2018 SilverScript Employer PDP sponsored by Hawaii Employer Union Health Benefits Trust Fund State of Hawaii Benefit Summary:

Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
Premium Please contact your former employer group, union, or trust for more information about the premium for this plan.
Deductible This plan does not have a deductible.
Initial Coverage You pay the following until your total yearly drug costs reach $3,750.00. 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.
Network Retail Pharmacy
Tier Up to a 30-day supply Up to a 90-day supply
Tier 1 (Generic) $5.00 copay $10.00 copay
Tier 2 (Preferred Brand) $15.00 copay $30.00 copay
Tier 3 (Non-Preferred Brand) $30.00 copay $60.00 copay
Tier 4 (High Cost Tier) 20% with a max of $250/fill N/A
Mail-Order Pharmacy
Tier Up to a 90-day supply
Tier 1 (Generic) $10.00 copay
Tier 2 (Preferred Brand) $30.00 copay
Tier 3 (Non-Preferred Brand) $60.00 copay
Tier 4 (High Cost Tier) N/A
Long-Term Care (LTC) Pharmacy
Tier Up to a 34-day supply
Tier 1 (Generic) $5.00 copay
Tier 2 (Preferred Brand) $15.00 copay
Tier 3 (Non-Preferred Brand) $30.00 copay
Tier 4 (High Cost Tier) 20% with a max of $250/fill
Coverage Gap Your former employer, union, or 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 $5,000.00, you pay the greater of:

   • 5% of the cost, or
   • $3.35 copay for generic (including brand drugs treated as generic) and a $8.35       copayment for all other drugs.

 

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