Transcription
2021Summaryof BenefitsWellCare Classic (PDP)S4802WellCare Wellness Rx (PDP)S4802WellCare Value Script (PDP)S4802WellCare Medicare Rx Select (PDP)S5810WellCare Medicare Rx Saver (PDP)S5810WellCare Medicare Rx Value Plus (PDP)S5768Y0070 PDP 58147E M WellCare 2020NA1PDGSOB58147E 0PDP
This booklet gives you a brief overview of what we cover and what you can expect to pay. It doesn't listevery service we cover or every limitation or exclusion. To get a complete list of services we cover, give usa call and ask for the "Evidence of Coverage." You can also find a copy on our website atwww.wellcare.com/PDP.A Prescription Drug Plan (PDP) is one option for individuals who want to enroll in the Medicare PartD prescription drug coverage, which subsidizes the costs of prescription drugs for enrollees. A prescriptiondrug plan (PDP) is a stand-alone plan, covering only prescription drugs.Who can join?To join WellCare Classic (PDP),WellCare Wellness Rx (PDP), WellCare Value Script (PDP), WellCareMedicare Rx Select (PDP), WellCare Medicare Rx Saver (PDP) and WellCare Medicare Rx Value Plus(PDP) you must be entitled to Medicare Part A, and/or be enrolled in Medicare Part B and live in ourservice area. Please refer to the Premium/Cost-Sharing Table to find out the premium/cost-sharing in yourarea.You can access and/or order your current "Medicare & You" handbook online at http://www.medicare.govor get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDDusers should call 1-877-486-2048.Which drugs are covered?You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on ourwebsite (www.wellcare.com/PDP). Or, call us and we will send you a copy of the formulary.How will I determine my drug costs?Our plans group each medication into one of five "tiers." You will need to use your formulary to locate whattier your drug is on to determine how much it will cost you. The amount you pay depends on the drug'stier and what stage of the benefit you have reached. Later in this document we discuss the benefit stagesthat occur after you meet your deductible, if applicable: Initial Coverage, Coverage Gap, and CatastrophicCoverage.1
Which pharmacies can I use?We have a network of pharmacies and you must generally use these pharmacies to fill your prescriptionsfor covered Part D drugs.Some of our network pharmacies have preferred cost-sharing. You may pay less if you use these pharmacies.You can see our plans' pharmacy directory at our website (www.wellcare.com/PDP). Or, call us and wewill send you a copy of the pharmacy directory.This document is available in languages other than English. For additional information, call usat 1-877-374-4056, (TTY/TDD 711).This booklet is also available in different formats, including braille, large print and audio compact disc (CD)Find Your StateFind the table with your state-specific pricing on the following 5249-50StateRegion 551-52Nebraska2551-52Nevada2959-60New Hampshire013-4New Jersey049-10New Mexico2653-54New York037-8North Carolina0817-182StateNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth est 051-5225-2645-4663-645-615-1661-6213-1433-3451-52
3
