Form i1020 Internet Application for Extra Help with Medicare Prescr

Welcome!, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Welcome!
The Medicare Prescription Drug program gives you a choice of prescription plans that offer various types of
coverage.
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. However, you must be enrolled in a Medicare Prescription
Drug plan to get this extra help.

OMB No. 0960-0696
Paperwork Reduction Act

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm

What Is This Application?

Related Links

This is an application for Extra Help and does not enroll you in a Medicare prescription drug plan. You will
have to enroll directly with an approved Medicare prescription drug provider for coverage. If you need
information about Medicare Prescription Drug plans or how to enroll in a plan, call 1-800-MEDICARE (TTY 1877-486-2048) or visit www.medicare.gov.

Information About This
Application:

Who Should Complete This Application For Extra Help With Medicare
Prescription Drug Plan Costs?
You should complete this application for Extra Help on the Internet if:
You have Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance); and
You live in one of the 50 States or the District of Columbia; and
Your combined savings, investments, and real estate are not worth more than $29,520, if you are married
and living with your spouse, or $14,790 if you are not currently married or not living with your spouse. (Do
NOT count your home, vehicles, personal possessions, life insurance, burial plots, irrevocable
burial contracts or back payments from Social Security or SSI.) If you have more than those
amounts, you may not qualify for the extra help. However, you can still enroll in an approved Medicare
prescription drug plan for coverage.
EXCEPTION: Even if you meet these conditions, DO NOT complete this application if you have Medicare and
Supplemental Security Income (SSI) or Medicare and Medicaid because you automatically will get the extra
help.

How Can You Get The Extra Help?
To get extra help with Medicare Prescription Drug plan costs, you must complete and submit this
application. We will review your application and send you a letter to let you know if you qualify for extra help.
NOTE: To apply, you must live in one of the 50 States or the District of Columbia.
If you need help completing this application, call Social Security toll-free at 1-800-772-1213 (TTY 1-800-3250778).
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 when you complete this application.
If you need information about Medicare Savings Programs, Medicare Prescription Drug plans or how to enroll in
a plan, call 1-800-MEDICARE (TTY 1-877-486-2048) or visit www.medicare.gov.
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.

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Ee001.htm[1/20/2021 11:48:22 AM]

What You Will Need
Other Ways To Apply
How The Online
Application Works
Legal and Official Information:
Internet Security Policy
Medicare Information:
About the Prescription
Drug Program
Official U.S. Government
Medicare Site
Centers For Medicare &
Medicaid Services

Your privacy is important.
For details about our use of
your information, we encourage
you to read our Privacy Act
Statement.

Welcome!, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

What Do You Want To Do?
Apply Now

Return to an Existing Application

Not Sure If You Should Use
This?
Find Out If You Qualify

Privacy Policy
 |  Website Policies & Other Important Information
 |  Site Map

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Ee001.htm[1/20/2021 11:48:22 AM]

Should You Use This Application?, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

OMB No. 0960-0696
Paperwork Reduction Act

Extra Help With Medicare Prescription Drug Plan Costs

Should You Use This Application?

Not everyone will be able to use the online Application For Extra Help With Medicare Prescription Drug Plan
Costs. You must answer a few questions to help determine if you should use this Internet form. Any time
there is a link at the end of a question that says “More Info,” you can follow that link to get help with that
question.
Are you assisting someone (other than your spouse who lives with you) with this application?
More Info
No

Yes
If you are helping another person fill out this application, answer the following questions as if you were the
person.
Did you (or your spouse, if married and living together) get an application in the mail from us?
More Info
No

Yes
Do you (or your spouse, if married and living together) have Medicare?

No

Yes

More Info

Are you (or your spouse, if married and living together) 64 years and 9 months old or older?
More Info
No

Yes
Have you (or your spouse, if married and living together) received Social Security disability
benefits for 24 months; disability benefits based on Lou Gehrig's disease (ALS); or Renal
dialysis treatments or a kidney transplant?
More Info
No

Yes
In which State do you (and your spouse, if married and living together) live?

More Info

--Alabama

What is your marital status?

More Info

--Married - Living Together

Do you have combined savings, investments and real estate worth more than $29,520 if you are
married and living with your spouse; or $14,790 if you are not married or not living with your
spouse?
More Info
Include the things you own by yourself, with your spouse or with someone else. Do NOT count your
home, vehicles, personal possessions, life insurance, burial plots, irrevocable burial contracts or
back payments from Social Security or SSI.
No or Not Sure

Next

Yes

Previous

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Ee002.htm[1/20/2021 11:48:27 AM]

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Welcome Back, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Welcome Back!

Please enter the applicant's Social Security and Reentry Numbers to return to the Application For Extra Help
With Medicare Prescription Drug Plan Costs already started. If you do not have the applicant's Reentry
Number, you will not be able to continue with the application already begun. You may start a new online
application up to three times. If you have a problem using this online application, call our toll-free number at
1-800-772-1213 (TTY 1-800-325-0778) and they will help you. However, Social Security cannot access the
applicant's Reentry Number.
Applicant's Social Security Number (SSN):

Reentry Number:

Next

Previous

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Ee003.html[1/20/2021 11:48:33 AM]

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Save & Exit, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs

Save & Exit
If you want to, you can stop now. Later, you can come back to where you left off and continue with this
application. You can review the parts you already completed and add or change information.

***-**-1212

Applicant's Social Security Number:

96351241

Reentry Number:

Print or save this page so you will have a copy of your Reentry Number.
Print this page

Reentry Instructions
To Come Back To This Application:

1. Go to this website: http://www.socialsecurity.gov/i1020/; and
2. Type in the Applicant's Social Security and Reentry Numbers shown above.

If you lose or forget your Reentry Number, you will have to begin this application again, and you will lose all
the information already entered. You can start a new application up to three times. Social Security can help
you start the process again, but we cannot look up the Reentry Number for you.

Last Date To Complete This Application

You need to complete an application by November 22, 2014; otherwise you may lose benefits.

Important Information

You might have received a notice from us advising you of an earlier time period for filing the application. If
you did, it was because you or someone on your behalf contacted us about filing before you started the
Internet application. Generally, it is to your advantage to file within that earlier period to receive the earliest
filing date.

Continue With This Application

Exit

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Ee004.html[1/20/2021 11:48:37 AM]

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

You Are Not Eligible For The Extra Help, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
You Are Not Eligible For The Extra Help
Based on the information you gave us about your combined savings, investments and real estate, you
are not eligible for extra help. You do not need to complete this application. However, if you need a letter
stating you are not eligible, complete the application. Whether or not you qualify for the extra help, you may still
enroll in an approved Medicare prescription drug plan for coverage. If you need information about Medicare
Prescription Drug plans or how to enroll in a plan, call 1-800-MEDICARE (TTY 1-877-486-2048) or visit
www.medicare.gov .
What You Can Do Next
1. You may begin the application process by selecting Apply Now,
2. You may go back to make changes by selecting Previous, or
3. You may Exit this application.
If you select Apply Now, you will get a Reentry Number after you fill in your name and address. If you choose to
Exit this application before it is complete, you may use your Reentry Number at any time to come back. You will
also be able to change your answers later.
What You Will Need
If you decide to complete this application, we will ask about your income (and your spouse's income, if married
and living together) and the things that you and your spouse own. Documents that may help you prepare
include:
Social Security card;
bank account statements, including checking, savings, and certificates of deposit;
Individual Retirement Accounts (IRAs), stocks, bonds, savings bonds, mutual funds, other investment
statements;
tax returns;
payroll slips; and
your most recent Social Security benefits award letters or statements for Railroad Retirement benefits,
Veterans benefits, pensions and annuities.
If you do not have these documents, provide us with your best estimate so that we can tell you whether you are
likely to qualify for extra help with your prescription drug costs. This information is to help you complete the
application. You will not have to submit the documents unless contacted by a Social Security representative.

