The Federal Government provides an extensive program for people needing financial assistance with the Medicare Part D program. Depending on your income and available financial resources , Medicare will provide 'Extra Help' that may cover 85% to 100% of prescription costs and may also pay a part or all of your Medicare Part D premiums.

1. Lis Copays 2021 List
2. Lis Copays 2021 Application

1. The Part D Senior Savings Model provides consistent copays for select insulin drugs in all stages until you reach the Catastrophic Coverage Stage. (If you reach that stage, the cost-sharing amounts on page 8 will apply.) If you receive “Extra Help,” you do not qualify for this program, and your Low-Income Subsidy (LIS) benefit will apply.
2. § Copay assistance is not valid for prescriptions reimbursed under Medicare, Medicaid, or similar federal or state programs. ¶llel; Medicare Part D patients with an annual income of ≤150% of the FPL are eligible for LIS assistance (also called 'Extra Help').

Rx Tier 3 1 LIS copays Rx Tier 4 1 LIS copays Rx Tier 5 1 LIS copays Dental $2,500 comprehensive every year. $0 copay for routine exams Vision $0 copay for 1 routine vision exam every year, and a $400 eyewear allowance every 2 years. Hearing $0 copay for 1 routine hearing exam every year, and a $2,000 hearing aid allowance every 2 years. 2021 Drug Cost Sharing Stages for Beneficiaries with Extra Help (LIS) LIS-Note 1 Deductible Initial Coverage Catastrophic-Note 2 Level 1 None Copays no more than $3.70 for generic and $9.20 for brand name drugs No copay Level 2 None Copays no more than $1.30 for generic and $4.00 for brand name drugs Level 3 None No copay Level 4 $92. Summary of Benefits 2021 Medicare Advantage Plan with Prescription Drugs Preferred Medicare Assist Plan 1 (HMO D-SNP) H1045-012-000 Look inside to take advantage of the health services and drug coverages the plan provides.

Who Qualifies for 'Extra Help'?

For the plan year 2021 If your income is below $19,320 per year for a single person (or $26,130 for a married couple living together or even more if you have dependent children or grandchildren living with you), AND if your assets (resources) are below $13,290* for a single person (or $26,520* if you are married). *These limits do not include the $1,500 per person burial exclusion, see more details below.

Lis Copays 2021 List

The following items are NOT included in income:

• Housing assistance,
• Medical treatment and drugs,
• Food stamp assistance, etc.

Click Here to see more payments that do NOT count toward income.

$1,500 per person Burial Exclusion:
All beneficiaries are permitted a $1,500 per person burial exclusion from their resources. This exclusion can be taken into account by either reducing your resources by $1,500 per person (Medicare & Your Handbook) or by increasing the resource limit by $1,500 per person (Most other Social Security Administration and Medicare documents). Below is a chart showing the resource figures with, and without taking into account the burial exclusion:

Maximum Resource Limit	With $1,500 Burial Exclusion	Without $1,500 Burial Exclusion
Individuals	$14,790	$13,290
Couples	$29,520	$26,520

The following items are included in resources:

• bank accounts,
• stocks and bonds,
• Real estate (other than your primary residence), etc.

The following items are NOT included in resources:

• the house you live in,
• your car,
• other personal possessions such as your furniture and jewelry, etc.
• burial plots,
• up to$1,500 for burial expenses (per person), or
• life insurance policies.

Click Here to see more assets that do NOT count toward resources.

Who Should You Contact for 'Extra Help'?

Medicare Beneficiaries Who are interested in qualifying for financial 'extra help' with the Medicare Part D Prescription Drug plans should visit http://www.socialsecurity.gov/i1020

Also see:

Low Income Subsidy Premium Table - 2021

If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.
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This table shows you what your monthly plan premium will be if you get extra help.

Year 2021

Your Level of Extra Help	Monthly Premium for Vitality Plus (HMO)*	Monthly Premium for Inter Valley Health Plan Service To Senior (HMO), Desert Preferred Choice (HMO)*
100%	$0.00	$0.00
75%	$7.95	$0.00
50%	$15.75	$0.00
25%	$23.60	$0.00

*This does not include any Medicare Part B premium you have to pay.

Inter Valley Health Plan’s premium includes coverage for both medical services and prescription drug coverage.
If you aren’t getting extra help, you can see if you qualify by calling:

• 1-800-Medicare or TTY users call 1-877-2048 (24 hours a day/7 days a week).
• Your State Medicaid Office, or
• The Social Security Administration at 1-800-772-1213. TTY users should call 1-800-325-0778 between 7 am and 7 pm Monday through Friday.

If you have any questions, please contact our Pharmacy Care Team at 800-523-3142 or TTY 711

• From October 1 to March 31, you can call us 7 days a week from 8 am to 8 pm. We are closed on Thanksgiving day & Christmas day.
• April 1 to September 30, you can call us Monday through Friday, from 8 am to 8 pm. We are closed on Federal Holidays.
  NOTE: When we are closed you have the option to leave a message. Messages received will be returned within one (1)​ business day.

The information is not a complete description of benefits. Contact the plan for more information. The actual complete terms and conditions of the health plan are set forth in the applicable Evidence of Coverage document.

Lis Copays 2021 Application

For a PDF of this information please click here

H0545_FUY2021_032_C

Updated 10/05/2020