| Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
| Premium |
Please contact World Bank Group for more information about the premium for this plan.
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| Deductible |
This plan does not have a deductible.
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| Maximum Out of Pocket (MOOP) |
After you reach your individual or family maximum out-of-pocket costs of $1,200 (individual) / $2,400 (family),
World Bank Group will pay the rest of your annual drug costs.
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| Initial Coverage |
During the Initial Coverage Stage, you pay a portion of your drug costs, and the plan pays its portion. The following tables show what you pay until your out-of-pocket covered Part D drug costs reach $2,100. Total yearly drug costs are the total drug costs paid by both you and SilverScript. You may get your drugs at network retail pharmacies or through the mail-order pharmacy.
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Your share of the cost when you get a 30-day supply of a covered Part D prescription drug:
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Network Retail Pharmacy
(Up to a 30-day supply available at any network pharmacy)
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Mail-Order
Pharmacy
(Up to a 30-day supply)
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Long-Term Care (LTC) Pharmacy
(Up to a 31-day supply)
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Tier 1 - Generics
|
10% of total cost
Maximum $25.00
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10% of total cost
Maximum $60.00
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10% of total cost
Maximum $25.00
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Tier 2 - Preferred Brands
|
25% of total cost
Maximum $70.00
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25% of total cost
Maximum $175.00
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25% of total cost
Maximum $70.00
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Tier 3 - Non-Preferred Brands
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40% of total cost
Maximum $120.00
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40% of total cost
Maximum $300.00
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40% of total cost
Maximum $120.00
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Tier 4 - High Cost/Specialty
|
Generics:
5% of total cost
Maximum $50.00
Preferred Brands:
25% of total cost
Maximum $100.00
Non-Preferred Brands:
40% of total cost
Maximum $150.00
|
Generics:
5% of total cost
Maximum $50.00
Preferred Brands:
25% of total cost
Maximum $100.00
Non-Preferred Brands:
40% of total cost
Maximum $150.00
|
Generics:
5% of total cost
Maximum $50.00
Preferred Brands:
25% of total cost
Maximum $100.00
Non-Preferred Brands:
40% of total cost
Maximum $150.00
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Your share of the cost when you get a long-term supply (up to 90 days) of a covered Part D prescription drug:
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Preferred Network Retail Pharmacy
(Up to a 90-day supply)
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Standard Network Retail Pharmacy
(Up to a 90-day supply)
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Mail-Order
Pharmacy
(Up to a 90-day supply)
|
Tier 1 - Generics
|
10% of total cost
Maximum $60.00
|
10% of total cost
Maximum $75.00
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10% of total cost
Maximum $60.00
|
Tier 2 - Preferred Brands
|
25% of total cost
Maximum $175.00
|
25% of total cost
Maximum $210.00
|
25% of total cost
Maximum $175.00
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Tier 3 - Non-Preferred Brands
|
40% of total cost
Maximum $300.00
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40% of total cost
Maximum $360.00
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40% of total cost
Maximum $300.00
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Tier 4 - High Cost/Specialty
|
Generics:
5% of total cost
Maximum $75.00
Preferred Brands:
25% of total cost
Maximum $150.00
Non-Preferred Brands:
40% of total cost
Maximum $225.00
|
Generics:
5% of total cost
Maximum $75.00
Preferred Brands:
25% of total cost
Maximum $150.00
Non-Preferred Brands:
40% of total cost
Maximum $225.00
|
Generics:
5% of total cost
Maximum $75.00
Preferred Brands:
25% of total cost
Maximum $150.00
Non-Preferred Brands:
40% of total cost
Maximum $225.00
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Note: You pay the same share of the cost for your drug filled through a retail pharmacy or the Mail-Order Pharmacy, whether you get a one-month supply or a long-term supply.This means that the copayment or coinsurance listed in the previous table is applicable for any order, regardless of the day supply.
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| Catastrophic Coverage |
During this payment stage, you pay nothing for your covered Part D drugs and for excluded drugs that are covered under the additional coverage provided by World Bank Group. |