How to Use Medicare Extra Help for Generic Prescriptions in 2025

If you’re on Medicare and taking generic medications, Medicare Extra Help could cut your drug costs by thousands each year. For many seniors, this program turns unaffordable prescriptions into $4.90 co-pays - and sometimes even less. But most people don’t know they qualify, or they give up after filling out the confusing application. Here’s exactly how it works in 2025, what you pay, who qualifies, and how to avoid the common mistakes that cost people their benefits.

What Medicare Extra Help Actually Covers

Medicare Extra Help, officially called the Part D Low-Income Subsidy (LIS), is a federal program that pays for the parts of your prescription drug plan you can’t afford. It doesn’t just lower your co-pays - it wipes out your monthly premium and yearly deductible completely. For generic drugs, you pay no more than $4.90 per prescription at any participating pharmacy. If you’re also on Medicaid and your income is below 100% of the Federal Poverty Level, you pay just $1.60 per generic.

Compare that to standard Medicare Part D. Without Extra Help, you’d first have to pay up to $595 out of pocket just to start getting coverage. Then, you’d pay 25% of the drug’s cost. A $50 generic would cost you $12.50 after the deductible. Multiply that by 12 prescriptions a month, and you’re looking at over $700 a year just in co-pays - not counting the $595 deductible or your $30-$50 monthly premium.

Extra Help removes all that. No deductible. No premium. Just $4.90 - or less - for every generic. That’s the difference between skipping pills because you can’t afford them and taking them as prescribed.

Who Qualifies in 2025

To get Extra Help, your income and resources must be below strict limits. These aren’t suggestions - they’re hard cutoffs. For 2025:

• Income limit: $23,475 per year for one person, $31,725 for a married couple living together.
• Resource limit: $17,600 for one person, $35,130 for a couple.

Income includes Social Security, pensions, wages, and veterans’ benefits. It does NOT include housing assistance, food stamps, or medical care payments.

Resources are things you own that can be turned into cash: bank accounts, stocks, bonds, mutual funds, IRAs, and second homes or land. Your primary home, one car, personal belongings, and life insurance policies don’t count. You also get a $1,500 exemption for burial expenses.

Many people think they don’t qualify because they own a home or have a small savings account. But if your only assets are your house, a car, and $10,000 in a savings account, you likely still qualify. The rules are tighter than people expect - but also more forgiving in some ways than they seem.

How to Apply - Step by Step

You don’t need a lawyer or a financial advisor. The application is free, and help is available everywhere. Here’s how to do it:

1. Check if you’re automatically enrolled. If you get Medicaid, Supplemental Security Income (SSI), or a Medicare Savings Program, you’re already signed up. No action needed.
2. If you’re not automatic, apply online. Go to ssa.gov/extrahelp. The form takes about 20 minutes. You’ll need your Social Security number, details about your income and resources, and your Medicare card.
3. Call if you can’t apply online. Dial 1-800-772-1213. Representatives can walk you through the form over the phone.
4. Visit your local Social Security office. Bring your documents. No appointment needed.
5. Get free help from SHIP. Every state has a State Health Insurance Assistance Program. They’re trained to help with Extra Help applications. Find yours at shiptacenter.org.

Processing takes 3 to 6 weeks. You’ll get a letter in the mail confirming your approval or denial. If you’re approved, your new co-pays start immediately - even if you’re still waiting for the letter.

What Happens Every Year

Extra Help isn’t a one-time thing. You have to reapply every year - but not from scratch. Each August, you’ll get a form in the mail called the “Annual Review.” It’s pre-filled with your information. All you do is check it, sign it, and return it.

Here’s the catch: you have 30 days to return it. If you miss the deadline, your Extra Help ends on January 1 of the next year. No warning. No grace period. Just gone.

Some people get a letter saying their benefits are ending because their income went up by $500. That’s not a mistake. The program doesn’t allow for small increases. If you’re just over the limit, you lose everything - even if you’re still struggling to pay for meds.

That’s called the “cliff effect.” And it’s why so many seniors lose coverage. One year, they’re paying $4.90. The next, they’re paying $1,200 a year in premiums and co-pays. One small raise from Social Security - and their prescriptions become unaffordable.

Real Stories: What Happens When People Get It - and When They Lose It

One man in Ohio, 78, takes six generic drugs for diabetes, high blood pressure, and cholesterol. Before Extra Help, he spent $320 a month just on co-pays. He skipped doses. His doctor noticed his numbers were worsening. After applying, his co-pays dropped to $4.90 each. His blood pressure stabilized. He said, “I didn’t realize I was slowly killing myself by saving $30 a month.”

A woman in Florida, 82, got Extra Help in 2023. Her income was $22,000. In 2024, her Social Security increased by $120 a month - just $1,440 a year. Her new income was $23,440. She was $35 over the limit. She lost Extra Help. Her monthly drug cost jumped from $29 to $185. She had to choose between her meds and her heating bill. She called the Medicare helpline. They told her there was no appeal. “I’m not rich,” she said. “I just got a little more money. That’s not a reason to take away my health.”

These aren’t rare cases. In 2024, over 37% of eligible seniors didn’t enroll. Another 1 in 5 lost benefits because they missed the annual review. Most didn’t know the deadline existed.

What You Can’t Do With Extra Help

Extra Help doesn’t cover everything. You still need a Medicare Part D plan. It doesn’t pay for non-covered drugs. You still have to use pharmacies in your plan’s network. Some plans have preferred pharmacies where your co-pay is even lower.

You also can’t use Extra Help to get brand-name drugs cheaper unless you have a medical exception. But if your doctor says a brand-name drug is medically necessary, you can request a formulary exception - and Extra Help recipients get faster approval.

And while Extra Help removes the coverage gap (the “donut hole”), you still have to pay your $4.90 co-pay even during that phase. The program just makes sure you never hit a wall where you owe thousands.

What’s Changing in 2025 and Beyond

This year, the $35 monthly cap on insulin became law for all Medicare Part D users - including those with Extra Help. That means even if you’re not eligible for Extra Help, insulin costs are now capped. But for those who are eligible, it’s just another layer of savings.

There’s also talk of expanding eligibility. The Biden administration proposed raising the income limit to 175% of the Federal Poverty Level - that’s about $28,500 for one person. If that passes, over a million more seniors could qualify. Right now, the program helps 15.2 million people. That number could grow to 18 million by 2027.

But until then, the rules stay the same. The income limits are tight. The deadlines are strict. And the savings are huge.

What to Do Next

If you take any generic drugs and your income is under $23,475 (or $31,725 if married), apply now. Don’t wait. Don’t assume you don’t qualify. Even if you think you’re just above the limit, call your local SHIP. They’ve seen cases where people were approved after a simple review of their assets.

If you already have Extra Help, mark your calendar: August 1. That’s when the renewal form comes. Set a reminder. Return it within 30 days. Don’t wait. Don’t ignore it. Losing this benefit can be devastating.

If you’re helping a parent or relative, sit with them during the application. The form is confusing. The terms are technical. But the reward - $5,900 or more in annual savings - is worth the 20 minutes it takes.

Medicare Extra Help isn’t a luxury. For millions of seniors, it’s the difference between staying healthy and falling through the cracks. If you qualify, don’t let bureaucracy steal your medicine.