Help with Medicare Prescription Drug Costs


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Medicare offers Extra Help (sometimes called Low Income Subsidy or LIS) to people with low incomes and limited assets. If you qualify, you’ll get help with drug costs that Medicare doesn't cover. Depending on your income and resources, you could save an average of $4,000per year.

Less than half of the people eligible for Extra Help sign up. If you think you might qualify, submit an application.

Do I qualify for Extra Help?

To be eligible for help with drug costs, you must:

  • Live in the United States or District of Columbia.2
  • Qualify for Medicare Part A and/or be enrolled in Medicare Part B.
  • Have less than $17,505 in annual income/$13,440 in assets (if single).3
  • Have less than $23,595 in annual income/$26,860 in assets (if married).3

1SSA.gov website, http://www.ssa.gov/prescriptionhelp

2Programs may vary if you live in Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or the Northern Mariana Islands. Income amounts will vary for Hawaii and Alaska.

3If you have more or less than these amounts, you still may qualify for Extra Help. The resource limits include $1,500 per person for burial expenses. These amounts may change each year. See Counting income and assets to see what is and is not included.

Best Available Evidence policy

The federal Best Available Evidence (BAE) policy requires that the plan adjust your subsidy if you provide updated information that changes the level of extra help you receive. A memo on the CMS website explains the procedures for updating a person's level of Extra Help.

Counting your assets

To determine your eligibility, Medicare may also look at your assets. Assets Medicare counts include:

  • Cash (including checking and savings accounts)
  • Certificates of deposit
  • Retirement accounts (like IRAs or 401(k)s)
  • Stocks, bonds and mutual funds
  • Promissory notes
  • Property that could be converted to cash within 20 days.
  • Mortgages
  • Life insurance policies

Medicare does not count these assets:

  • Your primary home
  • Your primary car
  • Burial plots or agreements
  • Funds set aside for burial expenses (up to $1,500)

Prescription drug benefits for members receiving Extra Help from Medicare1

  • Income Level

  • Estimated Monthly Premium

  • Estimated Annual
    Deductible

  • Estimated Co-payments/
    Co-insurance

Medicaid and Single:
Income $11,670 or less

Married:
Income $15,730 or less

$02

$0

  • $1.20 generic
  • $3.60 brand name
  • No drug co-pays after $4,700 out-of-pocket in 2015

 

Medicaid and Single:
Income over $11,670

Married:
Income over $15,730

$02

$0

  • $2.65 generic
  • $6.60 brand name
  • No drug co-pays after $4,700 out-of-pocket in 2015

Medicaid, institutionalized or living in a
nursing facility

$02

$0

No co-pays

Single:
Income less than $15,575.50, assets $8,660 or less

Married:
Income less than $21,235.50, assets $13,750 or less

$02

$0

  • $2.65 generic
  • $6.60 brand name
  • No drug co-pays after $4,700 out-of-pocket in 2015

Single:
Income less than $17,505. Assets more than $8,660 but less than $13,440


Married:
Income less than $23,595 Assets more than $13,750 but less than $26,860

$02

Up to $66

  • After deductible is met, assigned cost share or 15% of drug costs3, whichever is lower
  • $2.65 generic or $6.60 brand name after $4,700 out-of-pocket for drugs in 2015

Single:
Income less than $17,505, assets less than $13,440

Married:
Income less than $23,595, assets less than $26,860

Discounted premium (sliding scale based on income)

Up to $66

  • After deductible is met, assigned cost share or 15% of drug costs3, whichever is lower
  • $2.65 generic or $6.60 brand name after $4,700 out-of-pocket for drugs in 2015


1 Note: The income amounts and resource limits are for 2014. Both of these amounts can change each year. Income amounts will vary for Hawaii and Alaska.

