The Medicare Savings Programs (MSP) Model Application for Medicare Premium Assistance. If you think you might be able to get help from your state with Medicare costs, or if you are not sure, call your state medical assistance (Medicaid) office or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048).
This form is also avaiable in...
CMS publications on Medicare prescription drug coverage
- Your Guide to Medicare Prescription Drug Coverage (CMS Product No. 11109), Español
- How Medicare Prescription Drug Coverage Works with a Medicare Advantage Plan or Medicare Cost Plan (CMS Product No. 11135), Español
- Quick Facts about Medicare Plans and Protecting Your Personal Information (CMS Product No. 11147), Español