LOW INCOME SUBSIDY

Prime Solution

The amounts below include the medical premium for Prime Solution and the
Part D premium.

Level of Extra Help*

Plan Options 100% 75% 50% 25%
With Rx $80.80 $86.70 $92.60 $98.50
With Rx2 $99.00 $107.50 $115.90 $124.40

*Based on income and resource levels set by the Centers for Medicare and Medicaid Services premiums may vary based on the level of Extra Help you receive. Please contact Medica for further details.

Level of Extra Help*

Plan Options 100% 75% 50% 25%
With Rx $90.10 $99.00 $107.80 $116.70

*Based on income and resource levels set by the Centers for Medicare and Medicaid Services premiums may vary based on the level of Extra Help you receive. Please contact Medica for further details.

Level of Extra Help*

Plan Options 100% 75% 50% 25%
With Rx $164.40 $173.30 $182.10 $191.00
With Rx2 $195.70 $204.60 $213.40 $222.30

*Based on income and resource levels set by the Centers for Medicare and Medicaid Services premiums may vary based on the level of Extra Help you receive. Please contact Medica for further details.

Level of Extra Help*

Plan Options 100% 75% 50% 25%
With Rx $90.10 $96.60 $103.20 $109.70

*Based on income and resource levels set by the Centers for Medicare and Medicaid Services premiums may vary based on the level of Extra Help you receive. Please contact Medica for further details.

Level of Extra Help*

Plan Options 100% 75% 50% 25%
With Rx $204.20 $213.10 $221.90 $230.80

*Based on income and resource levels set by the Centers for Medicare and Medicaid Services premiums may vary based on the level of Extra Help you receive. Please contact Medica for further details.

Level of Extra Help*

Plan Options 100% 75% 50% 25%
With Rx $51.10 $60.50 $69.90 $79.30

*Based on income and resource levels set by the Centers for Medicare and Medicaid Services premiums may vary based on the level of Extra Help you receive. Please contact Medica for further details.

Level of Extra Help*

Plan Options 100% 75% 50% 25%
With Rx $187.00 $197.00 $206.90 $216.90

*Based on income and resource levels set by the Centers for Medicare and Medicaid Services premiums may vary based on the level of Extra Help you receive. Please contact Medica for further details.

Level of Extra Help*

Plan Options 100% 75% 50% 25%
With Rx $67.90 $76.40 $84.90 $93.40

*Based on income and resource levels set by the Centers for Medicare and Medicaid Services premiums may vary based on the level of Extra Help you receive. Please contact Medica for further details.

Advantage Solution

The amounts below include the medical premium for Advantage Solution and the
Part D premium.

Level of Extra Help*

Plan Options 100% 75% 50% 25%
H3632-001 (PPO) $18.30 $25.00 $31.60 $38.60
H6154-002 (HMO-POS) $42.70 $49.20 $55.70 $62.20
H8889-001 (PPO) $79.80 $86.10 $92.40 $98.70
H8889-002 (PPO) $92.90 $100.90 $108.90 $117.00
H8889-003 (PPO) $166.70 $173.60 $180.60 $187.50
H8889-004 (PPO) $81.70 $88.10 $94.40 $100.80

*Based on income and resource levels set by the Centers for Medicare and Medicaid Services premiums may vary based on the level of Extra Help you receive. Please contact Medica for further details.

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