Prescription Medications (No deductible for Rx)

Initial Coverage

• You pay the following until total yearly drug costs reach $2,830

Generic drugs

• Co-payment – $0 for 30-day supply or $0 for 90-day supply through mail order
• General Benefit Description – Pharmacy benefit that must be ordered from the plan formulary. See our formulary for details.

Elderplan-preferred brand name drugs

• Co-payment – $25 for 30-day supply or $62.50 for 90-day supply through mail order
• General Benefit Description – Pharmacy benefit that must be ordered from the plan formulary. See our formulary for details.

All other brand name drugs

• Co-payment – $75 for 30-day supply or $187.50 for 90-day supply through mail order
• General Benefit Description – Pharmacy benefit that must be ordered from the plan formulary. See our formulary for details.

Specialty drugs

• Co-payment – 25% co-insurance for 30-day and 90-day supply
• General Benefit Description – Pharmacy benefit that must be ordered from the plan formulary. See our formulary for details.

Coverage Gap

• The plan covers all Tier 1 formulary generics through the coverage gap.

Catastrophic Coverage

• After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of a $2.50 co-pay for generic (including brand drugs treated as generic) and a $6.30 co-pay for all other drugs, or 5% co-insurance.