| Annual Income/Assets | |||
|---|---|---|---|
| Your Annual Prescription Drug Expense |
LINE 1 | LINE 2 | LINE 3 |
| $250 | $16 | $500 | |
| $500 | $32 | $538 | |
| $750 | $48 | $575 | |
| $1,000 | $64 | $613 | $858 |
| $1,250 | $80 | $650 | $920 |
| $1,500 | $96 | $688 | $983 |
| $1,750 | $111 | $725 | $1,045 |
| $2,000 | $127 | $763 | $1,108 |
| $2,250 | $143 | $800 | $1,170 |
| $2,500 | $159 | $838 | $1,420 |
| $2,750 | $175 | $875 | $1,670 |
| $3,000 | $191 | $913 | $1,920 |
| $3,250 | $207 | $950 | $2,170 |
| $3,500 | $223 | $988 | $2,420 |
| $3,750 | $229 | $1,012 | $2,670 |
| $4,000 | $229 | $1,028 | $2,920 |
| $4,250 | $229 | $1,044 | $3,170 |
| $4,500 | $229 | $1,060 | $3,420 |
| $4,750 | $229 | $1,076 | $3,670 |
| $5,000 | $229 | $1,092 | $3,920 |
| $5,500 | $229 | $1,123 | $4,040 |
| $6,000 | $229 | $1,155 | $4,065 |
| $6,500 | $229 | $1,187 | $4,090 |
| $7,000 | $229 | $1,219 | $4,115 |
| $7,500 | $229 | $1,250 | $4,140 |
| $8,000 | $229 | $1,283 | $4,165 |
| $8,500 | $229 | $1,314 | $4,190 |
| $9,000 | $229 | $1,346 | $4,215 |
| $9,500 | $229 | $1,378 | $4,240 |
| $10,000 | $229 | $1,410 | $4,265 |
| $11,000 | $229 | $1,473 | $4,315 |
| $12,000 | $229 | $1,537 | $4,365 |
| $13,000 | $229 | $1,601 | $4,415 |
| $14,000 | $229 | $1,664 | $4,465 |
| $15,000 | $229 | $1,728 | $4,515 |
Legend
Poor Seniors
Annual Income $0 – $12,569 (single) or $0 – $16,862 (couple) AND
Assets $0 – $6,000 (single) or $0 – $9,000 (couple) OR
You qualify for Medicaid
Low Income Seniors
Annual Income $12,569 – $13,965 (single) or $16,862 – $18,735 (couple) AND
Assets $0 – $10,000 (single) or $0 – $20,000 (couple)
Line reflects maximum annual out-of-pocket, including deductible and premium
Moderate or Higher Income
Annual Income more than $13,965 (single) or $18,735 (couple) OR
Assets more than $10,000 (single) or $20,000 (couple)
Source: Health Care News and estimated from Chicago Tribune, November 26, 2003.
