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Eldercare Q&A

Getting “Extra Help” with drug costs

MoW.201Q: Can I get financial help with my Medicare drug costs?

A. Yes. There is a Medicare program called “Extra Help” that can assist you in paying for the costs of prescription drugs. If you meet certain income and resource limits, you may qualify for Extra Help from Medicare to pay the costs of Medicare drug coverage.

Eligible Medicare beneficiaries with limited income can receive financial assistance with prescription drug costs – roughly $4,000 a year – associated with their Medicare drug plan. This program can reduce or eliminate the premium and deductible for Medicare prescription drug coverage.

You may qualify for Extra Help if your yearly income and resources are below these limits:

  • Single person: income less than $17,505 and resources less than $13,440 per year.
  • Married person living with a spouse and no other dependents: income less than $23,595, and resources less than $26,860 per year.

“Resources” means money in a checking or savings account, stocks, bonds, mutual funds, and IRAs. (Your home, car, household items, burial plot, up to $1,500 for burial expenses per person, and life insurance policies are NOT counted as resources.)

If you qualify for Extra Help and join a Medicare drug plan, you’ll get help paying your drug plan’s monthly premium, deductible, coinsurance, and copayments. You will have no coverage gap (the “donut hole”) or late enrollment penalty.

You automatically qualify for Extra Help if you are enrolled in MassHealth or a Medicare Savings Program. You also qualify if you receive Supplement Security Income (SSI) payments. If you automatically qualify, Medicare will send you a purple letter – you will not need to apply if you get this letter. If you are not already in a Medicare drug plan, you will need to join one to use Extra Help. If you don’t join a plan, Medicare may enroll you in one and send you a yellow or green letter telling you when your drug coverage begins.

Different Medicare drug plans cover different drugs. You must check your plan’s list of drugs, called their “formulary,” to see if the drugs you use are covered, what their price is, and if the pharmacy you prefer is part of the plan. If you don’t like the Medicare drug plan you are in and you are in Extra Help, you can switch plans anytime you want.

In order to see what assistance you’ll receive from Extra Help, you’ll need to send to your Medicare plan some form of documentation indicating you qualify for Extra Help. In 2016, drug costs for most people who qualify for Extra Help are no more than $2.95 for each generic drug, and $7.40 for each brand-name covered drug.

Note: If you have employer or union drug coverage and you join a Medicare drug plan, you may lose your employer or union coverage even if you qualify for Extra Help. Call your employer’s benefit administrator before you decide to join a Medicare drug plan.

If you don’t automatically qualify for Extra Help, you call Social Security at 1-800-772-1213 to apply by phone anytime. Medicare gets information from your state or Social Security that tells whether you qualify for Extra Help. If Medicare doesn’t have the right information, you may be paying the wrong amount for your prescription drug coverage. Give your Medicare drug plan proof that you quality for Extra Help – like a MassHealth card. If you aren't already enrolled in a Medicare drug plan and you paid for prescriptions since you qualified for Extra Help, you may be able to get back part of what you paid. Keep your receipts and call your plan.

Nearly all Part D plans now have preferred pharmacy networks. Filling your prescriptions with your plan’s preferred pharmacy provider will save you money, especially on mail-order prescriptions. One way to lower your drug costs is to ask your doctor about generic drugs, and consider using mail-order pharmacies.

For more information on Extra Help, you can call the free SHINE (health insurance counseling) program’s regional office at 1-800-498-4232 or 413-773-5555.