Extra Help LIS Premium Summary Chart

Low Income Subsidy tables for 2019

Monthly premium

Subsidy Levels Complete Complete Plus Standard Standard Plus Dual Care Essential Advantage
Level 1 - 100% $30.30 $120.30 $65.30 $182.30 $0 $0
Level 2 - 100% $30.30 $120.30 $65.30 $182.30 $0 $0
Level 3 - 100% $30.30 $120.30 $65.30 $182.30 $0 $0
Level 4 - 100% $30.30 $120.30 $65.30 $182.30 $0 $0
Level 4 - 75% $36.70 $126.70 $71.70 $188.70 $6.20 $5.00
Level 4 - 50% $43.10 $133.10 $78.10 $195.10 $12.50 $10.00
Level 4 - 25% $49.60 $139.60 $84.60 $201.60 $18.70 $15.00

View Essential Advantage (HMO) LIS premium summary
View HMSA Akamai Advantage (PPO) LIS premium summary

Out-of-pocket drug costs

Subsidy Levels Annual Deductible Complete, Standard, Dual Care, and Essential Advantage Annual Deductible Complete Plus and Standard Plus Copayment / Coinsurance* Catastrophic Copayment**
Level 1 - 100% $0 $0 $3.40/$8.50 $0/$0
Level 2 - 100% $0 $0 $1.25/$3.80 $0/$0
Level 3 - 100% $0 $0 $0/$0 $0/$0
Level 4 - 100% $85 $0 15% $3.40/$8.50
Level 4 - 75% $85 $0 15% $3.40/$8.50
Level 4 - 50% $85 $0 15% $3.40/$8.50
Level 4 - 25% $85 $0 15% $3.40/$8.50

* Copayment amounts for generic/preferred multi-source and other drugs, respectively. For example, the first amount shown ($3.40) is the copayment for a generic drug filled for a member in the LIS Category 1.

** After the true-out-of-pocket limit is reached, the Catastrophic copayment for LIS Levels 1, 2, and 3 is $0 for both generic and brand drugs. The Catastrophic copayments for LIS Level 4 are $3.40 for generic/preferred multi-source drugs and $8.50 for other drugs.

HMSA Akamai Advantage is a PPO plan and Essential Advantage is an HMO plan with a Medicare contract. Enrollment in HMSA Akamai Advantage and Essential Advantage depends on contract renewal.

This information is not a complete description of benefits. Contact the plan for more information.

You must continue to pay your Medicare Part B premium.