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2017SUMMARY OF BENEFITS
Prescription Drug Plans
S4802January 1, 2017 - December 31, 2017
WellCare Classic (PDP)WellCare Extra (PDP)
S4802_NA034555_PDP_SOB_ENG CMS Accepted NA7PDPSOB76297E_0616©WellCare 2016 NA_06_16
Summary of BenefitsJanuary 1, 2017– December 31, 2017
This booklet gives you a brief overview of what we cover and what you can expect to pay. Itdoesn't list every service we cover or every limitation or exclusion. To get a complete list ofservices we cover, give us a call and ask for the "Evidence of Coverage." You can also find a copyon our website at www.wellcare.com/PDP. To join WellCare Classic and WellCare Extra,you must be entitled to Medicare Part A, and/or be enrolled in Medicare Part B, and live in ourservice area. Please refer to the Premium/Cost-Sharing Tables to find out the premium/cost-sharing in your area.You can access and/or order your current "Medicare & You" handbookonline at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE(1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.Contact information and hours
1 If you are not a member of this plan, call toll-free 1-866-537-1812 (TTY 711).1 If you are a member of this plan, call toll-free 1-888-550-5252 (TTY 1-888-816-5252).1 Our website: www.wellcare.com/PDP1 From October 1 to February 14, we’re here for you 7 days per week, 8 a.m. to 8 p.m.1 From February 15 to September 30, you can call us Monday–Friday, 8 a.m. to 8 p.m.
Which drugs are covered?You can see the complete plan formulary (list of Part D prescription drugs) and any restrictionson our website (www.wellcare.com/pdp). Or, call us at the number above and we will send youa copy of the formulary.How will I determine my drug costs?Our plans group each medication into one of five "tiers." You will need to use your formularyto locate what tier your drug is on to determine how much it will cost you. The amount you paydepends on the drug's tier and what stage of the benefit you have reached. Later in this documentwe discuss the benefit stages that occur after you meet your deductible, if applicable: InitialCoverage, Coverage Gap, and Catastrophic Coverage.Which pharmacies can I use?We have a network of pharmacies and you must generally use these pharmacies to fill yourprescriptions for covered Part D drugs.We also offer a mail service pharmacy with preferred cost-sharing. You may pay less if you usethis pharmacy.You can see our plans' pharmacy directory at our website (www.wellcare.com/pdp) or call us andwe will send you a copy of the pharmacy directory.This document is available in other formats such as Braille and large print.This document may be available in a non-English language. For additional information, call usat 1-888-550-5252, TTY 1-888-816-5252.
Summary of Benefits | 1
Summary of BenefitsJanuary 1, 2017– December 31, 2017
WellCare Extra (PDP)WellCare Classic (PDP)
Premiums and Benefits
You pay $58.10-$81.10You pay $20.40-$36.30Monthly Plan Premium
This plan does not have adeductible
$400 on Tiers 2-5Deductible
Please refer to the Premium/Cost-Sharing Tables to find out thepremium/cost sharing in your area.
Summary of Benefits | 2
WellCare Classic (PDP)
Part D Cost SharesPart D Information
You pay the following until your total yearly drug costs reach $3,700.Total yearly drug costs are the total drug costs paid by both you and
Initial Coverage
our Part D plan. You may get your drugs at network retail pharmaciesand mail service pharmacies.
Preferred mailservice cost-sharing
Standard retail andmail service
Standard retail andmail service and
Initial Coverage(After you pay your
cost-sharing(in-network)
preferred mail servicecost-sharing(in-network)
deductible, ifapplicable) (up to a 90-day
supply)(up to a90-day supply)(up to a 30-day
supply)
You pay $0You pay $0-$6You pay $0-$2Tier 1: PreferredGeneric Drugs
You pay $25-$50You pay $30-$60You pay $10-$20Tier 2: GenericDrugs
You pay$87.50-$117.50
You pay $105-$141You pay $35-$47Tier 3: PreferredBrand Drugs
You pay 41%-50%You pay 41%-50%You pay 41%-50%Tier 4:Non-PreferredDrugs
Not CoveredNot CoveredYou pay 25%Tier 5: SpecialtyTier Drugs
Cost-sharing may change depending on the pharmacy you choose, if you reside in a long termcare (LTC) facility or if you get your medication at a retail location or through mail service.When you move from one phase of the Part D benefit to another, your cost-sharing maychange as well. For more information on the additional pharmacy specific cost-sharing andthe phases of the benefit, please call us or access our Evidence of Coverage online.
Please refer to the Premium/Cost-Sharing Tables to find out thepremium/cost sharing in your area.
Summary of Benefits | 3
WellCare Extra (PDP)
Part D Cost SharesPart D Information
You pay the following until your total yearly drug costs reach $3,700.Total yearly drug costs are the total drug costs paid by both you and
Initial Coverage
our Part D plan. You may get your drugs at network retail pharmaciesand mail service pharmacies.
Preferred mailservice cost-sharing
Standard retail andmail servicecost-sharing(in-network)
Standard retail andmail service andpreferred mail servicecost-sharing(in-network)
Initial Coverage(After you pay yourdeductible, ifapplicable) (up to a 90-day
supply)(up to a 90-daysupply)(up to a 30-day
supply)
You pay $0You pay $0You pay $0Tier 1: PreferredGeneric Drugs
You pay $0-$22.50You pay $0-$27You pay $0-$9Tier 2: GenericDrugs
You pay $60-$85You pay $72-$102You pay $24-$34Tier 3: PreferredBrand Drugs
You pay 45%You pay 45%You pay 45%Tier 4:Non-PreferredDrugs
Not CoveredNot CoveredYou pay 33%Tier 5: SpecialtyTier Drugs
Cost-sharing may change depending on the pharmacy you choose, if you reside in a long termcare (LTC) facility or if you get your medication at a retail location or through mail service.When you move from one phase of the Part D benefit to another, your cost-sharing maychange as well. For more information on the additional pharmacy specific cost-sharing andthe phases of the benefit, please call us or access our Evidence of Coverage online.
Please refer to the Premium/Cost-Sharing Tables to find out thepremium/cost sharing in your area.
Summary of Benefits | 4
WellCare Classic (PDP)/WellCare Extra (PDP)
Most Medicare drug plans have a coverage gap (also called the "donuthole"). This means that there's a temporary change in what you will
Coverage Gap
pay for your drugs. The coverage gap begins after the total yearly drugcost (including what our plan has paid and what you have paid) reaches$3,700.After you enter the coverage gap, you pay 40% of the plan'scost for covered brand name drugs and 51% of the plan's cost forcovered generic drugs until your costs total $4,950, which is the endof the coverage gap.
After your yearly out-of-pocket drug costs (not including what theplan has paid, but including drugs you purchased through your retail
CatastrophicCoverage
pharmacy and through Mail Service) reach $4,950, you pay the greaterof:5% of the cost, or$3.30 co-pay for generic (including brand drugs treated as generic)and a $8.25 co-payment for all other drugs.
