The NYS EPIC application, Form DOH-5080, is a two-page form you complete with your income figures, Medicare details, and answers to a federal Extra Help screening section, then send to the EPIC office in Albany online, by mail, or by fax. You do not attach tax returns, benefit letters, or any other paperwork. EPIC verifies your information directly with the Social Security Administration and the New York State Department of Taxation and Finance.
Check Eligibility Before You Fill It Out
Three things have to be true before the form is worth completing. You must be at least 65 and a permanent New York resident, meaning your New York address is on your official documents and you live in the state on an ongoing basis. You must be enrolled in a Medicare Part D drug plan, or willing to enroll — EPIC will not pay benefits until Part D coverage is in place. And you cannot be receiving full Medicaid benefits, though a Medicaid spend-down is fine.
Income limits are $75,000 for a single applicant and $100,000 combined for a married couple. Below those ceilings, everyone who meets the other rules can apply; your income only determines which of two plans (Fee or Deductible) you land in.
Where to Get the Form
Form DOH-5080 is available as a PDF on the New York Department of Health website, through the EPIC online enrollment portal, and at many local pharmacies. You can also call the EPIC helpline at 1-800-332-3742 (TTY 1-800-290-9138), open weekdays 8:00 a.m. to 5:00 p.m., and ask them to mail one to you.
Filling Out DOH-5080 Section by Section
Lines 1–3: Income and Plan Assignment
The first three lines decide which EPIC plan you go into. On Line 1, enter your yearly Social Security or Railroad Retirement income. On Line 2, enter any other income. Line 3 is the total. If you are married and living with your spouse, combine both spouses’ figures even if only one of you is applying.
Flip the form over. The reverse side has a rate schedule keyed to your Line 3 total. Find your income row and it will tell you whether you fall into the Fee Plan (single income up to $20,000; married combined up to $26,000) or the Deductible Plan (above those thresholds up to the program ceilings), along with your annual fee or deductible amount. Fee Plan fees run from $8 a year at the bottom of the scale to $300 per person at the top married bracket. Deductible Plan members pay drug costs out of pocket until they hit the deductible the state assigns based on income, after which EPIC copays run $3 to $20 per prescription.
Personal and Medicare Information
Fill in your Medicare Claim Number, which appears on your red, white, and blue Medicare card. Then your Social Security Number, date of birth, sex, phone number, and home address.
For marital status, check “Single” if you are single, divorced, widowed, or your spouse does not live with you. Check “Married” only if you and your spouse share a household. Married applicants use one form for both spouses, and both must sign.
Lines 4–22: Extra Help Screening
This is the section most applicants get wrong, and it is what triggers the “incomplete application” letter that delays enrollment. Lines 4 through 22 exist so EPIC can screen you for the federal Extra Help program (also called the Low-Income Subsidy), which pays Part D premiums, deductibles, and copays for seniors with limited income and assets.
Lines 4 through 9 ask for current monthly income from Social Security, veterans benefits, pensions, and other sources. Lines 11 through 14 cover assets: bank accounts, stocks, bonds, investments, and cash on hand. Lines 15 through 22 ask about burial fund arrangements, real estate, dependents, and recent employment.
There is one shortcut. If you already qualify for a Medicare Savings Program, you can skip Lines 4 through 22 entirely and instead attach a copy of your determination letter from the Social Security Administration. Without either the completed lines or that letter, EPIC treats the application as incomplete and will write back asking for the missing information.
Signatures and Certification
The bottom of the form is the certification that your answers are true, your consent for EPIC to exchange data with other agencies, and an assignment of benefits. Sign and date it. Married couples: both spouses sign.
If someone helped you fill out the form, that person’s name, address, and phone number go in the assistance section at the bottom. An authorized representative holding Power of Attorney can sign on your behalf; if you are applying online, the representative uploads the POA documents during the application.
What Not to Send
No tax returns. No Social Security benefit statements. No pay stubs, bank statements, or photocopies of anything except a Medicare Savings Program determination letter if you are using it to skip the Extra Help section. EPIC pulls your income and enrollment data straight from SSA and the state tax department, so extra paperwork just clutters the file.
How to Submit It
You have three options:
- Online. Use the EPIC online enrollment portal linked from the Department of Health’s website. You check an acknowledgment box instead of signing on paper.
- Mail. Send the completed paper form to EPIC, P.O. Box 15018, Albany, NY 12212-5018.
- Fax or phone. Call 1-800-332-3742 (TTY 1-800-290-9138) weekdays 8:00 a.m. to 5:00 p.m. for the fax number or for help completing the form by phone.
After You Send It In
When your application is approved, EPIC mails you an enrollment notification and an EPIC identification card. At the pharmacy, hand over both the EPIC card and your Medicare Part D card so the secondary coverage applies.
If the file is incomplete, most often because Lines 4–22 were skipped without an MSP determination letter attached, EPIC sends a letter asking for what’s missing. Responding quickly keeps your enrollment on track.
You do not reapply on a fixed annual cycle. EPIC contacts you by mail when it is time to renew. Under New York Elder Law Section 242, each enrolled member is redetermined at least every 24 months, and at renewal you may be asked for updated income information or a current Extra Help determination letter.
One boundary worth naming: EPIC is always the secondary payer behind Medicare Part D, and it pays no benefits at all until you have a Part D plan in place. If you are not yet in Part D, enrolling in EPIC lets you join a Part D plan any time of year rather than waiting for open enrollment, because EPIC is a qualified State Pharmaceutical Assistance Program.