Low-Income Subsidy

If you get extra help from Medicare in paying for your Medicare prescription drug plan costs, your monthly plan premium will be lower than if you did not get that extra help. 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.

2012 Low-Income Subsidy

*This does not include the Medicare Part B premium you must continue to pay. Independence Blue Cross’s premium includes coverage for both medical services and prescription drug coverage. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

• 1-800-MEDICARE. TTY/TDD users call 1-877-486-2048 (24 hours a day/seven days a week);
• Pennsylvania Office of Medical Assistance Programs (Medicaid) at 1-717-787-1870;
• 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 Customer Service at 1-877-393-6733, (Speech- and hearing-impaired: 1-877-219-5457) from 8 a.m. to 8 p.m. EST, seven days a week.

Best Available Evidence Policy
Early in 2006, a number of factors contributed to the problem of incorrect cost-sharing levels for individuals eligible for Medicare and Medicaid, called full-benefit dual eligibles and other low-income (LIS) eligible individuals. The purpose of this link is to provide a member with information on CMS best available data policy, which is the policy CMS uses to determine eligibility in financial assistance programs.

In certain cases, CMS systems do not reflect a beneficiary's correct low-income subsidy (LIS) status at a particular point in time. To address these situations, CMS created the best available evidence (BAE) policy. This policy requires Plans to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate.

Learn more about the Best Available Evidence Policy.

You must continue to pay your Medicare Part B premium.

The Medicare Contract is renewed annually, and the availability of coverage beyond the end of the current year is not guaranteed.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change January 1, 2013. Members may enroll in the plan during specific times of the year. Contact the plan for more information. Please reference the Evidence of Coverage for information on premiums, cost-sharing, out-of-network coverage, rights and responsibilities upon disenrollment and any applicable conditions associated with using the plan benefits, as well as limitations, copayments, and restrictions. Members must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
• The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
• Your State Medicaid Office.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.”

You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor Keystone 65 HMO or Personal Choice 65 PPO will be responsible for the costs.

Please contact Keystone 65 HMO or Personal Choice 65 PPO Customer Service for more information.

Y0041_HM_12_300a Pending CMS Approval