You may be eligible to get Extra Help paying for your prescription drugs.

The Medicare prescription drug program gives you a choice of prescription plans that offer various types of coverage. In addition, 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.

Before we can help you, you must fill out this application, put it in the enclosed envelope and mail it today. Or you may complete an online application at www.ssa.gov. We will review your application and send you a letter to let you know if you qualify for Extra Help. To use the Extra Help, you must enroll in a Medicare prescription drug plan.

If you need help completing the application, call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You can find more information at www.ssa.gov.

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 by answering question 15 on this form.

If you need information about Medicare Savings Programs, Medicare prescription drug plans or how to enroll in a plan, call 1-800-MEDICARE (1-800-633-4227; 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 Medicare questions.