Copayment Amounts



Swedish American Health System

Drug Maintenance

Prescriptions are often sold in 30-day supplies. However, you can buy up to a 90-day supply on medications in tiers 1 to 4. Each 30-day supply will take one copay at a retail pharmacy. A 90-day supply equals three copays.

If you live in a long-term care facility, your copay is the same as in a retail pharmacy.

You can get prescriptions from an out-of-network pharmacy, but you may pay more.

Want to save money?

The mail order program may offer lower copays for your medications.

 

Elite D / Value D / Core D
Retail Copayments

Elite D / Value D / Core D
Mail Order Copayments

Annual Description Deductible

No Part D deductible.No Part D deductible.
Tier 1 (Preferred Generic)

One-month (30 day) supply - $3
Three-month (90 day) supply - $9

Three-month (90 day) supply - $7
Tier 2 (Generic)

One-month (30 day) supply - $12
Three-month (90 day) supply - $36

Three month (90 day) supply - $30
Tier 3 (Preferred Brand)

One-month (30 day) supply - $47
Three-month (90 day) supply - $141

Three month (90 day) supply - $118
Tier 4 (Non-Preferred Drug)

One-month (30 day) supply - 40% of cost
Three-month (90 day) supply - 40% of cost

Three month (90 day) supply - 40% of cost
Tier 5 (Specialty Medications)

One-month (30 day) supply - 28% of cost
We do not cover three-month (90 day) supplies of Tier 5 medications at retail pharmacies.

One-month (30 day) supply - 28% of cost
We do not cover three-month (90 day) supplies of Tier 5 medications through mail order pharmacy.

Coverage Gap

Most Medicare drug plans have a coverage gap every year.

You enter the coverage gap once the total amount spent on Part D drugs (your payments plus plan payments) reaches $4,020.

During this stage, you pay 25% of the price for drugs (plus a portion of the dispensing fee). You stay in this stage until your year-to-date “out-of-pocket costs” (your payments) reach a total of $6,350. This amount and rules for counting costs toward this amount have been set by Medicare.

Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $6,350, you pay the greater of 5% of the drug cost or $3.40 copay (for generic drugs) / $8.50 copay (for brand drugs).

This webpage was updated on September 1, 2020.