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LIS (Low Income Subsidy)

"Extra Help from Medicare” [2010]

Low Income Subsidy (updated 12/31/09)

Condition Code	Premium Subsidy	Cost sharing (up to $2,830) in the initial coverage level (30 day supply)	Cost sharing (up to $2,830) in the initial coverage level (90 day supply)	Cost sharing in the gap	Cost sharing Above $4,550 (Catastrophic Coverage)
NO SUBSIDY	0%	$5/$39/$69/33%	$10/$78/$138/33%	Member pays 100%	$2.50/$6.30 or 5% whichever is greater
LIP 100/LIC 1	100%	$2.50/$6.30*	$2.50/$6.30*	$2.50/$6.30*	$0
LIP 100/LIC 2	100%	$1.10/$3.30**	$1.10/$3.30**	$1.10/$3.30**	$0
LIP 100/LIC 3 (Institutional)	100%	$0	$0	$0	$0
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
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
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
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

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