Help with Medicare Prescription
Drug Costs
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 $4,0001 per 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 $18,090 in annual income/$13,820 in assets (if single).3
- Have less than $24,360 in annual income/$27,600 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
Medicaid and Single:
Income $12,060 or less
Married:
Income $16,240 or less
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- $1.20 generic
- $3.70 brand name
- No drug co-pays after $4,950 out-of-pocket in 2017
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Medicaid and Single:
Income over $12,060
Married:
Income over $16,240
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- $3.30 generic
- $8.25 brand name
- No drug co-pays after $4,950 out-of-pocket in 2017
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Medicaid, institutionalized or living in a
nursing facility
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Single:
Income less than $16,281, assets $8,890 or less
Married:
Income less than $21,924, assets $14,090 or less
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- $3.30 generic
- $8.25 brand name
- No drug co-pays after $4,950 out-of-pocket in 2017
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Single:
Income less than $15,079.5>, assets less than $8,440
Married:
Income less than $20,425.50, assets less than $13,410
Single:
Income less than $18,090. Assets more than $8,890 but less than $13,820
Married:
Income less than $24,360 Assets more than $14,090 but less than $27,600
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- After deductible is met, assigned cost share or 15% of drug costs3, whichever is lower
- $3.30 generic or $8.25 brand name after $4,950 out-of-pocket for drugs in 2017
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Single:
Income less than $18,090, assets less than $13,820
Married:
Income less than $24,360, assets less than $27,600
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Discounted premium (sliding scale based on income)
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- After deductible is met, assigned cost share or 15% of drug costs3, whichever is lower
- $3.30 generic or $8.25 brand name after $4,950 out-of-pocket for drugs in 2017
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1Note: The income and resources limit amounts are for 2017. Either 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)
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:
Page last updated: 12.15.2016 at 12:01 AM CT | Y0066_161028_162405 Accepted
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