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100.01 125.00 100.00 600.01 625.00 600.00 125.01 150.00 125.00 625.01 650.00 625.00 150.01 175.00 150.00 650.01 675.00 650.00 175.01 200.00 175.00 675.01 700.00 675.00 200.01 225.00 200.00 700.01 725.00 700.00 225.01 250.00 225.00 725.01 750.00 725.00 250.01 275.00 250.00 750.01 775.00 750.00 275.01 300.00 275.00 775.01 800.00 775.00 300.01 325.00 300.00 800.01 825.00 800.00 325.01 350.00 325.00 825.01 850.00 825.00 350.01 375.00 350.00 850.01 875.00 850.00 375.01 400.00 375.00 875.01 900.00 875.00 400.01 425.00 400.00 900.01 925.00 900.00 425.01 450.00 425.00 925.01 950.00 925.00 450.01 475.00 450.00 950.01 975.00 950.00 475.01 500.00 475.00 975.01 1000.00 975.00

1000.01 1025.00 1000.00 If the subtotal from the MAPP Premium Calculation Worksheet is more than $1,025 a month, the premium is equal to the exact whole dollar amount of the subtotal. This page last updated in Release Number: 20-03 Release Date: 08/03/2020 Effective Date: 08/01/2020 39.11 SeniorCare Income Limits 39.11.1 SeniorCare Income Limits Introduction For applicants determined eligible, SeniorCare pays for a portion of covered prescription drugs, depending on the person’s participation level. Effective with benefit periods starting September 1, 2003, there are four participation levels. The level of benefits an applicant receives depends on their annual income and, for some, on the amount they spend on covered prescription drugs during their 12-month benefit period. The participation levels are: • Level 1: Co-Payment (Annual income is at or below 160% of the Federal Poverty Level (FPL).) • Level 2a: Deductible $500 (Annual income is greater than 160% of the FPL and less than or equal to 200% of the FPL.) • Level 2b: Deductible $850 (Annual income is greater than 200% of the FPL and less than or equal to 240% of the FPL.) • Level 3: Spenddown (Annual income is above 240% of the FPL.)