Summary of Benefits | 5
Premium Tables for WellCare Classic (PDP)MonthlyPremiumPlan CodeState
$34.50S4802-096AK$28.30S4802-071AL$20.80S4802-073AR$22.70S4802-092AZ$34.90S4802-094CA$31.60S4802-091CO$28.10S4802-076CT$28.70S4802-079DC$28.70S4802-079DE$30.40S4802-083FL$31.70S4802-082GA$25.30S4802-095HI$28.60S4802-089IA$32.20S4802-021ID$26.50S4802-087IL$28.90S4802-086IN$28.90S4802-088KS$28.90S4802-086KY$30.10S4802-012LA$28.10S4802-076MA$28.70S4802-079MD$28.70S4802-075ME$29.10S4802-084MI$28.60S4802-089MN$27.40S4802-072MO$24.90S4802-074MS
MonthlyPremiumPlan CodeState
$28.60S4802-089MT$29.40S4802-081NC$28.60S4802-089ND$28.60S4802-089NE$28.70S4802-075NH$36.30S4802-078NJ$20.40S4802-090NM$26.40S4802-093NV$36.30S4802-077NY$26.30S4802-085OH$26.80S4802-014OK$26.10S4802-020OR$33.40S4802-080PA$28.10S4802-076RI$26.20S4802-070SC$28.60S4802-089SD$28.30S4802-071TN$25.20S4802-013TX$32.20S4802-021UT$27.20S4802-069VA$28.10S4802-076VT$26.10S4802-020WA$31.10S4802-097WI$33.40S4802-080WV$28.60S4802-089WY
Summary of Benefits | 6
Premium Tables for WellCare Extra (PDP)MonthlyPremiumPlan CodeState
$77.50S4802-130AK$71.70S4802-109AL$66.10S4802-115AR$59.20S4802-124AZ$67.50S4802-128CA$67.10S4802-123CO$65.90S4802-099CT$63.90S4802-102DC$63.90S4802-102DE$64.80S4802-108FL$68.50S4802-107GA$71.40S4802-129HI$70.30S4802-121IA$81.10S4802-127ID$62.70S4802-113IL$72.90S4802-112IN$71.60S4802-120KS$72.90S4802-112KY$70.10S4802-117LA$65.90S4802-099MA$63.90S4802-102MD$67.10S4802-098ME$61.80S4802-110MI$70.30S4802-121MN$67.70S4802-114MO$73.20S4802-116MS
MonthlyPremiumPlan CodeState
$70.30S4802-121MT$65.30S4802-105NC$70.30S4802-121ND$70.30S4802-121NE$67.10S4802-098NH$60.30S4802-101NJ$58.10S4802-122NM$64.70S4802-125NV$68.10S4802-100NY$65.50S4802-111OH$72.50S4802-119OK$74.90S4802-126OR$70.00S4802-103PA$65.90S4802-099RI$63.20S4802-106SC$70.30S4802-121SD$71.70S4802-109TN$62.40S4802-118TX$81.10S4802-127UT$63.20S4802-104VA$65.90S4802-099VT$74.90S4802-126WA$73.30S4802-131WI$70.00S4802-103WV$70.30S4802-121WY
Summary of Benefits | 7
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$2.0
0$2
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$2.0
0T
iers
2-5
on
$400
S480
2-09
6A
K$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
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-5 o
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802-
071
AL
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-07
3A
R$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
00S4
802-
092
AZ
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-09
4C
A$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
00S4
802-
091
CO
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-07
6C
T$0
.00
$3.0
0$1
.00
$1.0
0$1
.00
Tie
rs 2
-5 o
n $4
00S4
802-
079
DC
$0.0
0$3
.00
$1.0
0$1
.00
$1.0
0T
iers
2-5
on
$400
S480
2-07
9D
E$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
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802-
083
FL$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
00S4
802-
082
GA
$0.0
0$6
.00
$2.0
0$2
.00
$2.0
0T
iers
2-5
on
$400
S480
2-09
5H
I$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
00S4
802-
089
IA
Sum
mar
y of
Ben
efits
| 8
Cos
t-Sh
arin
g T
ables
for W
ellC
are C
lassic
(PD
P)T
ier 1
Pref
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ener
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rugs
Ded
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anSt
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90-d
ay su
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31-d
ay su
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30-d
ay su
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Pref
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Serv
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-of-N
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$0.0
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$0.0
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iers
2-5
on
$400
S480
2-02
1ID
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-08
7IL
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-08
6IN
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-08
8K
S$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
00S4
802-
086
KY
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-01
2LA
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-07
6M
A$0
.00
$3.0
0$1
.00
$1.0
0$1
.00
Tie
rs 2
-5 o
n $4
00S4
802-
079
MD
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-07
5M
E$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
00S4
802-
084
MI
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-08
9M
N$0
.00
$3.0
0$1
.00
$1.0
0$1
.00
Tie
rs 2
-5 o
n $4
00S4
802-
072
MO
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
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$400
S480
2-07
4M
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Sum
mar
y of
Ben
efits
| 9
Cos
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g T
ables
for W
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are C
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(PD
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ier 1
Pref
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Ded
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90-d
ay su
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31-d
ay su
pply
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ay su
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Pref
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d M
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dard
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-net
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$0.0
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$0.0
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$0.0
0T
iers
2-5
on
$400
S480
2-08
9M
T$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
00S4
802-
081
NC
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-08
9N
D$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
00S4
802-
089
NE
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-07
5N
H$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
00S4
802-
078
NJ
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-09
0N
M$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
00S4
802-
093
NV
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-07
7N
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.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
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085
OH
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-01
4O
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.00
$0.0
0$0
.00
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0$0
.00
Tie
rs 2
-5 o
n $4
00S4
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020
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$0.0
0$0
.00
$0.0
0$0
.00
$0.0
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iers
2-5
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$400
S480
2-08
0PA
Sum
mar
y of
Ben
efits
| 10
Cos
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g T
ables
for W
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are C
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(PD
P)T
ier 1
Pref
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d G
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rugs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
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ice C
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dard
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-net
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-Ter
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-of-N
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dard
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-net
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$0.0
0$0
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$0.0
0$0
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$0.0
0T
iers
2-5
on
$400
S480
2-07
6R
I$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
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070
SC$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
00S4
802-
089
SD$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
00S4
802-
071
TN
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-01
3T
X$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
00S4
802-
021
UT
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-06
9V
A$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
00S4
802-
076
VT
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-02
0W
A$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
00S4
802-
097
WI
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0T
iers
2-5
on
$400
S480
2-08
0W
V$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
Tie
rs 2
-5 o
n $4
00S4
802-
089
WY
Sum
mar
y of
Ben
efits
| 11
Cos
t-Sh
arin
g T
ables
for W
ellC
are C
lassic
(PD
P)T
ier 2
Gen
eric
Dru
gs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
and
pref
erre
dm
ail s
ervi
ceco
st-sh
arin
g (in
-ne
twor
k)
$50.
00$6
0.00
$20.
00$2
0.00
$20.
00T
iers
2-5
on
$400
S480
2-09
6A
K$3
0.00
$36.
00$1
2.00
$12.
00$1
2.00
Tie
rs 2
-5 o
n $4
00S4
802-
071
AL
$42.
50$5
1.00
$17.
00$1
7.00
$17.
00T
iers
2-5
on
$400
S480
2-07
3A
R$4
0.00
$48.
00$1
6.00
$16.
00$1
6.00
Tie
rs 2
-5 o
n $4
00S4
802-
092
AZ
$35.
00$4
2.00
$14.
00$1
4.00
$14.
00T
iers
2-5
on
$400
S480
2-09
4C
A$3
0.00
$36.
00$1
2.00
$12.
00$1
2.00
Tie
rs 2
-5 o
n $4
00S4
802-
091
CO
$40.
00$4
8.00
$16.
00$1
6.00
$16.
00T
iers
2-5
on
$400
S480
2-07
6C
T$3
0.00
$36.
00$1
2.00
$12.
00$1
2.00
Tie
rs 2
-5 o
n $4
00S4
802-
079
DC
$30.
00$3
6.00
$12.
00$1
2.00
$12.
00T
iers
2-5
on
$400
S480
2-07
9D
E$3
2.50
$39.
00$1
3.00
$13.
00$1
3.00
Tie
rs 2
-5 o
n $4
00S4
802-
083
FL$4
5.00
$54.
00$1
8.00
$18.
00$1
8.00
Tie
rs 2
-5 o
n $4
00S4
802-
082
GA
$30.
00$3
6.00
$12.
00$1
2.00
$12.
00T
iers
2-5
on
$400
S480
2-09
5H
I$3
2.50
$39.
00$1
3.00
$13.
00$1
3.00
Tie
rs 2
-5 o
n $4
00S4
802-
089
IA
Sum
mar
y of
Ben
efits
| 12
Cos
t-Sh
arin
g T
ables
for W
ellC
are C
lassic
(PD
P)T
ier 2
Gen
eric
Dru
gs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
and
pref
erre
dm
ail s
ervi
ceco
st-sh
arin
g (in
-ne
twor
k)
$27.
50$3
3.00
$11.
00$1
1.00
$11.
00T
iers
2-5
on
$400
S480
2-02
1ID
$42.
50$5
1.00
$17.
00$1
7.00
$17.
00T
iers
2-5
on
$400
S480
2-08
7IL
$30.
00$3
6.00
$12.
00$1
2.00
$12.
00T
iers
2-5
on
$400
S480
2-08
6IN
$45.
00$5
4.00
$18.
00$1
8.00
$18.
00T
iers
2-5
on
$400
S480
2-08
8K
S$3
0.00
$36.
00$1
2.00
$12.
00$1
2.00
Tie
rs 2
-5 o
n $4
00S4
802-
086
KY
$42.
50$5
1.00
$17.
00$1
7.00
$17.
00T
iers
2-5
on
$400
S480
2-01
2LA
$40.
00$4
8.00
$16.
00$1
6.00
$16.
