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2013 Low Income Subsidy (LIS) Premium Information

Medicare provides “Extra Help” to pay prescription drug costs for people who have limited income and resources. Resources include your savings and stocks, but not your home or car. If you qualify, you get help paying for any Medicare drug plan’s monthly premium, yearly deductible and prescription copayments. In addition, your premium will generally be lower when you receive help. This Extra Help also counts toward your out-of-pocket costs.

People with limited income and resources may qualify for Extra Help. Some people automatically qualify for Extra Help and don’t need to apply. Medicare mails a letter to people who automatically qualify for Extra Help.

If you think you may qualify for Extra Help, call Social Security at 1-800-772-1213, TTY users can call 1-800-325-0778. You may also be able to apply at your State Medicaid Office, call 1-800-926-2588, TTY users can call 1-208-332-7205. After you apply, you will get a letter letting you know if you qualify for Extra Help and what you need to do next.

The premiums listed above are for medical services and prescirption drug benefits, but do not include any Part B premium you may have to pay. 

True Blue HMO Rx Option I
Low-Income Subsidy

2012

2013

$0 deductfible

$0 deductible

$0 deductible

$0 deductible

$1.10 for generics and brands that are treated as generics  $3.30 for brand name drugs

$1.15 for generics and brands that are treated as generics  $3.50 for brand name drugs

$2.60 for generics and brands that are treated as generics  $6.50 for brand name drugs

$2.65 for generics and brands that are treated as generics  $6.60 for brand name drugs

15% coinsurance for all drugs

15% coinsurance for all drugs

True Blue HMO Rx Option I
2013 Part D Premium

Your level of extra help

Monthly Premium for True Blue HMO
Rx Option I

100%

$53.40

75%

$64.00

50%

$74.50

25%

$85.10

True Blue HMO Rx Option II
Low-Income Subsidy

2012

2013

$260 deductible

$300 deductible

$65 deductible

$66 deductible

$1.10 for generics and brands that are treated as generics  $3.30 for brand name drugs

$1.15 for generics and brands that are treated as generics  $3.50 for brand name drugs

$2.60 for generics and brands that are treated as generics  $6.50 for brand name drugs

$2.65 for generics and brands that are treated as generics  $6.60 for brand name drugs

15% coinsurance for all drugs

15% coinsurance for all drugs

True Blue HMO Rx Option II
2013 Part D Premium

Your level of extra help

Monthly Premium for True Blue HMO Rx Option II

100%

$0.00

75%

$8.10

50%

$16.10

25%

$24.20

 

 

True Blue Freedom HMO
Low-Income Subsidy

2012

2013

$0 deductible

$190 deductible

$65 deductible

$66 deductible

$1.10 for generics and brands that are treated as generics  $3.30 for brand name drugs

$1.15 for generics and brands that are treated as generics  $3.50 for brand name drugs

$2.60 for generics and brands that are treated as generics  $6.50 for brand name drugs

$2.50 for generics and brands that are treated as generics  $6.30 for brand name drugs

15% coinsurance for all drugs

15% coinsurance for all drugs

2013 Part D Premium
True Blue Freedom HMO

Your level of extra help

Monthly Premium for True Blue Freedom HMO

100%

$0.00

75%

$5.00

50%

$9.90

25%

$14.90

 

Secure Blue PPO H1302-001
Low-Income Subsidy

2012

2013

$0 deductible

$0 deductible

$0 deductible

$0 deductible

$1.10 for generics and brands that are treated as generics  $3.30 for brand name drugs

$1.15 for generics and brands that are treated as generics  $3.50 for brand name drugs

$2.60 for generics and brands that are treated as generics  $6.50 for brand name drugs

$2.65 for generics and brands that are treated as generics  $6.60 for brand name drugs

15% coinsurance for all drugs

15% coinsurance for all drugs

Secure Blue PPO H1302-001
2013 Part D Premium

Your level of extra help

Monthly Premium for Secure Blue PPO
H1302-001

100%

$2.60

75%

$13.20

50%

$23.70

25%

$34.30

Secure Blue PPO H1302-006
Low-Income Subsidy

2012

2013

N/A

$0 deductible

N/A

$0 deductible

N/A

$1.15 for generics and brands that are treated as generics  $3.50 for brand name drugs

N/A

$2.65 for generics and brands that are treated as generics  $6.60 for brand name drugs

N/A

15% coinsurance for all drugs

Secure Blue PPO H1302-006
2013 Part D Premium

Your level of extra help

Monthly Premium for Secure Blue PPO H1302-006

100%

$2.80

75%

$13.40

50%

$23.90

25%

$34.50

 

 

 

Y0010_MK 13121 Approved 12-31-2012
Last updated 11-14-2012