Page 96 - Evaluation for Tom Tappan

Important Information
You have the option not to enroll in the prescription drug plan that's combined with
Bank of America's Medicare Advantage plans. However, before deciding to opt out,
be sure you understand what happens if you decline this coverage.
Call the Bank of America Global HR Service Center at 800.556.6044 if you have questions.

What drug coverage will I have?
To find out if your drug is on the formulary (list of Part D prescription drugs), or about any restrictions, call
SilverScript Customer Care at 1-844-449-4726, 24 hours a day, 7 days a week. TTY users should call 711.

Our plan groups each medication into one of three tiers. 8VH WKH IRUPXODU\ WR GHWHUPLQH \RXU GUXJ¶V WLHU DQG
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(for example, the initial coverage stage or the catastrophic coverage stage).

Please note: Bank of America provides additional coverage that may cover prescription drugs not included in a
standard Medicare Part D benefit. There may be instances where your cost share may be more or less due to
this additional coverage. If you are unsure about your drug costs, or which drugs may or may not be covered,
please call SilverScript Customer Care.

Which pharmacies can I use?
To find out if your pharmacy is in our network, call SilverScript Customer Care at 1-844-449-4726, 24 hours a
day, 7 days a week. TTY users should call 711. If you use an out-of-network pharmacy, we will reimburse you
your total cost minus your cost-share amount for the drug. You must submit a paper claim in order to be
reimbursed.

More than 65,000 pharmacies nationwide make up the pharmacy network. These include retail, mail
service, long-term care, home infusion, and Indian Health and Indian Tribal pharmacies. You must use a
network pharmacy in order to receive full benefit coverage on your prescriptions.

SilverScript has over 9,600 preferred pharmacies, where you can get up to a 90-day supply of your
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Maintenance Choice program. Current preferred network pharmacies include CVS Pharmacy , Longs Drugs
(operated by CVS Pharmacy) and Navarro.

You may also get up to a 90-day supply of your medication at a non-preferred network pharmacy, but
your coinsurance or copayment will be higher than at a preferred pharmacy.

Preferred Network Standard Network
Prescription Retail Pharmacy Retail Pharmacy
Benefit Tier
(90-day supply) (90-day supply)
Initial Coverage: You pay the following:
You will be in the Initial Coverage Stage until your
total yearly drug costs reach $3,750.
Generic Drugs
$10.00 $15.00
Preferred Brand Drugs
$40.00 $60.00
Non-Preferred
Brand and Specialty Drugs $60.00 $90.00

For questions about maintenance drugs with additional coverage provided by Bank of America, including the
cost to fill these drugs, please contact SilverScript Customer Care.