2021 SilverScript Employer PDP sponsored by Fairfax County Public Schools Benefit Summary:



Mail Order pricing available for full 90 day supply when filled at a Preferred Network Retail pharmacy.

** Please Note: $50 max per 30-day supply of insulin

Maximum Out-of-Pocket: The most you will pay for your prescriptions is $1,500 individual/$3,000 family.
Preferred Network Retail Pharmacy Member Cost Share
Tier 1-30 day supply 31-60 day supply 61-83 day supply 84-90 day supply**
Tier 1

Generics
$7 $14 $21 $14
Tier 2

Preferred Brands
20% with a max. of $75 20% with a max. of $150 20% with a max. of $225 20% with a max. of $150
Tier 3

Non-Preferred Brands
20% with a max. of $75 20% with a max. of $150 20% with a max. of $225 20% with a max. of $150
Non-Preferred Network Retail Pharmacy Member Cost Share
Tier 1-30 day supply 31-60 day supply 61-90 day supply
Tier 1

Generics
$7 $14 $21
Tier 2

Preferred Brands
20% with a max. of $75 20% with a max. of $150 20% with a max. of $225
Tier 3

Non-Preferred Brands
20% with a max. of $75 20% with a max. of $150 20% with a max. of $225

**Maintenance Choice Program allows for Mail Order pricing at a Preferred Retail Pharmacy for 84-90 Day Supply of medications

Mail Order Member Cost Share
Tier 1-90 day supply
Tier 1

Generics
$14
Tier 2

Preferred Brands
20% with a max. of $150
Tier 3

Non-Preferred Brands
20% with a max. of $150


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