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Suggestion Box
How are We Doing?
Call us to learn more about CareSource:
Toll-free 1-888-460-0185
471-4106 (Grants Pass)
734-5520 (Medford)
TTY/TDD: 1-800-735-2900
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LIS (Low Income Subsidy)
"Extra Help from Medicare” [2010]
 Low Income Subsidy Chart and Premiums (updated 1/11/2010)
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EZ‐CAP
Condition Code |
Premium Subsidy |
Cost sharing
in the initial coverage level
(30 day supply) |
Cost sharing
in the initial coverage level
(90 day supply) |
Cost sharing
in the coverage gap |
Cost sharing
Above $4,550
(Catastrophic Coverage) |
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NO SUBSIDY |
0% |
$5/$39/$69/33% |
$10/$78/$138/33% |
Member pays 100% |
$2.50/$6.30 or 5% whichever is greater |
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LIP 100/LIC 1 |
100% |
$2.50/$6.30* |
$2.50/$6.30* |
$2.50/$6.30* |
$0 |
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LIP 100/LIC 2 |
100% |
$1.10/$3.30** |
$1.10/$3.30** |
$1.10/$3.30** |
$0 |
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LIP 100/LIC 3 (Institutional) |
100% |
$0 |
$0 |
$0 |
$0 |
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LIP 100/LIC 4 |
100% |
$5/$39/$69 or 15%, whichever is less |
$10/$78/$138 or 15%, whichever is less |
15% |
$2.50/$6.30* |
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LIP 075/LIC 4 |
75% |
$5/$39/$69 or 15%, whichever is less |
$10/$78/$138 or 15%, whichever is less |
15% |
$2.50/$6.30* |
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LIP 050/LIC 4 |
50% |
$5/$39/$69 or 15%, whichever is less |
$10/$78/$138 or 15%, whichever is less |
15% |
$2.50/$6.30* |
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LIP 025/LIC 4 |
25% |
$5/$39/$69 or 15%, whichever is less |
$10/$78/$138 or 15%, whichever is less |
15% |
$2.50/$6.30* |
*$2.50 copay for generic drugs and brand drugs treated as generic; $6.30 for all other drugs
**$1.10 copay for generic drugs and brand drugs treated as generic; $3.30 for all other drugs
LIC = Low Income Subsidy (cost sharing)
LIP = Low Income Premium
“Extra Help from Medicare” (LIS) Policy Premiums (per month) – 2010Ŧ
ŦThe member’s premium will generally be lower once the member receives extra help from Medicare. These premiums listed are for both medical services and prescription drug benefits, and do not include any Part B premium the member may have to pay.
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Plan Name
& Plan Number |
Premium ‐ No Subsidy |
100% Premium Subsidy |
75% Premium Subsidy |
50% Premium Subsidy |
25% Premium Subsidy |
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Gold Plus Rx (HMO) (H3810‐003)* |
$114.60 |
$79.00 |
$87.90 |
$96.80 |
$105.70 |
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Gold Plus Rx (HMO) (H3810‐010)** |
$134.70 |
$101.00 |
$109.40 |
$117.90 |
$126.30 |
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Platinum Plus Rx (HMO‐POS) (H3810‐005) |
$150.70 |
$115.10 |
$124.00 |
$132.90 |
$141.80 |
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Silver Plus Rx (HMO) (H3810‐007) |
$54.60 |
$42.10 |
$45.20 |
$48.40 |
$51.50 |
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Diamond Plus Rx (PPO) (H2481‐004) |
$142.60 |
$107.00 |
$115.90 |
$124.80 |
$133.70 |
*Josephine County, Oregon (including Rogue River & Gold Hill), Curry County, Douglas County (Glendale & Azalea only)
**Jackson County, Oregon (excluding Rogue River & Gold Hill)
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