Apply Now

Previous

Exit

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Ee005a.html[1/20/2021 11:48:40 AM]

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Preparing To Find Out If You Qualify, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Preparing To Find Out If You Qualify
Do not use your browser's Back button.
To go back, select Previous at the bottom of the page.
What information will you need?
To determine if you could be eligible for extra help with prescription drug plan costs, Social Security needs
information about your (and your spouse's, if married and living together) income and resources. Documents
that may help you prepare include:
Social Security card;
bank account statements, including checking, savings, and certificates of deposit;
Individual Retirement Accounts (IRAs), stocks, bonds, savings bonds, mutual funds, other investment
statements;
tax returns;
payroll slips; and
your most recent Social Security benefits award letters or statements for Railroad Retirement benefits,
Veterans Benefits, pensions and annuities.
If you do not have these documents, provide us with your best estimate so that we can tell you whether you are
likely to qualify for extra help with your prescription drug costs. This information is to help you complete the
application. You will not have to submit the documents unless contacted by a Social Security representative.
You may apply regardless of the Qualifier results. If you apply right away, the information you enter will be
saved in the application. Whatever you enter here will not affect your benefits or the application decision; you
can change your financial information when you enter the application.
What if you need to stop and come back later?
If you select Apply Now, you will get a Reentry Number after you fill in your name and address. If you choose to
Save & Exit this application before it is complete, you may use your Reentry Number at any time to come back.
You will also be able to change your answers later.
Can you edit your information?
When you have completed the application, you will get a full summary of the information you entered. You can
make changes if necessary prior to submission. After you submit the application electronically, you will be able
to print or save a receipt, and your submitted application.
How long can you work on each page?
For security reasons, there are time limits on each page. You will receive a warning after 25 minutes but you
can extend your time on that page. After the third warning on a page, you must move to another page or your
time will run out and all your work on that page will be lost.
If you have turned JavaScript off in your browser, you will not receive these warnings and, after 30 minutes on a
page, you must go to another page or your application session will end, and your work on the last page will be
lost.
If you are unsure about how to use this application, you can find more details on the following pages:
How the Online Application Works

Next

Previous

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Ee006a.html[1/20/2021 11:48:43 AM]

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm

Preparing To Use This Application, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Preparing To Use This Application
Do not use your browser's Back button.
To go back, select Previous at the bottom of the page.
What information will you need?
To determine if you could be eligible for extra help with prescription drug plan costs, Social Security needs
information about your (and your spouse's, if married and living together) income and resources. Documents
that may help you prepare include:
Social Security card;
bank account statements, including checking, savings, and certificates of deposit;
Individual Retirement Accounts (IRAs), stocks, bonds, savings bonds, mutual funds, other investment
statements;
tax returns;
payroll slips; and
your most recent Social Security benefits award letters or statements for Railroad Retirement benefits,
Veterans benefits, pensions and annuities.
If you do not have these documents, provide us with your best estimate so that we can tell you whether you are
likely to qualify for extra help with your prescription drug costs. This information is to help you complete the
application. You will not have to submit the documents unless contacted by a Social Security representative.
What if you need to stop and come back later?
If you select Apply Now, you will get a Reentry Number after you fill in your name and address. If you choose to
Save & Exit this application before it is complete, you may use your Reentry Number at any time to come back.
You will also be able to change your answers later.
Can you edit your information?
When you have completed the application, you will get a full summary of the information you entered. You can
make changes if necessary prior to submission. After you submit the application electronically, you will be able
to print or save a receipt, and your submitted application.
How long can you work on each page?
For security reasons, there are time limits on each page. You will receive a warning after 25 minutes but you
can extend your time on that page. After the third warning on a page, you must move to another page or your
time will run out and all your work on that page will be lost.
If you have turned JavaScript off in your browser, you will not receive these warnings and, after 30 minutes on a
page, you must go to another page or your application session will end, and your work on the last page will be
lost.
If you are unsure about how to use this application, you can find more details on the following pages:
How the Online Application Works

Next

Previous

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Ee006b.html[1/20/2021 11:48:47 AM]

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm

About You And Your Spouse, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Complete Application

Review

Submit

Print Receipt

About You And Your Spouse
We need some basic information about how to contact you and your spouse in case we have any questions
about this application. Once you complete all the information on this page, we will provide you with a reentry
number and you will be able to exit the application and return to complete it later.

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

About You
Your Name:
More Info
Enter your name as it appears on your most recent Social Security card.
First

M.I.

---

Last

Jr.
Suffix

Your Social Security Number (SSN):

What is your date of birth?

--January
Month

Day

More Info

More Info

Year

Have you worked in 2014 or 2015

No

Yes

More Info

About Your Spouse
Spouse's Name:
More Info
Enter your spouse's name as it appears on his or her most recent Social Security card.
First

M.I.

---

Last

Jr.
Suffix

Spouse's Social Security Number (SSN):

What is your spouse's date of birth?

--January
Month

Day

More Info

More Info

Year

Has your spouse worked in 2014 or 2015?

No

Yes

More Info

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc001a.html[1/20/2021 11:48:50 AM]

About You And Your Spouse, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Contact Information
We have changed our address within the last three months.
Your Mailing Address:

More Info

Street Line 1:
Add More Lines

Street Line 2:
City/Town:

State:

ZIP Code:

--Alabama

Your Phone Number:

More Info

10-digit Number

Other Information
If your spouse has Medicare (or expects to have it in the next three months), does he or she
also wish to apply?
More Info
No

Yes
Do you have combined savings, investments and real estate worth more than $27,250?
More
Info
Include the things you own by yourself, with your spouse, or with another person.Do NOT count your
home, vehicles, personal possessions, life insurance, burial plots, irrevocable burial contracts
or back payments from Social Security or SSI.
No or Not Sure

Yes

If you selected YES, you are not eligible for the Extra Help. But, your State may be able to help you with
your Medicare costs through their Medicare Savings Programs. To start your application process for
Medicare Savings Programs, please see the information below.
Information about Medicare Savings Programs: You may be able to get help from your State with your
Medicare costs under the Medicare Savings Programs. To start your application process for the Medicare
Savings Programs, Social Security will send information from this form to your State unless you tell us not to.
If you want help from the Medicare Savings Programs, do not complete the question below. Just
complete and submit your application and your State will contact you.
If you are not interested in filing for the Medicare Savings Programs, please select below.
No, do not send the information to the State.
OPTIONAL: If you want us to contact someone else if we have additional questions, please provide
the person's name and a daytime phone number.
More Info
Contact Person's Name:
First

Last

Contact's Phone Number:

More Info

10-digit Number

Next

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc001a.html[1/20/2021 11:48:50 AM]

About You, Step 2 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

About You

We need some basic information about how to contact you in case we have any questions about this
application. Once you complete all the information on this page, we will provide you with a reentry number
and you will be able to exit the application and return to complete it later.
Your Name:
More Info
Enter your name as it appears on your most recent Social Security card.
---

First

M.I.

Jr.
Suffix

Last

Your Social Security Number (SSN):

What is your date of birth?

--January

Month

Print Receipt

Day

More Info

More Info

Year

Have you worked in 2020 or 2021?

No

Yes

More Info

Contact Information
I have changed my address within the last three months.
Your Mailing Address:

More Info

Street Line 1:
Street Line 2:

Add Line

City/Town:

State:

ZIP Code:

----

Alabama

Your Phone Number:

More Info

10-digit Number

Other Information
OPTIONAL: If you want us to contact someone else if we have additional questions, please provide
the person's name and a daytime phone number.
More Info
Contact Person's Name:

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/MC001b.htm[1/20/2021 11:48:53 AM]

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

About You, Step 2 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

First

Last

Contact's Phone Number:

More Info

10-digit Number
Do you have combined savings, investments and real estate worth more than $14,790?
More
Info
Include the things you own by yourself or with another person.Do NOT count your home, vehicles,
personal possessions, life insurance, burial plots, irrevocable burial contracts or back payments
from Social Security or SSI.
No or Not Sure

Yes

If you selected YES, you are not eligible for the Extra Help. But, your State may be able to help you with
your Medicare costs through the Medicare Savings Programs. To start your application process for Medicare
Savings Programs, please see the information below.
Information about Medicare Savings Programs: You may be able to get help from your State with your
Medicare costs under the Medicare Savings Programs. To start your application process for the Medicare
Savings Programs, Social Security will send information from this form to your State unless you tell us not to.
If you want help from the Medicare Savings Programs, do not complete the question below. Just
complete and submit your application and your State will contact you.
If you are not interested in filing for the Medicare Savings Programs, please select below.
No, do not send the information to the State.

Next

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/MC001b.htm[1/20/2021 11:48:53 AM]

About The Person Completing The Form And The People You Are Helping, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Text Size

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Complete Application

Review

Submit

Print Receipt

About The Person Completing The Form And The People You Are Helping
We need some basic information about how to contact you and the people you are helping in case we have
any questions about this application. Once you complete all the information on this page, we will provide you
with a reentry number and you will be able to exit the application and return to complete it later.

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

About The Person Completing The Form
Form Completer's Name:
Form

First

Completer

M.I.

Last

Relationship to Applicant:

More Info

Family
Member
Family Member
Friend

If other, please indicate:

Form Completer's Phone Number:

More Info

1112223344

10-digit Number
Form Completer's Address:

Street Line 1:

More Info

123 Main Street

Add More Lines

Street Line 2:
City/Town:
Anywhere

State:
Maryland
Maryland
Massachusetts

ZIP Code:
34567

About The Person You Are Helping
Primary Applicant's Name:
John
Doe
Primary Applicant's Social Security Number (SSN):
743382701
What is the primary applicant's date of birth?
January 1, 1900
Has the primary applicant worked in 2014 or 2015?
More Info
Note: Changing your answer may delete information you have provided about this question or require
you to provide additional information.

