| |
DEDUCTIBLE
(The amount you pay before your plan starts to pay)
You Pay |
INITIAL COVERAGE
$0-$4,480– 30-Day Supply
You Pay |
COVERAGE GAP
Over $4,480
You Pay |
CATASTROPHIC
Over $7,400
You Pay |
|---|
| Tier 1 Preferred Generic Drugs |
$0 |
$2 |
25% of the cost |
5% or $4.15 |
| Tier 2 Generic Drugs |
$0 |
$15 |
25% of the cost |
5% or $4.15 |
| Tier 3 Preferred Brand Drugs* |
$325 |
$42 |
25% of the cost |
5% or $10.35 |
| Tier 4 Non-Preferred Drugs |
$325 |
$95 |
25% of the cost |
5% or $4.15 for generic/ preferred multisource drugs
5% or $10.35 for all other drugs
|
| Tier 5 Specialty Drugs |
$325 |
27% of the cost |
25% of the cost |
5% or $4.15 for generic/preferred multisource drugs
5% or $10.35 for all other drugs
|
Tier 6 Select Care Drugs
|
$0
|
$0
|
$0
|
5% or $4.15
|
*You pay no deductible and $0 for most covered Part D vaccines, and no more than $35 for a one-month supply of covered insulin.
You will pay the above cost-sharing when you use preferred pharmacies. You pay more when you use standard pharmacies. You may pay less if you get Extra Help. $0 Tier 1 and 2 generics are available through preferred mail order
Set up Home Delivery and Refills for Prescription Drugs
Have your prescriptions and refills delivered directly to your home through Express Scripts, Inc. (ESI), our home-delivery pharmacy.
Additional Pharmacy Information
Learn more about how to get money back for a drug, our Medication Management Therapy program, how to get help paying for Part D drugs through the Extra Help program (as known as Low-Income Subsidy), and much more.
