How to Use Medicare Extra Help to Pay Less for Generic Prescriptions

When you’re on a fixed income and need to take multiple generic medications every month, even a $4.90 copay can feel heavy-if you’re lucky enough to get it. Without Medicare Extra Help, that same pill could cost you $30, $50, or more. The difference isn’t just a few dollars. It’s whether you take your blood pressure medicine, your diabetes pills, or your cholesterol drug at all.

What Medicare Extra Help Actually Covers

Medicare Extra Help, also called the Part D Low-Income Subsidy (LIS), is a federal program that cuts your prescription drug costs to the bone. If you qualify, you pay $0 for your Part D plan premium. You pay $0 for the annual deductible. And for every generic prescription you fill, you pay no more than $4.90 in 2025. That’s it. No hidden fees. No surprise bills.

That’s not a discount. That’s a full reset of how much you pay. Compare that to standard Medicare Part D, where you might pay up to $595 just to start getting coverage, then 25% of the drug’s cost after that. A $50 generic drug would cost you $12.50 after the deductible. With Extra Help? $4.90. For the same drug. Every single time.

And if your income is below 100% of the Federal Poverty Level-meaning you’re also on Medicaid-you pay even less: just $1.60 per generic prescription. That’s less than the price of a coffee.

Who Qualifies for Extra Help in 2025

You don’t need to be broke to qualify, but you do need to be close. For 2025, the income limits are:

• Individual: $23,475 per year
• Married couple living together: $31,725 per year

Your income includes Social Security, pensions, wages, veterans’ benefits, and other regular payments. But it doesn’t include housing assistance, food stamps, or medical treatment costs.

Then there’s your resources-what you own. The limits are:

• Individual: $17,600
• Married couple: $35,130

Resources include bank accounts, stocks, bonds, mutual funds, and IRAs. Your primary home doesn’t count. Neither does your car or personal belongings. You also get a $1,500 allowance for burial expenses that doesn’t count against your total.

That’s it. No gray area. If you make $23,476 and you’re single? You’re out. If you have $17,601 in savings? You’re out. That’s the hard truth. Many people who are barely scraping by still don’t qualify because of this cliff effect.

How It Compares to Paying Full Price

Let’s say you take four generic medications every month. Each one costs $40 at full retail. Without Extra Help:

• You pay $595 deductible first (if your plan has one)
• Then 25% coinsurance: $10 per pill × 12 months × 4 pills = $480
• Plus monthly premium: $40 × 12 = $480
• Total: $1,555 per year

With Extra Help:

• No deductible
• No premium
• $4.90 per pill × 12 months × 4 pills = $235.20
• Total: $235.20 per year

You save $1,320. That’s not a little extra cash. That’s rent. That’s groceries. That’s filling your prescriptions without choosing between them and your heating bill.

How to Apply-and What to Watch Out For

Applying sounds simple. It isn’t. The form is long. The questions are confusing. And if you mess up one line, you get denied.

You can apply:

• Online at ssa.gov
• By phone: 1-800-772-1213
• In person at your local Social Security office

But here’s the secret: don’t do it alone.

State Health Insurance Assistance Programs (SHIPs) offer free, one-on-one help. They’ve seen every mistake. They know what documents you need. They’ll walk you through it. Find yours at shiptacenter.org. Call them. They won’t charge you. They won’t sell you anything.

And if you already get Medicaid, SSI, or a Medicare Savings Program? You’re automatically enrolled. No application needed. But check your mail-sometimes they send a letter confirming it. Don’t ignore it.

The Annual Review Trap

Extra Help isn’t a one-time thing. Every August, you’ll get a form in the mail. It asks for your income and resources for the past year. You have 30 days to return it.

Miss the deadline? Your benefits stop on January 1. No warning. No grace period. Just gone.

People think, “I didn’t get any raises. I’m still poor.” But the system doesn’t care. It only sees what’s on paper. A small Social Security cost-of-living increase? A $300 gift from a grandchild? That could push you over the line.

Set a calendar reminder. Mark August 1. Call your SHIP counselor. Get help filling it out. Don’t risk losing $1,300 in savings because you forgot to mail a form.

What You Can’t Do With Extra Help

Extra Help doesn’t cover everything. It doesn’t change which drugs your Part D plan covers. You still have to check your plan’s formulary. If your doctor prescribes a brand-name drug that’s not on the list, you might pay more-even with Extra Help.

But here’s the good news: Extra Help gives you a special enrollment period. You can switch your Part D plan once a month. So if your meds aren’t covered, you can change plans. You can even request an exception to get a drug covered if your doctor says it’s medically necessary.

Also, Extra Help doesn’t cover non-formulary drugs or over-the-counter medicines. It only works for prescriptions covered under Medicare Part D.

Real Stories From Real People

One man in Ohio, 78, takes six generic pills a day. He was paying $850 a year just in copays before Extra Help. After applying with help from his local SHIP, his cost dropped to $295. He started buying fresh vegetables again. He told his counselor, “I didn’t realize I could eat better if I could just afford my pills.”

A woman in Florida, 82, lost Extra Help because her Social Security increased by $42 a month. She didn’t report it-she didn’t think it mattered. Her copays jumped from $4.90 to $32 per pill. She skipped her heart medication for two months. She ended up in the hospital. Her total bill? $14,000. She got Extra Help back-but only after months of appeals.

These aren’t rare cases. The Medicare Rights Center says 68% of people who get Extra Help say it helped them take their meds regularly. But 42% say the process of keeping it was harder than getting it.

What’s Changing in 2026 and Beyond

The Inflation Reduction Act made insulin capped at $35 a month for all Medicare Part D users-no Extra Help needed. That’s a win.

But the real game-changer might be coming. The Biden administration proposed expanding Extra Help to people earning up to 175% of the Federal Poverty Level. That would raise the income limit to about $28,500 for a single person. That could help over a million more seniors.

Right now, the program covers 15.2 million people-28% of all Medicare Part D enrollees. If expanded, that could jump to 35% by 2027. That’s not just policy. That’s life-changing.

What to Do Now

If you or someone you know is on Medicare and takes generic prescriptions:

1. Check your income and resources against the 2025 limits.
2. If you’re close-apply. Even if you think you’re over, apply anyway. Sometimes the SSA makes exceptions.
3. Call your SHIP. Don’t wait. Don’t guess. Get help.
4. Mark August 1 on your calendar. That’s your renewal date.
5. If you’re already enrolled, double-check your Part D plan’s formulary. Make sure your meds are still covered.

This isn’t about getting a handout. It’s about staying healthy. It’s about not choosing between your medicine and your next meal. Extra Help exists for a reason. And if you qualify, you’re not asking for charity-you’re claiming what you’ve paid for through decades of taxes and contributions.

Don’t let bureaucracy steal your health. Find out if you qualify. Apply. Keep it.