brochure.

Married seniors with an income of $26,001 or lower must meet a deductible of $650 in order for the plan to start paying. The highest income level of $49,001 to $50,000 must meet a combined deductible of $1,715 before their benefits start.

Once you have your EPIC card, it must be presented to the pharmacy where the prescription is being filled. They transmit the information through their computers to EPIC, and EPIC keeps track of how much is spent and notifies the senior when they have met their deductible, making it an easy process for both the senior and the pharmacy to determine how much the prescription will cost.

The co-payments for both plans are as follows: for each prescription costing up to $15, the co-payment is $3, $15 to $35 prescriptions means the co-pay is $7, a $35 to $55 prescription costs $15 and prescriptions costing over $55 means that the member pays $20. With this information, one should weigh out the cost of the fees and deductibles versus the cost of prescriptions that they fill each year. EPIC and local pharmacies can help you with determining whether the plan would be beneficial.

Almost all prescriptions are covered on both plans, including insulin, insulin syringes and needles. The maximum allowed per month is a 30-day supply or 100 tablets or capsules. Brand name drugs as well as generics are covered.

For information, contact EPIC at 1-800-332-3742. Brochures are available at most local pharmacies or write to them at EPIC, P.O. Box 15018, Albany, NY 12212.