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 30-day supply is the same for a 90-day supply.
Level
There are four levels of Low Income Subsidy.
The “Level” is the cost responsibility of their medications and deductibles.
Subsidy
The Subsidy percentage is the amount paid toward their premium.
Levels 1-3 subsidize the premium amount 100% of the standard part D premium.
Level 4 subsidizes the premium amount at various rates as indicated in the table.
Deductible
Levels 1-3 have a $0 deductible.
Level 4 has a $92 deductible (the customer will pay the lesser of the Low Income Subsidy amount or the plan’s deductible.