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Extra Help

This chart shows what co-pays members will pay for generic and brand drug medications when they receive Extra Help. Depending on your level of Extra Help, you will pay no more than the following for generic and brand name drugs:

	Generic Drug Co-Pay	Brand Drug Co-Pay
*LEVEL 1 Full Benefit Dual Eligibles, Partial Dual Eligibles (Medicare and Medicaid Recipient), and other low-income beneficiaries You are single with monthly resources that are less than or equal to $704 ($8,440 annually); or You are married with monthly resources that are less than or equal to $1,118 ($13,410 annually).	$2.60	$6.50
LEVEL 2 Full Benefit Dual Eligibles (Medicare and Medicaid Recipient)	$1.10	$3.30
LEVEL 3 Full Benefit Dual Eligibles (Medicare and Medicaid Recipient) who are institutionalized	$0.00	$0.00
*LEVEL 4 Other low-income Beneficiaries You are single with monthly resources that are between $704 and $1,090 (between $8,440 and $13,070 annually); or You are married with monthly resources that are between $1,118 and $2,177 (between $13,410 and $26,120 annually).	15% Coinsurance	15% Coinsurance

When the total expense between you and the company reaches $4,700 for Levels 1-3, the co-pay changes to $0.00 at that time. For Level 4, the co-pay is $2.60 for generic drugs and $6.50 for brand drugs.

*These resource limits include $1,500 per person for burial expenses.

NOTE: 2012 resource levels are provided, but may vary in Alaska and Hawaii. Resources typically include cash, stocks, mortgages, life insurance policies, but does NOT include your house, car, or burial plot.

S5967_NA016406_PDP_WEB_ENG CMS Approved 10272011

Last modified: 12/01/2011