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Hospital Deductible: $1,260.00 / Benefit period

Hospital Coinsurance:

  • Days 0-60: $0
  • Days 61-90: $315 / Day
  • Days 91-150: $630/ Day

Skilled Nursing Facility Coinsurance:

  • Days 1-20: $0
  • Days 21-100: $157.50/ Day

Part A Premium (For voluntary enrollees only)

  • With 30-39 quarters of Social Security coverage: $224.00 / Month
  • With 29 or fewer quarters of Social Security coverage: $407.00 / Month

Part B

  • Deductible: $147.00 / Year
  • Standard Premium: $104.90 / Month*

Part B Income-Related Premium

Beneficiaries who file an individual tax return with income:

Beneficiaries who file a joint tax return with income:

Income-related monthly adjustment amount

 

Total monthly premium amount

Less than or equal to $85,000

Less than or equal to $170,000

$0

$104.90

Greater than $85,000 and less than or equal to $107,000

Greater than $170,000 and less than or equal to $214,000

$42.00

$146.90

Greater than $107,000 and less than or equal to $160,000

Greater than $214,000 and less than or equal to $320,000

$104.90

$209.80

Greater than $160,000 and less than or equal to $214,000

Greater than $320,000 and less than or equal to $428,000

$167.80

$272.70

Greater than $214

Greater than $428,000

$230.80

$335.70

PART B PREMIUM (cont.)

In addition, the monthly Part B premium rates to be paid by beneficiaries who are married, but file a separate return from their spouse and lived with their spouse at some time during the taxable year are:

Beneficiaries who are married but file a

separate tax return from their spouse:

Income-related monthly adjustment amount

Total monthly premium amount

Less than or equal to $85,000

$0.00

$104.90

Greater than $85,000 and less than or equal to $129,000

$167.80

$272.70

Greater than $129,000

$230.80

$335.70

Standard Part D Cost-Sharing for 2015

Note: The amounts in this table do not apply to the beneficiaries who have the Part D Low Income Subsidy (“Extra Help”)

Annual Deductible Maximum:                                $320.00

Initial Coverage Period:                                          
Members Pay 25% of the next…                               $2,640

Donut Hole Threshold Amount:                             $2,960
(Once the member AND the plan have spent
this amount, the member enters the Donut Hole)

Donut Hole                                                                 $3,720

Catastrophic Coverage Threshold                          $4,700
(Begins when the member’s true out-of-pocket
costs equals this amount, including
Donut Hole discounts)

Total spending before Catastrophic Coverage            $6,680

Cost Sharing During Catastrophic Coverage:             $2.65 (generics)
                                                                                    $6.60 (brand name)
                                                                                    OR 5%, whichever is greater

Low-Income Subsidy Co-Payments (LIS)

1.  Full Benefit Dual Eligibles Institutionalized or Receiving HCBS:  $0

2.  Full Benefit Dual Eligibles with incomes ≤ 100% Federal Poverty Level

  • Generic/Preferred Drugs:                   $1.20
  • Other:                                                 $3.60
  • Above Catastrophic Limit:                  $0.00

3.  Full Benefit Duals with Incomes >100% Federal Poverty Level & Other Full-Subsidy Eligible Beneficiaries

  • Deductible:                                         $0
  • Generic/preferred drugs:                    $2.65
  • Other:                                                 $6.60
  • Above Catastrophic Limit:                  $0.00

4.  Partial Subsidy Eligible Beneficiaries

  • Deductible:                                         $66.00
  • Co-ins. to Initial Coverage Limit:        15%
  • Generics above catastrophic limit:     $2.65
  • Others above catastrophic limit:         $6.60

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