2012 BRx Low Income Subsidy Premiums and Copayments

What is the Low Income Subsidy?

For people with limited incomes and resources, extra financial help, called Low Income Subsidy (LIS), may be available from the federal government. If you qualify for LIS assistance for your Medicare prescription drug coverage costs, the amount of your premium and cost at the pharmacy will be less.

How will the LIS change my BRx premium and copayments?

Subsidy	Monthly Premium	Annual Deductible	Copayment/ Coinsurance *	Catastrophic Copayment **
1 (100%)	$0.90	$0.00	$2.60/$6.50	$0.00/$0.00
2 (100%)	$0.90	$0.00	$1.10/$3.30	$0.00/$0.00
3 (100%)	$0.90	$0.00	$0.00/$0.00	$0.00/$0.00
4 (100%)	$0.90	$65.00	15%	$2.60/$6.50
4 (75%)	$8.50	$65.00	15%	$2.60/$6.50
4 (50%)	$16.10	$65.00	15%	$2.60/$6.50
4 (25%)	$23.70	$65.00	15%	$2.60/$6.50

* Copayment amounts for generic and brand drugs, respectively. For example, the first amount shown ($2.60) is the copayment for a generic drug filled for a member who is in the LIS Category 1.

** After the True-Out-of-Pocket Limit is reached, the Catastrophic Copayment for LIS Levels 1, 2, & 3 is $0.00 for both generic and brand drugs. The Catastrophic Copayment amounts for LIS Level 4 is $2.60 for generic drugs and $6.50 for brand drugs.

NOTE: Beneficiaries receiving extra help are responsible for paying the monthly premium amounts listed above. The monthly premium amounts do not include the premium for your 65C Plus (Cost) health plan. You must continue to pay HMSA for your 65C Plus (Cost) health plan premium and pay Medicare for your Part B premium.

How do I apply for the LIS?

Beneficiaries may apply for the LIS through Social Security or state Medicaid agency.

For more information and an application for LIS, please call Social Security at 1 (800) 772-1213 or visit www.ssa.gov. TTY users should call 1 (800) 325-0778, 7 a.m. to 7 p.m., Monday through Friday.

I already know that I qualify for the LIS. How do I get my premiums and copayments adjusted?

You must be a member of a Medicare Prescription Drug Plan, such as HMSA’s 65C Plus BRx (Cost) plan, to receive this extra help. If you are a member of BRx and you qualify for extra help, Medicare will notify HMSA that you qualify for extra help, and HMSA will apply the extra help to your premium and copayment amounts.

BRx members with LIS can also notify HMSA directly about their LIS. We will ask for documentation of your LIS award, such as a Medicaid card or an SSA award letter. This documentation is called "Best Available Evidence" and it will help us to apply the correct level of LIS as soon as possible.

You can find more information about presenting "Best Available Evidence" by visiting the CMS website.

65C Plus (Cost) has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program. This contract renews each year. At the end of each year, the contract is reviewed, and either 65C Plus (Cost) or CMS can decide to end it. It is possible for our contract to end at some other time during the year, too. If the contract should end, HMSA will provide advance notice to all 65C Plus (Cost) members.