00T
iers
2-5
on
$400
S480
2-07
6M
A$3
0.00
$36.
00$1
2.00
$12.
00$1
2.00
Tie
rs 2
-5 o
n $4
00S4
802-
079
MD
$25.
00$3
0.00
$10.
00$1
0.00
$10.
00T
iers
2-5
on
$400
S480
2-07
5M
E$3
2.50
$39.
00$1
3.00
$13.
00$1
3.00
Tie
rs 2
-5 o
n $4
00S4
802-
084
MI
$32.
50$3
9.00
$13.
00$1
3.00
$13.
00T
iers
2-5
on
$400
S480
2-08
9M
N$4
2.50
$51.
00$1
7.00
$17.
00$1
7.00
Tie
rs 2
-5 o
n $4
00S4
802-
072
MO
$50.
00$6
0.00
$20.
00$2
0.00
$20.
00T
iers
2-5
on
$400
S480
2-07
4M
S
Sum
mar
y of
Ben
efits
| 13
Cos
t-Sh
arin
g T
ables
for W
ellC
are C
lassic
(PD
P)T
ier 2
Gen
eric
Dru
gs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
and
pref
erre
dm
ail s
ervi
ceco
st-sh
arin
g (in
-ne
twor
k)
$32.
50$3
9.00
$13.
00$1
3.00
$13.
00T
iers
2-5
on
$400
S480
2-08
9M
T$2
7.50
$33.
00$1
1.00
$11.
00$1
1.00
Tie
rs 2
-5 o
n $4
00S4
802-
081
NC
$32.
50$3
9.00
$13.
00$1
3.00
$13.
00T
iers
2-5
on
$400
S480
2-08
9N
D$3
2.50
$39.
00$1
3.00
$13.
00$1
3.00
Tie
rs 2
-5 o
n $4
00S4
802-
089
NE
$25.
00$3
0.00
$10.
00$1
0.00
$10.
00T
iers
2-5
on
$400
S480
2-07
5N
H$3
7.50
$45.
00$1
5.00
$15.
00$1
5.00
Tie
rs 2
-5 o
n $4
00S4
802-
078
NJ
$47.
50$5
7.00
$19.
00$1
9.00
$19.
00T
iers
2-5
on
$400
S480
2-09
0N
M$2
7.50
$33.
00$1
1.00
$11.
00$1
1.00
Tie
rs 2
-5 o
n $4
00S4
802-
093
NV
$35.
00$4
2.00
$14.
00$1
4.00
$14.
00T
iers
2-5
on
$400
S480
2-07
7N
Y$4
7.50
$57.
00$1
9.00
$19.
00$1
9.00
Tie
rs 2
-5 o
n $4
00S4
802-
085
OH
$37.
50$4
5.00
$15.
00$1
5.00
$15.
00T
iers
2-5
on
$400
S480
2-01
4O
K$2
7.50
$33.
00$1
1.00
$11.
00$1
1.00
Tie
rs 2
-5 o
n $4
00S4
802-
020
OR
$40.
00$4
8.00
$16.
00$1
6.00
$16.
00T
iers
2-5
on
$400
S480
2-08
0PA
Sum
mar
y of
Ben
efits
| 14
Cos
t-Sh
arin
g T
ables
for W
ellC
are C
lassic
(PD
P)T
ier 2
Gen
eric
Dru
gs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
and
pref
erre
dm
ail s
ervi
ceco
st-sh
arin
g (in
-ne
twor
k)
$40.
00$4
8.00
$16.
00$1
6.00
$16.
00T
iers
2-5
on
$400
S480
2-07
6R
I$4
7.50
$57.
00$1
9.00
$19.
00$1
9.00
Tie
rs 2
-5 o
n $4
00S4
802-
070
SC$3
2.50
$39.
00$1
3.00
$13.
00$1
3.00
Tie
rs 2
-5 o
n $4
00S4
802-
089
SD$3
0.00
$36.
00$1
2.00
$12.
00$1
2.00
Tie
rs 2
-5 o
n $4
00S4
802-
071
TN
$35.
00$4
2.00
$14.
00$1
4.00
$14.
00T
iers
2-5
on
$400
S480
2-01
3T
X$2
7.50
$33.
00$1
1.00
$11.
00$1
1.00
Tie
rs 2
-5 o
n $4
00S4
802-
021
UT
$27.
50$3
3.00
$11.
00$1
1.00
$11.
00T
iers
2-5
on
$400
S480
2-06
9V
A$4
0.00
$48.
00$1
6.00
$16.
00$1
6.00
Tie
rs 2
-5 o
n $4
00S4
802-
076
VT
$27.
50$3
3.00
$11.
00$1
1.00
$11.
00T
iers
2-5
on
$400
S480
2-02
0W
A$2
7.50
$33.
00$1
1.00
$11.
00$1
1.00
Tie
rs 2
-5 o
n $4
00S4
802-
097
WI
$40.
00$4
8.00
$16.
00$1
6.00
$16.
00T
iers
2-5
on
$400
S480
2-08
0W
V$3
2.50
$39.
00$1
3.00
$13.
00$1
3.00
Tie
rs 2
-5 o
n $4
00S4
802-
089
WY
Sum
mar
y of
Ben
efits
| 15
Cos
t-Sh
arin
g T
ables
for W
ellC
are C
lassic
(PD
P)T
ier 3
Pref
erre
d Br
and
Dru
gs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
and
pref
erre
dm
ail s
ervi
ceco
st-sh
arin
g (in
-ne
twor
k)
$117
.50
$141
.00
$47.
00$4
7.00
$47.
00T
iers
2-5
on
$400
S480
2-09
6A
K$1
15.0
0$1
38.0
0$4
6.00
$46.
00$4
6.00
Tie
rs 2
-5 o
n $4
00S4
802-
071
AL
$117
.50
$141
.00
$47.
00$4
7.00
$47.
00T
iers
2-5
on
$400
S480
2-07
3A
R$1
17.5
0$1
41.0
0$4
7.00
$47.
00$4
7.00
Tie
rs 2
-5 o
n $4
00S4
802-
092
AZ
$115
.00
$138
.00
$46.
00$4
6.00
$46.
00T
iers
2-5
on
$400
S480
2-09
4C
A$1
17.5
0$1
41.0
0$4
7.00
$47.
00$4
7.00
Tie
rs 2
-5 o
n $4
00S4
802-
091
CO
$97.
50$1
17.0
0$3
9.00
$39.
00$3
9.00
Tie
rs 2
-5 o
n $4
00S4
802-
076
CT
$115
.00
$138
.00
$46.
00$4
6.00
$46.
00T
iers
2-5
on
$400
S480
2-07
9D
C$1
15.0
0$1
38.0
0$4
6.00
$46.
00$4
6.00
Tie
rs 2
-5 o
n $4
00S4
802-
079
DE
$117
.50
$141
.00
$47.
00$4
7.00
$47.
00T
iers
2-5
on
$400
S480
2-08
3FL
$117
.50
$141
.00
$47.
00$4
7.00
$47.
00T
iers
2-5
on
$400
S480
2-08
2G
A$1
17.5
0$1
41.0
0$4
7.00
$47.
00$4
7.00
Tie
rs 2
-5 o
n $4
00S4
802-
095
HI
$117
.50
$141
.00
$47.
00$4
7.00
$47.
00T
iers
2-5
on
$400
S480
2-08
9IA
Sum
mar
y of
Ben
efits
| 16
Cos
t-Sh
arin
g T
ables
for W
ellC
are C
lassic
(PD
P)T
ier 3
Pref
erre
d Br
and
Dru
gs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
and
pref
erre
dm
ail s
ervi
ceco
st-sh
arin
g (in
-ne
twor
k)
$87.
50$1
05.0
0$3
5.00
$35.
00$3
5.00
Tie
rs 2
-5 o
n $4
00S4
802-
021
ID$1
12.5
0$1
35.0
0$4
5.00
$45.
00$4
5.00
Tie
rs 2
-5 o
n $4
00S4
802-
087
IL$1
10.0
0$1
32.0
0$4
4.00
$44.
00$4
4.00
Tie
rs 2
-5 o
n $4
00S4
802-
086
IN$9
7.50
$117
.00
$39.
00$3
9.00
$39.
00T
iers
2-5
on
$400
S480
2-08
8K
S$1
10.0
0$1
32.0
0$4
4.00
$44.
00$4
4.00
Tie
rs 2
-5 o
n $4
00S4
802-
086
KY
$110
.00
$132
.00
$44.
