2017 SilverScript Employer PDP sponsored by Electrical Welfare Trust Fund Benefit Summary:

Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
Premium Your premium is included in your monthly payment to Electrical Welfare Trust Fund
Deductible This plan does not have a deductible.
Initial Coverage You pay the following until your total yearly drug costs reach $3,700.00. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies.
Preferred Network Retail Pharmacy
Tier Up to a 34-day supply Up to a 90-day supply
Tier 1 (Generic/Preferred Generic) $10 $20
Tier 2 (Brand/Preferred Brand) $25 $50
Tier 3 (Non-Preferred Brand) $35 $70
Non-Preferred Network Retail Pharmacy
Tier Up to a 34-day supply Up to a 90-day supply
Tier 1 (Generic/Preferred Generic) $10 $30
Tier 2 (Brand/Preferred Brand) $25 $75
Tier 3 (Non-Preferred Brand) $35 $105
Mail-Order Pharmacy
Tier Up to a 90-day supply
Tier 1 (Generic/Preferred Generic) $20
Tier 2 (Brand/Preferred Brand) $50
Tier 3 (Non-Preferred Brand) $70
Long-Term Care (LTC) Pharmacy
Tier Up to a 34-day supply
Tier 1 (Generic/Preferred Generic) $10
Tier 2 (Brand/Preferred Brand) $25
Tier 3 (Non-Preferred Brand) $35
Coverage Gap Your trust will provide additional coverage that will keep your copays/coinsurance consistent through the Coverage Gap, therefore you will see no change in copays until you qualify for Catastrophic Coverage.
Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,950.00, you pay the greater of:

   •  5% of the cost, or
   •  $3.30 copay for generic (including brand drugs treated as generic) (no         greater than $25 for up to a 90-day supply) and a $8.25 copayment for         all other drugs (no greater than $85 for up to 90-day supply).

 

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