Page 95 - Evaluation for Tom Tappan

Effective January 1, 2018, Medicare-eligible retirees will have a new prescription drug plan called SilverScript
®
Employer Prescription Drug Plan sponsored by Bank of America. This plan is offered by SilverScript
®
Insurance Company, a CVS Health company.
7KH WHUP ³UHWLUHH´ LV XVHG WKURXJKRXW WKHVH PDWHULDOV WR LQFOXGH Medicare-eligible retirees and individuals
covered under the Bank of America long-term disability plan who are Medicare-eligible. The term also includes
the Medicare-eligible dependents of retirees and individuals on long-term disability.

2018 SilverScript Summary of Benefits for Bank of America
Retirees and Medicare-Eligible Prescription Drug Participants
Your Medicare Part D premium is included in the
premium that you pay for coverage under a
Monthly Premium ®
UnitedHealthcare Group Medicare Advantage PPO plan.
Annual Deductible $0

Network Retail Pharmacy
Prescription (30-day supply) or Mail Service
Pharmacy
Benefit Tier Long-Term Care (LTC) (90-day supply)
Pharmacy (34-day supply)

Initial Coverage Limit Stage and Coverage You pay the following until your yearly out-of-pocket
Gap Stage Prescription Drug Copayments: drug costs reach $5,000:

Generic Drugs
$5.00 $10.00

Preferred Brand Drugs
$20.00 $40.00
Non-Preferred $30.00 $60.00
Brand and Specialty Drugs
Network Retail Pharmacy
Prescription (30-day supply) or Mail Service
Benefit Tier Long-Term Care (LTC) Pharmacy
Pharmacy (34-day supply) (90-day supply)

Catastrophic Coverage Stage Prescription After your yearly out-of-pocket costs reach $5,000,
Drug Copayments: you will pay the greater of:

Generics $3.35 or 5%,
(including name brand drugs treated as generic) but no greater than your plan copayment
All other drugs $8.35 or 5%,
but no greater than your plan copayment
If you are unsure about your drug costs, or which drugs may or may not be covered, please call
SilverScript Customer Care.
Your satisfaction is important to us. If you have any questions about your SilverScript
prescription drug benefit, please call SilverScript Customer Care at
1-844-449-4726, 24 hours a day, 7 days a week. TTY users should call 711.

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