00$4
4.00
$44.
00T
iers
2-5
on
$400
S480
2-01
2LA
$97.
50$1
17.0
0$3
9.00
$39.
00$3
9.00
Tie
rs 2
-5 o
n $4
00S4
802-
076
MA
$115
.00
$138
.00
$46.
00$4
6.00
$46.
00T
iers
2-5
on
$400
S480
2-07
9M
D$9
2.50
$111
.00
$37.
00$3
7.00
$37.
00T
iers
2-5
on
$400
S480
2-07
5M
E$1
07.5
0$1
29.0
0$4
3.00
$43.
00$4
3.00
Tie
rs 2
-5 o
n $4
00S4
802-
084
MI
$117
.50
$141
.00
$47.
00$4
7.00
$47.
00T
iers
2-5
on
$400
S480
2-08
9M
N$1
05.0
0$1
26.0
0$4
2.00
$42.
00$4
2.00
Tie
rs 2
-5 o
n $4
00S4
802-
072
MO
$117
.50
$141
.00
$47.
00$4
7.00
$47.
00T
iers
2-5
on
$400
S480
2-07
4M
S
Sum
mar
y of
Ben
efits
| 17
Cos
t-Sh
arin
g T
ables
for W
ellC
are C
lassic
(PD
P)T
ier 3
Pref
erre
d Br
and
Dru
gs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
and
pref
erre
dm
ail s
ervi
ceco
st-sh
arin
g (in
-ne
twor
k)
$117
.50
$141
.00
$47.
00$4
7.00
$47.
00T
iers
2-5
on
$400
S480
2-08
9M
T$1
10.0
0$1
32.0
0$4
4.00
$44.
00$4
4.00
Tie
rs 2
-5 o
n $4
00S4
802-
081
NC
$117
.50
$141
.00
$47.
00$4
7.00
$47.
00T
iers
2-5
on
$400
S480
2-08
9N
D$1
17.5
0$1
41.0
0$4
7.00
$47.
00$4
7.00
Tie
rs 2
-5 o
n $4
00S4
802-
089
NE
$92.
50$1
11.0
0$3
7.00
$37.
00$3
7.00
Tie
rs 2
-5 o
n $4
00S4
802-
075
NH
$117
.50
$141
.00
$47.
00$4
7.00
$47.
00T
iers
2-5
on
$400
S480
2-07
8N
J$1
05.0
0$1
26.0
0$4
2.00
$42.
00$4
2.00
Tie
rs 2
-5 o
n $4
00S4
802-
090
NM
$112
.50
$135
.00
$45.
00$4
5.00
$45.
00T
iers
2-5
on
$400
S480
2-09
3N
V$1
17.5
0$1
41.0
0$4
7.00
$47.
00$4
7.00
Tie
rs 2
-5 o
n $4
00S4
802-
077
NY
$110
.00
$132
.00
$44.
00$4
4.00
$44.
00T
iers
2-5
on
$400
S480
2-08
5O
H$9
2.50
$111
.00
$37.
00$3
7.00
$37.
00T
iers
2-5
on
$400
S480
2-01
4O
K$1
00.0
0$1
20.0
0$4
0.00
$40.
00$4
0.00
Tie
rs 2
-5 o
n $4
00S4
802-
020
OR
$117
.50
$141
.00
$47.
00$4
7.00
$47.
00T
iers
2-5
on
$400
S480
2-08
0PA
Sum
mar
y of
Ben
efits
| 18
Cos
t-Sh
arin
g T
ables
for W
ellC
are C
lassic
(PD
P)T
ier 3
Pref
erre
d Br
and
Dru
gs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
and
pref
erre
dm
ail s
ervi
ceco
st-sh
arin
g (in
-ne
twor
k)
$97.
50$1
17.0
0$3
9.00
$39.
00$3
9.00
Tie
rs 2
-5 o
n $4
00S4
802-
076
RI
$117
.50
$141
.00
$47.
00$4
7.00
$47.
00T
iers
2-5
on
$400
S480
2-07
0SC
$117
.50
$141
.00
$47.
00$4
7.00
$47.
00T
iers
2-5
on
$400
S480
2-08
9SD
$115
.00
$138
.00
$46.
00$4
6.00
$46.
00T
iers
2-5
on
$400
S480
2-07
1T
N$1
17.5
0$1
41.0
0$4
7.00
$47.
00$4
7.00
Tie
rs 2
-5 o
n $4
00S4
802-
013
TX
$87.
50$1
05.0
0$3
5.00
$35.
00$3
5.00
Tie
rs 2
-5 o
n $4
00S4
802-
021
UT
$117
.50
$141
.00
$47.
00$4
7.00
$47.
00T
iers
2-5
on
$400
S480
2-06
9V
A$9
7.50
$117
.00
$39.
00$3
9.00
$39.
00T
iers
2-5
on
$400
S480
2-07
6V
T$1
00.0
0$1
20.0
0$4
0.00
$40.
00$4
0.00
Tie
rs 2
-5 o
n $4
00S4
802-
020
WA
$117
.50
$141
.00
$47.
00$4
7.00
$47.
00T
iers
2-5
on
$400
S480
2-09
7W
I$1
17.5
0$1
41.0
0$4
7.00
$47.
00$4
7.00
Tie
rs 2
-5 o
n $4
00S4
802-
080
WV
$117
.50
$141
.00
$47.
00$4
7.00
$47.
00T
iers
2-5
on
$400
S480
2-08
9W
Y
Sum
mar
y of
Ben
efits
| 19
Cos
t-Sh
arin
g T
ables
for W
ellC
are C
lassic
(PD
P)T
ier 4
Non
-Pre
ferre
d D
rugs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
and
pref
erre
dm
ail s
ervi
ceco
st-sh
arin
g (in
-ne
twor
k)
41%
41%
41%
41%
41%
Tie
rs 2
-5 o
n $4
00S4
802-
096
AK
50%
50%
50%
50%
50%
Tie
rs 2
-5 o
n $4
00S4
802-
071
AL
50%
50%
50%
50%
50%
Tie
rs 2
-5 o
n $4
00S4
802-
073
AR
47%
47%
47%
47%
47%
Tie
rs 2
-5 o
n $4
00S4
802-
092
AZ
48%
48%
48%
48%
48%
Tie
rs 2
-5 o
n $4
00S4
802-
094
CA
45%
45%
45%
45%
45%
Tie
rs 2
-5 o
n $4
00S4
802-
091
CO
46%
46%
46%
46%
46%
Tie
rs 2
-5 o
n $4
00S4
802-
076
CT
49%
49%
49%
49%
49%
Tie
rs 2
-5 o
n $4
00S4
802-
079
DC
49%
49%
49%
49%
49%
Tie
rs 2
-5 o
n $4
00S4
802-
079
DE
47%
47%
47%
47%
47%
Tie
rs 2
-5 o
n $4
00S4
802-
083
FL50
%50
%50
%50
%50
%T
iers
2-5
on
$400
S480
2-08
2G
A50
%50
%50
%50
%50
%T
iers
2-5
on
$400
S480
2-09
5H
I44
%44
%44
%44
%44
%T
iers
2-5
on
$400
S480
2-08
9IA
Sum
mar
y of
Ben
efits
| 20
Cos
t-Sh
arin
g T
ables
for W
ellC
are C
lassic
(PD
P)T
ier 4
Non
-Pre
ferre
d D
rugs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
and
pref
erre
dm
ail s
ervi
ceco
st-sh
arin
g (in
-ne
twor
k)
49%
49%
49%
49%
49%
Tie
rs 2
-5 o
n $4
00S4
802-
021
ID49
%49
%49
%49
%49
%T
iers
2-5
on
$400
S480
2-08
7IL
50%
50%
50%
50%
50%
Tie
rs 2
-5 o
n $4
00S4
802-
086
IN45
%45
%45
%45
%45
%T
iers
2-5
on
$400
S480
2-08
8K
S50
%50
%50
%50
%50
%T
iers
2-5
on
$400
S480
2-08
6K
Y50
%50
%50
%50
%50
%T
iers
2-5
on
$400
S480
2-01
2LA
46%
46%
46%
46%
46%
Tie
rs 2
-5 o
n $4
00S4
802-
076
MA
49%
49%
49%
49%
49%
Tie
rs 2
-5 o
n $4
00S4
802-
079
MD
50%
50%
50%
50%
50%
Tie
rs 2
-5 o
n $4
00S4
802-
075
ME
49%
49%
49%
49%
49%
Tie
rs 2
-5 o
n $4
00S4
802-
084
MI
44%
44%
44%
44%
44%
Tie
rs 2
-5 o
n $4
00S4
802-
089
MN
50%
50%
50%
50%
50%
Tie
rs 2
-5 o
n $4
00S4
802-
072
MO
50%
50%
50%
50%
50%
Tie
rs 2
-5 o
n $4
00S4
802-
074
MS
Sum
mar
y of
Ben
efits
| 21
Cos
t-Sh
arin
g T
ables
for W
ellC
are C
lassic
(PD
P)T
ier 4
Non
-Pre
ferre
d D
rugs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
and
pref
erre
dm
ail s
ervi
ceco
st-sh
arin
g (in
-ne
twor
k)
44%
44%
44%
44%
44%
Tie
rs 2
-5 o
n $4
00S4
802-
089
MT
50%
50%
50%
50%
50%
Tie
rs 2
-5 o
n $4
00S4
802-
081
NC
44%
44%
44%
44%
44%
Tie
rs 2
-5 o
n $4
00S4
802-
089
ND
44%
44%
44%
44%
44%
Tie
rs 2
-5 o
n $4
00S4
802-
089
NE
50%
50%
50%
50%
50%
Tie
rs 2
-5 o
n $4
00S4
802-
075
NH
47%
47%
47%
47%
47%
Tie
rs 2
-5 o
n $4
00S4
802-
078
NJ
48%
48%
48%
48%
48%
Tie
rs 2
-5 o
n $4
00S4
802-
090
NM
49%
49%
49%
49%
49%
Tie
rs 2
-5 o
n $4
00S4
802-
093
NV
48%
48%
48%
48%
48%
Tie
rs 2
-5 o
n $4
00S4
802-
077
NY
48%
48%
48%
48%
48%
Tie
rs 2
-5 o
n $4
00S4
802-
085
OH
50%
50%
50%
50%
50%
Tie
rs 2
-5 o
n $4
00S4
802-
014
OK
50%
50%
50%
50%
50%
Tie
rs 2
-5 o
n $4
00S4
802-
020
OR
50%
50%
50%
50%
50%
Tie
rs 2
-5 o
n $4
00S4
802-
080
PA
Sum
mar
y of
Ben
efits
| 22
Cos
t-Sh
arin
g T
ables
for W
ellC
are C
lassic
(PD
P)T
ier 4
Non
-Pre
ferre
d D
rugs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
and
pref
erre
dm
ail s
ervi
ceco
st-sh
arin
g (in
-ne
twor
k)
46%
46%
46%
46%
46%
Tie
rs 2
-5 o
n $4
00S4
802-
076
RI
46%
46%
46%
46%
46%
Tie
rs 2
-5 o
n $4
00S4
802-
070
SC44
%44
%44
%44
%44
%T
iers
2-5
on
$400
S480
2-08
9SD
50%
50%
50%
50%
50%
Tie
rs 2
-5 o
n $4
00S4
802-
071
TN
49%
49%
49%
49%
49%
Tie
rs 2
-5 o
n $4
00S4
802-
013
TX
49%
49%
49%
49%
49%
Tie
rs 2
-5 o
n $4
00S4
802-
021
UT
50%
50%
50%
50%
50%
Tie
rs 2
-5 o
n $4
00S4
802-
069
VA
46%
46%
46%
46%
46%
Tie
rs 2
-5 o
n $4
00S4
802-
076
VT
50%
50%
50%
50%
50%
Tie
rs 2
-5 o
n $4
00S4
802-
020
WA
50%
50%
50%
50%
50%
Tie
rs 2
-5 o
n $4
00S4
802-
097
WI
50%
50%
50%
50%
50%
Tie
rs 2
-5 o
n $4
00S4
802-
080
WV
44%
44%
44%
44%
44%
Tie
rs 2
-5 o
n $4
00S4
802-
089
WY
Sum
mar
y of
Ben
efits
| 23
Cos
t-Sh
arin
g T
ables
for W
ellC
are C
lassic
(PD
P)T
ier 5
Spec
ialty
Tie
r Dru
gs
Ded
uctib
lePl
anSt
ate
31-d
ay su
pply
30-d
ay su
pply
Long
-Ter
m C
are
(LT
C) C
ost-
Shar
ing
Out
-of-N
etwo
rk C
ost-
Shar
ing
Stan
dard
Ret
ail a
ndM
ail S
ervi
ce an
dpr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-
netw
ork)
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
096
AK
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
071
AL
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
073
AR
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
092
AZ
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
094
CA
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
091
CO
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
076
CT
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
079
DC
