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Note The FPL may be adjusted annually (see SECTION 39.5 FPL TABLE for current FPLs). If the FPL changes during the eligibility determination process or before a redetermination can be completed, the new levels will be used.

SeniorCare Levels of Participation Income Limits* Annual Out-of-Pocket Expense Requirements and Benefits Level 1 Income at or below 160% of FPL At or below $25,536 per individual or $34,624 per couple annually.* • No deductible or spenddown. • $5 co-pay for each covered generic prescription drug. • $15 co-pay for each covered brand name prescription drug. Level 2a Income above 160% and at or below 200% FPL $25,537 to $31,920 per individual and $34,625 to $43,280 per couple annually.* • $500 deductible per person. • Pay the SeniorCare rate for drugs until the $500 deductible is met. • After $500 deductible is met, pay a $5 co-pay for each covered generic prescription drug and a $15 co-pay for each covered brand name prescription drug. Level 2b Income above 200% and at or below 240% of FPL $31,921 to $38,304 per individual and $43,281 to $51,936 per couple annually. • $850 deductible per person. • Pay the SeniorCare rate for most covered drugs until the $850 deductible is met. • After $850 deductible is met, pay a $5 co-pay for each covered generic prescription drug and a $15 co-pay for each covered brand name prescription drug. Level 3 Annual income is above 240% of the FPL $38,305 or higher per individual and $51,937 or higher per couple annually.* • Pay retail price for drugs equal to the difference between the member's income and $38,304 per individual or $51,936 per couple. This is called “spenddown.” • Covered drug costs for spenddown will be tracked automatically. During the spenddown, there is no discount on drug costs. • After spenddown is met, meet an $850 deductible per person. • Pay SeniorCare rate for most covered drugs until the $850 deductible is met. • After the $850 deductible is met, pay a $5 co-pay for each covered generic prescription drug and a $15 co-pay for each covered brand name prescription drug. * These income amounts are based on the 2026 federal poverty guidelines, which typically increase by a small amount each year. 39.11.2 Level 1: Copayment SeniorCare will pay for covered prescription drugs purchased from participating pharmacies except for participant copayments.