This is archive material for research purposes. Please see
PDPFinder.com or
MAFinder.com for current plans.
2022 Medicare Advantage Plan Prescription Drug Cost-Sharing Details
| 2022 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
|
Wellcare Giveback (HMO) (H0174-013-1) Benefit Details 
 | ||||||
| This plan is available in Williamson County, TX Click on a letter below to view the Wellcare Giveback (HMO) Formulary A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 | ||||||
| This Plan Uses Lower Cost-Sharing for Preferred Pharmacies | ||||||
| 30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
|||||
| Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
| Initial Deductible Phase Cost Sharing | ||||||
| Tier 1: Preferred Generic: | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) |
| Tier 2: Generic: | $2.00(E) | $7.00(E) | $2.00(E) | $6.00(E) | $21.00(E) | $0.00(E) |
| Tier 3: Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
| Tier 4: Non-Preferred Drug: | 100% | 100% | 100% | 100% | 100% | 100% |
| Tier 5: Specialty Tier: | 100% | 100% | 100% | 100% | 100% | 100% |
| Tier 6: Select Care Drugs: | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) |
| Initial Coverage Phase Cost-Sharing | ||||||
| Tier 1: Preferred Generic: | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic: | $2.00 | $7.00 | $2.00 | $6.00 | $21.00 | $0.00 |
| Tier 3: Preferred Brand: | $20.00 | $30.00 | $20.00 | $60.00 | $90.00 | $40.00 |
| Tier 4: Non-Preferred Drug: | $90.00 | $100.00 | $90.00 | $270.00 | $300.00 | $180.00 |
| Tier 5: Specialty Tier: | 28% | 28% | 28% | n/a | n/a | n/a |
| Tier 6: Select Care Drugs: | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 75% Generic and 75% Brand Donut Hole Discount applies | ||||||
| All Formulary Generic Drugs: | 25% | 25% | 25% | 25% | 25% | 25% |
| All Formulary Brand-Name Drugs: | 25% | 25% | 25% | 25% | 25% | 25% |
| Catastrophic Coverage Phase Cost Sharing | ||||||
| Generic & Preferred Multi-Source Drugs: | The greater of 5% or $3.95 | The greater of 5% or $3.95 | ||||
| Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $9.85 | The greater of 5% or $9.85 | ||||
| Notes: *The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing. (E) Drugs on this tier are excluded from the Initial Deductible and do not count toward meeting the deductible. | ||||||
| Go to the Wellcare Giveback (HMO) 2022 Formulary Browser by choosing a letter below: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 | ||||||