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
079
DE
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
083
FL
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
082
GA
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
095
HI
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
089
IA
Sum
mar
y of
Ben
efits
| 24
Cos
t-Sh
arin
g T
ables
for W
ellC
are C
lassic
(PD
P)T
ier 5
Spec
ialty
Tie
r Dru
gs
Ded
uctib
lePl
anSt
ate
31-d
ay su
pply
30-d
ay su
pply
Long
-Ter
m C
are
(LT
C) C
ost-
Shar
ing
Out
-of-N
etwo
rk C
ost-
Shar
ing
Stan
dard
Ret
ail a
ndM
ail S
ervi
ce an
dpr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-
netw
ork)
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
021
ID
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
087
IL
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
086
IN
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
088
KS
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
086
KY
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
012
LA
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
076
MA
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
079
MD
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
075
ME
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
084
MI
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
089
MN
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
072
MO
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
074
MS
Sum
mar
y of
Ben
efits
| 25
Cos
t-Sh
arin
g T
ables
for W
ellC
are C
lassic
(PD
P)T
ier 5
Spec
ialty
Tie
r Dru
gs
Ded
uctib
lePl
anSt
ate
31-d
ay su
pply
30-d
ay su
pply
Long
-Ter
m C
are
(LT
C) C
ost-
Shar
ing
Out
-of-N
etwo
rk C
ost-
Shar
ing
Stan
dard
Ret
ail a
ndM
ail S
ervi
ce an
dpr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-
netw
ork)
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
089
MT
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
081
NC
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
089
ND
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
089
NE
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
075
NH
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
078
NJ
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
090
NM
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
093
NV
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
077
NY
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
085
OH
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
014
OK
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
020
OR
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
080
PA
Sum
mar
y of
Ben
efits
| 26
Cos
t-Sh
arin
g T
ables
for W
ellC
are C
lassic
(PD
P)T
ier 5
Spec
ialty
Tie
r Dru
gs
Ded
uctib
lePl
anSt
ate
31-d
ay su
pply
30-d
ay su
pply
Long
-Ter
m C
are
(LT
C) C
ost-
Shar
ing
Out
-of-N
etwo
rk C
ost-
Shar
ing
Stan
dard
Ret
ail a
ndM
ail S
ervi
ce an
dpr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-
netw
ork)
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
076
RI
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
070
SC
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
089
SD
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
071
TN
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
013
TX
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
021
UT
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
069
VA
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
076
VT
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
020
WA
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
097
WI
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
080
WV
25%
25%
25%
Tie
rs 2
-5 o
n $4
00S4
802-
089
WY
Sum
mar
y of
Ben
efits
| 27
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 1
Pref
erre
d G
ener
ic D
rugs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-13
0A
K$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
109
AL
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-11
5A
R$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
124
AZ
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-12
8C
A$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
123
CO
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-09
9C
T$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
102
DC
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-10
2D
E$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
108
FL$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
107
GA
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-12
9H
I$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
121
IA
Sum
mar
y of
Ben
efits
| 28
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 1
Pref
erre
d G
ener
ic D
rugs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-12
7ID
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-11
3IL
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-11
2IN
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-12
0K
S$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
112
KY
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-11
7LA
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-09
9M
A$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
102
MD
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-09
8M
E$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
110
MI
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-12
1M
N$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
114
MO
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-11
6M
S
Sum
mar
y of
Ben
efits
| 29
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 1
Pref
erre
d G
ener
ic D
rugs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-12
1M
T$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
105
NC
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-12
1N
D$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
121
NE
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-09
8N
H$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
101
NJ
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-12
2N
M$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
125
NV
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-10
0N
Y$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
111
OH
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-11
9O
K$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
126
OR
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-10
3PA
Sum
mar
y of
Ben
efits
| 30
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 1
Pref
erre
d G
ener
ic D
rugs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-09
9R
I$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
106
SC$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
121
SD$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
109
TN
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-11
8T
X$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
127
UT
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-10
4V
A$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
099
VT
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-12
6W
A$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
131
WI
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-10
3W
V$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
121
WY
Sum
mar
y of
Ben
efits
| 31
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 2
Gen
eric
Dru
gs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
reta
ilan
d m
ail s
ervi
cean
d pr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-n
etwo
rk)
$12.