Region 01State(s) ME, NHMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Initial Coverage Stage (afteryou pay your deductible, ifapplicable)WellCareClassic (PDP)Preferred MailWellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic dayTier 1: Preferred GenericDrug 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Tier 2: Generic Drug 2.00 6.00 6.00 18.00 7.00 21.00 2.00 5.00Tier 3: PreferredBrand Drug 30.00 90.00 40.00 120.00 43.00 129.00 30.00 75.00Tier 4: Non-Preferred Drug33%33%46%46%47%47%33%33%Tier 5: Specialty Tier Drug25%N/A25%N/A25%N/A25%N/ARegion 01State(s) ME, NHMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Preferred MailWellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareRxValue Plus dayTier 1: PreferredGeneric Drug 0.00 0.00 0.00 0.00 1.00 3.00 0.00 0.00Tier 2: Generic Drug 3.00 9.00 5.00 15.00 4.00 12.00 3.00 7.50Tier 3: PreferredBrand Drug 47.00 141.00 36.00 108.00 47.00 141.00 47.00 117.50Tier 4: Non-PreferredDrug42%42%41%41%50%50%42%42%Tier 5: Specialty Tier Drug25%N/A25%N/A33%N/A25%N/AInitial Coverage Stage (afteryou pay your deductible, ifapplicable)4WellCare MedicareRx Select (PDP)
WellCare Classic (PDP) 26.70WellCare Wellness Rx (PDP) 15.20WellCare Value Script (PDP) 17.20 445on all tiers 445Tiers 3 to 5 445Tiers 3 to 5cost-sharingStandard Retail and Mail Service cost-sharing (in network)WellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic (PDP)WellCareWellness Rx (PDP)WellCareValue Script day30-day90-day 0.00 0.00 0.00 0.00 1.00 3.00 8.00 24.00 5.00 15.00 6.00 15.00 7.00 17.50 6.00 18.00 15.00 45.00 12.00 36.00 40.00 100.00 43.00 107.50 40.00 120.00 47.00 141.00 47.00 %N/A25%N/A25%N/AWellCare Medicare Rx Select (PDP) 24.70WellCare Medicare RxSaver (PDP) 35.50WellCare Medicare Rx ValuePlus (PDP) 75.60 445Tiers 3 to 5 445on all tiersNo Deductiblecost-sharingWellCare MedicareRx Saver (PDP)Standard Retail and Mail Service cost-sharing (in network)WellCareValue Plus (PDP)WellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareValue Plus day30-day90-day 0.00 0.00 1.00 0.00 15.00 45.00 2.00 6.00 10.00 30.00 5.00 12.50 4.00 10.00 20.00 60.00 10.00 30.00 20.00 60.00 36.00 90.00 47.00 117.50 47.00 141.00 47.00 141.00 47.00 %N/A25%N/A33%N/A5
Region 02State(s) CT, MA, RI, VTMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Initial Coverage Stage (afteryou pay your deductible, ifapplicable)WellCareClassic (PDP)Preferred MailWellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic dayTier 1: Preferred GenericDrug 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Tier 2: Generic Drug 2.00 6.00 8.00 24.00 8.00 24.00 2.00 5.00Tier 3: PreferredBrand Drug 30.00 90.00 40.00 120.00 43.00 129.00 30.00 75.00Tier 4: Non-Preferred Drug34%34%46%46%47%47%34%34%Tier 5: Specialty Tier Drug25%N/A25%N/A25%N/A25%N/ARegion 02State(s) CT, MA, RI, VTMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Preferred MailWellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareRxValue Plus dayTier 1: PreferredGeneric Drug 0.00 0.00 0.00 0.00 1.00 3.00 0.00 0.00Tier 2: Generic Drug 3.00 9.00 2.00 6.00 4.00 12.00 3.00 7.50Tier 3: PreferredBrand Drug 47.00 141.00 42.00 126.00 47.00 141.00 47.00 117.50Tier 4: Non-PreferredDrug42%42%37%37%47%47%42%42%Tier 5: Specialty Tier Drug25%N/A25%N/A33%N/A25%N/AInitial Coverage Stage (afteryou pay your deductible, ifapplicable)6WellCare MedicareRx Select (PDP)
