Plan Design – SilverScript Choice
| Stage | SilverScript Choice | |||||||||||
| Premium | $32.00 | |||||||||||
| Annual Deductible | $0 applies to all tiers | |||||||||||
| Initial Coverage (ICL) | SilverScript Choice is a $0 deductible plan meaning members’ initial coverage stage begins the day the plan takes effect. | |||||||||||
| Standard Retail Pharmacy | Preferred Mail Service Pharmacy | |||||||||||
| 30-day | 90-day | 90-day | ||||||||||
| Tier 1 | $3 | $7.50 | $7.50 | |||||||||
| Tier 2 | $20 | $50 | $50 | |||||||||
| Tier 3 | $47 | $117.50 | $117.50 | |||||||||
| Tier 4 | 50% | 50% | 50% | |||||||||
| Tier 5 | 33% | N/A | N/A | |||||||||
| Coverage Gap(donut hole) | Members leave the ICL stage and enter the Medicare Coverage Gap when they have reached $3,700 in total yearly drug costs (not including monthly premiums) Generic drugs: Members pay 51% of the cost Brand drugs: Members pay 40% of the cost |
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| Catastrophic Coverage(after donut hole) | Members enter the catastrophic coverage stage when they have spent $4,950 out of pocket (not including monthly premiums) Generic drugs: Members pay the greater of 5% coinsurance or $3.30 copay All other drugs: Members pay the greater of 5% coinsurance or $8.25 copay |
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* Not all Tier 5 drugs may be available through mail
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