2 If you choose a plan that has a premium at or under the amount Medicare has agreed to pay (CMS benchmark), your plan premium will be $0. If you choose a plan which has a premium above the amount Medicare has agreed to pay, your premium will be the difference between the amount Medicare has agreed to pay and the plan’s premium. See the 2015 benchmarks below. The amount Medicare has agreed to pay is subject to change annually.

Please note that the premiums listed do not include any Part B premium that you may be responsible for paying. Premiums listed are for both medical services and prescription drug benefits (MAPDs only).

 

Medicare premium amounts for members receiving Extra Help (CMS benchmarks by state)

  • State

  • Subsidy

  • Region

AK

32.86

34

AL

30.20

12

AR

24.76

19

AZ

32.89

28

CA

28.84

32

CO

28.93

27

CT

29.65

2

DC

30.61

5

DE

30.61

5

FL

25.83

11

GA

26.47

10

HI

27.91

33

IA

30.00

25

ID

39.74

31

IL

28.23

17

IN

31.79

15

KS

30.32

24

KY

31.79

15

LA

31.28

21

MA

29.65

2

MD

30.61

5

ME

29.60

1

MI

31.46

13

MN

30.00

25

MO

28.28

18

MS

29.33

20

MT

30.00

25

NC

29.34

8

ND

30.00

25

NE

30.00

25

NH

29.60

1

NJ

37.64

4

NM

21.19

26

NV

24.25

29

NY

36.94

3

OH

28.64

14

OK

29.97

23

OR

33.81

30

PA

33.91

6

RI

29.65

2

SC

28.78

9

SD

30.00

25

TN

30.20

12

TX

27.31

22

UT

39.74

31

VA

29.47

7

VT

29.65

2

WA

33.81

30

WI

35.32

16

WV

33.91

6

WY

30.00

25


3 For the first $66 in drug costs, assigned co-pay or 100% of drug costs, whichever is lower. Subsidies for United States Territories (Puerto Rico, U.S. Virgin Islands, Guam, American Samoa and Northern Mariana Islands) that have low income assistance available may be different than those stated in the chart above.

How to apply for Extra Help

Step 1: Choose a drug plan provider

Whether you qualify for Extra Help or not, you must enroll for prescription drug coverage in order to apply for Extra Help.

Step 2: Complete an application for Extra Help

The easiest way to apply is to download an application and submit it online. You can also fill out a paper copy. If you haven't already received a copy of the application by mail, request one toll-free at 1-800-772-1213, 7 am to 7 p.m., Monday through Friday. TTY: 1-877-325-0778.

Mail completed applications to:
Social Security Administration
Wilkes-Barre Data Operations Center
P.O. Box 1020
Wilkes-Barre, PA 18767-9910

After submitting your application, you’ll hear within 8 weeks if you qualify for Extra Help with Part D costs.

You may automatically receive Extra Help

If you meet any one of the criteria below, you will automatically receive Extra Help from Medicare to help with your Part D costs. There’s no need to apply.

  • You receive both Medicare and Medicaid.
  • You receive both Supplemental Security Income (SSI) benefits and have Medicare.
  • The state pays your Medicare premiums.

If you aren't getting Extra Help, you can see if you qualify by calling:

  • 1-800-Medicare (toll-free; TTY/TDD users call 1-877-486-2048), 24 hours a day/7 days a week,
  • Your State Medicaid Office, or
  • The Social Security Administration toll-free at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.

If you have any questions, please contact UnitedHealthcare Customer Service.

State Pharmaceutical Assistance Programs

A State Pharmaceutical Assistance Program (SPAP) provides state-funded prescription drug assistance to people who need help paying for their monthly prescription drug plan premiums, deductibles, co-pays and co-insurance.

 

For most programs, members must meet specific income guidelines and additional requirements that vary by state.

All UnitedHealthcare Medicare prescription drug plans coordinate assistance with these states' programs:



You may be eligible for Extra Help through your state. To learn how to contact your state SPAP, visit www.medicare.gov/pharmaceutical-assistance-program/state-programs.aspx