WellCare Classic (PDP) 31.00WellCare Wellness Rx (PDP) 14.40WellCare Value Script (PDP) 16.20 445on all tiers 445Tiers 3 to 5 445Tiers 3 to 5cost-sharingStandard Retail and Mail Service cost-sharing (in network)WellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic (PDP)WellCareWellness Rx (PDP)WellCareValue Script day30-day90-day 0.00 0.00 0.00 0.00 2.00 6.00 8.00 24.00 5.00 15.00 8.00 20.00 8.00 20.00 6.00 18.00 15.00 45.00 13.00 39.00 40.00 100.00 43.00 107.50 35.00 105.00 47.00 141.00 47.00 %N/A25%N/A25%N/AWellCare Medicare Rx Select (PDP) 26.40WellCare Medicare RxSaver (PDP) 35.70WellCare Medicare Rx ValuePlus (PDP) 74.40 400Tiers 3 to 5 445on all tiersNo Deductiblecost-sharingWellCare MedicareRx Saver (PDP)Standard Retail and Mail Service cost-sharing (in network)WellCareValue Plus (PDP)WellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareValue Plus day30-day90-day 0.00 0.00 1.00 0.00 15.00 45.00 2.00 6.00 10.00 30.00 2.00 5.00 4.00 10.00 20.00 60.00 6.00 18.00 20.00 60.00 42.00 105.00 47.00 117.50 47.00 141.00 47.00 141.00 47.00 %N/A25%N/A33%N/A7
Region 03State(s) NYMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Initial Coverage Stage (afteryou pay your deductible, ifapplicable)WellCareClassic (PDP)Preferred MailWellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic dayTier 1: Preferred GenericDrug 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Tier 2: Generic Drug 4.00 12.00 5.00 15.00 6.00 18.00 4.00 10.00Tier 3: PreferredBrand Drug 30.00 90.00 40.00 120.00 43.00 129.00 30.00 75.00Tier 4: Non-Preferred Drug33%33%46%46%47%47%33%33%Tier 5: Specialty Tier Drug25%N/A25%N/A25%N/A25%N/ARegion 03State(s) NYMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Preferred MailWellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareRxValue Plus dayTier 1: PreferredGeneric Drug 0.00 0.00 0.00 0.00 1.00 3.00 0.00 0.00Tier 2: Generic Drug 3.00 9.00 2.00 6.00 4.00 12.00 3.00 7.50Tier 3: PreferredBrand Drug 47.00 141.00 42.00 126.00 47.00 141.00 47.00 117.50Tier 4: Non-PreferredDrug42%42%35%35%43%43%42%42%Tier 5: Specialty Tier Drug27%N/A25%N/A33%N/A27%N/AInitial Coverage Stage (afteryou pay your deductible, ifapplicable)8WellCare MedicareRx Select (PDP)
WellCare Classic (PDP) 34.80WellCare Wellness Rx (PDP) 15.60WellCare Value Script (PDP) 17.70 445on all tiers 445Tiers 3 to 5 445Tiers 3 to 5cost-sharingStandard Retail and Mail Service cost-sharing (in network)WellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic (PDP)WellCareWellness Rx (PDP)WellCareValue Script day30-day90-day 0.00 0.00 0.00 0.00 1.00 3.00 8.00 24.00 5.00 15.00 5.00 12.50 6.00 15.00 7.00 21.00 15.00 45.00 11.00 33.00 40.00 100.00 43.00 107.50 36.00 108.00 47.00 141.00 47.00 %N/A25%N/A25%N/AWellCare Medicare Rx Select (PDP) 40.20WellCare Medicare RxSaver (PDP) 36.80WellCare Medicare Rx ValuePlus (PDP) 82.00 300Tiers 3 to 5 445on all tiersNo Deductiblecost-sharingWellCare MedicareRx Saver (PDP)Standard Retail and Mail Service cost-sharing (in network)WellCareValue Plus (PDP)WellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareValue Plus day30-day90-day 0.00 0.00 1.00 0.00 15.00 45.00 2.00 6.00 10.00 30.00 2.00 5.00 4.00 10.00 20.00 60.00 7.00 21.00 20.00 60.00 42.00 105.00 47.00 117.50 47.00 141.00 47.00 141.00 47.00 %N/A25%N/A33%N/A9
