Page 38 - APPENDICES for Hans Burkhardt

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 D
File Joint Tax Return
IRMAA Tier
File Individual Tax Return
premium
premium
1
$88,000 or less
$148.50
$176,000 or less
Plan premium
(baseline)
above $88,000 up to
2
$207.90
$111,000
$12.30
$222,000
above $222,000 up to
Plan premium +
above $111,000 up to
$297.00
3
$31.80
$276,000
$138,000
above $138,000 up to above $176,000 up to Monthly Part B Plan premium +
Plan premium +
above $276,000 up to
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.