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 through 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.

2021 Copayment Amounts

 

30-day

Retail
60-Day

90-Day 

Mail Order
90-Day

 Yearly Deductible$150 Tiers 4-5$150 Tiers 4-5$150 Tiers 4-5$150 Tiers 4-5
 Tier 1 (Preferred Generic)$0$0$0$0
 Tier 2 (Generic)$12$24 $36 $30 
 Tier 3 (Preferred Brand)$47$94 $141 $118 
 Tier 4 (Non-Preferred Drug)  30% of cost 30% of cost 30% of cost 30% of cost
 Tier 5 (Specialty) 30% of cost N/A N/AN/A 

 

Initial Coverage Gap begins at: $4,130
Catastrophic Coverage begins at: $6,550

2020 Copayment Amounts

 

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 reaches $4,020. This includes your payments plus plan payments.

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 (OOP) costs (your payments) reach a total of $6,350. Medicare sets this amount as well as the rules for what counts toward your OOP costs.

Catastrophic Coverage

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

This webpage was updated on November 1, 2020.