Region 04State(s) NJMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Initial Coverage Stage (afteryou pay your deductible, ifapplicable)WellCareClassic (PDP)Preferred MailWellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic dayTier 1: Preferred GenericDrug 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Tier 2: Generic Drug 5.00 15.00 5.00 15.00 6.00 18.00 5.00 12.50Tier 3: PreferredBrand Drug 30.00 90.00 41.00 123.00 43.00 129.00 30.00 75.00Tier 4: Non-Preferred Drug34%34%48%48%49%49%34%34%Tier 5: Specialty Tier Drug25%N/A25%N/A25%N/A25%N/ARegion 04State(s) NJMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Preferred MailWellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareRxValue Plus dayTier 1: PreferredGeneric Drug 0.00 0.00 0.00 0.00 1.00 3.00 0.00 0.00Tier 2: Generic Drug 3.00 9.00 3.00 9.00 4.00 12.00 3.00 7.50Tier 3: PreferredBrand Drug 47.00 141.00 42.00 126.00 47.00 141.00 47.00 117.50Tier 4: Non-PreferredDrug42%42%36%36%46%46%42%42%Tier 5: Specialty Tier Drug26%N/A25%N/A33%N/A26%N/AInitial Coverage Stage (afteryou pay your deductible, ifapplicable)10WellCare MedicareRx Select (PDP)
WellCare Classic (PDP) 33.90WellCare Wellness Rx (PDP) 14.80WellCare Value Script (PDP) 16.30 445on all tiers 445Tiers 3 to 5 445Tiers 3 to 5cost-sharingStandard Retail and Mail Service cost-sharing (in network)WellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic (PDP)WellCareWellness Rx (PDP)WellCareValue Script day30-day90-day 0.00 0.00 0.00 0.00 1.00 3.00 8.00 24.00 5.00 15.00 5.00 12.50 6.00 15.00 8.00 24.00 15.00 45.00 11.00 33.00 41.00 102.50 43.00 107.50 35.00 105.00 47.00 141.00 47.00 %N/A25%N/A25%N/AWellCare Medicare Rx Select (PDP) 28.50WellCare Medicare RxSaver (PDP) 35.50WellCare Medicare Rx ValuePlus (PDP) 78.80 345Tiers 3 to 5 445on all tiersNo Deductiblecost-sharingWellCare MedicareRx Saver (PDP)Standard Retail and Mail Service cost-sharing (in network)WellCareValue Plus (PDP)WellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareValue Plus day30-day90-day 0.00 0.00 1.00 0.00 15.00 45.00 2.00 6.00 10.00 30.00 3.00 7.50 4.00 10.00 20.00 60.00 8.00 24.00 20.00 60.00 42.00 105.00 47.00 117.50 47.00 141.00 47.00 141.00 47.00 %N/A25%N/A33%N/A11
Region 05State(s) DC, DE, MDMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Initial Coverage Stage (afteryou pay your deductible, ifapplicable)WellCareClassic (PDP)Preferred MailWellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic dayTier 1: Preferred GenericDrug 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Tier 2: Generic Drug 4.00 12.00 8.00 24.00 8.00 24.00 4.00 10.00Tier 3: PreferredBrand Drug 32.00 96.00 40.00 120.00 43.00 129.00 32.00 80.00Tier 4: Non-Preferred Drug33%33%46%46%47%47%33%33%Tier 5: Specialty Tier Drug25%N/A25%N/A25%N/A25%N/ARegion 05State(s) DC, DE, MDMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Preferred MailWellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareRxValue Plus dayTier 1: PreferredGeneric Drug 0.00 0.00 0.00 0.00 1.00 3.00 0.00 0.00Tier 2: Generic Drug 3.00 9.00 4.00 12.00 4.00 12.00 3.00 7.50Tier 3: PreferredBrand Drug 47.00 141.00 43.00 129.00 47.00 141.00 47.00 117.50Tier 4: Non-PreferredDrug42%42%36%36%47%47%42%42%Tier 5: Specialty Tier Drug25%N/A25%N/A33%N/A25%N/AInitial Coverage Stage (afteryou pay your deductible, ifapplicable)12WellCare MedicareRx Select (PDP)