50$1
5.00
$5.0
0$5
.00
$5.0
0$0
.00
S480
2-13
0A
K$2
.50
$3.0
0$1
.00
$1.0
0$1
.00
$0.0
0S4
802-
109
AL
$7.5
0$9
.00
$3.0
0$3
.00
$3.0
0$0
.00
S480
2-11
5A
R$2
2.50
$27.
00$9
.00
$9.0
0$9
.00
$0.0
0S4
802-
124
AZ
$20.
00$2
4.00
$8.0
0$8
.00
$8.0
0$0
.00
S480
2-12
8C
A$1
5.00
$18.
00$6
.00
$6.0
0$6
.00
$0.0
0S4
802-
123
CO
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-09
9C
T$1
0.00
$12.
00$4
.00
$4.0
0$4
.00
$0.0
0S4
802-
102
DC
$10.
00$1
2.00
$4.0
0$4
.00
$4.0
0$0
.00
S480
2-10
2D
E$1
5.00
$18.
00$6
.00
$6.0
0$6
.00
$0.0
0S4
802-
108
FL$7
.50
$9.0
0$3
.00
$3.0
0$3
.00
$0.0
0S4
802-
107
GA
$15.
00$1
8.00
$6.0
0$6
.00
$6.0
0$0
.00
S480
2-12
9H
I$1
5.00
$18.
00$6
.00
$6.0
0$6
.00
$0.0
0S4
802-
121
IA
Sum
mar
y of
Ben
efits
| 32
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 2
Gen
eric
Dru
gs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
reta
ilan
d m
ail s
ervi
cean
d pr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-n
etwo
rk)
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-12
7ID
$20.
00$2
4.00
$8.0
0$8
.00
$8.0
0$0
.00
S480
2-11
3IL
$2.5
0$3
.00
$1.0
0$1
.00
$1.0
0$0
.00
S480
2-11
2IN
$12.
50$1
5.00
$5.0
0$5
.00
$5.0
0$0
.00
S480
2-12
0K
S$2
.50
$3.0
0$1
.00
$1.0
0$1
.00
$0.0
0S4
802-
112
KY
$5.0
0$6
.00
$2.0
0$2
.00
$2.0
0$0
.00
S480
2-11
7LA
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-09
9M
A$1
0.00
$12.
00$4
.00
$4.0
0$4
.00
$0.0
0S4
802-
102
MD
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-09
8M
E$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
110
MI
$15.
00$1
8.00
$6.0
0$6
.00
$6.0
0$0
.00
S480
2-12
1M
N$1
0.00
$12.
00$4
.00
$4.0
0$4
.00
$0.0
0S4
802-
114
MO
$10.
00$1
2.00
$4.0
0$4
.00
$4.0
0$0
.00
S480
2-11
6M
S
Sum
mar
y of
Ben
efits
| 33
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 2
Gen
eric
Dru
gs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
reta
ilan
d m
ail s
ervi
cean
d pr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-n
etwo
rk)
$15.
00$1
8.00
$6.0
0$6
.00
$6.0
0$0
.00
S480
2-12
1M
T$1
7.50
$21.
00$7
.00
$7.0
0$7
.00
$0.0
0S4
802-
105
NC
$15.
00$1
8.00
$6.0
0$6
.00
$6.0
0$0
.00
S480
2-12
1N
D$1
5.00
$18.
00$6
.00
$6.0
0$6
.00
$0.0
0S4
802-
121
NE
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-09
8N
H$2
2.50
$27.
00$9
.00
$9.0
0$9
.00
$0.0
0S4
802-
101
NJ
$22.
50$2
7.00
$9.0
0$9
.00
$9.0
0$0
.00
S480
2-12
2N
M$1
2.50
$15.
00$5
.00
$5.0
0$5
.00
$0.0
0S4
802-
125
NV
$5.0
0$6
.00
$2.0
0$2
.00
$2.0
0$0
.00
S480
2-10
0N
Y$5
.00
$6.0
0$2
.00
$2.0
0$2
.00
$0.0
0S4
802-
111
OH
$2.5
0$3
.00
$1.0
0$1
.00
$1.0
0$0
.00
S480
2-11
9O
K$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
126
OR
$7.5
0$9
.00
$3.0
0$3
.00
$3.0
0$0
.00
S480
2-10
3PA
Sum
mar
y of
Ben
efits
| 34
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 2
Gen
eric
Dru
gs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
reta
ilan
d m
ail s
ervi
cean
d pr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-n
etwo
rk)
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-09
9R
I$2
2.50
$27.
00$9
.00
$9.0
0$9
.00
$0.0
0S4
802-
106
SC$1
5.00
$18.
00$6
.00
$6.0
0$6
.00
$0.0
0S4
802-
121
SD$2
.50
$3.0
0$1
.00
$1.0
0$1
.00
$0.0
0S4
802-
109
TN
$22.
50$2
7.00
$9.0
0$9
.00
$9.0
0$0
.00
S480
2-11
8T
X$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
127
UT
$20.
00$2
4.00
$8.0
0$8
.00
$8.0
0$0
.00
S480
2-10
4V
A$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0S4
802-
099
VT
$0.0
0$0
.00
$0.0
0$0
.00
$0.0
0$0
.00
S480
2-12
6W
A$2
.50
$3.0
0$1
.00
$1.0
0$1
.00
$0.0
0S4
802-
131
WI
$7.5
0$9
.00
$3.0
0$3
.00
$3.0
0$0
.00
S480
2-10
3W
V$1
5.00
$18.
00$6
.00
$6.0
0$6
.00
$0.0
0S4
802-
121
WY
Sum
mar
y of
Ben
efits
| 35
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 3
Ded
uctib
lePl
anSt
ate
Pref
erre
d Br
and
Dru
gs90
-day
supp
ly31
-day
supp
ly30
-day
supp
ly
Pref
erre
dM
ail S
ervi
ceC
ost-
Shar
ing
Stan
dard
Ret
ail a
ndM
ail S
ervi
ceC
ost-
Shar
ing
(in-n
etwo
rk)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-
Net
work
Cos
t-Sh
arin
g
Stan
dard
Ret
ail a
ndM
ail S
ervi
ceC
ost-
Shar
ing
(in-n
etwo
rk)
$77.
50$9
3.00
$31.
00$3
1.00
$31.
00$0
.00
S480
2-13
0A
K$7
5.00
$90.
00$3
0.00
$30.
00$3
0.00
$0.0
0S4
802-
109
AL
$75.
00$9
0.00
$30.
00$3
0.00
$30.
00$0
.00
S480
2-11
5A
R$7
7.50
$93.
00$3
1.00
$31.
00$3
1.00
$0.0
0S4
802-
124
AZ
$77.
50$9
3.00
$31.
00$3
1.00
$31.
00$0
.00
S480
2-12
8C
A$7
7.50
$93.
00$3
1.00
$31.
00$3
1.00
$0.0
0S4
802-
123
CO
$70.
00$8
4.00
$28.
00$2
8.00
$28.
00$0
.00
S480
2-09
9C
T$7
2.50
$87.
00$2
9.00
$29.
00$2
9.00
$0.0
0S4
802-
102
DC
$72.
50$8
7.00
$29.
00$2
9.00
$29.
00$0
.00
S480
2-10
2D
E$8
0.00
$96.
00$3
2.00
$32.
00$3
2.00
$0.0
0S4
802-
108
FL$7
5.00
$90.
00$3
0.00
$30.
00$3
0.00
$0.0
0S4
802-
107
GA
$77.
50$9
3.00
$31.
00$3
1.00
$31.
00$0
.00
S480
2-12
9H
I$8
0.00
$96.
00$3
2.00
$32.
00$3
2.00
$0.0
0S4
802-
121
IA
Sum
mar
y of
Ben
efits
| 36
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 3
Pref
erre
d Br
and
Dru
gs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
reta
ilan
d m
ail s
ervi
cean
d pr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-n
etwo
rk)
$60.
00$7
2.00
$24.
00$2
4.00
$24.
00$0
.00
S480
2-12
7ID
$85.
00$1
02.0
0$3
4.00
$34.
