Help with Medicare Prescription Drug Costs

Medicare offers extra help 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 $17,235 in annual income/$13,440 in assets (if single).3
  • Have less than $23,265 in annual income/$26,860 in assets (if married).3

1SSA.gov website, .

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 requires that the plan adjust your subsidy if you provide updated information that changes the level of extra help you receive. A on the CMS website explains the procedures for updating a person's level of extra help.

Note: PDF (Portable Document Format) files can be viewed with Adobe® Reader®. If you don't already have this viewer on your computer, download it free from the .

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).

Drug benefits for members receiving extra help from Medicare1

Income Level Estimated
Monthly
Premium
Estimated
Annual
Deductible
Estimated
Copayments/
Coinsurance

Medicaid and Single:
Income $11,490 or less

Married:
Income $15,510 or less

$02

$0

  • $1.20 generic
  • $3.60 brand name
  • No drug copays after $4,550 out-of-pocket in 2014

Medicaid and Single:
Income over $11,490

Married:
Income over $15,510

$02

$0

  • $2.55 generic
  • $6.35 brand name
  • No drug copays after $4,550 out-of-pocket in 2014

Medicaid, institutionalized or living in a nursing facility

$02

$0

No copays

Single:
Income less than $15,511.50, assets $8,660 or less

Married:
Income less than $20,938.50, assets $13,750 or less

$02

$0

  • $2.55 generic
  • $6.35 brand name
  • No drug copays after $4,550 out-of-pocket in 2014

Single:
Income less than $17,235. Assets more than $8,660 but less than $13,440

Married:
Income less than $23,265. Assets more than $13,750 but less than $26,660

$02

$63

  • $2.55 generic
  • $6.35 brand name
  • After deductible is met, assigned copay or 15% of drug costs3, whichever is lower; after $4,550 out-of-pocket for drugs in 2014

Single:
Income and assets between $8,710 and $13,520

Married:
Income and assets between $13,820 and $27,020

Discounted premium (sliding scale based on income)

$63

  • $2.55 generic
  • $6.35 brand name
  • After deductible is met, assigned copay or 15% of drug costs3, whichever is lower; after $4,550 out-of-pocket for drugs in 2014

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

2If 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 2013 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 37.07 34
AL 29.67 12
AR 30.03 19
AZ 27.49 28
CA 28.10 32
CO 26.90 27
CT 27.99 2
DC 32.34 5
DE 32.34 5
FL 22.13 11
GA 29.32 10
HI 25.69 33
IA 32.23 25
ID 39.02 31
IL 28.59 17
IN 34.95 15
KS 34.21 24
KY 34.95 15
LA 31.75 21
MA 27.99 2
MD 32.34 5
ME 27.78 1
MI 32.46 13
MN 32.23 25
MO 31.21 18
MS 30.56 20
MT 32.23 25
NC 28.28 8
ND 32.23 25
NE 32.23 25
NH 27.78 1
NJ 37.10 4
NM 19.92 26
NV 22.78 29
NY 37.23 3
OH 28.93 14
OK 30.18 23
OR 34.82 30
PA 35.50 6
RI 27.99 2
SC 33.87 9
SD 32.23 25
TN 29.67 12
TX 27.73 22
UT 39.02 31
VA 29.34 7
VT 27.99 2
WA 34.82 30
WI 37.03 16
WV 35.50 6
WY 32.23 25

3For the first $63 in drug costs, assigned copay 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 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 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 of 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 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, copays and coinsurance.

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:

State Program Website
California
Colorado
Connecticut
Delaware
Indiana
Maine
Maryland  OR
Massachusetts
Missouri
Montana
New Jersey
New York
Nevada
Pennsylvania
Texas
Vermont
U.S. Virgin Islands

You may be eligible for extra help through your state. To learn how to contact your state SPAP, visit .

Questions? Call UnitedHealthcare at:
1-877-699-5710
(TTY 711)
Hours: 8 a.m.-8 p.m. local time,
7 days a week

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Optional supplemental service (rider)

Additional coverage you can add to your Medicare Advantage plan. Examples of optional plan services covered with riders include: dental coverage and fitness programs.