WellCare Classic (PDP) 28.30WellCare Wellness Rx (PDP) 14.90WellCare Value Script (PDP) 16.20 445on all tiers 445Tiers 3 to 5 445Tiers 3 to 5cost-sharingStandard Retail and Mail Service cost-sharing (in network)WellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic (PDP)WellCareWellness Rx (PDP)WellCareValue Script day30-day90-day 0.00 0.00 0.00 0.00 3.00 9.00 8.00 24.00 5.00 15.00 8.00 20.00 8.00 20.00 8.00 24.00 15.00 45.00 13.00 39.00 40.00 100.00 43.00 107.50 40.00 120.00 47.00 141.00 47.00 %N/A25%N/A25%N/AWellCare Medicare Rx Select (PDP) 26.40WellCare Medicare RxSaver (PDP) 30.00WellCare Medicare Rx ValuePlus (PDP) 76.60 425Tiers 3 to 5 445on all tiersNo Deductiblecost-sharingWellCare MedicareRx Saver (PDP)Standard Retail and Mail Service cost-sharing (in network)WellCareValue Plus (PDP)WellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareValue Plus day30-day90-day 0.00 0.00 1.00 0.00 15.00 45.00 1.00 3.00 10.00 30.00 4.00 10.00 4.00 10.00 20.00 60.00 9.00 27.00 20.00 60.00 43.00 107.50 47.00 117.50 47.00 141.00 47.00 141.00 47.00 %N/A25%N/A33%N/A13
Region 06State(s) PA, WVMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Initial Coverage Stage (afteryou pay your deductible, ifapplicable)WellCareClassic (PDP)Preferred MailWellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic dayTier 1: Preferred GenericDrug 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Tier 2: Generic Drug 3.00 9.00 5.00 15.00 6.00 18.00 3.00 7.50Tier 3: PreferredBrand Drug 33.00 99.00 40.00 120.00 43.00 129.00 33.00 82.50Tier 4: Non-Preferred Drug34%34%46%46%47%47%34%34%Tier 5: Specialty Tier Drug25%N/A25%N/A25%N/A25%N/ARegion 06State(s) PA, WVMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Preferred MailWellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareRxValue Plus dayTier 1: PreferredGeneric Drug 0.00 0.00 0.00 0.00 1.00 3.00 0.00 0.00Tier 2: Generic Drug 3.00 9.00 3.00 9.00 4.00 12.00 3.00 7.50Tier 3: PreferredBrand Drug 47.00 141.00 40.00 120.00 47.00 141.00 47.00 117.50Tier 4: Non-PreferredDrug42%42%40%40%50%50%42%42%Tier 5: Specialty Tier Drug25%N/A25%N/A33%N/A25%N/AInitial Coverage Stage (afteryou pay your deductible, ifapplicable)14WellCare MedicareRx Select (PDP)
WellCare Classic (PDP) 33.80WellCare Wellness Rx (PDP) 15.70WellCare Value Script (PDP) 17.80 445on all tiers 445Tiers 3 to 5 445Tiers 3 to 5cost-sharingStandard Retail and Mail Service cost-sharing (in network)WellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic (PDP)WellCareWellness Rx (PDP)WellCareValue Script day30-day90-day 0.00 0.00 0.00 0.00 3.00 9.00 8.00 24.00 5.00 15.00 5.00 12.50 6.00 15.00 8.00 24.00 15.00 45.00 11.00 33.00 40.00 100.00 43.00 107.50 38.00 114.00 47.00 141.00 47.00 %N/A25%N/A25%N/AWellCare Medicare Rx Select (PDP) 26.40WellCare Medicare RxSaver (PDP) 35.90WellCare Medicare Rx ValuePlus (PDP) 75.60 415Tiers 3 to 5 445on all tiersNo Deductiblecost-sharingWellCare MedicareRx Saver (PDP)Standard Retail and Mail Service cost-sharing (in network)WellCareValue Plus (PDP)WellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareValue Plus day30-day90-day 0.00 0.00 1.00 0.00 15.00 45.00 1.00 3.00 10.00 30.00 3.00 7.50 4.00 10.00 20.00 60.00 7.00 21.00 20.00 60.00 40.00 100.00 47.00 117.50 47.00 141.00 47.00 141.00 47.00 %N/A25%N/A33%N/A15
