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PRESCRIPTION DRUG PLANS | Summary of Benefits | Continued
CATASTROPHIC COVERAGE
After your yearly out-of-pocket costs reach $6,550, you are responsible for the following copayment or coinsurances.
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
$3.70 or 5%, whichever is greater
$3.70 or 5%, whichever is greater
$3.70 or 5%, whichever is greater
All Brand Drugs
$9.20 or 5%, whichever is greater
$9.20 or 5%, whichever is greater
$9.20 or 5%, whichever is greater
IMPORTANT PLAN INFORMATION
• The amount you pay may differ depending on what type of pharmacy you use; for example, retail
or home delivery.
• To find a network pharmacy, visit www.Express-Scripts.com.
• This plan uses a formulary – a list of covered drugs. To access this list visit www.Express-Scripts. com. The amount you pay depends on the drug’s tier and on the coverage stage you’ve reached.
• For a list of drugs covered under the ITDR Low Cost Generic Drug Program visit www.itdr.com,
or call Express Scripts Medicare Customer Service at (844) 470-1529. Prescriptions must be filled at a Medicare Preferred Value Pharmacy.
• You may receive up to a 90-day supply of certain medications taken on a long-term basis and delivered by mail through the Express Scripts. There is no charge for standard shipping. Not all drugs are available at a 90-day supply.
• Your healthcare provider must get prior authorization from Express Scripts Medicare for certain drugs, when required to do so by Medicare. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.
• If your medication has restrictions (such as prior authorization, step therapy or quantity limits), Medicare guidelines allow at least a one-month, temporary supply of that drug, to give you time to speak with Express Scripts and/or your doctor about switching your drug or requesting an exception.
• You must live in the plan’s service area to participate, which includes all 50 states, Washington, D.C., Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands and American Samoa.
This information is not a complete description of benefits. Limitations, copayments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract. Enrollment in Express Scripts Medicare depends on contract renewal.
Insurance Trust For Delta Retirees | 2021 Benefits & Resources Guide | 43