Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - Paper Version

Instructions for Completing the Appeal of Determination for
Extra Help with Medicare Prescription Drug Plan Costs
WHEN TO USE THIS FORM: Use Form SSA-1021 to appeal Social Security's
determination regarding eligibility or continuing eligibility for Extra Help with your
Medicare prescription drug plan costs.
1.

APPLICANT'S NAME:
Print your name as it appears on your Social Security card.

2.

SOCIAL SECURITY NUMBER:
Print your Social Security number as it appears on your Social Security card.

3.

MEDICARE NUMBER:
Print your Medicare number as it appears on your Medicare card.

4.

SPOUSE'S NAME:
If you are not married or do not live with your spouse, go to question 7. If you live with
your spouse, print your spouse's name as it appears on your spouse's Social Security card.

5.

SPOUSE'S SOCIAL SECURITY NUMBER:
If you are married and live with your spouse, print your spouse's Social Security number as
it appears on your spouse's Social Security card.

6.

SPOUSE'S MEDICARE NUMBER:
If you are married and live with your spouse, print your spouse's Medicare number, if
applicable, as it appears on your spouse’s Medicare card.

7.

PLEASE EXPLAIN WHY YOU DISAGREE WITH OUR DECISION:
Briefly tell us the decision you disagree with and why you disagree. You can add to this
statement by attaching additional pages.

8.

DO YOU HAVE ADDITIONAL INFORMATION TO SUPPORT YOUR APPEAL:
If there is more information you want us to see, you can mail it with this form to:
Social Security Administration
Wilkes-Barre Direct Operations Center
P.O. Box 1030
Wilkes-Barre, PA 18767-1030

9.

DO YOU WANT A HEARING?
Our hearings are conducted by telephone. Check "YES" if you want a hearing or check
"NO" if you do not want a hearing. If you do not want a hearing, we will make a decision

based on the information we have available and any additional information you provide.
We call this a case review.

10. DO YOU WANT A HEARING SOONER IF SCHEDULING PERMITS?
We allow at least 20 days from the date we receive your appeal request and the date we
schedule the hearing to give you time to prepare. If you want a hearing sooner, check
"YES." Check "NO" if you want us to schedule the hearing at least 20 days from the date
we receive your appeal request.
Form SSA-1021-INST (10-2024)

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11. DO YOU NEED AN INTERPRETER?
Check "YES" and specify the language you prefer, and we will provide interpreter services.
Check "NO" if you do not need an interpreter.
12. ARE YOU HEARING IMPAIRED?
Check "YES" if you require the use of a telecommunications device for the deaf to
communicate. Check "NO" if you are not hearing impaired.
13. WILL YOU HAVE OTHER PEOPLE AT THE HEARING?
Check "YES" if you will have people other than yourself at the telephone hearing. Check
"NO" if you will not have other people at the telephone hearing. If "YES," will you and the
other people need to talk to us from more than one telephone number? Check "YES" if you
will have people calling in from a telephone number different from yours. Otherwise, check
"NO."

SEND THE FORM:
Please return your completed appeal form, including the signature page, and any
additional information to:
Social Security Administration
Wilkes-Barre Direct Operations Center
P.O. Box 1030
Wilkes-Barre, PA 18767-1030

Form SSA-1021-INST (10/2024)

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