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc001c.html[1/20/2021 11:48:57 AM]

About The Person Completing The Form And The People You Are Helping, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

No

Yes

If the spouse has Medicare (or expects to have it in the next three months), does he or she also
wish to apply?
More Info
No

Yes
Do the applicants have combined savings, investments and real estate worth more than
$27,250?
More Info
Include the things owned by the primary applicant seperately, jointly with his or her spouse, or with
another person. Do NOT count the home they live in, vehicles, personal possessions, life
insurance, burial plots, irrevocable burial contracts or back payments from Social Security or
SSI.
No or Not Sure

Yes

If you selected YES, they are not eligible for the Extra Help. But, their State may be able to help them with
their Medicare costs through their Medicare Savings Programs. To start their application process for
Medicare Savings Programs, please see the information below.
Information about Medicare Savings Programs: The applicants may be able to get help from their State
with their Medicare costs under the Medicare Savings Programs. To start their application process for the
Medicare Savings Programs, Social Security will send information from this form unless they tell us not to. If
they want help from the Medicare Savings Programs, do not complete the question below. Just
complete and submit the application and their State will contact them.
If they are not interested in filing for the Medicare Savings Programs, please select below.
No, do not send the information to the State.

About The Applicant's Spouse
Spouse's Name:
Jane
Doe
Spouse's Social Security Number (SSN):
743382201
What is the spouse's date of birth?
February 2, 1901
Has the applicant's spouse worked in 2014 or 2015?
More Info
Note: Changing your answer may delete information you have provided about this question or require
you to provide additional information.
No

Yes

Applicant's Contact Information
The applicant has changed his/her address within the last three months.
Mailing Address:
More Info
Street Line 1: 123 Main Street
Add More Lines

Street Line 2:
City/Town:

State:
Maryland
Maryland

Anywhere

ZIP Code:
34567

Massachusetts

Phone Number:

More Info

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc001c.html[1/20/2021 11:48:57 AM]

About The Person Completing The Form And The People You Are Helping, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security
5405559876

10-digit Number

Other Information
OPTIONAL: If you want us to contact someone else if we have additional questions, please provide
the person's name and a daytime phone number.
More Info
Contact Person's Name:
First

Last

Contact's Phone Number:

More Info

10-digit Number

Next

Save & Exit

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc001c.html[1/20/2021 11:48:57 AM]

About The Person Completing The Form And The Person You Are Helping, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Complete Application

Review

Submit

Print Receipt

About The Person Completing The Form And The Person You Are Helping
We need some basic information about how to contact you and the person you are helping in case we have
any questions about this application. Once you complete all the information on this page, we will provide you
with a reentry number and you will be able to exit the application and return to complete it later.

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

About The Person Completing The Form
Form Completer's Name:
First

M.I.

Last

Relationship to Applicant:

More Info

--Family Member

If other, please indicate:

Form Completer's Phone Number:

More Info

10-digit Number
Form Completer's Address:

More Info

Street Line 1:
Add More Lines

Street Line 2:
City/Town:

State:

ZIP Code:

--Alabama

About The Person You Are Helping
Applicant's Name:
More Info
Enter the name as it appears on the applicant's most recent Social Security card.
First

M.I.

---

Last

Jr.
Suffix

Applicant's Social Security Number:

More Info

What is the applicant's date of birth?

More Info

--January
Month

Day

Year

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc001d.html[1/20/2021 11:49:01 AM]

About The Person Completing The Form And The Person You Are Helping, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Has the applicant worked in 2014 or 2015?

No

Yes

More Info

Applicant's Contact Information
The applicant has changed his/her address within the last three months.
Mailing Address:

More Info

Street Line 1:
Add More Lines

Street Line 2:
City/Town:

State:

ZIP Code:

---

Alabama

Phone Number:

More Info

10-digit Number

Other Information
OPTIONAL: If you want us to contact someone else if we have additional questions, please provide
the person's name and a daytime phone number.
More Info
Contact Person's Name:
First

Last

Contact's Phone Number:

More Info

10-digit Number
Does the applicant have combined savings, investments and real estate worth more than
More Info
$13,640?
Include the things the applicant owns separately or with another person. Do NOT count the home he
or she lives in, vehicles, personal possessions, life insurance, burial plots, irrevocable burial
contracts or back payments from Social Security or SSI.
No or Not Sure

Yes

If you selected YES, the applicant is not eligible for the Extra Help. But, his or her State may be able to help
him or her with their Medicare costs through their Medicare Savings Programs. To start his or her application
process for Medicare Savings Programs, please see the information below.
Information about Medicare Savings Programs: The applicant may be able to get help from his or her
State with his or her Medicare costs under the Medicare Savings Programs. To start his or her application
process for the Medicare Savings Programs, Social Security will send information from this form to his or her
State unless they tell us not to. If the applicant wants help from the Medicare Savings Programs, do not
complete the question below. Just complete and submit the application and the State will contact the
applicant.
If the applicant is not interested in filing for the Medicare Savings Programs, please select below.
No, do not send the information to the State.

Next

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc001d.html[1/20/2021 11:49:01 AM]

Print The Re-entry Number, Step 2 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

Print The Re-entry Number
Before going any further, we are giving you a Reentry Number. If you get disconnected, or if you decide
to continue the application later, you will need this number. It will let you come back to the application
and continue where you left off without losing any information you already entered.
Applicant's Social Security Number:

Re-entry Number:

***-**-3456

65647326

Print or save this page so you will have a copy of your Reentry Number.
Print this page

Reentry Instructions
To Come Back To This Application:

1. Go to this website: http://www.socialsecurity.gov/i1020; and
2. Type in the Social Security and Reentry Numbers shown above.

If you lose or forget your Reentry Number, you will have to begin this application again, and you will lose all
the information already entered. You can start a new application up to three times. Social Security can help
you start the process again, but we cannot look up the Reentry Number for you.

Last Date To Complete This Application

You need to complete an application by March 14, 2021; otherwise you may lose benefits.

Important Information

You might have received a notice from us advising you of an earlier time period for filing the application. If
you did, it was because you or someone on your behalf contacted us about filing before you started the
Internet application. Generally, it is to your advantage to file within that earlier period to receive the earliest
filing date.

Next

Print Receipt

Save & Exit

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/MC002.htm[1/20/2021 11:49:06 AM]

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

About Your Living Situation, Step 2 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

About Your Living Situation
For this question, a relative is someone related to you by blood, adoption, or marriage. How
many relatives live with you and depend on you for at least one-half of their financial support?
Please do not include yourself in the number you enter. If your household consists only of you,
enter “0”.
More Info
We ask this because your household size may affect the amount of help you can get.
0

Next

Previous

Save & Exit

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/MC003.htm[1/20/2021 11:49:09 AM]

Print Receipt

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

About Your And Your Spouse's Living Situation, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Complete Application

Review

Submit

Print Receipt

About Your And Your Spouse's Living Situation
For this question, a relative is someone related to you by blood, adoption, or marriage (but not
including your spouse). How many relatives live with you and depend on you or your spouse for
at least one-half of their financial support? Please do not include yourself or your spouse in the
number you enter. If your household consists only of you and your spouse, enter “0”.
More
Info
We ask this because your household size may affect the amount of help you can get.

Next

Previous

Save & Exit

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc003a.html[1/20/2021 11:49:15 AM]

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Wages And Earnings, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Complete Application

Review

Submit

Print Receipt

Wages And Earnings

To qualify for extra help with your prescription drug costs, we need to know your and your spouse's
combined income, including wages and self-employment income. However, if your spouse lives at a different
address permanently, like a nursing home, we do not count your spouse's income when we determine your
eligibility for extra help.
Have you worked in 2014 or 2015?

No

Yes

More Info

Has your spouse worked in 2014 or 2015?

No

Yes

Need Help?

More Info

Do you expect to earn wages this calendar year?

No

Yes

More Info

Does your spouse expect to earn wages this calendar year?

No

Yes

More Info

What do you expect your net earnings from self-employment to be this calendar year?

Info
None

Net EARNINGS

Net LOSS

More

What does your spouse expect the net earnings from self-employment to be this calendar year?
More Info
None

Net EARNINGS

Net LOSS
Have these wages or self-employment earnings decreased in the last two years?

No

Yes

More Info

Have you stopped working in 2014 or 2015, or plan to stop working in 2015 or 2016?

