Extra Help is the federal program that helps pay your prescription drug costs if you have a limited income. If you do not have full Medicaid or SSI, you can receive Extra Help in one of two ways:
- You will automatically receive Extra Help if you have a Medicare Savings Program (MSP).
- You can get Extra Help through the Social Security Administration if you complete an Extra Help application form and meet the income and eligibility requirements.
If you do not have full Medicaid or SSI but have Extra Help, you should be able to get immediate coverage for your medications. Medicare will automatically enroll you in a benchmark Part D plan that starts within two months of your application being approved. Medicare will send you a green letter telling you which plan it has enrolled you in and what its costs are.
- If this plan does not fit your needs, you should choose another plan. When choosing a plan it is important to find a plan that has your drugs on its formulary with as few restrictions as possible. A formulary is a list of drugs that the plan covers. Examples of restrictions are when a plan requires you to get permission before you can get the drug, or when a plan limits the amount of a drug you can get. Having Extra Help allows you to change your drug plan at anytime.
- If you have certain types of retiree coverage you may not need to enroll in a Part D plan. Some retiree plans do not work with Part D, and if you enroll in a Part D plan you may lose your retiree or union coverage. If you have prescription drug insurance through an employer, check with your employer to see if you can get a Part D plan and still keep your current coverage. If you cannot have both, you will want to think carefully about whether you should get a Part D plan, especially if your employer plan covers more than just prescription drugs. This is also important if it covers your spouse or dependents who are not eligible for Medicare coverage. If you choose not to take Part D, you will need to contact your state Medicaid office to find out what steps you should take to decline Part D coverage and still keep your Medicaid.
- If you already had a Part D plan before you qualified for Extra Help, Medicare will not enroll you in another plan. You Part D plan should automatically pay you back for anything you paid above the Extra Help copayment amount after you qualified for Extra Help. You should receive a check in the mail from your plan. If you are in a plan that is above the benchmark amount you may want to consider switching to a plan that is at or below the benchmark amount. If you stay in your plan that is above the benchmark amount, you will have to pay the amount above the benchmark amount.
- Until your Part D coverage starts, the low income newly eligible transition program (LI NET) should cover your prescriptions. LI NET must cover all your prescriptions, at any pharmacy, as long as Medicare allows coverage of them. You should show the pharmacist the green letter from Medicare to prove that LI NET should cover you. You can also use other forms of proof (Best Available Evidence) such as your Medicaid card or a letter from Medicaid.