Page 42 - Demo

PRESCRIPTION DRUG PLAN | Summary Of Benefits
INITIAL COVERAGE
You are responsible for the following copayments and coinsurance after you meet your $150 Brand- only deductible. Generic Drugs have no deductible.
DRUG CATEGORY/TIER
A 31-Day Supply When Your Rx Is Filled At A Pharmacy
In Our Preferred Value Network
A 31-Day Supply When Your Rx Is Filled At A Standard, Network Pharmacy
A 90-Day Supply When Your Rx Is Filled By Mail For Home Delivery
Generic Drugs
$15
No deductible applies
$20
No deductible applies
$37.50
No deductible applies
Preferred Brand Drugs
$25
$30
$62.50
Non-Preferred Brand Drugs
$50
$55
$125
Specialty Drugs (Including Generic Specialty Drugs)
25% of total cost
30% of total cost
25% of total cost
If the actual drug cost is less than the copayment, then the member pays the lower price. For prescriptions with less than a 31-day supply, the member pays a prorated amount of the copayment based on the actual supply.
The Preferred Value Network includes more than 32,000 pharmacies, including Walgreens, Walmart, Costco, Safeway, RiteAid, Sam’s Club, Kroger, and Albertsons, among others.
COVERAGE GAP
If your prescription drug costs reach or exceed $4,130 in a year, you are responsible for the following copayment and coinsurances until your out-of-pocket yearly drug costs reach $6,550.
DRUG CATEGORY/TIER
A 31-Day Supply When Your Rx Is Filled At A Pharmacy
In Our Preferred Value Network
A 31-Day Supply When Your Rx Is Filled At A Standard, Network Pharmacy
A 90-Day Supply When Your Rx Is Filled By Mail For Home Delivery
Generic Drugs
$15
$20
$37.50
All Brand Drugs*
25% plus a portion of the dispensing fee
25% plus a portion of the dispensing fee
25% plus a portion of the dispensing fee
*In addition to your 25%, 70% of brand-name prescription drug prices apply toward your yearly out-of-pocket total, even though you are not paying that 70%. This helps you reach your out-of-pocket total faster.
42 | Insurance Trust For Delta Retirees | 2021 Benefits & Resources Guide