Page 23 - ITDR Benefits & Resources guide 2019
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PRESCRIPTION DRUG PLAN
Prescription Drug Plan Benefit Overview
Express Scripts Medicare® (PDP) for the Insurance Trust for Delta Retirees (ITDR)
Here is a summary of what you will pay for covered prescription drugs across the different stages of your Medicare Part D benefit.
SERVICE
MEDICARE PAYS
Deductible: Stage 1
You pay a $150 yearly deductible for Brand Name Only Drugs.
NOTE: The deductible will no longer apply to Generic drugs in 2019.
Initial Coverage: Stage 2
After you pay your yearly deductible, you will pay the following* until your total yearly drug costs (what you and the plan pay) reach $3,820:
Tier
2019
Tier 1: Generic Drugs
31-day supply filled at a retail network pharmacy
90-day supply filled through home delivery
Preferred cost-sharing (Medicare Preferred Value Network): You pay $15 per prescription or the cost of the drug, whichever is lower.
Standard cost-sharing: You pay $20 per prescription or the cost of the drug, whichever is lower.*
You pay $37.50 per prescription or the cost of the drug, whichever is lower.
Tier 2: Preferred Brand Drugs
31-day supply filled at a retail network pharmacy
90-day supply filled through home delivery
Preferred cost-sharing (Medicare Preferred Value Network): You pay $25 per prescription or the cost of the drug, whichever is lower.
Standard cost-sharing: You pay $30 per prescription or the cost of the drug, whichever is lower.
You pay $62.50 per prescription or the cost of the drug, whichever is lower
Tier 3: Non-Preferred Brand Drugs
31-day supply filled at a retail network pharmacy
90-day supply filled through home delivery
Preferred cost-sharing (Medicare Preferred Value Network): You pay $50 per prescription or the cost of the drug, whichever is lower.
Standard cost-sharing: You pay $55 per prescription or the cost of the drug, whichever is lower.
You pay $125 per prescription or the cost of the drug, whichever is lower.
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Prescription Drug Plan
