Some people with limited resources and income also may be able to get "Extra Help" to pay for the costs—monthly premiums, annual deductibles and prescription co-payments—related to a Medicare prescription drug plan.

You automatically qualify and do not need to apply for Extra Help if you have Medicare and meet one of the following conditions:

  • Have full Medicaid coverage;
  • Have Supplemental Security Income (SSI); or
  • Participate in a state program that pays your Medicare premiums.

If you have questions about "Extra Help," call:

  • 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week;
  • The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778; or
  • State Medicaid Office

If you believe that you are paying an incorrect cost-sharing amount when you get your prescription at a pharmacy, our plan has established a process that allows you to either request assistance in obtaining evidence of your proper copayment level, or, if you already have the evidence, to provide this evidence to us.

As a part D plan sponsor, CMS regulations require that we have a process for helping to determine if an individual is eligible for the Low Income Subsidy (LIS) when some of the documentation may be missing or there is a conflict between CMS system and the actual status of the individual.

The purpose of this document is for plans to inform potential enrollees of what their plan premium will be once they are eligible and receive the low-income subsidy. Plans that do not use the model must ensure that the following information is available for each PBP they offer:

  • Your premiums will be lower once you receive Extra Help from Medicare,
  • Your premium amounts may vary based on your level of Extra Help,
  • The premiums listed do not include any Part B premium you may have to pay, and
  • The premiums listed are for both medical services and prescription drug benefits.

 

For Tribute Health Plan of Oklahoma  (HMO SNP) 2018

Your Level of Extra Help Monthly Premium for Tribute Health Plans
100% $0
75% $6.90
50% $13.80
25% $20.70

For Tribute Health Plan of Arkansas (HMO-POS SNP) 2018

Please visit 2018 Superior Select Health Plans website

 

For Tribute Health Plan of Arkansas (HMO-POS SNP) 2017

Your Level of Extra Help Monthly Premium for Tribute Health Plan of Arkansas (HMO-POS SNP)
100% $0
75% $0
50% $0
25%  

For Tribute Health Plan of Oklahoma (HMO SNP) 2017

Your Level of Extra Help Monthly Premium for Tribute Health Plan of Oklahoma (HMO-SNP)
100% $0
75% $7.15
50% $14.30
25% $21.45

Tribute will accepts the following forms of evidence to establish the subsidy status of a full benefit dual eligible individual:

  • Copy of valid State Medicaid card
  • Copy of valid document from State Medicaid confirming active status
  • Printed report from State Medicaid confirming active status
  • Screen print from State Medicaid confirming active status
  • Other material from State Medicaid confirming active status

For Tribute Health Plan of Oklahoma: 

Material can be mailed to 909 S. Meridian, Suite 425, Oklahoma City, Ok 73108

For Tribute Health Plan of Arkansas:

Material can be mailed to 1401 West Capitol Ave., Suite 430, Little Rock, AR 72201