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Low Income Subsidy

Prime Solution

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

Enhanced

Level of Extra Help*
Plan Options
100%
75%
50%
25%
With Rx
$157.70
$166.70
$175.60
$184.60
With Rx2
$168.50
$177.10
$185.70
$194.40

Basic

Level of Extra Help*
Plan Options
100%
75%
50%
25%
With Rx
$79.00
$87.20
$95.30
$103.50
With Rx2
$92.90
$101.10
$109.40
$117.60

Value

Level of Extra Help*
Plan Options
100%
75%
50%
25%
With Rx
$67.00
$74.60
$82.10
$89.70

Thrift

Level of Extra Help*
Plan Options
100%
75%
50%
25%
With Rx
$49.00
$57.00
$64.90
$72.90

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%
H6154-001
(HMO–POS)
$2.00
$8.10
$14.20
$20.30
H6154-002
(HMO–POS)
$43.80
$50.00
$56.20
$62.50
H8889-001 (PPO)
$68.60
$76.10
$83.50
$91.00
H8889-002 (PPO)
$93.30
$100.90
$108.60
$116.20
H8889-003 (PPO)
$158.70
$167.70
$176.60
$185.60
H8889-004 (PPO)
$81.70
$89.00
$96.40
$103.70

Prime Solution

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

Premier

Level of Extra Help*
Plan Options
100%
75%
50%
25%
With Rx
$193.70
$202.70
$211.60
$220.60

Core

Level of Extra Help*
Plan Options
100%
75%
50%
25%
With Rx
$79.90
$88.90
$97.80
$106.80

Thrift

Level of Extra Help*
Plan Options
100%
75%
50%
25%
With Rx
$49.00
$57.00
$64.90
$72.90

Prime Solution

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

Total

Level of Extra Help*
Plan Options
100%
75%
50%
25%
With Rx
$179.00
$188.20
$197.50
$206.70

Focus

Level of Extra Help*
Plan Options
100%
75%
50%
25%
With Rx
$89.00
$97.10
$105.30
$113.40

Thrift

Level of Extra Help*
Plan Options
100%
75%
50%
25%
With Rx
$49.00
$57.00
$64.90
$72.90

Need Help?

1-877-704-7864 
(TTY: 711)
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*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.

Medica is a Cost, HMO-POS and PPO plan with a Medicare contract. Enrollment in Medica depends on contract renewal.

This information is not a complete description of benefits. Call Medica at 1-877-704-7864 (TTY: 711) for more information.

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Last Updated: October 2018