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Low Income Subsidy Premium Table - 2020

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 2020

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% $8.00 $0.00
50% $16.00 $0.00
25% $24.00 $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.

For a PDF of this information please click here

 

H0545_FUY2020_51_C_LIS Premium Notice 

Updated 10/03/2019