Low Income Subsidy Premium Table

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.

This table shows you what your monthly plan premium will be if you get extra help.

Year 2017

  Your Level of Extra Help  Monthly Premium for Value Preferred Choice (HMO)* Monthly Premium for Inter Valley Health Plan Service To Senior (HMO), Dsesert Preferred Choice (HMO), OC Preferred (HMO)
100% $0.00 $0.00
75% $9.05 $0.00
50% $18.10 $0.00
25% $27.15 $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/TDD 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/TDD users should call 1-800-325-0778 between 7 a.m. and 7 p.m. Monday through Friday.


If you have any questions, please call Inter Valley Health Plan Member Services at 800-251-8191 or TTY 711, 7:30 a.m. to 8 p.m., 7 days a week.

The information is not a complete description of benefits.  Contact the plan for more information.  You must continue to pay your Medicare Part B premium.  Limitations, copayments and restrictions may apply.  Benefits, premiums and/or copayments/co-insurance may change on January 1 of each year.  The actual complete terms and conditions of the health plan are set for in the applicable Evidence of Coverage document.

H0545_FUY2017_041


H0545_RAY2010_113 (CMS Approved) 12/15/09
Updated 10/03/2016