Region 07State(s) VAMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Initial Coverage Stage (afteryou pay your deductible, ifapplicable)WellCareClassic (PDP)Preferred MailWellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic dayTier 1: Preferred GenericDrug 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Tier 2: Generic Drug 3.00 9.00 7.00 21.00 8.00 24.00 3.00 7.50Tier 3: PreferredBrand Drug 30.00 90.00 40.00 120.00 43.00 129.00 30.00 75.00Tier 4: Non-Preferred Drug34%34%46%46%47%47%34%34%Tier 5: Specialty Tier Drug25%N/A25%N/A25%N/A25%N/ARegion 07State(s) VAMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Preferred MailWellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareRxValue Plus dayTier 1: PreferredGeneric Drug 0.00 0.00 0.00 0.00 1.00 3.00 0.00 0.00Tier 2: Generic Drug 3.00 9.00 5.00 15.00 4.00 12.00 3.00 7.50Tier 3: PreferredBrand Drug 47.00 141.00 37.00 111.00 47.00 141.00 47.00 117.50Tier 4: Non-PreferredDrug42%42%42%42%49%49%42%42%Tier 5: Specialty Tier Drug25%N/A25%N/A33%N/A25%N/AInitial Coverage Stage (afteryou pay your deductible, ifapplicable)16WellCare MedicareRx Select (PDP)
WellCare Classic (PDP) 24.50WellCare Wellness Rx (PDP) 14.80WellCare Value Script (PDP) 16.30 445on all tiers 445Tiers 3 to 5 445Tiers 3 to 5cost-sharingStandard Retail and Mail Service cost-sharing (in network)WellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic (PDP)WellCareWellness Rx (PDP)WellCareValue Script day30-day90-day 0.00 0.00 0.00 0.00 2.00 6.00 8.00 24.00 5.00 15.00 7.00 17.50 8.00 20.00 9.00 27.00 15.00 45.00 13.00 39.00 40.00 100.00 43.00 107.50 35.00 105.00 47.00 141.00 47.00 %N/A25%N/A25%N/AWellCare Medicare Rx Select (PDP) 20.10WellCare Medicare RxSaver (PDP) 34.50WellCare Medicare Rx ValuePlus (PDP) 74.60 445Tiers 3 to 5 445on all tiersNo Deductiblecost-sharingWellCare MedicareRx Saver (PDP)Standard Retail and Mail Service cost-sharing (in network)WellCareValue Plus (PDP)WellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareValue Plus day30-day90-day 0.00 0.00 1.00 0.00 15.00 45.00 1.00 3.00 10.00 30.00 5.00 12.50 4.00 10.00 20.00 60.00 8.00 24.00 20.00 60.00 37.00 92.50 47.00 117.50 47.00 141.00 47.00 141.00 47.00 %N/A25%N/A33%N/A17
Region 08State(s) NCMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Initial Coverage Stage (afteryou pay your deductible, ifapplicable)WellCareClassic (PDP)Preferred MailWellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic dayTier 1: Preferred GenericDrug 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Tier 2: Generic Drug 3.00 9.00 6.00 18.00 7.00 21.00 3.00 7.50Tier 3: PreferredBrand Drug 30.00 90.00 43.00 129.00 43.00 129.00 30.00 75.00Tier 4: Non-Preferred Drug35%35%48%48%49%49%35%35%Tier 5: Specialty Tier Drug25%N/A25%N/A25%N/A25%N/ARegion 08State(s) NCMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Preferred MailWellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareRxValue Plus dayTier 1: PreferredGeneric Drug 0.00 0.00 0.00 0.00 1.00 3.00 0.00 0.00Tier 2: Generic Drug 3.00 9.00 5.00 15.00 4.00 12.00 3.00 7.50Tier 3: PreferredBrand Drug 47.00 141.00 40.00 120.00 47.00 141.00 47.00 117.50Tier 4: Non-PreferredDrug42%42%35%35%47%47%42%42%Tier 5: Specialty Tier Drug26%N/A25%N/A33%N/A26%N/AInitial Coverage Stage (afteryou pay your deductible, ifapplicable)18WellCare MedicareRx Select (PDP)
WellCare Classic (PDP) 24.90WellCare Wellness Rx (PDP) 15.30WellCare Value Script (PDP) 17.20 445on all tiers 445Tiers 3 to 5 445Tiers 3 to 5cost-sharingStandard Retail and Mail Service cost-sharing (in network)WellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic (PDP)WellCareWellness Rx (PDP)WellCareValue Script day30-day90-day 0.00 0.00 0.00 0.00 2.00 6.00 8.00 24.00 5.00 15.00 6.00 15.00 7.00 17.50 8.00 24.00 15.00 45.00 12.00 36.00 43.00 107.50 43.00 107.50 38.00 114.00 47.00 141.00 47.00 %N/A25%N/A25%N/AWellCare Medicare Rx Select (PDP) 26.40WellCare Medicare RxSaver (PDP) 26.50WellCare Medicare Rx ValuePlus (PDP) 76.60 365Tiers 3 to 5 445on all tiersNo Deductiblecost-sharingWellCare MedicareRx Saver (PDP)Standard Retail and Mail Service cost-sharing (in network)WellCareValue Plus (PDP)WellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareValue Plus day30-day90-day 0.00 0.00 1.00 0.00 15.00 45.00 2.00 6.00 10.00 30.00 5.00 12.50 4.00 10.00 20.00 60.00 8.00 24.00 20.00 60.00 40.00 100.00 47.00 117.50 47.00 141.00 47.00 141.00 47.00 %N/A25%N/A33%N/A19
Region 09State(s) SCMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Initial Coverage Stage (afteryou pay your deductible, ifapplicable)WellCareClassic (PDP)Preferred MailWellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic dayTier 1: Preferred GenericDrug 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Tier 2: Generic Drug 3.00 9.00 8.00 24.00 8.00 24.00 3.00 7.50Tier 3: PreferredBrand Drug 30.00 90.00 40.00 120.00 43.00 129.00 30.00 75.00Tier 4: Non-Preferred Drug33%33%46%46%47%47%33%33%Tier 5: Specialty Tier Drug25%N/A26%N/A26%N/A25%N/ARegion 09State(s) SCMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Preferred MailWellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareRxValue Plus dayTier 1: PreferredGeneric Drug 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Tier 2: Generic Drug 3.00 9.00 6.00 18.00 4.00 12.00 3.00 7.50Tier 3: PreferredBrand Drug 47.00 141.00 42.00 126.00 47.00 141.00 47.00 117.50Tier 4: Non-PreferredDrug42%42%36%36%47%47%42%42%Tier 5: Specialty Tier Drug25%N/A25%N/A33%N/A25%N/AInitial Coverage Stage (afteryou pay your deductible, ifapplicable)20WellCare MedicareRx Select (PDP)
WellCare Classic (PDP) 34.20WellCare Wellness Rx (PDP) 16.70WellCare Value Script (PDP) 19.70 445on all tiers 350Tiers 3 to 5 350Tiers 3 to 5cost-sharingStandard Retail and Mail Service cost-sharing (in network)WellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic (PDP)WellCareWellness Rx (PDP)WellCareValue Script day30-day90-day 0.00 0.00 0.00 0.00 3.00 9.00 8.00 24.00 5.00 15.00 8.00 20.00 8.00 20.00 9.00 27.00 15.00 45.00 13.00 39.00 40.00 100.00 43.00 107.50 40.00 120.00 47.00 