Form Ssa-1020-Inst - General Instructions For Completing The Application For Extra Help With Medicare Prescription Drug Plan Costs

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Social Security Administration
Important Information
THIS COVER LETTER IS FOR INFORMATION ONLY. DO NOT
COMPLETE THE FOLLOWING PAGES. THIS IS NOT AN
APPLICATION.
You may be eligible to get Extra Help paying for your prescription drugs.
The Medicare prescription drug program gives you a choice of prescription plans that offer various
types of coverage. In addition, 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.
But before we can help you, you must fill out this application, put it in the
enclosed envelope and mail it today. Or you may complete an online application at
We will review your application and send you a letter to let you
know if you qualify for Extra Help. To use the Extra Help, you must enroll in a Medicare
prescription drug plan.
If you need help completing the application, call Social Security at 1-800-772-1213
(TTY 1-800-325-0778). You can find more information at
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 by
answering question 15 on this form.
If you need information about Medicare Savings Programs, Medicare prescription drug plans
or how to enroll in a plan, call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048)
or visit 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.
Please mail your application today.
Carolyn W. Colvin
Acting Commissioner
SSA-1020-INST
Form
(01-2014) Recycle prior editions

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