Extra Help is a cost-assistance program that helps you pay for prescription drugs while on Medicare. It works by paying for your Part D premium (up to a state-specific benchmark amount) while lowering the cost of your prescription drugs.

Note: You pay no premium if you have a basic Part D drug plan with a premium at or below the Extra Help premium limit for your area. You will likely still owe a premium if you have an enhanced Part D plan, even if the premium is below the benchmark.

Some extra perks are that if you qualify for Extra Help and have a Part D late enrollment penalty, it will eliminate that fee. It also gives you Special Enrollment Periods to enroll in Part D or switch between plans throughout the year.

You should automatically be enrolled in Extra Help if you have Medicaid, Supplemental Security Income, or a Medicare Savings Program. If that’s not the case for you, you might still be eligible if you have limited assets and your income is below $1,903 per month as an individual or $2,575 as part of a couple.

Apply online through the Social Security Administration or contact the Medicare Rights Center for assistance applying.

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Good news from Medicare! It now covers prescriptions for the oral antiviral COVID-19 treatment, Paxlovid, through the end of 2024. You can access it in a couple of different ways.

If your Part D plan participates in the Paxlovid patient assistance program, you can have your prescription filled free of cost at your pharmacy. Contact your plan to find out if it participates.

If your plan doesn’t participate, or you simply don’t have drug coverage, you can still get Paxlovid at no charge. You’ll just need to enroll in the U.S. Government Patient Assistance Program (USG PAP) operated by Pfizer. 

If you choose a Part D plan, you can search for Paxlovid and add it as a prescription drug when comparing drug plan costs on Medicare’s Plan Finder. This will allow you to choose a drug plan that automatically covers the medication.

If you decide on a drug plan that does not cover Paxlovid, you can still obtain the medication through the USG PAP mentioned above.

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The donut hole—the coverage gap—can be very confusing! Here’s what you need to know:

There are four phases of Part D coverage in 2024: the deductible, initial coverage period, coverage gap (or donut hole), and catastrophic coverage. During the deductible, you are responsible for the full cost of your medications. After you spend a certain amount, set by the plan, you reach the initial coverage period, where your plan pays a portion of your drug costs, and you pay a copay or coinsurance. After your total drug costs (what you have paid and what the plan has paid) reach a certain amount ($5,030 for most plans in 2024), you then enter the donut hole. (Note: If you have Extra Help, the following doesn’t apply to you, as you won’t have a donut hole.)

Once in the donut hole, you’ll be responsible for 25% of the cost of your drugs. You may notice a difference in what you paid for your drugs during your plan’s initial coverage phase and the donut hole. For example, if your drug costs $100 and you paid your plan’s $15 copay while in the initial coverage period, you’ll begin paying $25 for the same drug once you’ve entered the donut hole. 

The donut hole phase ends when you’ve reached an out-of-pocket amount of $8,000 for covered drugs. This will put you into the next phase, called catastrophic coverage, during which you’ll have no cost-sharing for your drugs for the rest of the year. Out-of-pocket costs that count toward this $8,000 limit include:

• Amounts you paid during the deductible period
• What you paid during the initial coverage period
• Almost the full cost of brand-name drugs (including the manufacturer’s discount) purchased during the coverage gap
• Amounts paid by others (family members, charities, and other persons on your behalf)
• Amounts paid by State Pharmaceutical Assistance Programs (SPAPs), AIDS Drug Assistance Programs, and the Indian Health Service
• Some costs do not count towards the $8,000 limit. These include:
• Monthly premiums
• Any amount your plan pays toward drug costs
• Non-covered drug costs
• The cost of covered drugs from pharmacies outside your plan’s network
• The 75% generic discount

Your plan should keep track of how much money you’ve spent out of pocket for covered drugs and your progression through coverage periods. You can find current information in your monthly statements!

