The SilverScript Employer PDP sponsored by California's Valued Trust 2020 Benefit Summary:

Monthly Premium and Limits on How Much You Pay for Covered Services
Premium Please contact California’s Valued Trust (CVT) for more information about the premium for this plan.
Deductible This plan does not have a deductible.
Initial Coverage You pay the amounts in the tables below until your total yearly drug costs reach $4,020. Total yearly drug costs are the amounts paid by both you and the plan for Part D drugs. You may get your drugs at network retail pharmacies and mail order pharmacies. Some of our network pharmacies are preferred network retail pharmacies where you pay the same cost as mail order for a 90-day supply of a non-specialty maintenance medication.
Your share of the cost when you get a 30-day supply of a covered Part D prescription drug:

Network Retail Pharmacy
(Up to a 30-day supply available at any network pharmacy)
Long-Term Care (LTC) Pharmacy
(Up to a 31-day supply)
Tier 1 - Generics
$7.00
$7.00
Tier 2 - Preferred Brands
$25.00
$25.00
Tier 3 - Non-Preferred Brands
$40.00
$40.00
Tier 4 - High Cost/Specialty
Applicable tier copay
Applicable tier copay
Your share of the cost when you get a long-term supply (up to 90 days) of a covered Part D prescription drug:

Preferred Network Retail Pharmacy
(Up to a 90-day supply)
Non-Preferred Network Retail Pharmacy
(Up to a 90-day supply)
Mail-Order Pharmacy
(Up to a 90-day supply)
Tier 1 - Generics
$15.00
$21.00
$15.00
Tier 2 - Preferred Brands
$60.00
$75.00
$60.00
Tier 3 - Non-Preferred Brands
$90.00
$120.00
$90.00
Tier 4 - High Cost/Specialty
N/A
N/A
N/A
Coverage Gap Due to the additional coverage provided by California's Valued Trust, you have the same copayments that you had during the Initial Coverage Stage. Therefore, you may see no change in your copayment until you qualify for catastrophic coverage.
Catastrophic Coverage

After you reach $6,350 in Medicare out-of-pocket costs for the year, you are in the Catastrophic Coverage stage.

During the Catastrophic Coverage stage, the plan will pay most of the cost for your drugs. You will pay the 
lower of:

  • The same California’s Valued Trust (CVT) copayment that you paid during the Initial Coverage Period,

      or

  • The Medicare Catastrophic Coverage cost-share, which is the greater of:
    • 5% of the cost of the drug or $3.60 for generic drugs (or drugs treated as generic)
    • 5% of the cost of the drug or $8.95 for all other drugs. 

The plan will pay the rest of the cost for the calendar year.


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