141.00 47.00 %N/A26%N/A26%N/AWellCare Medicare Rx Select (PDP) 26.90WellCare Medicare RxSaver (PDP) 23.60WellCare Medicare Rx ValuePlus (PDP) 79.20 445Tiers 3 to 5 445on all tiersNo Deductiblecost-sharingWellCare MedicareRx Saver (PDP)Standard Retail and Mail Service cost-sharing (in network)WellCareValue Plus (PDP)WellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareValue Plus day30-day90-day 0.00 0.00 0.00 0.00 15.00 45.00 2.00 6.00 8.00 24.00 6.00 15.00 4.00 10.00 20.00 60.00 8.00 24.00 20.00 60.00 42.00 105.00 47.00 117.50 47.00 141.00 47.00 141.00 47.00 %N/A25%N/A33%N/A21
Region 10State(s) GAMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Initial Coverage Stage (afteryou pay your deductible, ifapplicable)WellCareClassic (PDP)Preferred MailWellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic dayTier 1: Preferred GenericDrug 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00Tier 2: Generic Drug 2.00 6.00 7.00 21.00 8.00 24.00 2.00 5.00Tier 3: PreferredBrand Drug 32.00 96.00 39.00 117.00 43.00 129.00 32.00 80.00Tier 4: Non-Preferred Drug33%33%46%46%47%47%33%33%Tier 5: Specialty Tier Drug25%N/A25%N/A25%N/A25%N/ARegion 10State(s) GAMonthly Premium:Annual Deductible:Preferred Retail cost-sharing (in-network)Preferred MailWellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareRxValue Plus dayTier 1: PreferredGeneric Drug 0.00 0.00 0.00 0.00 1.00 3.00 0.00 0.00Tier 2: Generic Drug 3.00 9.00 5.00 15.00 4.00 12.00 3.00 7.50Tier 3: PreferredBrand Drug 47.00 141.00 36.00 108.00 47.00 141.00 47.00 117.50Tier 4: Non-PreferredDrug42%42%37%37%49%49%42%42%Tier 5: Specialty Tier Drug25%N/A25%N/A33%N/A25%N/AInitial Coverage Stage (afteryou pay your deductible, ifapplicable)22WellCare MedicareRx Select (PDP)
WellCare Classic (PDP) 31.50WellCare Wellness Rx (PDP) 15.10WellCare Value Script (PDP) 17.00 445on all tiers 445Tiers 3 to 5 445Tiers 3 to 5cost-sharingStandard Retail and Mail Service cost-sharing (in network)WellCareWellness Rx (PDP)WellCareValue Script (PDP)WellCareClassic (PDP)WellCareWellness Rx (PDP)WellCareValue Script day30-day90-day 0.00 0.00 0.00 0.00 2.00 6.00 8.00 24.00 5.00 15.00 7.00 17.50 8.00 20.00 7.00 21.00 15.00 45.00 13.00 39.00 39.00 97.50 43.00 107.50 37.00 111.00 47.00 141.00 47.00 %N/A25%N/A25%N/AWellCare Medicare Rx Select (PDP) 26.40WellCare Medicare RxSaver (PDP) 24.90WellCare Medicare Rx ValuePlus (PDP) 78.30 445Tiers 3 to 5 445on all tiersNo Deductiblecost-sharingWellCare MedicareRx Saver (PDP)Standard Retail and Mail Service cost-sharing (in network)WellCareValue Plus (PDP)WellCare MedicareRx Select (PDP)WellCare MedicareRx Saver (PDP)WellCare MedicareValue Plus day30-day90-day 0.00 0.00 1.00 0.00 15.00 45.00 1.00 3.00 10.00 30.00 5.00 12.50 4.00 10.00 20.00 60.00 8.00 24.00 20.00 60.00 36.00 90.00 47.00 117.50 47.00 141.00 47.00 141.00 47.00 %N/A25%N/A33%N/A23
Region 11State(s) F
Medicare Rx Select (PDP), WellCare Medicare Rx Saver (PDP) and WellCare Medicare Rx Value Plus (PDP) you must be entitled to Medicare Part A, and/or be enrolled in Medicare Part B and live in our service area. Please refer to the Premium/Cost-Sharing Table to find out the premium/cost-sharing in your area. You can access and/or order your .
