Cigna-HealthSpring Rx (PDP) Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs

Transcription

1 Cigna-HealthSpring Rx (PDP) Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs 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. Region 1: NH/ME 100% $0.00 $ % $7.50 $ % $15.00 $ % $22.60 $44.50 Region 2: CT/MA/RI/VT 100% $22.70 $ % $31.60 $ % $40.50 $ % $49.40 $46.50 Region 3: NY 100% $0.00 $ % $9.80 $ % $19.50 $ % $29.30 $52.30

2 Region 4: NJ 100% $38.80 $ % $47.80 $ % $56.80 $ % $65.80 $43.90 Region 5: DE/DC/MD 100% $0.00 $ % $7.50 $ % $14.90 $ % $22.40 $45.20 Region 6: PA/WV 100% $0.00 $ % $9.80 $ % $19.10 $ % $28.40 $45.80 Region 7: VA 100% $28.00 $ % $35.60 $ % $43.10 $ % $50.60 $48.00

3 Region 8: NC 100% $27.10 $ % $34.70 $ % $42.20 $ % $49.80 $45.80 Region 9: SC 100% $32.70 $ % $38.40 $ % $44.20 $ % $49.90 $50.30 Region 10: GA 100% $39.30 $ % $45.40 $ % $51.50 $ % $57.70 $50.00 Region 11: FL 100% $47.20 $ % $54.50 $ % $61.80 $ % $69.00 $49.40

4 Region 12: AL/TN 100% $23.90 $ % $31.50 $ % $39.20 $ % $46.80 $45.50 Region 13: MI 100% $0.00 $ % $7.90 $ % $15.80 $ % $23.80 $39.00 Region 14: OH 100% $18.90 $ % $26.90 $ % $34.90 $ % $42.90 $44.90 Region 15: IN/KY 100% $0.00 $ % $7.60 $ % $15.30 $ % $22.90 $47.30

5 Region 16: WI 100% $0.00 $ % $9.70 $ % $19.40 $ % $29.10 $47.00 Region 17: IL 100% $0.00 $ % $6.30 $ % $12.50 $ % $18.80 $46.20 Region 18: MO 100% $37.30 $ % $44.80 $ % $52.30 $ % $59.80 $50.60 Region 19: AR 100% $18.50 $ % $24.20 $ % $29.80 $ % $35.50 $45.70

6 Region 20: MS 100% $15.20 $ % $21.60 $ % $28.10 $ % $34.50 $44.00 Region 21: LA 100% $16.30 $ % $24.00 $ % $31.70 $ % $39.50 $47.50 Region 22: TX 100% $0.00 $ % $5.90 $ % $11.80 $ % $17.80 $48.50 Region 23: OK 100% $0.00 $ % $6.80 $ % $13.60 $ % $20.40 $44.60

7 Region 24: KS 100% $25.20 $ % $33.00 $ % $40.90 $ % $48.70 $40.00 Region 25: IA/MN/MT/ND/SD/NE/WY 100% $23.90 $ % $32.40 $ % $40.90 $ % $49.40 $42.80 Region 26: NM 100% $10.10 $ % $16.20 $ % $22.40 $ % $28.50 $41.40 Region 27: CO 100% $22.80 $ % $31.40 $ % $39.90 $ % $48.50 $48.50

8 Region 28: AZ 100% $0.00 $ % $7.80 $ % $15.70 $ % $23.50 $44.80 Region 29: NV 100% $27.90 $ % $34.70 $ % $41.50 $ % $48.20 $48.40 Region 30: OR/WA 100% $0.00 $ % $7.20 $ % $14.30 $ % $21.50 $40.80 Region 31: ID/UT 100% $0.00 $ % $9.30 $ % $18.60 $ % $28.00 $38.70

9 Region 32: CA 100% $51.40 $ % $60.30 $ % $69.10 $ % $78.00 $55.60 Region 33: HI 100% $17.10 $ % $23.50 $ % $29.80 $ % $36.20 $38.90 Region 34: AK 100% $0.00 $ % $7.40 $ % $14.70 $ % $22.10 $57.40 *This does not include any Medicare Part B premium you may have to pay. If you aren t getting extra help, you can see if you qualify by calling: Medicare of TTY users call (24 hours a day/7 days a week), Your State Medicaid Office, or The Social Security Administration at TTY users should call between 7 a.m. and 7 p.m., Monday through Friday. If you have any questions, please call Customer Service at , TTY: 711, from 8am - 8pm local time, 7 days a week. Our automated phone system may answer your call during weekends from Feb. 15 Sept. 30.

10 This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Cigna-HealthSpring Rx (PDP) is a Medicare Prescription Drug Plan (PDP) with a Medicare contract. Enrollment in Cigna-HealthSpring depends on contract renewal. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY 711), 8am 8pm local time, 7 days a week. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY 711). 注意 : 如果您使用繁體 / 中文, 您可以免費獲得語言援助服務請致電 (TTY 711). Cigna-HealthSpring Rx complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna-HealthSpring Rx cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.