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SeniorCare RX (Cost) Plan Low Income Subsidy Table
Low Income Subsidy
Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.
This table shows you what your monthly plan premium will be if you get extra help.
| Plan Premium for Plan: | Your level of extra help | |||
| 100% | 75% | 50% | 25% | |
| Preferred Plus with Basic Rx | $167.10 | $174.10 |
$181.00 |
$188.00 |
| Preferred with Basic Rx | $111.90 | $118.20 | $124.40 | $130.70 |
| Select with Basic Rx | $49.10 | $55.60 | $62.00 | $68.50 |
| Preferred Plus with Enhanced Rx | $221.40 | $229.40 | $237.50 | $245.60 |
| Preferred with Enhanced Rx | $163.40 | $171.40 | $179.50 | $187.60 |
| Select with Enhanced Rx | $101.40 | $109.40 | $117.50 | $125.60 |
| Preferred Plus with Value Rx | $172.80 | $180.80 | $188.90 | $197.00 |
| Preferred with Value Rx | $114.80 | $122.80 | $130.90 | $139.00 |
| Select with Value Rx | $52.80 | $60.80 | $68.90 | $77.00 |
*This does not include any Medicare Part B premium you may have to pay.
The above premium chart includes coverage for both medical services and prescription drug coverage.
The benefit information provided is not comprehensive. Additional information should be requested before making a decision about your coverage.
You must receive all routine care from plan providers.
If you aren't getting extra help, you can see if you qualify by calling:
- 1-800-Medicare or TTY/TDD users call 1-877-486-2048 (24 hours a day/7 days a week),
- Your State Medicaid Office, or
- The Social Security Administration at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.
If you have any questions, please call Scott & White Health Plan Customer Service at 254-298-3000 or 866-334-3141, (TTY/TDD: 1-800-735-2989) from 8:00 a.m. to 8:00 p.m. Monday through Sunday.
The above information is current as of January 2011.
"A Health Plan with a Medicare Contract"
H4564_WEB_SC_LIS_2011 CMS Approved 11/17/2010