Low-Income Subsidy & Best Available Evidence Policy

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.

2014 Low-Income Subsidy

Keystone 65 Select HMOs

Monthly premium without extra help

Your plan premium based on your income level of extra help

   

100%

75%

50%

25%

Keystone 65 Select Rx HMO

(medical + prescription drug coverage)
$0.00 (Philadelphia and Bucks residents)

$43.00 (Chester, Delaware, and Montgomery residents)
$0.00 (Philadelphia and Bucks residents)

$20.50 (Chester, Delaware, and Montgomery residents)
$0.00 (Philadelphia and Bucks residents)

$26.10 (Chester, Delaware, and Montgomery residents)
$0.00 (Philadelphia and Bucks residents)

$31.70 (Chester, Delaware, and Montgomery residents)
$0.00 (Philadelphia and Bucks residents)

$37.40 (Chester, Delaware, and Montgomery residents)

Keystone 65 Select Rx HMO with Choice Program

(medical + hearing, dental, and vision coverage + prescription drug coverage)
$7.00 (Philadelphia and Bucks residents)

$50.00 (Chester, Delaware, and Montgomery residents)
$7.00 (Philadelphia and Bucks residents)

$27.50 (Chester, Delaware, and Montgomery residents)
$7.00 (Philadelphia and Bucks residents)

$33.10 (Chester, Delaware, and Montgomery residents)
$7.00 (Philadelphia and Bucks residents)

$38.70 (Chester, Delaware, and Montgomery residents)
$7.00 (Philadelphia and Bucks residents)

$44.40 (Chester, Delaware, and Montgomery residents)

Keystone 65 Preferred Rx HMO

(medical coverage including hearing, dental, and vision + prescription drug)
$182.60 (Philadelphia and Bucks residents)

$252.00 (Chester, Delaware, and Montgomery residents)
$147.10 (Philadelphia and Bucks residents)

$216.50 (Chester, Delaware, and Montgomery residents)
$156.00 (Philadelphia and Bucks residents)

$225.40 (Chester, Delaware, and Montgomery residents)
$164.80 (Philadelphia and Bucks residents)

$234.20 (Chester, Delaware, and Montgomery residents)
$173.70 (Philadelphia and Bucks residents)

$243.10 (Chester, Delaware, and Montgomery residents)

Personal Choice 65 PPOs

Monthly premium without extra help

Your plan premium based on your income level of extra help¹

   

100%

75%

50%

25%

Personal Choice 65 Rx PPO

(medical + prescription drug coverage)
$222.50 (Philadelphia and Bucks residents)

$98.50 (Chester, Delaware, and Montgomery residents)
$187.00 (Philadelphia and Bucks residents)

$63.00 (Chester, Delaware, and Montgomery residents)
$195.90 (Philadelphia and Bucks residents)

$71.90 (Chester, Delaware, and Montgomery residents)
$204.70 (Philadelphia and Bucks residents)

$80.70 (Chester, Delaware, and Montgomery residents)
$213.60 (Philadelphia and Bucks residents)

$89.60 (Chester, Delaware, and Montgomery residents)

¹ 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. By clicking the link you will be leaving the Medicare-specific web pages.


Website last updated: 12/16/2013
Y0041_HM_14_9866d Approved 12/23/2013