Prescription Drug Assistance
Great Lakes Program
600 West Madison
Date: November 23, 2005
Social Security Number: 123-00-6789
JOHN Q. PUBLIC
123 MAIN ST
SPRINGFIELD OH 45501
You are eligible for extra help with your Medicare prescription drug plan costs. To
take advantage of this benefit, you must enroll in a Medicare approved prescription
drug plan or Medicare Advantage plan with prescription drug coverage, if you are not
already enrolled in one. If you do not choose a Medicare prescription drug plan, Medicare
will choose one for you to be sure you get this benefit. You will receive more information
The rest of this letter explains the extra help with the prescription drug plan costs,
the information used to determine your eligibility, how to sign up for a Medicare
prescription drug plan, what to do if your situation changes, and your appeal rights.
Information About This Help With Your Prescription
Drug Plan Costs
You are eligible for full help to pay your Medicare prescription drug premium, also
known as subsidy, because your income is below the limits established by the law.
Because your resources are less than or equal to $6000, you are also eligible for
lower prescription drug co-payments and annual deductibles. You are eligible for:
100% subsidy to help pay your Medicare prescription drug plan premiums;
$0.00 prescription drug annual deductible; and
Reduced co-payment amounts when you have a prescription filled.
Information Used To Determine Your Eligibility
You have no resources.
You have 1 person in your household. When we determine the size of your household,
we count you, your spouse who lives with you, and any relative who lives with you
and receives one-half support from you or your spouse.
You have the following yearly income:
Social Security benefits (before any Medicare premium deductions) of $3290.
Your income we count is less than 135% of the Federal Poverty Level. The enclosed
worksheet shows you how we counted your income.
How To Sign Up for A Medicare Prescription
This decision is about the help you can get paying for the costs related to your Medicare
prescription drug plan, such as help paying for the deductible, premiums and co-payments.
To get Medicare prescription drug coverage, you will need to choose and enroll in
a Medicare prescription drug plan or a Medicare Advantage Plan or other Medicare Health
Plan with drug coverage. Visit www.medicare.gov or call toll-free 1-800-MEDICARE (1-800-633-4227)
for a list of the prescription drug plans with no premium in your area, other drug
coverage options and help comparing plans and joining a plan that works for you. If
you are deaf or hard of hearing, you may call the Medicare TTY number toll-free at
What To Do If Your Situation Changes
If your mailing address changes, report it to us right away by calling toll-free 1-800-772-1213.
Certain changes in your situation may affect the amount of extra help you can receive
to pay for your prescription drug plan costs. You can contact Social Security to tell
us if any of the following changes happens:
you and your spouse who lives with you divorce;
your spouse who lives with you dies;
you and your spouse separate;
you and your spouse have your marriage annulled; or
you and your separated spouse begin living together again.
If You Disagree With The Decision
If you disagree with the decision, you have the right to appeal. We will provide you
with a hearing by telephone or a case review. We will look at any new information
you have. The person who will conduct the hearing or case review had no prior involvement
in the first decision. We will review those parts of the decision which you believe
are wrong and will look at any new facts you have. We may also review those parts
which you believe are correct and may make them unfavorable or less favorable to you.
If you want this appeal, either by a hearing or a case review, you may request it
by calling toll-free 1-800-772-1213.
You have 60 days to ask for an appeal.
The 60 days start the day after you get this letter. We assume you got this letter
5 days after the date on it unless you show us that you did not get it within the
You must have a good reason for waiting more than 60 days.
You can call to request an appeal. You can also obtain a copy of the form SSA-1021,
“Request for Appeal of Determination for Help with Medicare Prescription Drug Plan
Costs” from www.socialsecurity.gov. Contact us if you need help.
If You Want Help With Your Appeal
You can have a lawyer, friend, or someone else help you. Your local Social Security
office has a list of groups that can help you. These groups can find a lawyer or give
you free legal services if you qualify. There are also lawyers who do not charge unless
you win your appeal.
Information About Medicare Savings Programs
You may be able to get more help with your Medicare health care costs through programs
run by your State. The additional help from these Medicare Savings Programs can be
worth more than $900 a year. To get this help, please call your State’s medical assistance
(Medicaid) office or your social service office and ask about the Medicare Savings
Programs. You can get the local phone number for these offices by calling Medicare
toll-free at 1-800-MEDICARE (1-800-633-4227). If you are deaf or hard of hearing,
you may call the Medicare TTY number toll-free at 1-877-486-2048.
How You May Be Able to Receive SSI
You may be eligible for Supplemental Security Income (SSI) benefits. If you have not
already filed an SSI application, it is important that you get in touch with Social
Security right away to file an SSI application. You may call us toll-free at 1-800-772-1213.
If you file the application more than 60 days from the date of this notice, and you
are found eligible, you may lose SSI benefits.
Information About Food Stamps
You may also be eligible for food stamp benefits. These benefits can help you stretch
your food dollars to buy nutritious food for better health. For more information,
contact your local social services office or call the Food Stamp Program information
line toll-free at 1-800-221-5689.
If You Have Any Questions
For information about the Medicare prescription drug plans or other Medicare issues,
visit www.medicare.gov on the Internet or call toll-free 1-800-MEDICARE (1-800-633-4227). If you are deaf
or hard of hearing, you may call the Medicare TTY number toll-free at 1-877-486-2048.
For information about the extra help with the costs related to the Medicare prescription
drug plans or general information about Social Security, visit our website at www.socialsecurity.gov on the Internet. You may also call Social Security toll-free at 1-800-772-1213. If
you are deaf or hard of hearing, you may call our TTY number toll-free at 1-800-325-0778.
We can answer most questions by phone.
If you do call, please have this letter with you. It will help us answer your questions.