00$3
4.00
$0.0
0S4
802-
113
IL$7
2.50
$87.
00$2
9.00
$29.
00$2
9.00
$0.0
0S4
802-
112
IN$7
7.50
$93.
00$3
1.00
$31.
00$3
1.00
$0.0
0S4
802-
120
KS
$72.
50$8
7.00
$29.
00$2
9.00
$29.
00$0
.00
S480
2-11
2K
Y$7
7.50
$93.
00$3
1.00
$31.
00$3
1.00
$0.0
0S4
802-
117
LA$7
0.00
$84.
00$2
8.00
$28.
00$2
8.00
$0.0
0S4
802-
099
MA
$72.
50$8
7.00
$29.
00$2
9.00
$29.
00$0
.00
S480
2-10
2M
D$6
2.50
$75.
00$2
5.00
$25.
00$2
5.00
$0.0
0S4
802-
098
ME
$77.
50$9
3.00
$31.
00$3
1.00
$31.
00$0
.00
S480
2-11
0M
I$8
0.00
$96.
00$3
2.00
$32.
00$3
2.00
$0.0
0S4
802-
121
MN
$77.
50$9
3.00
$31.
00$3
1.00
$31.
00$0
.00
S480
2-11
4M
O$7
5.00
$90.
00$3
0.00
$30.
00$3
0.00
$0.0
0S4
802-
116
MS
Sum
mar
y of
Ben
efits
| 37
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 3
Pref
erre
d Br
and
Dru
gs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
reta
ilan
d m
ail s
ervi
cean
d pr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-n
etwo
rk)
$80.
00$9
6.00
$32.
00$3
2.00
$32.
00$0
.00
S480
2-12
1M
T$7
5.00
$90.
00$3
0.00
$30.
00$3
0.00
$0.0
0S4
802-
105
NC
$80.
00$9
6.00
$32.
00$3
2.00
$32.
00$0
.00
S480
2-12
1N
D$8
0.00
$96.
00$3
2.00
$32.
00$3
2.00
$0.0
0S4
802-
121
NE
$62.
50$7
5.00
$25.
00$2
5.00
$25.
00$0
.00
S480
2-09
8N
H$7
5.00
$90.
00$3
0.00
$30.
00$3
0.00
$0.0
0S4
802-
101
NJ
$77.
50$9
3.00
$31.
00$3
1.00
$31.
00$0
.00
S480
2-12
2N
M$7
7.50
$93.
00$3
1.00
$31.
00$3
1.00
$0.0
0S4
802-
125
NV
$72.
50$8
7.00
$29.
00$2
9.00
$29.
00$0
.00
S480
2-10
0N
Y$7
5.00
$90.
00$3
0.00
$30.
00$3
0.00
$0.0
0S4
802-
111
OH
$67.
50$8
1.00
$27.
00$2
7.00
$27.
00$0
.00
S480
2-11
9O
K$7
0.00
$84.
00$2
8.00
$28.
00$2
8.00
$0.0
0S4
802-
126
OR
$75.
00$9
0.00
$30.
00$3
0.00
$30.
00$0
.00
S480
2-10
3PA
Sum
mar
y of
Ben
efits
| 38
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 3
Pref
erre
d Br
and
Dru
gs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
reta
ilan
d m
ail s
ervi
cean
d pr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-n
etwo
rk)
$70.
00$8
4.00
$28.
00$2
8.00
$28.
00$0
.00
S480
2-09
9R
I$7
0.00
$84.
00$2
8.00
$28.
00$2
8.00
$0.0
0S4
802-
106
SC$8
0.00
$96.
00$3
2.00
$32.
00$3
2.00
$0.0
0S4
802-
121
SD$7
5.00
$90.
00$3
0.00
$30.
00$3
0.00
$0.0
0S4
802-
109
TN
$75.
00$9
0.00
$30.
00$3
0.00
$30.
00$0
.00
S480
2-11
8T
X$6
0.00
$72.
00$2
4.00
$24.
00$2
4.00
$0.0
0S4
802-
127
UT
$75.
00$9
0.00
$30.
00$3
0.00
$30.
00$0
.00
S480
2-10
4V
A$7
0.00
$84.
00$2
8.00
$28.
00$2
8.00
$0.0
0S4
802-
099
VT
$70.
00$8
4.00
$28.
00$2
8.00
$28.
00$0
.00
S480
2-12
6W
A$7
5.00
$90.
00$3
0.00
$30.
00$3
0.00
$0.0
0S4
802-
131
WI
$75.
00$9
0.00
$30.
00$3
0.00
$30.
00$0
.00
S480
2-10
3W
V$8
0.00
$96.
00$3
2.00
$32.
00$3
2.00
$0.0
0S4
802-
121
WY
Sum
mar
y of
Ben
efits
| 39
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 4
Non
-Pre
ferre
d D
rugs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
reta
ilan
d m
ail s
ervi
cean
d pr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-n
etwo
rk)
45%
45%
45%
45%
45%
$0.0
0S4
802-
130
AK
45%
45%
45%
45%
45%
$0.0
0S4
802-
109
AL
45%
45%
45%
45%
45%
$0.0
0S4
802-
115
AR
45%
45%
45%
45%
45%
$0.0
0S4
802-
124
AZ
45%
45%
45%
45%
45%
$0.0
0S4
802-
128
CA
45%
45%
45%
45%
45%
$0.0
0S4
802-
123
CO
45%
45%
45%
45%
45%
$0.0
0S4
802-
099
CT
45%
45%
45%
45%
45%
$0.0
0S4
802-
102
DC
45%
45%
45%
45%
45%
$0.0
0S4
802-
102
DE
45%
45%
45%
45%
45%
$0.0
0S4
802-
108
FL45
%45
%45
%45
%45
%$0
.00
S480
2-10
7G
A45
%45
%45
%45
%45
%$0
.00
S480
2-12
9H
I45
%45
%45
%45
%45
%$0
.00
S480
2-12
1IA
Sum
mar
y of
Ben
efits
| 40
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 4
Non
-Pre
ferre
d D
rugs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
reta
ilan
d m
ail s
ervi
cean
d pr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-n
etwo
rk)
45%
45%
45%
45%
45%
$0.0
0S4
802-
127
ID45
%45
%45
%45
%45
%$0
.00
S480
2-11
3IL
45%
45%
45%
45%
45%
$0.0
0S4
802-
112
IN45
%45
%45
%45
%45
%$0
.00
S480
2-12
0K
S45
%45
%45
%45
%45
%$0
.00
S480
2-11
2K
Y45
%45
%45
%45
%45
%$0
.00
S480
2-11
7LA
45%
45%
45%
45%
45%
$0.0
0S4
802-
099
MA
45%
45%
45%
45%
45%
$0.0
0S4
802-
102
MD
45%
45%
45%
45%
45%
$0.0
0S4
802-
098
ME
45%
45%
45%
45%
45%
$0.0
0S4
802-
110
MI
45%
45%
45%
45%
45%
$0.0
0S4
802-
121
MN
45%
45%
45%
45%
45%
$0.0
0S4
802-
114
MO
45%
45%
45%
45%
45%
$0.0
0S4
802-
116
MS
Sum
mar
y of
Ben
efits
| 41
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 4
Non
-Pre
ferre
d D
rugs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
reta
ilan
d m
ail s
ervi
cean
d pr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-n
etwo
rk)
45%
45%
45%
45%
45%
$0.0
0S4
802-
121
MT
45%
45%
45%
45%
45%
$0.0
0S4
802-
105
NC
45%
45%
45%
45%
45%
$0.0
0S4
802-
121
ND
45%
45%
45%
45%
45%
$0.0
0S4
802-
121
NE
45%
45%
45%
45%
45%
$0.0
0S4
802-
098
NH
45%
45%
45%
45%
45%
$0.0
0S4
802-
101
NJ
45%
45%
45%
45%
45%
$0.0
0S4
802-
122
NM
45%
45%
45%
45%
45%
$0.0
0S4
802-
125
NV
45%
45%
45%
45%
45%
$0.0
0S4
802-
100
NY
45%
45%
45%
45%
45%
$0.0
0S4
802-
111
OH
45%
45%
45%
45%
45%
$0.0
0S4
802-
119
OK
45%
45%
45%
45%
45%
$0.0
0S4
802-
126
OR
45%
45%
45%
45%
45%
$0.0
0S4
802-
103
PA
Sum
mar
y of
Ben
efits
| 42
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 4
Non
-Pre
ferre
d D
rugs
Ded
uctib
lePl
anSt
ate
90-d
ay su
pply
31-d
ay su
pply
30-d
ay su
pply
Pref
erre
d M
ail
Serv
ice C
ost-
Shar
ing
Stan
dard
Ret
ail
and
Mai
l Ser
vice
Cos
t-Sh
arin
g(in
-net
work
)
Long
-Ter
mC
are (
LTC
)C
ost-
Shar
ing
Out
-of-N
etwo
rkC
ost-
Shar
ing
Stan
dard
reta
ilan
d m
