Medicare 2026

Charged Too Much at the Pharmacy With Extra Help? How to Prove It and Get a Refund

If you qualify for Extra Help (also called the Part D Low-Income Subsidy) but your pharmacy is charging you more than the program allows, you are not stuck with the bill. Medicare has a long-standing rule — the "best available evidence" (BAE) policy — that requires your Part D plan to fix the price when you show proof that your Extra Help status is real, even if the plan's computer system doesn't show it yet. Here is how the rule works, what proof to bring, and how to get refunded for what you overpaid.

Why the pharmacy sometimes charges the wrong amount

CMS created the "best available evidence" policy back in 2006 because its records sometimes do not reflect a person's current Extra Help status. Maybe your Medicaid eligibility was just approved, you just started receiving Supplemental Security Income (SSI), or paperwork hasn't caught up with the plan's system. Whatever the reason, federal regulations say your drug plan must accept proof from you (or someone acting on your behalf) and update your low-income subsidy (LIS) status accordingly. Once it does, your cost sharing has to be adjusted — including going back and refunding what you already paid.

What counts as "best available evidence"

Under the regulation, BAE is documentation or information tied to a state agency or the Social Security Administration that confirms Extra Help eligibility. Medicare.gov lists examples you can send to your plan:

• A yellow, green, purple, or orange letter from Medicare about Extra Help.
• A Social Security award letter if you receive SSI.
• For people on Medicaid: a Medicaid card, a Medicaid award letter, or another state document showing current Medicaid enrollment.

For people on Medicaid who live in a nursing home or other long-term care facility, or who receive home- and community-based services (HCBS), additional proof can include:

• A bill from the facility, or a state document, showing Medicaid paid for at least a month of the stay.
• A state document confirming you receive HCBS.

This matters because full-benefit dual eligibles living in an institution or getting HCBS pay nothing for covered Part D drugs — a big savings you shouldn't miss out on if your paperwork proves it.

The 2027 Extra Help amounts to measure against

So you know what you should be paying at the counter in 2027:

• $0 plan deductible.
• No more than $5.80 for each generic drug at a plan's participating pharmacy.
• No more than $14.40 for each brand-name drug.
• $0 for covered drugs once your out-of-pocket costs reach the Part D cap of $2,400 (certain payments made on your behalf, including through Extra Help, count toward that cap).

If the pharmacy is charging more, something is off — and BAE is how you fix it.

Step-by-step: getting your price fixed and getting refunded

1. Call your Part D plan. Tell them you have Extra Help, that your cost sharing is wrong, and that you are submitting best available evidence. Say how many days of medication you have left so the plan treats it as urgent. 2. Send your proof. Use one of the documents listed above. Keep copies. 3. Call 1-800-MEDICARE. They can confirm your Extra Help level directly and help push the correction through with your plan. 4. Ask for a refund of what you overpaid. Federal rules require the drug plan to pay back excess premiums and cost sharing you paid after the effective date of your Extra Help eligibility, and to issue refunds from retroactive claim adjustments within 45 days of getting complete information.

Changing plans if your current one isn't working

Since 2025, people with Medicaid or Extra Help have a monthly Special Enrollment Period to move to Original Medicare paired with a stand-alone Part D plan, or to switch stand-alone Part D plans. Full-benefit dual-eligible individuals can also join an integrated Dual-Eligible Special Needs Plan (D-SNP) in any month. (The old once-per-quarter limit no longer applies.) You also always have the Annual Enrollment Period — October 15 through December 7, 2026 for coverage that starts January 1, 2027.

If you are weighing Original Medicare with a stand-alone Part D plan (and possibly a Medigap policy) versus Medicare Advantage with drug coverage, there are trade-offs either way. Original Medicare lets you use any provider that accepts Medicare nationwide and pairs with a separate drug plan; Medicare Advantage often bundles medical and drug coverage with extra benefits but typically uses provider networks and plan-specific rules. Neither is "best" — it depends on your providers, prescriptions, travel, and budget.

A few other national figures worth knowing for 2027

• Part D out-of-pocket cap: $2,400 (up from $2,100 in 2026).
• Maximum Part D deductible any plan may charge: $700 (people with Extra Help pay $0).
• Part D base beneficiary premium: $41.33, a national figure used to calculate the late-enrollment penalty. Actual plan premiums vary.
• Social Security announced a 3.6% cost-of-living adjustment for benefits payable beginning January 2027.

The 2027 Part B standard premium and deductible, and the IRMAA income brackets, had not been released at the time of writing — CMS announces them in the fall, usually November.

Where to go for help

For official information and to check or update your Extra Help status, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227), available 24/7 (TTY 1-877-486-2048). Keep your proof documents handy when you call — that is exactly what the BAE process is built around.