Page 25 - Cover Letter and Evaluation for Michael Boucher

2021 Part B & Part D premiums for people with higher incomes

Income levels shown are for Modified Adjusted Gross Income (MAGI) based 2019 tax returns*

Monthly Part B Monthly Part D
IRMAA Tier File Individual Tax Return File Joint Tax Return
premium premium

1 $88,000 or less $176,000 or less $148.50 Plan premium
(baseline)

above $88,000 up to above $176,000 up to Plan premium +
2 $207.90
$111,000 $222,000 $12.30

above $111,000 up to above $222,000 up to Plan premium +
3 $297.00
$138,000 $276,000 $31.80

above $138,000 up to above $276,000 up to Plan premium +
4 $386.10
$165,000 $330,000 $51.20

above $165,000 and less above $330,000 and Plan premium +
5 $475.20
than $500,000 less than $750,000 $70.70

Plan premium +
6 $500,000 and above $750,000 and above $504.90
$77.10

*Modified adjusted gross income (MAGI) equals adjusted gross income (AGI) plus tax-exempt interest
income.