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Selected Plan:WellCare Simple (PDP) (S2505-005-0)
Cick on the first letter of your drug name to browse the formulary:

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2016 Medicare Part D Plan Formulary Information
WellCare Simple (PDP) (S2505-005-0)
Benefits & Contact Info           
The WellCare Simple (PDP) (S2505-005-0)
Formulary Drugs Starting with the Letter U

in CMS PDP Region 20 which includes: MS
Plan Monthly Premium: $26.80 Deductible: $360 Qualifies for LIS: Yes
Drugs Starting with Letter U

Drug Name
Drug Tier Information Cost-Sharing Drug
UCERIS 9 MG ER TABLET   5 Specialty Tier 25%N/ANone
ULORIC TABLETS 40MG 30 BOT   3 Preferred Brand $47.00$117.50S
ULORIC TABLETS 80MG 30 BOT   3 Preferred Brand $47.00$117.50S
UNITHROID 100 MCG TABLET   2 Generic $8.00$20.00None
UNITHROID 112 MCG TABLET   2 Generic $8.00$20.00None
UNITHROID 125 MCG TABLET   2 Generic $8.00$20.00None
UNITHROID 150 MCG TABLET   2 Generic $8.00$20.00None
UNITHROID 175 MCG TABLET   2 Generic $8.00$20.00None
UNITHROID 200 MCG TABLET   2 Generic $8.00$20.00None
UNITHROID 25 MCG TABLET   2 Generic $8.00$20.00None
Drug Name Tier
UNITHROID 300 MCG TABLET   2 Generic $8.00$20.00None
UNITHROID 50 MCG TABLET   2 Generic $8.00$20.00None
UNITHROID 75 MCG TABLET   2 Generic $8.00$20.00None
UNITHROID 88 MCG TABLET   2 Generic $8.00$20.00None
Ursodiol 250mg/1   4 Non-Preferred Brand 50%50%None
Ursodiol 300 MG CAPSULE   4 Non-Preferred Brand 50%50%None
Ursodiol 500mg/1   4 Non-Preferred Brand 50%50%None

Chart Legend:

What does all this mean? Below are a few notes to help you understand the above 2016 Medicare Part D WellCare Simple (PDP) Plan Formulary.

  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the the standard $360 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons wit the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.

  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.

  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on which tier the drug is in. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3310) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).

  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

    (Chart Source: Centers for Medicare and Medicaid files: CMS Data January 2016 )

    Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.