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Plan Details

Horizon Medicare Blue Rx Standard (PDP)

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MONTHLY PREMIUM

$63.80

ENROLL
BENEFIT TYPE IN NETWORK BENEFIT
Annual Deductible
Annual Deductible $480 per year for Part D prescription drugs.
Initial Coverage
Initial Coverage

Standard Pharmacy One-month supply:

  • Tier 1 (Preferred Generic): $0 Copay
  • Tier 2 (Generic): $11 Copay
  • Tier 3 (Preferred Brand): $28 Copay
  • Tier 4 (Non-Preferred Drug): 40% Copay
  • Tier 5 (Specialty Tier): 25% of the cost

Standard Mail Order Three-month supply:

  • Tier 1 (Preferred Generic): $0 Copay
  • Tier 2 (Generic): $16.50 Copay
  • Tier 3 (Preferred Brand): $84 Copay
  • Tier 4 (Non-Preferred Drug): 40% of the cost
  • Tier 5 (Specialty Tier): Not offered

If you reside in a long-term facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy.

Coverage Gap
Coverage Gap

The Coverage Gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,430. After you enter the Coverage Gap , you pay 25% of the plan’s cost for covered brand name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $7,050.

Catastrophic Coverage
Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reaches $7,050, you pay the greater of:

  • 5% of the cost, or
  • $3.95 Copay for generic (including brand drugs treated as generic) and an $9.85 Copay for all other drugs.

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