The Empire Plan Medicare Rx prescription drug plan sponsored by NYSHIP 2021 features:

Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
Premium Please contact NYSHIP for more information about your plan premium.
Deductible This plan does not have a deductible.
Initial Coverage & Coverage Gap Empire Plan Medicare Rx provides supplemental coverage that keeps your cost sharing consistent throughout the Initial Coverage and the Coverage Gap stages. Therefore, you will see no change in cost sharing until you reach the Catastrophic Coverage Stage. You pay the following until your total yearly drug costs reach $6,550. Total yearly drug costs are the total drug costs paid by both you and Empire Plan Medicare Rx.

You may get your drugs at retail pharmacies and the Mail Service Pharmacy.
Tier Standard Retail Cost Sharing
(In Network)
(Up to a 30-day Supply)
Standard Retail Cost Sharing
(In Network)
(Up to a 90-day Supply)
Tier 1 - Generic
$5.00
$10.00
Tier 2 - Preferred Brand
$30.00
$60.00
Tier 3 - Non-Preferred Brand
$60.00
$120.00
Tier Mail Service Cost Sharing
(Up to a 30-day Supply)
Mail Service Cost Sharing
(Up to a 90-day Supply)
Tier 1 - Generic
$5.00
$5.00
Tier 2 - Preferred Brand
$30.00
$55.00
Tier 3 - Non-Preferred Brand
$60.00
$110.00
Tier Long-Term Care (LTC) Cost Sharing
(Up to a 31-day Supply)
Tier 1 - Generic
$5.00
Tier 2 - Preferred Brand
$30.00
Tier 3 - Non-Preferred Brand
$60.00
Catastrophic Coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail service) reach $6,550, you pay the greater of:

  • 5% coinsurance (not to exceed the plan’s normal applicable copayment), or
  • $3.70 copayment for generic drugs (including brand drugs treated as generic) and an $9.20 copayment for all other drugs.

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