Info
No

Yes

More

Has your spouse stopped working in 2014 or 2015, or plan to stop working in 2015 or 2016?
More Info
No

Yes
Does your spouse have to pay for things related to a disability or blindness that enable him or
her to work?
More Info
We will only count part of your spouse's earnings towards the income limit if your spouse works and
receives Social Security benefits based on a disability or blindness and has work-related expenses for
which he/she is not reimbursed. Examples of such expenses are: the cost of medical treatment and
drugs for AIDS, cancer, depression or epilepsy; a wheelchair; personal attendant services; vehicle
modification, driver assistance, or other special work-related transportation needs; work-related
assistive technology; guide dog expenses; sensory and visual aids; and Braille translations.
No

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm

Yes

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc004a_WITH.html[1/20/2021 11:49:21 AM]

Wages And Earnings, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Next

Previous

Save & Exit

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Wages And Earnings, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Complete Application

Review

Submit

Print Receipt

Wages And Earnings

To qualify for extra help with your prescription drug costs, we need to know your and your spouse's
combined income, including wages and self-employment income. However, if your spouse lives at a different
address permanently, like a nursing home, we do not count your spouse's income when we determine your
eligibility for extra help.
Have you worked in 2014 or 2015?

No

Yes

More Info

Has your spouse worked in 2014 or 2015?

No

Yes

Need Help?

More Info

Do you expect to earn wages this calendar year?

No

Yes

More Info

What do you expect your net earnings from self-employment to be this calendar year?

Info
None

Net EARNINGS

Net LOSS
Have these wages or self-employment earnings decreased in the last two years?

No

Yes

Previous

Save & Exit

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc004a_Without.html[1/20/2021 11:49:26 AM]

More

More Info

Have you stopped working in 2014 or 2015, or plan to stop working in 2015 or 2016?

Info
No

Yes

Next

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm

More

Wages And Earnings, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Complete Application

Review

Submit

Print Receipt

Wages And Earnings

To qualify for extra help with Medicare prescription drug plan costs, we need to know your income, including
wages and self-employment income.
Have you worked in 2014 or 2015?

No

Yes

More Info

Do you expect to earn wages this calendar year?

No

Yes

Need Help?
More Info

What do you expect your net earnings from self-employment to be this calendar year?

Info
None

Net EARNINGS

Net LOSS
Have these wages or self-employment earnings decreased in the last two years?

No

Yes

More

More Info

Have you stopped working in 2014 or 2015, or plan to stop working in 2015 or 2016?

Info
No

Yes

More

Do you have to pay for things related to a disability or blindness that enable you to work?
More Info
We will only count part of your earnings toward the income limit if you work and receive Social Security
benefits based on a disability or blindness and you have work-related expenses for which you are not
reimbursed. Examples of such expenses are: the cost of medical treatment and drugs for AIDS,
cancer, depression or epilepsy; a wheelchair; personal attendant services; vehicle modification, driver
assistance, or other special work-related transportation needs; work-related assistive technology; guide
dog expenses; sensory and visual aids; and Braille translations.
No

Next

Yes

Previous

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm

Save & Exit

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc004b_WITH.html[1/20/2021 11:49:30 AM]

Income Other Than Wages And Earnings, Step 2 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

Print Receipt

Income Other Than Wages And Earnings

If you receive income from any of the sources listed below, please enter the total amount you receive
each month. If the amount changes from month to month or you do not receive it every month, enter the
average monthly income for the past year for each type in the appropriate fields.
Do NOT list wages and self-employment, interest income, public assistance, medical reimbursements or
foster care payments here. If you do not receive income from a source listed below, select No for that
source.
If you need help adding your pensions or annuities, select Add Pensions Or Annuities. If you need help
adding your other income, select Add Other Income. The total dollar amount calculated will appear in the
dollar amount field on this page when Add And Use Total is selected on the page calculating the totals.
Do you receive Social Security benefits?

No

Yes

More Info

Do you receive Railroad Retirement benefits?

No

Yes
Do you receive Veterans benefits?

No

Yes

More Info

More Info

Do you receive income from other pensions or annuities?
More Info
(Do NOT include annuities from certificates of deposit, stocks, bonds, mutual funds, Individual
Retirement Accounts (IRAs) or any other investments.)
No

Yes

Do you receive other income not listed above, including alimony, net rental income, workers'
compensation, unemployment, private or State disability payments, etc.?
More Info
(Do NOT include help with rent or utilities, money you have in bank accounts, stocks, bonds, savings
bonds, mutual funds, Individual Retirement Accounts (IRAs) or any similar investments, or any cash at
home or anywhere else.)
No

Yes

Has any of the income from these sources decreased in the last two years?

No

Yes

Next

Previous

Save & Exit

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/MC005.htm[1/20/2021 11:49:33 AM]

More Info

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Income Other Than Wages And Earnings, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Text Size

Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Complete Application

Review

Submit

Print Receipt

Income Other Than Wages And Earnings

If you or your spouse receive income from any of the sources listed below, please enter the total
amount you receive each month. If the amount changes from month to month or you do not receive it
every month, enter the average monthly income for the past year for each type in the appropriate fields.
Do NOT list wages and self-employment, interest income, public assistance, medical reimbursements or
foster care payments here. If you do not receive income from a source listed below, select No for that
source.
If you need help adding your pensions or annuities, select Add Pensions Or Annuities. If you need help
adding your other income, select Add Other Income. The total dollar amount calculated will appear in the
dollar amount field on this page when Add And Use Total is selected on the page calculating the totals.
Do you receive Social Security benefits?

No

Yes

More Info

Does your spouse receive Social Security benefits?

No

Yes
Do you receive Railroad Retirement benefits?

No

Yes

More Info

More Info

Does your spouse receive Railroad Retirement benefits?

No

Yes
Do you receive Veterans benefits?

No

Yes

More Info

More Info

Does your spouse receive Veterans benefits?

No

Yes

More Info

Do you receive income from other pensions or annuities?
More Info
(Do NOT include annuities from certificates of deposit, stocks, bonds, mutual funds, Individual
Retirement Accounts (IRAs) or any other investments.)
No

Yes

Does your spouse receive income from other pensions or annuities?
More Info
(Do NOT include annuities from certificates of deposit, stocks, bonds, mutual funds, Individual
Retirement Accounts (IRAs) or any other investments.)
No

Yes

Do you receive other income not listed above, including alimony, net rental income, workers'
compensation, unemployment, private or State disability payments, etc.?
More Info
(Do NOT include help with rent or utilities, money you have in bank accounts, stocks, bonds, savings
bonds, mutual funds, Individual Retirement Accounts (IRAs) or any similar investments, or any cash at
home or anywhere else.)
No

Yes

Does your spouse receive other income not listed above, including alimony, net rental income,
workers' compensation, unemployment, private or State disability payments, etc.?
More Info
(Do NOT include help with rent or utilities, money you have in bank accounts, stocks, bonds, savings

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc005a.html[1/20/2021 11:49:39 AM]

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Income Other Than Wages And Earnings, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

bonds, mutual funds, Individual Retirement Accounts (IRAs) or any similar investments, or any cash at
home or anywhere else.)
No

Yes

Has any of the income from these sources decreased in the last two years?

No

Yes

Next

Previous

Save & Exit

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc005a.html[1/20/2021 11:49:39 AM]

More Info

Income Other Than Wages And Earnings, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Complete Application

Review

Submit

Print Receipt

Income Other Than Wages And Earnings

If you receive income from any of the sources listed below, please enter the total amount you receive
each month. If the amount changes from month to month or you do not receive it every month, enter the
average monthly income for the past year for each type in the appropriate fields.
Do NOT list wages and self-employment, interest income, public assistance, medical reimbursements or
foster care payments here. If you do not receive income from a source listed below, select No for that
source.
If you need help adding your pensions or annuities, select Add Pensions Or Annuities. If you need help
adding your other income, select Add Other Income. The total dollar amount calculated will appear in the
dollar amount field on this page when Add And Use Total is selected on the page calculating the totals.
Do you receive Social Security benefits?

No

Yes

More Info

Do you receive Railroad Retirement benefits?

No

Yes
Do you receive Veterans benefits?

No

Yes

More Info

More Info

Do you receive income from other pensions or annuities?
More Info
(Do NOT include annuities from certificates of deposit, stocks, bonds, mutual funds, Individual
Retirement Accounts (IRAs) or any other investments.)
No

Yes

Do you receive other income not listed above, including alimony, net rental income, workers'
compensation, unemployment, private or State disability payments, etc.?
More Info
(Do NOT include help with rent or utilities, money you have in bank accounts, stocks, bonds, savings
bonds, mutual funds, Individual Retirement Accounts (IRAs) or any similar investments, or any cash at
home or anywhere else.)
No

Yes

Has any of the income from these sources decreased in the last two years?

