Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Albany |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Allegany |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Bronx |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Broome |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Cattaraugus |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Cayuga |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Chautauqua |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Chemung |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Chenango |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Clinton |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Columbia |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Cortland |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Delaware |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Dutchess |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Erie |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Essex |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Franklin |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Fulton |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Genesee |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Greene |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Hamilton |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Herkimer |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Jefferson |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Kings |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Lewis |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Madison |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Monroe |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Montgomery |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Nassau |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Niagara |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Oneida |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Onondaga |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Ontario |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Orange |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Oswego |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Otsego |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Putnam |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Queens |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Rensselaer |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Richmond |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Rockland |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
St. Lawrence |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Saratoga |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Schenectady |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Schoharie |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Schuyler |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Seneca |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Steuben |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Suffolk |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Sullivan |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Tioga |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Tompkins |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Ulster |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Warren |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Washington |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Wayne |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Westchester |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Wyoming |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) in NY - H2775-105-0
Benefit Details
|
Yates |
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|