Horizon Medicare Advantage

LIS Premium Summary Sheet

Horizon Medicare Blue Value with Rx Std /Rx Enhanced /Rx Plus or Horizon Medicare Blue Access with Rx Std /Rx Enhanced /Rx Plus or Horizon Medicare Blue Solutions Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs

If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.

This table shows you what your monthly plan premium will be if you get extra help.

^*This does not include any Medicare Part B premium you may have to pay.

The above Horizon Medicare Advantage Plan premiums include coverage for both medical services and prescription drug coverage.

If you aren't getting extra help, you can see if you qualify by calling:

• 1-800-Medicare or TTY/TDD users call 1-877-486-2048 (24 hours a day/7 days a week),
• Your State Medicaid Office, or
• The Social Security Administration at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.

If you have any questions, please call Customer Service at 1-866-236-7373, (TTY/TDD: 1-866-236-1069), 24 hours a day, 7 days a week, ET.