Application For Help With Medicare Prescription Drug Plan Costs - Social Security Administration


What You Need To Complete The Application For
Help With Medicare Prescription Drug Plan Costs
ocial Security and the Centers for
Documents that will help you
Medicare & Medicaid Services are work-
prepare in advance include:
ing together to get you extra help with your
prescription drug costs. To determine if you
• Statements that show your account bal-
could be eligible for this extra help, Social
ances at banks, credit unions or other
Security will need to know your income
financial institutions;
and the value of your savings, investments
• Investment statements;
and real estate (other than your home). You
• Life insurance policy statements;
may qualify for extra help if you have:
• Stock certificates;
• Limited income (below $14,355 for an
• Tax returns;
individual or $19,245 for a married cou-
ple living together). Even if your annual
• Pension award letters; and
income is higher, you still may be able to
• Payroll slips.
get some help with your monthly premi-
ums, annual deductibles and prescription
How you can get more information
co-payments. Some examples where your
income may be higher include if you or
If you need an application form, contact
your spouse:
Social Security and ask for the Application
for Help with Medicare Prescription Drug
—Support other family members who
Plan Costs (SSA-1020).
live with you;
Beginning July 1, 2005, you also will
—Have earnings from work; or
be able to apply online at
—Live in Alaska or Hawaii; and
• Limited resources (below $10,000 for an
To learn more about the Medicare
individual or $20,000 for a married cou-
prescription drug plan, call
ple living together). These resource lim-
1-800-MEDICARE (1-800-633-4227)
its can be slightly higher (an additional
or visit
$1,500 per person) if you will use some
of your money for burial expenses.
Please continue to the opposite side of the
page to complete the worksheet.
What you need to know
Identify the things you own by yourself,
with your spouse or with someone else, but
do not include your home, vehicles, burial
plots or personal possessions.
Review all your income.
Gather your records in advance to save
Remember that this worksheet is not an
application. This worksheet can assist you
in completing the actual application for
extra help.
What You Need To Complete The Application For
w w w . s o c i a l s e c u r i t y . g o v
Help With Medicare Prescription Drug Plan Costs


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