What is Covered by Medicare Part D Drug Programs?

All NYS plans are required to cover a wide array of prescription medications that Medicare beneficiaries use, including those in a number of "protected classes."  For example, those used to treat HIV/AIDS and cancer. 

Every plan has its own formulary, which is a list of the medications that are covered by the plan. Numerous plans categorize their formularies of medications into various "tiers" or levels. Each tier of drugs has a distinct price. For instance, you will often pay less for a medicine in a lower tier than one in a higher tier.

• Tier 1 (Preferred Generic Drugs) includes preferred generic drugs and may include some brand drugs.
  • Preferred copayment range: $3 - $18
  • Standard copayment: $19

• Tier 2 (Generic Drugs) includes generic drugs and may include some brand drugs.
  • Preferred copayment range: $15 - $19
  • Standard copayment: $20

• Tier 3 (Preferred Brand) includes preferred brand drugs and may include some generic drugs.
  You won’t pay more than $35 for a one-month supply of each covered insulin product on this tier. If the tier cost-sharing is lower than $35, you will pay the lower cost for your insulin.
  
  • Preferred Coinsurance range: 19% - 24%
  • Standard Coinsurance range: 19% - 25%

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  • Tier 4 (Non-Preferred Drugs) includes non-preferred brand and non-preferred generic drugs.
    You won’t pay more than $35 for a one-month supply of each covered insulin product on this tier. If the tier cost-sharing is lower than $35, you will pay the lower cost for your insulin.
    
    • Preferred Copayment/Coinsurance range: $100 / 34% - 48%
    • Standard Copayment/Coinsurance range: $100 / 34% - 48%

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  • Tier 5 (Specialty Tier) includes high cost brand and generic drugs. Drugs in this tier are not eligible for exceptions for payment at a lower tier.
    • Preferred coinsurance: 25%
    • Standard coinsurance: 25%

• Our Medicare Advantage Plans are designed to help our members live better, healthier lives. You’re our critical partner in helping our future members understand all we have to offer and how they can take advantage of all of their benefits.

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• The Healthy Food Program engages food-insecure members by encouraging healthy food purchases in-store and online, with no prior authorization or referral needed. Members will automatically receive a prepaid card used to buy healthy foods at certain retailers and the available funds ($25 or $50, varying by plan) will replenish each month. (Note: Any unused funds will not carry over into the next month).

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• Healthy Foods Benefits and $0 Rx copays are just one way our Medicare Advantage plans and supplemental benefits support our member’s whole health. More plan and benefit information is available in your other sales materials, including the Portfolios At A Glance and the Benefit Highlights.  You can also explore our other supplemental benefit videos to learn more about how Wellcare goes beyond healthcare benefits to help our members live fuller lives.