No

Yes

Next

Previous

Save & Exit

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc005b.html[1/20/2021 11:49:45 AM]

More Info

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Resources, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Complete Application

Review

Submit

Print Receipt

Resources
Please enter the money amounts of all bank accounts, investments or cash that either you, your spouse, or
both of you own. Also include items that either of you own with another person.
If you need help adding your bank accounts, select Add Accounts. If you need help adding your investments,
select Add Investments. The total dollar amount calculated will appear in the dollar amount field on this page
when Add And Use Total is selected on the page calculating the totals.
Do you or your spouse have bank accounts (checking, savings and certificates of deposit)?
More Info
No

Yes
Do you or your spouse have stocks, bonds, savings bonds, mutual funds, Individual Retirement
More Info
Accounts (IRAs) or other similar investments?
No

Yes
Do you or your spouse have any other cash at home or anywhere else?

No

Yes

More Info

Will some money from any of the sources listed above be used to pay for your funeral or burial
expenses?
More Info
This includes any bank accounts, investments, and cash that you listed.
If Yes, skip to the next question. If no, select No and then go to the next question.
No
Will some money from any of the sources listed above be used to pay for your spouse's funeral
or burial expenses?
More Info
This includes any bank accounts, investments, and cash that you listed.
If Yes, skip to the next question. If no, select No and then go to the next question.
No
Other than your home and the property on which it is located, do you or your spouse own any
real estate?
More Info
Examples of other real estate are summer homes, rental properties or undeveloped land you own
which is separate from your home.
No

Next

Yes

Previous

Save & Exit

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc006a.html[1/20/2021 11:49:49 AM]

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Resources, Step 2 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

Print Receipt

Resources
Please enter the money amounts of all bank accounts, investments or cash that you own. Also include items
that you own with another person.
If you need help adding your bank accounts, select Add Accounts. If you need help adding your investments,
select Add Investments. The total dollar amount calculated will appear in the dollar amount field on this page
when Add And Use Total is selected on the page calculating the totals.
Do you have bank accounts (checking, savings and certificates of deposit)?

No

Yes

More Info

Do you have stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts (IRAs)
More Info
or other similar investments?
No

Yes
Do you have any other cash at home or anywhere else?

No

Yes

More Info

Will some money from any of the sources listed above be used to pay for your funeral or burial
expenses?
More Info
This includes any bank accounts, investments, and cash that you listed.
If Yes, skip to the next question. If no, select No and then go to the next question.
No
Other than your home and the property on which it is located, do you own any real estate?
More Info
Examples of other real estate are summer homes, rental properties or undeveloped land you own which
is separate from your home.
No

Next

Yes

Previous

Save & Exit

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/MC006b.htm[1/20/2021 11:49:52 AM]

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Tool: Add Up Your Accounts, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Text Size

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Complete Application

Review

Submit

Print Receipt

Tool: Add Up Your Accounts
We have provided a tool to help you accurately calculate the total value of your bank accounts. Enter the
appropriate amounts and we will calculate it for you.
Note: Once you leave this page, this tool will not save the individual amounts.

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Bank Accounts: Checking Accounts
Checking Account 1:
$
Checking Account 2:
$
Checking Account 3:
$
Checking Account 4:
$

Bank Accounts: Savings Accounts
Savings Account 1:
$
Savings Account 2:
$
Savings Account 3:
$
Savings Account 4:
$

Bank Accounts: Certificates of Deposit (CD)
Certificate of Deposit Account 1:
$
Certificate of Deposit Account 2:
$

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc007a.html[1/20/2021 11:49:56 AM]

Tool: Add Up Your Accounts, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Certificate of Deposit Account 3:
$
Certificate of Deposit Account 4;
$

Add And Use Total

Cancel

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc007a.html[1/20/2021 11:49:56 AM]

Tool: Add Up Your Investments, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Text Size

| Accessibility Help

Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Complete Application

Review

Submit

Print Receipt

Tool: Add Up Your Investments
We have provided a tool to help you accurately calculate the total value of your investments. Enter the
appropriate amounts and we will calculate it for you.
Note: Once you leave this page, this tool will not save the individual amounts.

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Investments: Stocks, Bonds, Savings Bonds, Mutual Funds, Individual Retirement Accounts (IRAs)
Investment Type 1:
$
Investment Type 2:
$
Investment Type 3:
$
Investment Type 4:
$
Investment Type 5:
$
Investment Type 6:
$
Investment Type 7:
$
Investment Type 8:
$

Add And Use Total

Cancel

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc007b.html[1/20/2021 11:50:00 AM]

Tool: Add Up Your Other Pensions And Annuities, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Text Size

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Complete Application

Review

Submit

Print Receipt

Tool: Add Up Your Other Pensions And Annuities
We have provided a tool to help you accurately calculate the total value of your pensions and annuities.
Enter the appropriate amounts and we will calculate it for you.
Note: Once you leave this page, this tool will not save the individual amounts.
You said that your other pensions and annuities total: $500.00
If you use the amounts you enter here, the new total will replace your previous answer.

Other Pensions and Annuities
Pension or Annuity Type 1:
$
Pension or Annuity Type 2:
$
Pension or Annuity Type 3:
$
Pension or Annuity Type 4:
$
Pension or Annuity Type 5:
$
Pension or Annuity Type 6:
$
Pension or Annuity Type 7:
$
Pension or Annuity Type 8:
$

Add And Use Total

Cancel

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc007c.html[1/20/2021 11:50:03 AM]

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Tool: Add Up Your Types Of Income, Step 1 of 4, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Complete Application

Review

Submit

Print Receipt

Tool: Add Up Your Types Of Income
We have provided a tool to help you accurately calculate the total value of your other types of income. Enter
the appropriate amounts and we will calculate it for you.
Note: Once you leave this page, this tool will not save the individual amounts.
You said that your other income totals: $500.00
If you use the amounts you enter here, the new total will replace your previous answer.

Other Types of Income (including alimony, net rental income, workers compensation,
unemployment, private or State disability payments, etc.)
Other Income Type 1:
$
Other Income Type 2:
$
Other Income Type 3:
$
Other Income Type 4:
$
Other Income Type 5:
$
Other Income Type 6:
$
Other Income Type 7:
$
Other Income Type 8:
$

Add And Use Total

Cancel

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Mc007d.html[1/20/2021 11:50:09 AM]

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Find Out If You Qualify: Part 1, Step 1 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Text Size

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

Find Out If You Qualify: Part 1
The next few pages provide a tool that can tell you if you are likely to qualify for extra help to pay for your
prescription drug costs so that you do not have to go through the entire application process unnecessarily. If
this tool suggests that it is unlikely you will qualify, you may still apply. We will save your answers only if you
decide to apply now. You may change your answers at any time until you submit your application.
Have you worked in this calendar year?

No

Yes
Are you UNDER age 65?

No

Yes

More Info

More Info

For this question, a relative is someone related to you by blood, adoption, or marriage. How
many relatives live with you and depend on you for at least one-half of their financial support?
Please do not include yourself in the number you enter. If your household consists only of you,
enter “0”.
More Info
We ask this because your household size may affect the amount of help you can get.

Next

Previous

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/QU001.htm[1/20/2021 11:50:12 AM]

Print Receipt

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Find Out If You Qualify: Part 1, Step 1 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Text Size

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

Find Out If You Qualify: Part 1
The next few pages provide a tool that can tell you if you are likely to qualify for extra help to pay for your
prescription drug costs so that you do not have to go through the entire application process unnecessarily. If
this tool suggests that it is unlikely you will qualify, you may still apply. We will save your answers only if you
decide to apply now. You may change your answers at any time until you submit your application.
Have you worked in this calendar year?

No

Yes
Are you UNDER age 65?

No

Yes

More Info

More Info

For this question, a relative is someone related to you by blood, adoption, or marriage. How many
relatives live with you and depend on you for at least one-half of their financial support? Please
do not include yourself in the number you enter. If your household consists only of you, enter
“0”.
More Info
We ask this because your household size may affect the amount of help you can get.

Next

Print Receipt

Previous

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Qu001b.html[1/20/2021 11:50:16 AM]

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Find Out If You And Your Spouse Qualify: Part 3 Of 3, Step 1 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Text Size

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

Find Out If You And Your Spouse Qualify: Part 3 Of 3

Please continue to enter the information below so that we can tell you if you are likely to qualify for extra
help.
Have you worked in this calendar year?

No

Yes

More Info

Has your spouse worked in this calendar year?

