There are several programs that can help people with low income pay for prescription drugs. Some of these programs coordinate with the Medicare prescription drug benefit (Part D).
- Medicare drug benefit Extra Help. Extra Help is a federal program that helps you pay for some or most of the costs of Medicare prescription drug coverage (Part D). You may be eligible for Extra Help paying for the Medicare prescription drug benefit if your monthly income is up to $1,505 ($2,022 for couples) in 2016 and assets are below specified limits. Even if your income or assets are above the limits you may still qualify because certain types of income and assets may not be counted. You can apply for Extra Help at any time. If you qualify, you can sign up for Part D without penalty, even if you are enrolling after you were first eligible for the benefit.
Note: The above income limits include a $20 income disregard that the Social Security Administration automatically subtracts from your monthly unearned income.
- Medicaid. If your monthly income is below the Medicaid limit, you may be eligible for full drug coverage from Medicaid. If you have both Medicare and Medicaid, you must generally enroll in the Medicare drug benefit (Part D). You will automatically receive Extra Help paying for the benefit and do not have to apply. You will continue to get the rest of your health benefits through Medicaid.
- Medicare Savings Programs. If your income is too high for Medicaid, there are also other government programs called Medicare Savings programs that help pay for your Medicare premiums, coinsurance and deductibles. These can help free up money that you can use to pay for your prescriptions.
If you are enrolled in an MSP or receive Supplemental Security Income (SSI), you also automatically qualify for Extra Help paying for Medicare’s prescription drug benefit (Part D). You do not have to apply for this extra assistance.
- State pharmaceutical assistance programs (SPAPs). Some states have pharmaceutical assistance programs that help save people money on their prescriptions. Some of these programs require that you join a Part D drug plan in order to be eligible (they will generally help you pay for Part D costs).
- Charity programs. There may be some charities that can help reduce your prescription costs. If you have Part D, in some cases, the amount the charity pays counts toward your catastrophic coverage limit for Medicare drug coverage.
- Patient Assistance Programs (PAPs). You may be able to get free or low-cost drugs directly from the company that makes them. Many companies have their own programs. In most cases, your doctor must apply for you. While many patient assistance programs do not allow you to apply if you are eligible for the Medicare drug benefit (Part D), some do.
Generally, PAPs require your doctor to be involved in the application process. You may be required to pay a co-payment. If you have Part D, your PAP co-payments will count toward meeting your Part D plan’s out-of-pocket limit ($4,850 in 2016), but you will need to submit your receipts to your plan, and any other required documentation in order for what you pay to count. What your PAP pays for your prescription drugs will not count toward the $4,850 in out-of-pocket costs that you must spend before catastrophic coverage begins and your drug costs go down significantly.
- Prescription drug discount programs. You may be able to get reduced prices on the medications you need from national and local discount programs. You cannot use a prescription drug discount program and your Part D coverage at the same time. You will have to choose between them at the pharmacy.
If you have Part D, it is best to use your discount card only during your plan’s deductible and coverage gap periods. It is only during these times that what you pay for a drug technically on your Part D plan’s formulary (list of covered drugs) can count toward meeting your out-of-pocket maximum before catastrophic coverage begins. You will need to tell the pharmacist to refill your medication without using your Medicare drug coverage and submit your receipts to your plan, and any other required documentation, in order for this amount to count towards reaching the catastrophic coverage limit. Find out what your plan requires by calling the customer service number listed on the back of your Medicare drug plan insurance card.
- Safety Net providers. Pharmacies in certain government-funded hospitals and community health centers and clinics may provide medication at low cost and charge you based on your income. These centers and clinics include federally qualified health centers (FQHCs) and rural health clinics (RHCs). If you have Part D, some centers may waive copayments for Part D drugs if you request assistance. Talk to the facility nearest you to see if your copayments can be waived, and how the copayments that are waived will count toward reaching catastrophic coverage.