Extra Help With Medicare Prescription Drug Plan Costs
The Medicare Prescription Drug program gives you a choice of prescription plans that offer various types of coverage.
You may be able to get extra help to pay for the monthly premiums, annual deductibles, and co-payments related to the Medicare Prescription Drug program. However, you must be enrolled in a Medicare Prescription Drug Plan to get this extra help.

What Is This Application?

This is an application for Extra Help and does not enroll you in a Medicare prescription drug plan. You will have to enroll directly with an approved Medicare prescription drug provider for coverage. If you need information about Medicare Prescription Drug plans or how to enroll in a plan, call 1-800-MEDICARE (TTY 1-877-486-2048) or visit www.medicare.gov.

Who Should Complete This Application For Extra Help With Medicare Prescription Drug Plan Costs?

You should complete this application for Extra Help on the Internet if:
EXCEPTION: Even if you meet these conditions, DO NOT complete this application if you have Medicare and Supplemental Security Income (SSI) or Medicare and Medicaid because you automatically will get the extra help.

How Can You Get The Extra Help?

To get extra help with Medicare Prescription Drug plan costs, you must complete and submit this application. We will review your application and send you a letter to let you know if you qualify for extra help.
NOTE: To apply, you must live in one of the 50 States or the District of Columbia.
If you need help completing this application, call Social Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778).
You also may be able to get help from your State with other Medicare costs under the Medicare Savings Programs. By completing this form, you will start your application process for a Medicare Savings Program. We will send information to your State who will contact you to help you apply for a Medicare Savings Program unless you tell us not to when you complete this application.
If you need information about Medicare Savings Programs, Medicare Prescription Drug plans, or how to enroll in a plan, call 1-800-MEDICARE (TTY 1-877-486-2048) or visit www.medicare.gov. You also can request information about how to contact your State Health Insurance Counseling and Assistance Program (SHIP). The SHIP offers help with your Medicare questions.

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