No

Yes

Yes, for blindness

Yes, for a disability

Does your spouse have to pay for things related to a disability or blindness that enable your
spouse to work?
More Info
We will only count part of your spouse's earnings towards the income limit if your spouse works and
receives Social Security benefits based on a disability or blindness and has work-related expenses for
which he/she is not reimbursed. Examples of such expenses are: the cost of medical treatment and
drugs for AIDS, cancer, depression, or epilepsy; a wheelchair; personal attendant services; vehicle
modification, driver assistance, or other special work-related transportation needs; work-related
assistive technology; guide dog expenses; sensory and visual aids; and Braille translations.
No

Yes, for blindness

Yes, for a disability

Do you expect to earn wages this calendar year?

No

Yes

More Info

Does your spouse expect to earn wages this calendar year?

No

Yes

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

More Info

Do you have to pay for things related to a disability or blindness that enable you to work?
More Info
We will only count part of your earnings toward the income limit if you work and receive Social Security
benefits based on a disability or blindness and you have work-related expenses for which you are not
reimbursed. Examples of such expenses are: the cost of medical treatment and drugs for AIDS,
cancer, depression, or epilepsy; a wheelchair; personal attendant services; vehicle modification, driver
assistance, or other special work-related transportation needs; work-related assistive technology; guide
dog expenses; sensory and visual aids; and Braille translations.
No

Print Receipt

More Info

What do you expect your net earnings from self-employment to be this calendar year?

Info
None

Net EARNINGS

Net LOSS

More

What does your spouse expect the net earnings from self-employment to be this calendar year?
More Info
None

Net EARNINGS

Net LOSS
Have you stopped working in 2014 or 2015, or plan to stop working in 2015 or 2016?

Info
No

Yes

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Qu002a_WITH.html[1/20/2021 11:50:19 AM]

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Find Out If You And Your Spouse Qualify: Part 3 Of 3, Step 1 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Has your spouse stopped working in 2014 or 2015, or plan to stop working in 2015 or 2016?
More Info
No

Yes

Next

Previous

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Qu002a_WITH.html[1/20/2021 11:50:19 AM]

Find Out If You And Your Spouse Qualify: Part 3 Of 3, Step 1 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Text Size

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

Find Out If You And Your Spouse Qualify: Part 3 Of 3

Please continue to enter the information below so that we can tell you if you are likely to qualify for extra
help.
Have you worked in this calendar year?

No

Yes

More Info

Has your spouse worked in this calendar year?

No

Yes
Do you expect to earn wages this calendar year?

No

Yes

More Info

More Info

What do you expect your net earnings from self-employment to be this calendar year?

Info
None

Net EARNINGS

Net LOSS

More

What does your spouse expect the net earnings from self-employment to be this calendar year?
More Info
None

Net EARNINGS

Net LOSS
Have you stopped working in 2014 or 2015, or plan to stop working in 2015 or 2016?

Info
No

Yes

More

Has your spouse stopped working in 2014 or 2015, or plan to stop working in 2015 or 2016?
More Info
No

Yes

Next

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

More Info

Does your spouse expect to earn wages this calendar year?

No

Yes

Print Receipt

Previous

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Qu002a_Without.html[1/20/2021 11:50:24 AM]

Find Out If You Qualify: Part 3 Of 3, Step 1 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Text Size

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

Find Out If You Qualify: Part 3 Of 3

Please continue to enter the information below so that we can tell you if you are likely to qualify for extra
help.
Have you worked in this calendar year?

No

Yes

More Info

Yes, for blindness

Yes, for a disability

Do you expect to earn wages this calendar year?

No

Yes

More Info

What do you expect your net earnings from self-employment to be this calendar year?

Info
None

Net EARNINGS

Net LOSS
Have you stopped working in 2014 or 2015, or plan to stop working in 2015 or 2016?

Info
No

Yes

Next

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Do you have to pay for things related to a disability or blindness that enable you to work?
More Info
We will only count part of your earnings toward the income limit if you work and receive Social Security
benefits based on a disability or blindness and you have work-related expenses for which you are not
reimbursed. Examples of such expenses are: the cost of medical treatment and drugs for AIDS,
cancer, depression, or epilepsy; a wheelchair; personal attendant services; vehicle modification, driver
assistance, or other special work-related transportation needs; work-related assistive technology; guide
dog expenses; sensory and visual aids; and Braille translations.
No

Print Receipt

Previous

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Qu002b_WITH.html[1/20/2021 11:50:28 AM]

More

More

Find Out If You Qualify: Part 3 Of 3, Step 1 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Text Size

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

Find Out If You Qualify: Part 3 Of 3

Please continue to enter the information below so that we can tell you if you are likely to qualify for extra
help.
Have you worked in this calendar year?

No

Yes

More Info

Do you expect to earn wages this calendar year?

No

Yes

Have you stopped working in 2014 or 2015, or plan to stop working in 2015 or 2016?

Info
No

Yes

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

More Info

What do you expect your net earnings from self-employment to be this calendar year?

Info
None

Net EARNINGS

Net LOSS

Next

Print Receipt

Previous

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Qu002b_WITHOUT.html[1/20/2021 11:50:32 AM]

More

More

Find Out If You Qualify: Part 2 Of 2, Step 1 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

Find Out If You Qualify: Part 2 Of 2

Please continue to enter the information below so that we can tell you if you are likely to qualify for extra
help.
If you receive income from any of the sources listed below, please enter the total amount you receive each
month. If the amount changes from month to month or you do not receive it every month, enter the average
monthly income for the past year for each type in the appropriate fields.
Do NOT list wages and self-employment, interest income, public assistance, medical reimbursements or
foster care payments here. If you do not receive income from a source listed below, select No for that
source.
If you need help adding your pensions or annuities, select Add Pensions Or Annuities. If you need help
adding your other income, select Add Other Income. The total dollar amount calculated will appear in the
dollar amount field on this page when Add And Use Total is selected on the page calculating the totals.
Do you receive Social Security benefits?

No

Yes

More Info

Do you receive Railroad Retirement benefits?

No

Yes
Do you receive Veterans benefits?

No

Yes

More Info

More Info

Do you receive income from other pensions or annuities?
More Info
(Do NOT include annuities from certificates of deposit, stocks, bonds, mutual funds, Individual
Retirement Accounts (IRAs) or any other investments.)
No

Yes

Do you receive other income not listed above, including alimony, net rental income, workers'
compensation, unemployment, private or State disability payments, etc.?
More Info
(Do NOT include help with rent or utilities, money you have in bank accounts, stocks, bonds, savings
bonds, mutual funds, Individual Retirement Accounts (IRAs) or any similar investments, or any cash at
home or anywhere else.)
No

Next

Yes

Previous

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/QU003.htm[1/20/2021 11:50:35 AM]

Print Receipt

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Find Out If You And Your Spouse Qualify: Part 2 Of 3, Step 1 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Text Size

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

Find Out If You And Your Spouse Qualify: Part 2 Of 3

Please continue to enter the information below so that we can tell you if you are likely to qualify for extra
help.
If you or your spouse receive income from any of the sources listed below, please enter the total amount you
receive each month. If the amount changes from month to month or you do not receive it every month, enter
the average monthly income for the past year for each type in the appropriate fields.
Do NOT list wages and self-employment, interest income, public assistance, medical reimbursements or
foster care payments here. If you do not receive income from a source listed below, select No for that
source.
If you need help adding your pensions or annuities, select Add Pensions Or Annuities. If you need help
adding your other income, select Add Other Income. The total dollar amount calculated will appear in the
dollar amount field on this page when Add And Use Total is selected on the page calculating the totals.
Do you receive Social Security benefits?

No

Yes

More Info

Does your spouse receive Social Security benefits?

No

Yes
Do you receive Railroad Retirement benefits?

No

Yes

More Info

More Info

Does your spouse receive Railroad Retirement benefits?

No

Yes
Do you receive Veterans benefits?

No

Yes

More Info

More Info

Does your spouse receive Veterans benefits?

