2021 LIS Table
Level | Subsidy % | Deductible | Generic/Preferred Drugs | Other Drugs | Above Catastrophic Limit |
Level 1 | 100% | $0 | $3.70** | $9.20** | $0.00 |
Level 2 | 100% | $0 | $1.30** | $4.00** | $0.00 |
Level 3 | 100% | $0 | $0.00 | $0.00 | $0.00 |
Level 4 | 25% | $92 |
15% Coinsurance |
15% Coinsurance
| $3.70 or 5% whichever is greater $9.20 or 5% whichever is greater |
Level 4 | 50% | $92 |
15% Coinsurance |
15% Coinsurance | $3.70 or 5% whichever is greater $9.20 or 5% whichever is greater |
Level 4 | 75% | $92 |
15% Coinsurance |
15% Coinsurance | $3.70 or 5% whichever is greater $9.20 or 5% whichever is greater |
Level 4 | 100% | $92 |
15% Coinsurance |
15% Coinsurance | $3.70 or 5% whichever is greater $9.20 or 5% whichever is greater |
Notes
Copayments for a 30-day supply is the same for a 90-day supply.
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