In 2021, you fall into the Medicare Part D gap when the negotiated retail cost of your medications reaches $4,130. Once in the gap, you are now responsible for 25% of the negotiated retail cost for brand name medications, and 25% for generics. Prescription Advantage, a state-run program, can assist you in this gap and/or put a cap on your out-of-pocket cost for medications.
Eligibility is based on income only and there is no asset limit.
If you are a Massachusetts resident and eligible for Medicare, the income limits are:
- Age 65 or over: $64,400 or less for a single person, or $87,100 or less for a married couple.
- Under age 65 and disabled: $24,214 or less for a single person, or $32,750 or less for a married couple.
There is no charge for joining Prescription Advantage if you have an annual income at or less than $38,640 for a single person or $52,260 for a married couple. However, there is a $200 per person annual enrollment fee for those with higher incomes.
You may also join if you are 65 years or older and not eligible for Medicare. If you are not eligible for Medicare, Prescription Advantage will be your primary prescription drug plan and there is no income limit.
Medicare also has a program, called “Extra Help,” which can assist with the cost of your Medicare Part D plan’s premium, deductible, and copays. Please call your Council on Aging to make an appointment with a SHINE counselor for more information on these programs or assistance with any Medicare issue. Trained SHINE volunteers offer free, confidential counseling on all aspects of Medicare and related health insurance programs.