No

Yes

More Info

Do you receive income from other pensions or annuities?
More Info
(Do NOT include annuities from certificates of deposit, stocks, bonds, mutual funds, Individual
Retirement Accounts (IRAs) or any other investments.)
No

Yes

Does your spouse receive income from other pensions or annuities?
More Info
(Do NOT include annuities from certificates of deposit, stocks, bonds, mutual funds, Individual
Retirement Accounts (IRAs) or any other investments.)
No

Yes

Do you receive other income not listed above, including alimony, net rental income, workers'
compensation, unemployment, private or State disability payments, etc.?
More Info
(Do NOT include help with rent or utilities, money you have in bank accounts, stocks, bonds, savings
bonds, mutual funds, Individual Retirement Accounts (IRAs) or any similar investments, or any cash at
home or anywhere else.)
No

Yes

Does your spouse receive other income not listed above, including alimony, net rental income,

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Qu003a.html[1/20/2021 11:50:40 AM]

Print Receipt

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Find Out If You And Your Spouse Qualify: Part 2 Of 3, Step 1 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

workers' compensation, unemployment, private or State disability payments, etc.?
More Info
(Do NOT include help with rent or utilities, money you have in bank accounts, stocks, bonds, savings
bonds, mutual funds, Individual Retirement Accounts (IRAs) or any similar investments, or any cash at
home or anywhere else.)
No

Next

Yes

Previous

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Qu003a.html[1/20/2021 11:50:40 AM]

Find Out If You Qualify: Part 2 Of 3, Step 1 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Text Size

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

Find Out If You Qualify: Part 2 Of 3

Please continue to enter the information below so that we can tell you if you are likely to qualify for extra
help.
If you receive income from any of the sources listed below, please enter the total amount you receive each
month. If the amount changes from month to month or you do not receive it every month, enter the average
monthly income for the past year for each type in the appropriate fields.
Do NOT list wages and self-employment, interest income, public assistance, medical reimbursements or
foster care payments here. If you do not receive income from a source listed below, select No for that
source.
If you need help adding your pensions or annuities, select Add Pensions Or Annuities. If you need help
adding your other income, select Add Other Income. The total dollar amount calculated will appear in the
dollar amount field on this page when Add And Use Total is selected on the page calculating the totals.
Do you receive Social Security benefits?

No

Yes

More Info

Do you receive Railroad Retirement benefits?

No

Yes
Do you receive Veterans benefits?

No

Yes

More Info

More Info

Do you receive income from other pensions or annuities?
More Info
(Do NOT include annuities from certificates of deposit, stocks, bonds, mutual funds, Individual
Retirement Accounts (IRAs) or any other investments.)
No

Yes

Do you receive other income not listed above, including alimony, net rental income, workers'
compensation, unemployment, private or State disability payments, etc.?
More Info
(Do NOT include help with rent or utilities, money you have in bank accounts, stocks, bonds, savings
bonds, mutual funds, Individual Retirement Accounts (IRAs) or any similar investments, or any cash at
home or anywhere else.)
No

Next

Yes

Print Receipt

Previous

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Qu003b.html[1/20/2021 11:50:44 AM]

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Find Out If You Qualify: Results - You Should Apply, Step 1 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Text Size

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

Print Receipt

Find Out If You Qualify: Results - You Should Apply
Based on the answers you provided, you probably qualify for the extra help with prescription drug costs.

What You Can Do Next
1. You may begin the application process by selecting Apply Now,
2. You may go back to make changes by selecting Previous, or
3. You may select Start Over to reenter your information.
If you select Apply Now, you will get a Reentry Number after you fill in your name and address. If you choose to
Save & Exit this application before it is complete, you may use your Reentry Number at any time to come back.
You will also be able to change your answers later.
What You Will Need To Apply
If you decide to complete this application, we will ask about your income (and your spouse's income, if married
and living together) and the things that you and your spouse own. Documents that may help you prepare
include:
Social Security card;
bank account statements, including checking, savings, and certificates of deposit;
Individual Retirement Accounts (IRAs), stocks, bonds, savings bonds, mutual funds, other investment
statements;
tax returns;
payroll slips; and
your most recent Social Security benefits award letters or statements for Railroad Retirement benefits,
Veterans benefits, pensions and annuities.
If you do not have these documents, provide us with your best estimate so that we can tell you whether you are
likely to qualify for extra help with your prescription drug costs. This information is to help you complete the
application. You will not have to submit the documents unless contacted by a Social Security representative.

Apply Now

Previous

Start Over

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/QU004a.htm[1/20/2021 11:50:48 AM]

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Find Out If You Qualify: Results - You Probably Do Not Qualify, Step 1 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Text Size

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

Print Receipt

Find Out If You Qualify: Results - You Probably Do Not Qualify
Based on the answers you provided, you probably do not qualify for extra help. You do not need to
complete this application. However, if there is any doubt about your entries or you need a letter stating you
are not eligible, complete the application. Whether or not you qualify for the extra help, you may still enroll in
an approved Medicare prescription drug plan for coverage. For information about enrolling in a prescription
drug plan, call 1-800-MEDICARE (TTY 1-877-486-2048) or visit www.medicare.gov.

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

What You Can Do Next
1.
2.
3.
4.

You may begin the application process by selecting Apply Now,
You may go back to make changes by selecting Previous,
You may select Start Over to reenter your information, or
You may Exit this application.

If you select Apply Now, you will get a Reentry Number after you fill in your name and address. If you choose to
Save & Exit this application before it is complete, you may use your Reentry Number at any time to come back.
You will also be able to change your answers later.
What You Will Need To Apply
If you decide to complete this application, we will ask about your income (and your spouse's income, if married
and living together) and the things that you and your spouse own. Documents that may help you prepare
include:
Social Security card;
bank account statements, including checking, savings, and certificates of deposit;
Individual Retirement Accounts (IRAs), stocks, bonds, savings bonds, mutual funds, other investment
statements;
tax returns;
payroll slips; and
your most recent Social Security benefits award letters or statements for Railroad Retirement benefits,
Veterans benefits, pensions and annuities.
If you do not have these documents, provide us with your best estimate so that we can tell you whether you are
likely to qualify for extra help with your prescription drug costs. This information is to help you complete the
application. You will not have to submit the documents unless contacted by a Social Security representative.

Apply Now

Previous

Start Over

Exit

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Qu004b.html[1/20/2021 11:50:55 AM]

Review Your Information, Step 3 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

Review Your Information

Review the items you completed below before you submit this application. If you need to make changes,
select the Edit button in the margin just left of the page where the changes are necessary. Changes on one
page may require additional information to be entered or changed on subsequent pages. You can print this
summary before you submit it. Once you submit it, you will be able to print a receipt that shows exactly what
is on your application.

Print Receipt

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

About You
My Information
Name: Joe Single
Social Security Number: *
*
*
-
*
*
-
3456
Date of Birth: February 12, 1950

Edit

About You

Work Status:

I did not work in 2020 or 2021.

I do not have combined savings, investments, and real estate worth more than $14,790.
Medicare Savings Programs:

You are not interested in the Medicare Savings Programs. If this is not correct, select Edit to go back
and change your answer.
I am not interested in the Medicare Savings Programs.

Mailing Address / Phone
Address: 123 Fake Street, Fakeville, Maryland, 21042
Phone: (123) 456-7890
I have not changed my address within the last three months.
Contact Person:
None given

Edit

About Your Living Situation

Number of Dependents: 0

Edit

Resources

Bank accounts, investments, cash:

I have no bank accounts.

I have no stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts (IRAs), or

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/RS001.htm[1/20/2021 11:50:58 AM]

Review Your Information, Step 3 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

similar investments.

I have no cash at home or anywhere else.

Burial expenses:

No money from the sources mentioned will be used to pay for my funeral or burial expenses.

Real estate:

I do not own any real estate other than my home and the property on which it is located.

Income Other Than Wages And Earnings

Edit

Income from pensions, annuities, and other sources:

I do not receive Social Security benefits.

I do not receive Railroad Retirement benefits.

I do not receive Veterans benefits.

I do not receive other pensions or annuities.

I do not receive other income.

Decrease in income other than wages and earnings:

My income from these sources has not decreased in the last two years.

Next

Save & Exit

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/RS001.htm[1/20/2021 11:50:58 AM]

Ready To Submit, Step 4 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

Important:
After you submit this application, you will not be able to come back to it. Check the box next to your
name to indicate that you have read and are signing the statement below.

Ready To Submit?

Terms of Agreement
I, Joe Single, understand that the Social Security Administration (SSA) will check my statements and
compare its records with records from Federal, State, and local government agencies, including the Internal
Revenue Service (IRS) to make sure the determination is correct.
By submitting this application, I am authorizing SSA to obtain and disclose information related to my income,
resources, and assets, foreign and domestic, consistent with applicable privacy laws. This information may
include, but is not limited to, information about my wages, account balances, investments, benefits, and
pensions.
Unless otherwise indicated on this application, I am authorizing SSA to disclose the financial information
entered earlier from my file, such as my name, date of birth, gender, Social Security Number, etc., to the
State to start the application process for Medicare Savings Programs.
I am declaring under penalty of perjury that I have examined all the information on this form, and it is true
and correct to the best of my knowledge.
*I, Joe Single, agree with the terms of agreement above.

Previous

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

If you are ready to submit your Application for Extra Help With Medicare Prescription Drug Plan Costs, read
the statement below. Checking the box next to your name means that you agree with the statement and
have signed your application.

