What You Need To Complete The Application For 

Help With Medicare Prescription Drug Plan Costs

What You Need To Complete The Application For 

Help With Medicare Prescription Drug Plan Costs

Social Security and the Centers for

Medicare & Medicaid Services are working together to get you extra help with your

prescription drug costs. To determine if you

could be eligible for this extra help, Social

Security will need to know your income

and the value of your savings, investments

and real estate (other than your home). You

may qualify for extra help if you have:

• Limited income (below $14,355 for an

individual or $19,245 for a married couple living together). Even if your annual

income is higher, you still may be able to

get some help with your monthly premiums, annual deductibles and prescription

co-payments. Some examples where your

income may be higher include if you or

your spouse:

—Support other family members who

live with you;

—Have earnings from work; or

—Live in Alaska or Hawaii; and

• Limited resources (below $10,000 for an

individual or $20,000 for a married couple living together). These resource limits can be slightly higher (an additional

$1,500 per person) if you will use some

of your money for burial expenses.

Identify the things you own by yourself,

with your spouse or with someone else, but

do not include your home, vehicles, burial

plots or personal possessions.

Review all your income.

Gather your records in advance to save

time. 

Remember that this worksheet is not an

application. This worksheet can assist you

in completing the actual application for

extra help.

What you need to know

(over)

www.socialsecurity.gov

• Statements that show your account balances at banks, credit unions or other

financial institutions; 

• Investment statements; 

• Life insurance policy statements;

• Stock certificates;

• Tax returns;

• Pension award letters; and

• Payroll slips.

If you need an application form, contact

Social Security and ask for the Application

for Help with Medicare Prescription Drug

Plan Costs (SSA-1020).

Beginning July 1, 2005, you also will

be able to apply online at

www.socialsecurity.gov. 

To learn more about the Medicare

prescription drug plan, call

1-800-MEDICARE (1-800-633-4227)

or visit www.medicare.gov.

Please continue to the opposite side of the

page to complete the worksheet.

How you can get more information

Documents that will help you

prepare in advance include:
We need to know information about your (and your spouse’s, if you’re married and living

together) income and resources: 

You may choose to have someone help you when you do business with Social Security.

We will work with that person, just as we would work with you. 

Income Monthly Amount

Railroad Retirement $ _____________________________________

Veterans benefits $ _____________________________________

Other pensions or annuities $ _____________________________________

Alimony $ _____________________________________

Net rental income $ _____________________________________

Workers’ compensation $ _____________________________________

Help from other people to pay for household expenses, such as food, mortgage or

rent, heating fuel or gas, electricity, water

and property taxes $ _____________________________________

Wages $ _____________________________________

Self-employment net earnings $ _____________________________________

Other income $ _____________________________________

Resources Value

Bank accounts, including checking, savings

and certificates of deposit $ _____________________________________

Stocks, bonds, savings bonds, mutual

funds, individual retirement accounts 

(IRAs) or other investments $ _____________________________________

Cash at home or anywhere else $ _____________________________________

Life insurance policies for you (and your

spouse, if married and living together) $ _____________________________________

NOTE: Social Security needs to know how much money you would get if you cashed in

your life insurance policies today. Check with your insurance company or agent to get

the exact cash value. This probably will be less than the amount you are insured for. 

Any real estate other than your home $ _____________________________________

Printed on recycled paper

www.socialsecurity.gov

Social Security Administration

SSA Publication No. 05-10128

ICN 480068

Unit of Issue - HD (one hundred)

April 2005