Exit Survey

Hello! Thank you for visiting the PremiumAssist pre-screening web page. The Medicare Savings Program and Extra Help program can save you up to $174.70 per month on your Medicare Part B premiums and provide additional assistance with prescription drug costs.

This is a secure site. Any personal health or financial information you provide will be kept private and will not be shared or sold. We will use this information for the sole purpose of determining potential eligibility for the program. Your participation is voluntary and will not affect your benefits as a health plan member. The appropriate state Medicaid agency will make the final eligibility determination.

It’s also totally FREE. Your health plan provides this service free of charge.

The questions are simple, and this should only take a few minutes.

If you are potentially eligible based upon the information you provided, you will be contacted by a PremiumAssist Representative within 7 Business Days. You can also call 877-236-4471 if you have any questions.

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Please provide your member number located on your Health Plan Membership Card:

Name of Health Plan:

I am completing this form for:

Member Information:

Please also provide the member's E-mail Address:

Please list an emergency contact or someone authorized to speak on the member's behalf:

Is this member married?

Please list below the current monthly income for each:

  Self Spouse
Social Security $ $
Is this amount after the Part B premium is taken out?
Pension $ $
Veteran's Benefits $ $
Work/Self-Employed Wages $ $
Other Income $ $

Please list below the current balance in your accounts:




Do you have life insurance?

Do you own a vehicle?

Do we have permission to submit your application without talking to you if you are eligible for the MSP or LIS Programs?

Thank you very much! Now just click on the "Done" button...