The SilverScript Employer PDP sponsored by the World Bank Group 2021 Benefit Summary:

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.
Deductible This plan does not have a deductible.
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.
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 total yearly drug costs reach $4,130. 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.
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
10% of total cost
Maximum $25.00
10% of total cost
Maximum $25.00
Tier 2 - Preferred Brands
25% of total cost
Maximum $70.00
25% of total cost
Maximum $70.00
Tier 3 - Non-Preferred Brands
40% of total cost
Maximum $120.00
40% of total cost
Maximum $120.00
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
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
10% of total cost
Maximum $60.00
10% of total cost
Maximum $75.00
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
Tier 3 - Non-Preferred Brands
40% of total cost
Maximum $300.00
40% of total cost
Maximum $360.00
40% of total cost
Maximum $300.00
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

Note: You pay the same share of the cost for your drug filled through 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.
Coverage Gap Due to the additional coverage provided by World Bank Group, you have the same copayments or coinsurance that you had during the Initial Coverage Stage. Therefore, you may see no change in your copayment and/or coinsurance until you qualify for catastrophic coverage.
Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,550, you pay the following for your drugs and the plan will pay the rest:

  • Generics (or a drug that is treated like a generic)
  • For up to a 30-day supply, you pay a $3.70 copayment or 5% of the drug cost, whichever is greater, but no more than 10% of the total cost, maximum $25.00.
  • Preferred Brands 
  • For up to a 30-day supply, you pay an $9.20 copayment or 5% of the drug cost, whichever is greater, but no more than 25% of the total cost, maximum $70.00.
  • Non-Preferred Brands 
  • For up to a 30-day supply, you pay an $9.20 copayment or 5% of the drug cost, whichever is greater, but no more than 40% of the total cost, maximum $120.00.

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