Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Alamance |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Alexander |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Alleghany |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Anson |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Ashe |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Avery |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Bladen |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Buncombe |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Burke |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Cabarrus |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Caldwell |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Caswell |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Catawba |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Chatham |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Cleveland |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Columbus |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Cumberland |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Davidson |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Davie |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Duplin |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Durham |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Forsyth |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Gaston |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Graham |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Granville |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Guilford |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Harnett |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Haywood |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Henderson |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Hoke |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Iredell |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Jackson |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Johnston |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Lee |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Lincoln |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
McDowell |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Macon |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Madison |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Mecklenburg |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Mitchell |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Montgomery |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Moore |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Orange |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Person |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Polk |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Randolph |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Richmond |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Robeson |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Rowan |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Rutherford |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Scotland |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Stanly |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Stokes |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Swain |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Transylvania |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Union |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Vance |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Wake |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
|
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Warren |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Watauga |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Wilkes |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Yadkin |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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|
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Wellcare Assist Open (PPO) in NC - H7175-003-0
Benefit Details
|
Yancey |
$32.90 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 43% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
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