Optional supplemental service (rider)

Additional coverage you can add to your Medicare Advantage plan. Examples of optional plan services covered with riders include: dental coverage and fitness programs.

Optional supplemental plan (rider)

Additional coverage you can add to your Medicare Advantage plan. Examples of optional plan services covered with riders include: dental coverage, vision and hearing coverage and fitness programs.

Creditable Coverage

Refers to prescription drug coverage that offers benefits the same as or better than coverage available through Medicare.

Tier 1: Preferred Generic. Lowest Copay.

This tier includes lower-cost, commonly used generic drugs. Use Tier 1 drugs for the lowest out-of-pocket costs.

Tier 2: Non-Preferred Generic. Low Copay.

This tier includes most generic drugs. Use Tier 2 drugs, instead of Tier 3 or 4, to help reduce your out-of-pocket costs.

Tier 5 : Specialty Tier. Coinsurance.

This tier includes unique and/or very high-cost drugs. You pay a percentage of the total drug cost, called coinsurance.

Tier 4: Non-Preferred Brand. Highest Copay.

This tier includes non-preferred generic and non-preferred brand drugs. Many Tier 4 drugs have lower-cost options in Tier 1, 2 or 3. Ask your doctor if you can switch to one of these drugs to help reduce your out-of-pocket costs.

Tier 3: Preferred Brand. Medium Copay.

This tier includes many common brand name drugs, called preferred brands, and some higher-cost generic drugs. Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you.

Tier 4: Non-Preferred Brand. Highest Copay.

This tier includes non-preferred generic and non-preferred brand drugs. Many Tier 4 drugs have lower-cost options in Tier 1, 2 or 3. Ask your doctor if you can switch to one of these drugs to help reduce your out-of-pocket costs.

Drug List tool tip

A list of drugs covered by your Medicare Part D plan. A drug list may also be referred to as a covered prescription drugs list (CML), a preferred drug list (PDL), a select drug list or a formulary. These drugs are dispensed through participating network pharmacies to covered members. Drug lists may differ between Medicare prescription drug plans.


Carefully weigh the differences in drug lists against the plan costs and other features when choosing a plan that may best meet your needs. A drug list may change during the year.

Tier 2: Low Copay

This tier includes most generic drugs. Use Tier 2 drugs, instead of drugs in Tiers 3 or 4 to help reduce your out-of-pocket costs.

Coverage Gap Stage:

During the Coverage Gap Stage, you (or others on your behalf) will pay no more than 72% of the total cost for generic drugs or 47.5% of the total cost for brand name drugs, for any drug tier until the total amount you (or others on your behalf) have paid reaches $4,550 in year-to-date out-of-pocket costs.

You may pay less if your plan has better coverage in the gap.

Always use your Medicare Part D member ID card during the coverage gap to get the plan's discounted drug rates. The money you spend using your card counts toward your out-of-pocket costs.

Out-of-Pocket Costs:

The amount you (or others pay on your behalf) pay for prescription drugs starting January 1, 2013 not including premiums.

Premium (or monthly premium)

The monthly fee you pay for Medicare coverage.

Deductible/annual deductible

The pre-set, fixed amount you must pay for healthcare or prescription drug costs before Medicare or the plan begins to pay.

Deductible/Annual deductible

The pre-set, fixed amount you must pay for healthcare or prescription drugs costs before the insurance company or Medicare begins to pay.

Coinsurance

A kind of cost sharing where you pay a percentage of the cost of a service. For example, a plan might pay 75% and you would pay 25%. In Medicare Advantage, coinsurance varies depending on the plan.

Copay

A kind of cost sharing where you pay a predictable, pre-set amount for a service, such as an annual check-up.

Copay

A kind of cost sharing where you pay a predictable, pre-set amount for a service, such as an office visit.

Primary Care Physician's name and ID

Your primary care physician (PCP) plays an important role in your health care, and we want you to have the opportunity to select one you are comfortable with. Your PCP can:

  • Help you make good lifestyle choices to maintain and improve your health.
  • Serve as a direct point of contact in case of an emergency.
  • Manage the drugs prescribed to you and identify potential adverse interactions.
  • Coordinate the care of specialists who may diagnose and treat your conditions.
  • Help ensure that you are getting the care you need while helping to minimize your out-of-pocket costs.

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