Get help paying for your drug coverage

"Extra Help" from Medicare. If you meet certain income and resource limits, you may qualify for Extra Help. This program helps pay for your Medicare drug coverage costs, such as plan premiums, deductibles, and costs when you fill your prescriptions. To see if you qualify for Extra Help, complete an application online at https://secure.ssa.gov/i1020/start. You can also call Social Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778).

Help from your State Pharmaceutical Assistance Program. Many states have State Pharmaceutical Assistance Programs (SPAPs) that help people pay for prescription drugs based on financial need, age, or medical condition. Each state has different rules. To find out if your state has a State Pharmaceutical Assistance Program, visit Medicare.gov and search for "SPAP." Or, check with your local State Health Insurance Assistance Program (SHIP).

Get help with drug coverage or payment problems

Your Evidence of Coverage has step-by-step instructions that explain what to do if you have problems related to your drug coverage and costs. Here are the chapters to look for:

[MA-PD insert: Chapter 7.] [PDP insert: Chapter 5.] Asking the plan to pay its share of a bill you have received for covered services or drugs.

[MA-PD insert: Chapter 9.] [PDP insert: Chapter 7.] What to do if you have a problem or complaint (coverage decisions, appeals, complaints)

this site Note: see: appeals level chart overview.

Here are things to keep in mind:

• When we decide whether a drug is covered and how much you pay, it’s called a "coverage decision." If you disagree with our coverage decision, you can appeal our decision (see [MA-PD insert: Chapter 9] [PDP insert: Chapter 7] of the Evidence of Coverage).
• Medicare has set the rules for how coverage decision and appeal are handled. These are legal procedures and the deadlines are important. The process can take place if your doctor tells us that your health requires a quick decision.

Get more details in the Evidence of Coverage [if EOB is for a member with LIS, insert "and LIS Rider"

The Evidence of Coverage is our plan’s benefits booklet. It explains your drug coverage and the rules you need to follow when you are using your drug coverage.

To get a copy of the Evidence of Coverage in your mail or email, call [insert plan name] Member Services at [insert Member Services phone number] (TTY [insert TTY number]). You can also get this document online at [insert plan website URL]

[If EOB is for a member with LIS, insert: Your LIS Rider ("Evidence of Coverage Rider for People Who Get Extra Help Paying for their Prescriptions") is a short separate document that tells what you pay for your prescriptions.]

Your right to appeal

When we decide whether a drug is covered and how much you must pay, it’s called a “coverage decision.” If you disagree with our coverage decision, you can appeal (see [MA-PD insert: Chapter 9] [PDP insert: Chapter 7] of the Evidence of Coverage).

Medicare sets the rules for how coverage decisions and appeals are handled. These are legal procedures and the deadlines are important. The process can be expedited if your prescriber tells us that your health requires a quick decision.