An Extra Help prescription plan won’t cover my medication



Dear Lance,

I applied for Extra Help with prescription drugs through the Social Security Administration. The letter I received from them said that generic medications would have a copayment of $3.30, and for brand name medications it would be $8.25. Social Security enrolled me in a prescription drug plan, and I received a card from the insurance company to present to the pharmacy when I fill prescriptions.

When I went to pick up my medications, one of them that was a brand name drug cost me $226! This is several times more than the copayment of the same medication when I had a different drug plan prior to receiving Extra Help. The pharmacist said that this medication is not covered by my plan. How can this happen?

I am very upset.

Dear Upset,

I certainly understand why you are distressed. Let me explain what is happening here and what you can do about the situation.

Extra Help (sometimes called the Low Income Subsidy) is a program through Social Security that provides a prescription drug plan premium and copayment assistance to individuals who have limited income and financial assets. There are several levels of Extra Help benefits depending on income and financial assets. Your benefit level provides a drug plan with no monthly premium for you (for plans that have a monthly premium up to $29.13 in 2017) and copayments of $3.30 for generic drugs and $8.25 for brand-name medications.

However, these copayment amounts only apply to medications that are covered under the plan’s drug formulary (or list of covered medications). Unfortunately, your drug plan does not cover one of your medications; therefore, the copayment amounts for which you are entitled at your benefit level do not apply.

You have several options at this point:

• Speak to your physician and show the drug formulary that you received from your plan. Ask if a covered medication can be prescribed instead of the one that is not covered.

• This year, there are three prescription drug plans that Social Security can provide with no monthly premium cost to you because they have a premium less than $29.13. The plan that you received was assigned to you on a rotating basis with the other two plans. It may be that one, or both, of the other two plans covers the medication that your present plan does not.

• A SHINE volunteer counselor can determine whether the other two plans cover your medication. If one of the other plans covers the medication and because you are receiving Extra Help, you can change to a different plan immediately without penalty. This changing of plans is called a Special Enrollment Period. The new plan usually is effective on the first day of the following month.

• Finally, sometimes none of the three plans that can be selected will cover a particular medication. Where this is the case, a SHINE counselor might find a plan that covers your medication but for which you would have a small monthly premium payment. If you are entitled to receive a plan with a monthly premium up to $29.13 and you select one that costs more than that amount, the difference between the two amounts would be what your cost is. Once again, you can change plans immediately because you are receiving Extra Help and qualify for the Special Enrollment Period.

I recently assisted a client in your situation, and none of the three plans covered one of her medications. However, another plan covers it for a premium payment of $2.20. She is happy to pay it!

SHINE volunteer counselors are well trained to assist you with Medicare matters. They can also help you determine whether you are likely to qualify for Extra Help with prescription drug costs.

SHINE (Serving Health Insurance Needs of Elders) is an award-winning statewide volunteer program that provides free, unbiased and confidential counseling and information for people on Medicare, their families and caregivers. SHINE is a program of the Florida Department of Elder Affairs and is administered in partnership with the state’s 11 Aging and Disability Resource Centers (ADRCs). In Brevard County, our ADRC is the Senior Resource Alliance, located in Orlando.

To contact a SHINE volunteer counselor for confidential and unbiased assistance, call the Elder Helpline toll-free at 1-800-963-5337, or call 321-752-8080 locally. SHINE has counseling locations throughout Brevard County. Counselors can assist you by telephone or in person. To find a SHINE counseling site near you, go to or call the telephone numbers listed above.