SilverScript Plus (PDP) has a monthly premium of $92.60. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.

Part B	Part C	Part D	Part B Give Back	Total
$0.00	$	$92.60	$0.00	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.
You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

SilverScript Plus (PDP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$200.00
Initial Coverage Limit:	$5,030.00
Catastrophic Coverage Limit:	$8,000.00
Drug Benefit Type:	Enhanced
Additional Gap Coverage:	Yes
Formulary Link:	Formulary Link

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part D	LIS Full
$92.60	$62.00

Initial Coverage Phase

After you pay your $200.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1 (Preferred Generic)	$0.00 copay	$5.00 copay	$0.00 copay	$5.00 copay
2 (Generic)	$0.00 copay	$10.00 copay	$0.00 copay	$10.00 copay
3 (Preferred Brand)	$47.00 copay	$47.00 copay	$47.00 copay	$47.00 copay
4 (Non-Preferred Drug)	50%	50%	50%	50%
5 (Specialty Tier)	30%	30%	30%	30%

60 Day

90 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1 (Preferred Generic)	$0.00 copay	$15.00 copay	$0.00 copay	$15.00 copay
2 (Generic)	$0.00 copay	$30.00 copay	$0.00 copay	$30.00 copay
3 (Preferred Brand)	$141.00 copay	$141.00 copay	$141.00 copay	$141.00 copay
4 (Non-Preferred Drug)	50%	50%	50%	50%
5 (Specialty Tier)

Gap Coverage Phase

30 Day

90 Day

30 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1 (Preferred Generic)	$0.00 copay	$5.00 copay	$0.00 copay	$5.00 copay
2 (Generic)	$0.00 copay	$10.00 copay	$0.00 copay	$10.00 copay
1 (Preferred Generic)
2 (Generic)
3 (Preferred Brand)
4 (Non-Preferred Drug)
5 (Specialty Tier)

90 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1 (Preferred Generic)	$0.00 copay	$15.00 copay	$0.00 copay	$15.00 copay
2 (Generic)	$0.00 copay	$30.00 copay	$0.00 copay	$30.00 copay
1 (Preferred Generic)
2 (Generic)
3 (Preferred Brand)
4 (Non-Preferred Drug)
5 (Specialty Tier)

Tier	Cost
All other tiers (Generic)	25%
All other tiers (Brand-name)	25%

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced benefit type.

Ready to sign up for SilverScript Plus (PDP) ?

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Call 1-877-354-4611 / TTY 711.

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Sat-Sun: 8:00 am – 9:00 pm EST

SilverScript Plus (PDP)

Locations

Plan Overview

Premium Breakdown

Drug Info

Part D Premium Reduction

Initial Coverage Phase

Gap Coverage Phase

Catastrophic Coverage Phase

Table of Contents

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