Medicare Assistance Programs

Medicare Assistance Programs

Need help paying for prescriptions? Medicare Part D Assistance Programs can lower or smooth your drug costs through several options. The big ones are Extra Help (LIS) for low-income subsidies, Medicare Savings Programs (which can auto-qualify you for Extra Help), State Pharmaceutical Assistance Programs (SPAPs), and manufacturer/charity Prescription Assistance Programs (PAPs).

Medicare Assistance Programs Table (2025)

Program	Helps Pay For	Who Qualifies	Where to Apply
Extra Help (LIS)	Premiums, deductibles, copays	Low-income beneficiaries	Social Security
Medicare Savings Programs (MSPs)	Part A & B premiums	Low-income seniors	State Medicaid office
State Pharmaceutical Assistance Programs (SPAPs)	Drug copays or discounts	Varies by state	State program office
Prescription Assistance program (PAPs)	Specific brand-name or specialty drugs	Based on income and need	Manufacturer or nonprofit
IRA Drug/Vaccine Caps	Limits cost of insulin & vaccines	All Part D enrollees	Automatically applied

Extra Help (Low-Income Subsidy - LIS)

MAPD prescription benefits follow the four standard Part D coverage phases, which reset each year.

What It Is:
The Extra Help program (also called the Low-Income Subsidy or LIS) helps qualified Medicare beneficiaries pay for:

Monthly Part D premiums.
Annual deductible.
Copays and coinsurance.
Costs in the coverage gap (donut hole).

It’s administered by the Social Security Administration (SSA) and Medicare.

Eligibility:
You must have:

Medicare Part A and/or Part B.
Live in the U.S.
Limited income and resources.

How to Apply:
You can apply:

📞 By phone: 1-800-772-1213 (Social Security).
💻 Online: www.ssa.gov/extrahelp.
📨 In person: Visit your local Social Security office.
✅ Automatic Enrollment:
You’re automatically enrolled if you already receive:

Medicaid.
Supplemental Security Income (SSI).
Medicare Savings Program (QMB, SLMB, or QI).

Qualification Type	Income Limit (2025)	Resource Limit (2025)
Full Extra Help	≤ $22,590 (individual) / ≤ $30,660 (couple)	≤ $17,220 (individual) / ≤ $34,360 (couple)
Partial Extra Help	Slightly above limits	Slightly above limits

(Income and asset limits adjust yearly; Social Security uses your previous year’s income tax data.)

What You Pay with Extra Help (2025):
If you qualify, you’ll have:

$0 premium (for benchmark plans).
$0 deductible.
$4.50 (generic) / $11.20 (brand-name) maximum copay until the catastrophic cap is reached.
$0 copay after reaching the out-of-pocket maximum.

🔹 Those with Full Extra Help pay nothing for monthly premiums, deductible, or catastrophic coverage.

Medicare Savings Programs (MSPs)

These state-run programs help pay for Medicare Part A and/or B premiums, which can make it easier to afford Part D.

Program	Pays For	Eligibility
QMB (Qualified Medicare Beneficiary)	Part A & B premiums, deductibles, coinsurance	≤ 100% FPL
SLMB (Specified Low-Income Medicare Beneficiary)	Part B premium	100–120% FPL
QI (Qualified Individual)	Part B premium (state-limited funds)	120–135% FPL

Enrolling in one of these programs automatically qualifies you for Full Extra Help for Part D.

State Pharmaceutical Assistance Programs (SPAPs)

Designed for residents age 65+ or with disabilities.
Offers discounts on prescription drugs for low-income individuals who don’t qualify for Medicaid or other help.

Check your state’s availability at:

👉 www.medicare.gov/plan-compare/#/pharmaceutical-assistance-programs

Prescription Assistance Programs (PAPs)

If you don’t qualify for Extra Help or state programs, you may still get help directly from:

Pharmaceutical companies (e.g., Pfizer, AstraZeneca, Lilly Cares).
Nonprofit foundations (e.g., PAN Foundation, NeedyMeds, Patient Access Network).
These programs often cover high-cost specialty drugs or gap costs not paid by Medicare.

Find programs at:
🌐 www.rxassist.org
🌐 www.needymeds.org

IRA Insulin and Vaccine Savings (2025)

Thanks to the Inflation Reduction Act (IRA):

Insulin costs are capped at $35/month for each covered insulin product.
Adult vaccines (like shingles, Tdap, flu, RSV, pneumococcal) are covered at $0 cost under all Part D plans.

Medicare Assistance Programs Table (2025)

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