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

For many seniors on Medicare, the cost of daily medications can feel impossible to manage. A blood pressure pill, a diabetes medicine, a cholesterol reducer - all generics, all essential - but together they add up to hundreds of dollars a month. That’s where Medicare Extra Help comes in. It’s not a fancy program. It doesn’t make headlines. But for over 15 million people, it’s the difference between taking your medicine or skipping it.

What Medicare Extra Help Actually Does for Generic Drugs

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 nothing for your Part D plan premium or deductible. And for every generic prescription you fill, you pay no more than $4.90 - no matter how much the drug actually costs.

That’s not a discount. That’s a full subsidy. A $50 generic pill? You pay $4.90. A $100 generic? Still $4.90. And if you’re also on Medicaid and your income is below 100% of the Federal Poverty Level, you pay just $1.60 per generic.

Compare that to standard Part D coverage in 2025: you’d pay up to $595 just to get started (the deductible), then 25% of the drug’s price after that. For a $50 generic, that’s $12.50 per pill - over 2.5 times what Extra Help costs. If you take 12 generics a month, that’s $748 a year in copays alone - not counting the $595 deductible or your monthly premium. With Extra Help? $705.60 a year total. And you never pay the deductible or premium at all.

Who Qualifies for Extra Help in 2025

It’s not as hard to qualify as you might think - but the rules are strict. For 2025, you’re eligible if your yearly income is under $23,475 as a single person, or $31,725 if you’re married and living with your spouse. Your resources - things like bank accounts, stocks, bonds, and investment properties (but not your home or car) - must be under $17,600 for one person or $35,130 for a couple.

There’s also a $1,500 allowance for burial expenses that doesn’t count against your resource limit. Social Security, pensions, wages, and veterans benefits all count as income. But housing assistance, food stamps, and medical bills don’t.

Here’s the catch: if you make $23,476, you get nothing. No sliding scale. No partial help. Just a hard cutoff. That’s why so many people fall through the cracks. A small raise, a one-time bonus, or even a modest increase in Social Security can knock you out of eligibility. People who are just above the limit often pay more out of pocket than those below it - and they’re not even allowed to apply.

How to Apply - and What Happens If You Miss the Deadline

You don’t have to be a financial expert to apply. You can do it online at SSA.gov, by calling 1-800-772-1213, or by visiting your local Social Security office. If you already get Supplemental Security Income (SSI), Medicaid, or a Medicare Savings Program, you’re automatically enrolled. No paperwork needed.

But if you’re not auto-enrolled, you need to fill out the application. It’s not simple. You’ll need your Social Security number, proof of income (tax returns, benefit letters), and details about your assets. Most people need help. That’s where State Health Insurance Assistance Programs (SHIPs) come in. They’re free, local, and trained to walk you through every step. Find yours at shiptacenter.org.

Once you’re approved, you’ll get a letter from Social Security. But here’s the part most people forget: you have to reapply every year. The review starts in August. You’ll get a form in the mail. You have 30 days to return it. If you don’t? Your Extra Help ends on January 1. No warning. No grace period. Just gone.

One woman in Ohio told her SHIP counselor she missed the deadline because she was sick and didn’t open her mail. She went from paying $4.90 for her insulin to $120 a month. She didn’t know she could call and ask for an extension until it was too late.

What You Can and Can’t Do With Extra Help

Extra Help doesn’t just lower your copays - it gives you flexibility. You can switch your Part D plan once a month, instead of just once a year. That means if your pharmacy changes or a new generic becomes available, you can switch without waiting.

You can also request formulary exceptions more easily. If your doctor says you need a brand-name drug because the generic doesn’t work for you, Extra Help makes it easier to get approval.

But here’s what it doesn’t do: it doesn’t cover drugs that aren’t on your plan’s formulary. You still have to check which generics your plan covers. And it doesn’t cover non-prescription drugs - no vitamins, no over-the-counter pain relievers. And it doesn’t apply to drugs bought outside the U.S.

Also, Extra Help only works with Medicare Part D plans. You can’t use it with Medicare Advantage plans that don’t include drug coverage. Make sure your plan has Part D built in.

Real Stories: The Good, the Bad, and the Unfair

One retired nurse in Florida started paying $4.90 for her heart medication after getting Extra Help. She hadn’t filled her prescription in six months because it cost $70. After approval, she refilled it immediately. Her blood pressure stabilized. She says it saved her life.

But another man in California lost his Extra Help because his Social Security check went up by $42 a month. He made $23,500 instead of $23,475. Suddenly, his $200-a-month generic medications jumped to $1,200 a year in premiums and copays. He had to choose between food and medicine. He chose food.

These aren’t rare cases. A 2024 report from the Medicare Rights Center found that 37% of people who qualify for Extra Help never enroll. Many don’t know it exists. Others are scared of the paperwork. Some think they make too much - even when they don’t.

What’s Changing in 2025 and Beyond

Good news: the Part D coverage gap - the infamous "donut hole" - is gone for Extra Help recipients. You don’t have to hit a spending threshold before your discounts kick in. You’re covered from day one.

Also in 2025, insulin costs are capped at $35 a month for all Medicare beneficiaries - even if you don’t have Extra Help. That’s a big win. But for most other drugs, Extra Help is still your best shot at affordability.

The Biden administration is pushing to raise the income limit to 175% of the Federal Poverty Level - that’s about $28,500 for a single person. If that happens, over a million more seniors could qualify. But until then, the rules stay the same: strict, simple, and unforgiving.

What to Do Next

If you’re on Medicare and take one or more generic prescriptions every month, you should check your eligibility - even if you think you make too much. Many people qualify without realizing it. Use the SSA’s online screening tool at ssa.gov/extrahelp. It takes less than 10 minutes.

If you’re unsure, call your local SHIP. They’ll help you fill out the form. They’ve done it thousands of times. No judgment. No fee. Just help.

And if you already have Extra Help? Don’t ignore that August letter. Set a reminder. Get it in on time. One missed deadline can cost you hundreds - or thousands - in drug costs.

Medicare Extra Help isn’t perfect. The rules are harsh. The system is confusing. But for millions of people, it’s the only thing standing between them and skipping their meds. If you qualify, take it. It’s not a handout. It’s a lifeline.