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Limits on Drug Costs

Medicare Part D plans have different coverage phases throughout the year. During these coverage phases, you pay different amounts for your drugs. In all Part D plans, you enter the catastrophic coverage phase after you reach $8,000 in out-of-pocket costs for covered drugs. This amount comprises what you pay for covered drugs and some costs that others pay.

In 2024, you have $0 cost-sharing during catastrophic coverage. This means you will not be responsible for any of the cost of your Part D-covered drugs once reaching the catastrophic coverage phase. In the past, you owed 5% of the cost of your covered drugs for the remainder of the year once in this coverage phase.

Note that beginning in 2025, your out-of-pocket drug costs will be capped at $2,000.

Extra Help

Extra Help is a federal program that helps pay for most of the out-of-pocket costs of Medicare prescription drug coverage. You are eligible for the program if your income and assets are below federally set limits. Until 2024, you would qualify for either full or partial Extra Help, depending on your income and assets.

In 2024, the Extra Help program is expanding so that all people with Medicare earning less than 150% of the federal poverty level will be eligible for full Extra Help.

The 2024 income limits have not been released yet. Until they are released, you may qualify based on your 2023 income if you also have limited assets.

The 2023 monthly income limit was $1,843 for individuals and $2,485 for couples.

To actively apply or learn more about eligibility, contact your Social Security Administration branch. Find your local branch or call the national line at 800-772-1213.

 In 2024, those with full Extra Help will pay a low or no premium for their drug plan, a $0 deductible, and $4.50 copayments for generic and $11.20 copayments for brand-name drugs—those with Medicaid pay lower copays.

Drug Savings and COVID-19 Coverage

$35 Insulin

Copays for insulin for people with Medicare are limited to $35 per one month’s supply. This applies to all insulin covered by your Part D plan or under Medicare Part B.

No Cost-Sharing for Vaccines

You owe no copays or deductibles for vaccines covered by your Part D plan, including the shingles and RSV vaccines.

COVID-19 Vaccine

Original Medicare Part B covers COVID-19 vaccines and boosters, regardless of whether you have Original Medicare or a Medicare Advantage Plan. You owe no cost-sharing (deductibles, copayments, or coinsurance).

COVID-19 Testing

COVID-19 testing is covered under Medicare Part B. You pay nothing for the test if you have Original Medicare and see a participating provider or if you have a Medicare Advantage Plan and see an in-network provider.

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A newly effective Inflation Reduction Act (IRA) provision is improving prescription drug affordability for many people with Medicare Part D — but too few know about it, potentially limiting its efficacy.

As of January 1, 2024, Part D enrollees are no longer required to pay 5% coinsurance after they reach the catastrophic threshold. According to a new KFF report, this means that in 2024, Part D enrollees will pay no more than about $3,300 for all brand-name drugs they take. Starting in 2025, out-of-pocket (OOP) drug spending will be capped at an even lower amount, $2,000, indexed annually for growth in Part D costs.

Although 5% may not seem like much, with many drugs priced at $150,000 or more per year, it can add up quickly. Affording thousands of dollars in medication costs a year can be particularly burdensome for people with Medicare, many of whom live on fixed or limited incomes that cannot keep pace with high and rising prescription drug prices.

To illustrate the impact of this coinsurance change, KFF examined three commonly taken cancer drugs, each priced at well over $100,000 a year. In 2023, Medicare Part D enrollees who used any of these drugs for the entire year faced nearly $12,000 in OOP costs. In 2024, their portion will drop by eight to nine thousand dollars. And next year, when the $2,000 cap takes effect, they’ll save even more.

Notably, recent KFF polling finds only a quarter of older adults know about this change to Part D coinsurance rules. This suggests an urgent need for beneficiary outreach and education, as cost concerns may prevent some people from getting the treatment they need. If you or someone you know has questions about navigating or affording Medicare, call the Medicare Rights National Helpline at 800-333-4114, or your local SHIP.