Submit Now

Print Receipt

Save & Exit

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/RS003.htm[1/20/2021 11:51:02 AM]

Successful Submission - Print Or Save Your Receipt, Step 5 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Find Out If You Qualify

Complete Application

Review

Submit

The Application For Extra Help With Medicare Prescription Drug Plan Costs was received by
Social Security on January 13, 2021, 3:22:55 PM.
We highly recommend that you print or save a copy of the receipt for your records. For instructions on
how to save or view the saved file, please refer to the Save/View Guide.
View & Print Your Receipt

Print Receipt

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Successful Submission
About You
You
Name: Joe Single
Social Security Number: *
*
*
-
*
*
-
3456
Date of Birth: February 12, 1950

About You
You
Have you worked in 2020 or 2021? No
Mailing Address: 123 Fake Street, Fakeville, Maryland, 21042
I have not changed my address within the last three months
Telephone Number: (123) 456-7890
Do you have combined savings, investments, and real estate worth more than $14,790? No or Not Sure
Medicare Savings Programs:
Not Interested

If you would prefer that we contact someone else if we have additional questions, please provide the
person's name and daytime phone number: None Provided

About Your Living Situation
For this question, a relative is someone related to you by blood, adoption, or marriage. How many relatives
live with you and depend on you for at least one-half of their financial support? 0

Resources
Do you have bank accounts (checking, savings and certificates of deposit)?
No

Do you have stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts (IRAs) or other
similar investments?
No

Do you have any other cash at home or anywhere else?
No

Will some money from any of these sources be used to pay for your funeral or burial expenses? No
Other than your home and the property on which it is located, do you own any real estate? No

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/RS004.htm[1/20/2021 11:51:05 AM]

Successful Submission - Print Or Save Your Receipt, Step 5 of 5, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

Income Other Than Wages And Earnings
Do you receive income from Social Security benefits? No

Do you receive income from Railroad Retirement benefits? No

Do you receive income from Veterans benefits?
No

Do you receive income from other pensions and annuities?
No

Do you receive other income not listed above, including alimony, net rental income, workers' compensation,
unemployment, private or State disability payments, etc.? No

Has any of the income from these sources decreased in the last two years? No

Next

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/RS004.htm[1/20/2021 11:51:05 AM]

Next Steps, Extra Help With Medicare Prescription Drug Plan Costs, Social Security

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Social Security
The Official Website of the U.S. Social Security Administration

Extra Help With Medicare Prescription Drug Plan Costs
Next Steps
What you just did:
You completed the Application for Extra Help With Medicare Prescription Drug Plan Costs.
What we will do:
We will process your application as quickly as possible. We will contact you if we need more information.
When we finish, we will send a letter to advise whether you qualify for extra help.
What you need to do:
Carefully read the letter we provide. It will say what to do next. Please remember, if you or the person/people
you are helping qualify for this extra help, enrollment in a Medicare prescription drug plan is required.
If you do not choose a Medicare prescription drug plan, Medicare will select one for you to be sure this
benefit is received. However, if you wait for Medicare to choose, there may be months for which there is no
prescription drug coverage.
For information about prescription drug plans in your area, you may call toll-free 1-800-MEDICARE (1-800633-4227) or visit www.medicare.gov .
If you are deaf or hard of hearing, you may call the Medicare TTY
number toll-free at 1-877-486-2048.

Exit

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/RS005.htm[1/20/2021 11:51:09 AM]

If you need help completing this
application, call Social Security
toll-free at:
1-800-772-1213 or
TTY 1-800-325-0778,
Monday-Friday 7am-7pm
Need Help?

Print Now

The Application For Extra Help With Medicare Prescription Drug Plan Costs was received by Social
Security on February 5, 2018, 3:54:46 PM.

Successful Submission
About You and Your Spouse
You
Name: John Doe
Social Security Number: 743382601
Date of Birth: January 1, 1900
Have you worked in 2011 or 2012? Yes
Spouse
Name: Jane Doe
Social Security Number: 743382201
Date of Birth: February 2, 1901
Has your spouse worked in 2011 or 2012? No
Mailing Address: 123 Main Street, Anywhere, Maryland 34567
We have not changed our address within the last three months
Telephone Number: 5405559876
If your spouse has Medicare (or expects to have it in the next three months), does he or she also wish to apply?
Yes
Do you have combined savings, investments, and real estate worth more than $26,120? No or Not Sure
Medicare Savings Programs:
Interested

If you would prefer that we contact someone else if we have additional questions, please provide the person's
name and daytime phone number: None Provided

About Your And Your Spouse's Living Situation
For this question, a relative is someone related to you by blood, adoption, or marriage (but not including your
spouse). How many relatives live with you and depend on you or your spouse for at least one-half of their financial
support? 0

Resources
Do you or your spouse have bank accounts (checking, savings and certificates of deposit)?
No

Do you or your spouse have stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts (IRAs) or
other similar investments?
No

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Rs007_NO_MARRIED.html[1/20/2021 11:51:13 AM]

Do you or your spouse have any other cash at home or anywhere else?
No

Will some money from any of these sources be used to pay for your funeral or burial expenses? No
Will some money from any of these sources be used to pay for your spouse's funeral or burial expenses? No
Other than your home and the property on which it is located, do you or your spouse own any real estate? No

Income Other Than Wages And Earnings
Do you receive income from Social Security benefits? No

Does your spouse receive income from Social Security benefits?
No

Do you receive income from Railroad Retirement benefits? No

Does your spouse receive income from Railroad Retirement benefits?
No

Do you receive income from Veterans benefits?
No

Does your spouse receive income from Veterans benefits?
No

Do you receive income from other pensions and annuities?
Yes, $500.00 per month

Does your spouse receive income from other pensions or annuities?
No

Do you receive income from other income not listed above, including alimony, net rental income, workers'
compensation, unemployment, private or State disability payments, etc.? Yes, $500.00 per month from Other
Income

Does your spouse receive income from other income not listed, including alimony, net rental income, workers'
compensation, unemployment, private or State disability payments, etc.? No

Has any of the income from these sources decreased in the last two years? No

Wages And Earnings
Do you expect to earn wages this calendar year?
Yes, $2,500.00 before taxes and deductions

Does your spouse expect to earn wages this calendar year?
Yes, $5,000.00 before taxes and deductions

What do you expect your net earnings from self-employment to be this calendar year?
Net earnings of $2,500.00
this year

What does your spouse expect their net earnings from self-employment to be this calendar year?
Net earnings of
$2,500.00 this year

Have these wages or self-employment earnings decreased in the last two years? No
Have you stopped working in 2014 or 2015, or plan to stop working in 2015 or 2016?
Yes, stopped/plan to stop October, 2015

Has your spouse stopped working in 2014 or 2015, or plan to stop working in 2015 or 2016?

Yes, stopped/plan to stop November, 2015

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Rs007_NO_MARRIED.html[1/20/2021 11:51:13 AM]

Print Now

The Application For Extra Help With Medicare Prescription Drug Plan Costs was received by Social
Security on February 5, 2018, 3:54:46 PM.

Successful Submission
About You
You
Name: John Doe
Social Security Number: 743382201
Date of Birth: January 1, 1900
Have you worked in 2011 or 2012? Yes
Mailing Address: 123 Main Street, Anywhere, Maryland 34567
I have not changed my address within the last three months
Telephone Number: 5405559876
Do you have combined savings, investments, and real estate worth more than $13,070? No or Not Sure
Medicare Savings Programs:
Not Interested

If you would prefer that we contact someone else if we have additional questions, please provide the person's
name and daytime phone number: None Provided

About Your Living Situation
For this question, a relative is someone related to you by blood, adoption, or marriage. How many relatives live with
you and depend on you for at least one-half of their financial support? 0

Resources
Do you have bank accounts (checking, savings and certificates of deposit)?
No

Do you have stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts (IRAs) or other similar
investments?
No

Do you have any other cash at home or anywhere else?
No

Will some money from any of these sources be used to pay for your funeral or burial expenses? No
Other than your home and the property on which it is located, do you own any real estate? No

Income Other Than Wages And Earnings
Do you receive income from Social Security benefits? No

Do you receive income from Railroad Retirement benefits? No

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Rs007_NO_SINGLE.html[1/20/2021 11:51:17 AM]

Do you receive income from Veterans benefits?
No

Do you receive income from other pensions and annuities?
No

Do you receive income from other income not listed above, including alimony, net rental income, workers'
compensation, unemployment, private or State disability payments, etc.? No

Has any of the income from these sources decreased in the last two years? No

Wages And Earnings
Do you expect to earn wages this calendar year?
Yes, $1,500.00 before taxes and deductions

What do you expect your net earnings from self-employment to be this calendar year?
None

Have these wages or self-employment earnings decreased in the last two years? No
Have you stopped working in 2011 or 2012, or plan to stop working in 2012 or 2013?
Yes, stopped/plan to stop September, 2012

file:///BA/esefdata/OSES/Medicare/2021%20SCREENS/Rs007_NO_SINGLE.html[1/20/2021 11:51:17 AM]