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2023 Medicare Prescription Drug Plan Cost-Sharing Details
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
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2023 Medicare Advantage Prescription Drug
Formulary (Drug List) Cost-Sharing Details
Wellcare Low Premium Open (PPO) (H0111-002-0)
Benefit Details        
all covered insulin pay $35 or less
This plan is available in Appling County, GA

Click on a letter below to view the
Wellcare Low Premium Open (PPO) 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: $0.00(E) $10.00(E) $0.00(E) $0.00(E) $30.00(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: $0.00 $10.00 $0.00 $0.00 $30.00 $0.00
Tier 3: Preferred Brand: $35.00 $47.00 $35.00 $105.00 $141.00 $70.00
Tier 4: Non-Preferred Drug: 45% 46% 45% 45% 46% 45%
Tier 5: Specialty Tier: 30% 30% 30% 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
75% Generic and 75% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap
Tier 6: Select Care Drugs: $0.00(P) $0.00(P) $0.00(P) $0.00(P) $0.00(P) $0.00(P)
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 $4.15 The greater of 5% or $4.15
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): The greater of 5% or $10.35 The greater of 5% or $10.35
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.
(A) Coverage Gap cost-sharing applies to all drugs on the designated tier. Drugs that are covered in the coverage gap also receive the donut hole discount.
(P) Coverage Gap cost-sharing applies to only some of drugs on the designated drug tier. Drugs that are covered in the coverage gap also receive the donut hole discount.
Go to the Wellcare Low Premium Open (PPO) 2023 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 
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