ail s
ervi
cean
d pr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-n
etwo
rk)
45%
45%
45%
45%
45%
$0.0
0S4
802-
099
RI
45%
45%
45%
45%
45%
$0.0
0S4
802-
106
SC45
%45
%45
%45
%45
%$0
.00
S480
2-12
1SD
45%
45%
45%
45%
45%
$0.0
0S4
802-
109
TN
45%
45%
45%
45%
45%
$0.0
0S4
802-
118
TX
45%
45%
45%
45%
45%
$0.0
0S4
802-
127
UT
45%
45%
45%
45%
45%
$0.0
0S4
802-
104
VA
45%
45%
45%
45%
45%
$0.0
0S4
802-
099
VT
45%
45%
45%
45%
45%
$0.0
0S4
802-
126
WA
45%
45%
45%
45%
45%
$0.0
0S4
802-
131
WI
45%
45%
45%
45%
45%
$0.0
0S4
802-
103
WV
45%
45%
45%
45%
45%
$0.0
0S4
802-
121
WY
Sum
mar
y of
Ben
efits
| 43
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 5
Spec
ialty
Tie
r Dru
gs
Ded
uctib
lePl
anSt
ate
31-d
ay su
pply
30-d
ay su
pply
Long
-Ter
m C
are
(LT
C) C
ost-
Shar
ing
Out
-of-N
etwo
rk C
ost-
Shar
ing
Stan
dard
reta
il an
dm
ail s
ervi
ce an
dpr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-n
etwo
rk)
33%
33%
33%
$0.0
0S4
802-
130
AK
33%
33%
33%
$0.0
0S4
802-
109
AL
33%
33%
33%
$0.0
0S4
802-
115
AR
33%
33%
33%
$0.0
0S4
802-
124
AZ
33%
33%
33%
$0.0
0S4
802-
128
CA
33%
33%
33%
$0.0
0S4
802-
123
CO
33%
33%
33%
$0.0
0S4
802-
099
CT
33%
33%
33%
$0.0
0S4
802-
102
DC
33%
33%
33%
$0.0
0S4
802-
102
DE
33%
33%
33%
$0.0
0S4
802-
108
FL33
%33
%33
%$0
.00
S480
2-10
7G
A33
%33
%33
%$0
.00
S480
2-12
9H
I33
%33
%33
%$0
.00
S480
2-12
1IA
Sum
mar
y of
Ben
efits
| 44
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 5
Spec
ialty
Tie
r Dru
gs
Ded
uctib
lePl
anSt
ate
31-d
ay su
pply
30-d
ay su
pply
Long
-Ter
m C
are
(LT
C) C
ost-
Shar
ing
Out
-of-N
etwo
rk C
ost-
Shar
ing
Stan
dard
reta
il an
dm
ail s
ervi
ce an
dpr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-n
etwo
rk)
33%
33%
33%
$0.0
0S4
802-
127
ID33
%33
%33
%$0
.00
S480
2-11
3IL
33%
33%
33%
$0.0
0S4
802-
112
IN33
%33
%33
%$0
.00
S480
2-12
0K
S33
%33
%33
%$0
.00
S480
2-11
2K
Y33
%33
%33
%$0
.00
S480
2-11
7LA
33%
33%
33%
$0.0
0S4
802-
099
MA
33%
33%
33%
$0.0
0S4
802-
102
MD
33%
33%
33%
$0.0
0S4
802-
098
ME
33%
33%
33%
$0.0
0S4
802-
110
MI
33%
33%
33%
$0.0
0S4
802-
121
MN
33%
33%
33%
$0.0
0S4
802-
114
MO
33%
33%
33%
$0.0
0S4
802-
116
MS
Sum
mar
y of
Ben
efits
| 45
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 5
Spec
ialty
Tie
r Dru
gs
Ded
uctib
lePl
anSt
ate
31-d
ay su
pply
30-d
ay su
pply
Long
-Ter
m C
are
(LT
C) C
ost-
Shar
ing
Out
-of-N
etwo
rk C
ost-
Shar
ing
Stan
dard
reta
il an
dm
ail s
ervi
ce an
dpr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-n
etwo
rk)
33%
33%
33%
$0.0
0S4
802-
121
MT
33%
33%
33%
$0.0
0S4
802-
105
NC
33%
33%
33%
$0.0
0S4
802-
121
ND
33%
33%
33%
$0.0
0S4
802-
121
NE
33%
33%
33%
$0.0
0S4
802-
098
NH
33%
33%
33%
$0.0
0S4
802-
101
NJ
33%
33%
33%
$0.0
0S4
802-
122
NM
33%
33%
33%
$0.0
0S4
802-
125
NV
33%
33%
33%
$0.0
0S4
802-
100
NY
33%
33%
33%
$0.0
0S4
802-
111
OH
33%
33%
33%
$0.0
0S4
802-
119
OK
33%
33%
33%
$0.0
0S4
802-
126
OR
33%
33%
33%
$0.0
0S4
802-
103
PA
Sum
mar
y of
Ben
efits
| 46
Cos
t-Sh
arin
g T
ables
for W
ellC
are E
xtra
(PD
P)T
ier 5
Spec
ialty
Tie
r Dru
gs
Ded
uctib
lePl
anSt
ate
31-d
ay su
pply
30-d
ay su
pply
Long
-Ter
m C
are
(LT
C) C
ost-
Shar
ing
Out
-of-N
etwo
rk C
ost-
Shar
ing
Stan
dard
reta
il an
dm
ail s
ervi
ce an
dpr
efer
red
mai
l ser
vice
cost-
shar
ing
(in-n
etwo
rk)
33%
33%
33%
$0.0
0S4
802-
099
RI
33%
33%
33%
$0.0
0S4
802-
106
SC33
%33
%33
%$0
.00
S480
2-12
1SD
33%
33%
33%
$0.0
0S4
802-
109
TN
33%
33%
33%
$0.0
0S4
802-
118
TX
33%
33%
33%
$0.0
0S4
802-
127
UT
33%
33%
33%
$0.0
0S4
802-
104
VA
33%
33%
33%
$0.0
0S4
802-
099
VT
33%
33%
33%
$0.0
0S4
802-
126
WA
33%
33%
33%
$0.0
0S4
802-
131
WI
33%
33%
33%
$0.0
0S4
802-
103
WV
33%
33%
33%
$0.0
0S4
802-
121
WY
Sum
mar
y of
Ben
efits
| 47
WellCare (PDP) is a Medicare-approved Part D sponsor. Enrollment in WellCare (PDP)depends on contract renewal. This information is not a complete description of benefits.Contact the plan for more information. Limitations, co-payments and restrictions mayapply. Benefits, premiums and/or co-payments/coinsurance may change on January 1 ofeach year. The formulary and/or pharmacy network may change at any time. You willreceive notice when necessary. You must continue to pay your Medicare Part B premium.You have the choice to sign up for automated mail service delivery. You can get prescriptiondrugs shipped to your home through our network mail service delivery program. You shouldexpect to receive your prescription drugs within 7–10 business days from the time that themail service pharmacy receives the order. If you do not receive your prescription drugs within this time, please contact us at1-866-892-9006 (TTY 1-866-507-6135), 24 hours a day, seven days a week, or visit www.wellcare.com/medicare/mail_order_pharmacy_coverage. WellCare uses a formulary. Pleasecontact WellCare for details.
This information is available for free in other languages. Please call our customer servicenumber at 1-888-550-5252 (TTY 1-888-816-5252), Monday-Friday, 8 a.m. to 8 p.m.Between October 1 and February 14, representatives are available Monday-Sunday, 8 a.m.to 8 p.m.Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro númerode Servicio al Cliente al 1-888-550-5252, de lunes a viernes, de 8 a.m. a 8 p.m. Entre el 1de octubre y el 14 de febrero, los representantes están disponibles de lunes a domingo de8 a.m. a 8 p.m. Los usuarios de TTY deben llamar al 1-888-816-5252.
www.wellcare.com/PDP
7629
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