EPIC Fee Plan vs Deductible Plan in New York
Two Plans, One Program
New York's EPIC program runs two separate plans for seniors 65 and older who need help paying for prescriptions. Which plan your parent ends up on is determined entirely by their prior-year gross income. They do not choose between the two — the income bracket assigns them automatically.
Understanding the difference matters because the out-of-pocket structure is fundamentally different. One plan charges a small annual fee but covers prescriptions immediately. The other charges no fee but requires spending through an annual deductible before EPIC copays kick in.
The Fee Plan (Income Up to $20,000 Single / $26,000 Married)
The Fee Plan is for the lowest-income EPIC-eligible seniors. Annual income under $20,000 (single) or $26,000 (married) lands your parent here.
Annual membership fee: $8 to $300, based on income. The fee is billed in four quarterly installments. At the lowest income levels, the fee is nominal — $8 a year is $2 a quarter. At the top of the range ($20,000 single), it reaches $300 a year. If your parent also qualifies for Extra Help (the federal Low-Income Subsidy), the annual fee is waived entirely.
No EPIC deductible: EPIC copays apply after any Part D deductible. There is no separate EPIC spending threshold to meet before its copays apply.
Part D premium assistance: EPIC pays your parent's Part D plan premium directly, up to the New York benchmark of $58.82 per month in 2026. If their Part D plan's premium is at or below the benchmark, the premium costs them nothing. If it exceeds the benchmark, they pay the difference. Choosing a benchmark-eligible plan means zero premium.
EPIC copays: $3 to $20 per prescription, based on the drug's cost:
- Drug cost $15 or less: $3
- Drug cost $15.01–$35: $7
- Drug cost $35.01–$55: $15
- Drug cost above $55: $20
For a senior filling four prescriptions a month with typical generics, the out-of-pocket cost under the Fee Plan might total $12–$28 a month. Compare that to paying full Part D copays and premiums without EPIC.
The Deductible Plan (Income $20,001–$75,000 Single / $26,001–$100,000 Married)
The Deductible Plan covers a wider income range but requires your parent to meet an annual out-of-pocket deductible before EPIC copays apply.
No membership fee: There is nothing to pay to join.
Annual deductible: Ranges from $530 to $3,215, sliding with income. A parent earning $25,000 a year pays a smaller deductible than one earning $60,000. Until the deductible is met, your parent pays full out-of-pocket costs at the pharmacy (though Part D still processes as primary). Once the deductible is met, EPIC copays of $3–$20 apply for the rest of the year.
Part D premium tiering: If your parent's income is $20,001–$23,000 (single) or $26,001–$29,000 (married), EPIC pays the Part D premium up to the $58.82 benchmark — same as the Fee Plan. Above those thresholds, your parent pays the Part D premium directly, but EPIC reduces the annual deductible by approximately $705.84 (the annual value of the benchmark premium).
Same copay schedule: Once the deductible is met, the $3–$20 copay tiers are identical to the Fee Plan.
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How EPIC Works at the Pharmacy Counter
Both plans coordinate the same way. Your parent presents two cards at the pharmacy: their Medicare Part D card and their EPIC card. The pharmacy system processes the Part D claim first — applying any Part D deductible, coinsurance, or copay. The remaining balance is transmitted in real time to EPIC, which either applies it toward the annual deductible (Deductible Plan) or charges the EPIC copay (Fee Plan members and Deductible Plan members who have met their deductible).
EPIC also covers certain Part D-excluded drugs — prescription vitamins, prescription cough and cold preparations — where Part D does not pay. For those drugs, EPIC acts as primary payer.
The $2,100 Out-of-Pocket Cap
Under the Inflation Reduction Act, total out-of-pocket spending on Part D drugs is capped at $2,100 in 2026. Payments made by Part D, Extra Help, and EPIC all count toward this cap. Once reached, the Part D plan provides 100% coverage and copays drop to $0 for the rest of the calendar year. This cap applies regardless of which EPIC plan your parent is on.
Which Plan Is Better?
Your parent does not choose — income determines the plan. But knowing the structure helps with planning:
- Fee Plan members should enroll in a benchmark-eligible Part D plan to get $0 premiums and apply for MSP or Extra Help to waive the annual fee entirely.
- Deductible Plan members in the lower income range ($20,001–$23,000) should also pick benchmark plans to get the premium paid. Higher-income members benefit from the deductible reduction.
If your parent's income falls within MSP limits (QMB under $1,856/month or QI under $2,494/month for an individual), applying for MSP first is the priority — MSP triggers automatic Extra Help, which provides even more generous drug coverage than EPIC alone. EPIC and Extra Help stack: the EPIC fee is waived, and Extra Help further reduces copays.
For a walkthrough of how EPIC, Extra Help, and MSP work together — including which to apply for first and a pharmacy-cost comparison table — see the New York Medicare Savings Programs, Extra Help & EPIC Guide.
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