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If your Part D plan covers your medication but your copayment is expensive, it could be that the medication is on a high tier. Part D plans use tiers to categorize prescription drugs. Higher tiers are more expensive and have higher cost-sharing amounts. Each plan sets its tiers, and plans may change their tiers from year to year.

 If you can’t afford your copay, you can ask for a tiering exception by using the Part D appeal process. A tiering exception is a way to request lower cost-sharing. To request a tiering exception, you or your doctor must show that the drugs for the treatment of your condition that are on the lower tiers of your plan’s formulary are ineffective or dangerous for you. Here is some guidance on requesting a tiering exception:

If you are charged a high copay at the pharmacy, talk to your pharmacist and your plan to find out why. If your copay is high because your prescription is on a higher tier than other drugs to treat your condition on the formulary, you can ask for a tiering exception.

Note that you can’t request a tiering exception if the drug you need is in a specialty tier. The specialty tier is limited to drugs above a certain dollar amount and plans may not require more than 33% coinsurance for drugs on this tier.

Ask your plan how to send your tiering exception request. It’s usually helpful to include a letter of support from your prescribing healthcare provider. This letter should explain why similar drugs on the plan’s formulary at lower tiers are ineffective or harmful to you.

If your plan approves your tiering exception request, your drug will be covered at cost-sharing that applies to the lower tier. Normally, an approved exception will be in effect until the end of the current calendar year. If your plan denies your request, it should send you a letter titled Notice of Denial of Medicare Prescription Drug Coverage. You can appeal this decision.

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Extra Help is a federal program that helps pay for some to most of the out-of-pocket costs of Medicare prescription drug coverage. It is also known as the Part D Low-Income Subsidy (LIS).

Extra Help eligibility

If your monthly income is up to $1,843 in 2023 ($2,485 for couples) and your assets are below specified limits, you may be eligible for Extra Help (see the Extra Help income and asset limit chart for details). These limits include a $20 income disregard that the Social Security Administration (SSA) automatically subtracts from your monthly unearned income (e.g., retirement income).

Even if your income or assets are above the eligibility limits, you could still qualify for Extra Help because certain types of income and assets may not be counted, in addition to the $20 mentioned above.

If you are enrolled in Medicaid, Supplemental Security Income (SSI), or a Medicare Savings Program (MSP), you automatically qualify for Extra Help regardless of whether you meet Extra Help’s eligibility requirements. You should receive a purple-colored notice from the Centers for Medicare & Medicaid Services (CMS) informing you that you do not need to apply for Extra Help.

Extra Help benefits

The Extra Help program (also called the Part D Low-Income Subsidy) offers the following benefits:

• Pays for your Part D premium up to a state-specific benchmark amount
• Lowers the cost of your prescription drugs
• Gives you a Special Enrollment Period (SEP) once per calendar quarter during the first nine months of the year to enroll in a Part D plan or to switch between plans (You cannot use the Extra Help SEP during the fourth calendar quarter of the year (October through December). You should use Fall Open Enrollment during this time to make prescription drug coverage changes.)
• Eliminates any Part D late enrollment penalty you may have incurred if you delayed Part D enrollment
• Depending on your income and assets, you may qualify for either full or partial Extra Help. Both programs provide assistance with the cost of your drugs. To receive such assistance, your prescriptions should be on your plan’s formulary and you should use pharmacies in your plan’s network.

Remember that Extra Help is not a replacement for Part D or a plan on its own: You must still have a Part D plan to receive Medicare prescription drug coverage and Extra Help assistance. If you do not choose a plan, you will in most cases be automatically enrolled in one.

Making an Extra Help decision when you have other forms of prescription drug coverage

If you are eligible for Extra Help and already have other creditable drug coverage, you should evaluate your costs and coverage when deciding whether to enroll in Part D and Extra Help or to keep your current drug coverage. Be sure to ask your former employer or union if you can get a Part D plan without losing the retiree benefits you want to keep, and check if disenrolling from retiree drug coverage makes you ineligible for other retiree health benefits. If you cannot have Part D and your retiree benefits, or if keeping both is not cost-effective, think carefully about whether you should get a Part D plan, especially if your retiree plan also covers your spouse or dependents. If you later want Part D, you will have a two-month SEP after you lose creditable coverage.

