| Benefit Category |
Original Care |
Citrus Part D |
Citrus Part D Plus |
| 1.Premium and Other Important Information |
Not covered. |
You pay $25.30 each month for your Medicare Part D prescription benefits. |
You pay $49.40 each month for your Medicare Part D prescription benefits. |
| 2.Prescription Drugs |
Not covered. |
Drugs Covered under Medicare Part D General
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.citrushc.com on the web. Different out-ofpocket costs may apply for people who:
• have limited incomes,
• live in long term care facilities, or
• have access to Indian/Tribal/ Urban (Indian Health Service).
The plan offers national innetwork prescription coverage. This means that you will pay the same amount for your prescription drugs if you get them at an in-network pharmacy outside of the plans service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and the plan. |
Drugs Covered under Medicare Part D General
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.citrushc.com on the web. Different out-ofpocket costs may apply for people who:
• have limited incomes,
• live in long term care facilities, or
• have access to Indian/Tribal/ Urban (Indian Health Service).
The plan offers national innetwork prescription coverage. This means that you will pay the same amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan’s service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and the plan. |
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The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Citrus Part D for certain drugs. The plan will pay for certain over-the counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details. |
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Citrus Part D Plus for certain drugs. The plan will pay for certain overthe counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details. |
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You must go to certain pharmacies for a very limited number of drugs, due to the special handling requirements of these drugs. These drugs are listed on the plan’s website, formulary, and printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.If a drug costs less than the normal co-pay amount, you will pay the co-pay for that drug. |
You must go to certain pharmacies for a very limited number of drugs, due to the special handling requirements of these drugs. These drugs are listed on the plan’s website, formulary, and printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If a drug costs less than the normal co-pay amount, you will pay the co-pay for that drug. |
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In-Network
$100 deductible.
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In-Network
$0 deductible. |
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Initial Coverage
You pay the following until total yearly drug costs reach $2510: |
Initial Coverage
You pay the following until total yearly drug costs reach $2510: |
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Retail Pharmacy |
Retail Pharmacy |
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Generic
• $5 co-pay for a one-month (31-day) supply of drugs |
Generic
• $5 co-pay for a one-month (31-day) supply of drugs |
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Brands Plus
• $20 co-pay for a one-month (31-day) supply of drugs |
Brands Plus
• $15 co-pay for a one-month (31-day) supply of drugs |
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Preferred Brands
• $40 co-pay for a one-month (31-day) supply of drugs |
Preferred Brands
• $30 co-pay for a one-month (31-day) supply of drugs |
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Brands
• $60 co-pay for a one-month (31-day) supply of drugs |
Brands
• $60 co-pay for a one-month (31-day) supply of drugs |
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Specialty
• 25% coinsurance for a onemonth (31-day) supply of drugs |
Specialty
• 25% coinsurance for a onemonth (31-day) supply of drugs |
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Long Term Care Pharmacy |
Long Term Care Pharmacy |
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Generic
• $5 co-pay for a one-month (31-day) supply of drugs |
Generic
• $5 co-pay for a one-month (31-day) supply of drugs |
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Brands Plus
• $20 co-pay for a one-month (31-day) supply of drugs |
Brands Plus
• $15 co-pay for a one-month(31- day) supply of drugs |
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Preferred Brands
• $40 co-pay for a one-month (31-day) supply of drugs |
Preferred Brands
• $30 co-pay for a one-month (31-day) supply of drugs |
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Brands
• $60 co-pay for a one-month (31-day) supply of drugs |
Brands
• $60 co-pay for a one-month (31-day) supply of drugs |
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Specialty
• 25% coinsurance for a onemonth (31-day) supply of drugs |
Specialty
• 25% coinsurance for a onemonth (31-day) supply of drugs |
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Coverage Gap |
Coverage Gap |
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No gap coverage.
You pay 100% of the cost of the drugs. |
You pay the following:
The plan covers All Generics, Only Brands Plus through the gap. |
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Retail Pharmacy |
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Generic
• $5 co-pay for a one-month (31-day) supply of drugs |
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Brands Plus
• $15 co-pay for a one-month (31-day) supply of drugs |
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Long Term Care Pharmacy |
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Generic
• $5 co-pay for a one-month (31-day) supply of drugs |
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Brands Plus
• $15 co-pay for a one-month (31-day) supply of drugs |
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For all other covered drugs, after your total yearly drug costs reach $2510, you pay 100% until your yearly out-of-pocket drug costs reach $4050. |
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Catastrophic Coverage |
Catastrophic Coverage |
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After your yearly out-of-pocket drug costs reach $4050, you pay the greater of:
• $2.25 co-pay for generic (including brand drugs treated as generic) and $ 5.60 co-pay for all other drugs, or
• 5% coinsurance. |
After your yearly out-of-pocket drug costs reach $4050, you pay the greater of:
• $2.25 co-pay for generic (including brand drugs treated as generic) and $5.60 co-pay for all other drugs, or
• 5% coinsurance. |
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Out-of-Network |
Out-of-Network |
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Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan’s service area where there is no network pharmacy. You may pay more than the co-pay if you get your drugs at an out-ofnetwork pharmacy. |
Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan’s service area where there is no network pharmacy. You may pay more than the co-pay if you get your drugs at an out-ofnetwork pharmacy. |
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Out-of-Network Initial Coverage |
Out-of-Network Initial Coverage |
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You pay the following until total yearly drug costs reach $2510: |
You pay the following until total yearly drug costs reach $2510: |
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Out-of-Network Pharmacy |
Out-of-Network Pharmacy |
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Generic
• $5 co-pay for a one-month (31-day) supply of drugs |
Generic
• $5 co-pay for a one-month (31-day) supply of drugs |
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Brands Plus
• $20 co-pay for a one-month (31-day) supply of drugs |
Brands Plus
• $15 co-pay for a one-month (31-day) supply of drugs |
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Preferred Brands
• $40 co-pay for a one-month (31-day) supply of drugs |
Preferred Brands
• $30 co-pay for a one-month (31-day) supply of drugs |
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Brands
• $60 co-pay for a one-month (31-day) supply of drugs |
Brands
• $60 co-pay for a one-month (31-day) supply of drugs |
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Specialty
• 25% coinsurance for a onemonth (31-day) supply of drugs |
Specialty
• 25% coinsurance for a onemonth (31-day) supply of drugs |
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Out-of-Network Coverage Gap |
Out-of-Network Coverage Gap |
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No gap coverage. You pay 100% of the cost of the drugs. |
You pay the following: |
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Generic
• $5 co-pay for a one-month (31-day) supply of drugs |
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Brands Plus
• $15 co-pay for a one-month (31-day) supply of drugs |
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Out-of-Network Catastrophic Coverage |
Out-of-Network Catastrophic Coverage |
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After your yearly out-of-pocket drug costs reach $4050, you pay the greater of:
• $2.25 co-pay for generic (including brand drugs treated as generic) and $5.60 co-pay for all other drugs, or
• 5% coinsurance. |
After your yearly out-of-pocket drug costs reach $4050, you pay the greater of:
• $2.25 co-pay for generic (including brand drugs treated as generic) and $5.60 co-pay for all other drugs, or
• 5% coinsurance. |