2019 Medicare Prescription Drug Plan Cost-Sharing Details

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2019 Medicare Part D Prescription Drug
Formulary (Drug List) Cost-Sharing Details
WellCare Value Script (PDP) (S4802-145-0)
Benefit Details        
This plan is available in CMS PDP Region 10
Monthly Premium: $14.50
Rx Deductible: $415
Initial Coverage Limit: $3,820 Qualifies for LIS: No


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WellCare Value Script (PDP) Formulary
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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) $3.00(E) $0.00(E) $0.00(E) $9.00(E) $0.00(E)
Tier 2: Generic: $7.00(E) $10.00(E) $7.00(E) $21.00(E) $30.00(E) $17.50(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%
Initial Coverage Phase Cost-Sharing
Tier 1: Preferred Generic: $0.00 $3.00 $0.00 $0.00 $9.00 $0.00
Tier 2: Generic: $7.00 $10.00 $7.00 $21.00 $30.00 $17.50
Tier 3: Preferred Brand: $39.00 $47.00 $39.00 $117.00 $141.00 $97.50
Tier 4: Non-Preferred Drug: 46% 50% 46% 46% 50% 46%
Tier 5: Specialty Tier: 25% 25% 25% n/a n/a n/a
Coverage Gap (Donut Hole) Phase Cost Sharing
Plan offers no Gap Coverage 63% Generic and 75% Brand Donut Hole Discount applies
All Formulary Generic Drugs: 37% 37% 37% 37% 37% 37%
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 $3.40 The greater of 5% or $3.40
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): The greater of 5% or $8.50 The greater of 5% or $8.50
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.
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