Finally, those with Medicaid and certain kinds of employer, union, or retiree drug coverage may in some cases not be enrolled in Extra Help or can ask not to be. Contact your local Medicaid office to learn how to decline Part D without losing your Medicaid coverage. If you later want Part D, you can enroll at any time without penalty if you are still enrolled in Medicaid or eligible for Extra Help.

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Medicare covers both inpatient and outpatient mental health care. And Medicare prescription drug plans cover medications used to treat mental health conditions, but be sure to check the formulary to ensure the brands and dosages you take are included.

 Medicare Part B covers outpatient mental health care, including the following services:

• Individual and group therapy
• Substance use disorder treatment
• Tests to make sure you are getting the right care
• Occupational therapy
• Activity therapies, such as art, dance, or music therapy
• Training and education (such as training on how to inject a needed medication or education about your condition)
• Family counseling to help with your treatment
• Laboratory tests
• Prescription drugs that you cannot administer yourself, such as injections that a doctor must give you
• An annual depression screening

 Be sure to ask any provider you see if they take your Medicare insurance before you begin receiving services. If they don’t, you will likely be responsible for the full cost of the care. Psychiatrists are more likely than any other type of physician to opt out of Medicare, meaning Medicare will not cover any of the cost of the care from those doctors. Additionally, not all non-medical providers (like psychologists or clinical social workers) are Medicare-certified. If you need a list of providers near you who accept Medicare, you can go to www.medicare.gov/care-compare. 

 Medicare Part A covers inpatient mental health care that you receive in either a psychiatric hospital (a hospital that only treats mental health patients) or a general hospital. Your provider should determine which hospital setting you need.

If you receive care in a psychiatric hospital, Medicare covers up to 190 days of inpatient care in your lifetime. If you have used your lifetime days but need additional mental health care, Medicare may cover your care at a general hospital.

 Medicare Part D covers most prescription drugs used to treat mental health conditions. You may have Part D coverage through a Medicare Advantage Plan or through a stand-alone Part D plan. All Part D plans must cover at least two drugs from most drug categories and must cover all drugs available in certain categories, including antidepressants and antipsychotic medications.

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It is usually best if someone enrolls in Medicare when they are first eligible. As you mentioned, many people who delay enrolling in Medicare must wait for the General Enrollment Period and then may owe a late enrollment penalty for life.

Beginning this year, though, if someone misses a first-time enrollment period, there are certain situations when they might qualify for exceptional circumstances Special Enrollment Period (SEP).  One of these new SEPs is for people who were released from the custody of a penal authority, including a prison, after January 1, 2023.

To be eligible for this SEP, he would have to:

• Be eligible for Medicare
• Have failed to enroll in Medicare while he was incarcerated
• Be released on or after January 1, 2023

Note that Medicare defines “incarcerated” as individuals who are in the custody of certain authorities, including people under arrest, imprisoned, residing in halfway houses, living under home detention, or confined completely or partially in any way under a penal statute or rule.

• If he is eligible, the SEP lasts for twelve months.
• The SEP starts the day he was released.
• The SEP ends the last day of the twelfth month after his release.

He can choose to have his coverage begin on the first of the month after he signs up, or to have it begin up to six months retroactively (but not before January 1, 2023, or before his release ). If he uses this SEP to enroll in Medicare, he will not owe a late enrollment penalty. To use this SEP, he should contact SSA.

If he then wants to enroll in a Medicare Advantage Plan or stand-alone Part D prescription drug plan, he should contact 1-800-MEDICARE (1-800-633-4227) to learn more about his enrollment period options. He may qualify for a Medicare Advantage or Part D SEP or have other enrollment periods available, depending on when he enrolls in Part B.

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