Summary of BenefitsWellCare Signature (PDP) | WellCare Classic (PDP)

Prescription Drug Plans

S5967_NA014903_PDP_SOB_ENG CMS Approved 09142011 NAPDPSOB38900_0411 ©WellCare 2011 NA_04_11_PDP

S5967

01/01/12–12/31/12

Section I – Introduction to Summary of Benefits

Summary of Benefits | 1

Thank you for your interest in WellCare Signature (PDP) and WellCare Classic (PDP). Our plans are offered by WellCare Prescription Insurance, Inc./WellCare, a Medicare Prescription Drug Plan that contracts with the federal government. This Summary of Benefits tells you some features of our plans. It doesn’t list every drug we cover, every limitation or exclusion. To get a complete list of our benefits, please call WellCare Signature (PDP) and WellCare Classic (PDP) and ask for the “Evidence of Coverage.”

You have choices in your Medicare prescription drug coverageAs a Medicare beneficiary, you can choose from different Medicare prescription drug coverage options. One option is to get prescription drug coverage through Medicare Prescription Drug Plans, like WellCare Signature (PDP) or WellCare Classic (PDP). Another option is to get your prescription drug coverage through a Medicare Advantage Plan that offers prescription drug coverage. You make the choice.

How can I compare my options?The charts in this booklet list some important drug benefits. You can use this Summary of Benefits to compare the benefits offered by WellCare Signature (PDP) and WellCare Classic (PDP) to the benefits offered by other Medicare Prescription Drug Plans or Medicare Advantage Plans with prescription drug coverage.

Where are WellCare Signature (PDP) and WellCare Classic (PDP) available?There is more than one plan listed in this Summary of Benefits. If you are enrolled in one plan and wish to switch to another plan, you may do so only during certain times of the year. Please call Customer Service for more information.

Who is eligible to join?You can join these plans if you are entitled to Medicare Part A and/or enrolled in Medicare Part B and live in the service area.

If you are enrolled in an MA coordinated care (HMO or PPO) plan or an MA PFFS plan that includes Medicare prescription drugs, you may not enroll in a PDP unless you disenroll from the HMO, PPO or MA PFFS plan.

Enrollees in a Private Fee-For-Service plan (PFFS) that does not provide Medicare prescription drug coverage, or an MA Medical Savings Account (MSA) plan, may enroll in a PDP. Enrollees in an 1876 Cost plan may enroll in a PDP.

Where can I get my prescriptions?WellCare Signature (PDP) and WellCare Classic (PDP) have formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We will not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases.

Section I – Introduction to Summary of Benefits

Summary of Benefits | 2

WellCare Signature (PDP) and WellCare Classic (PDP) have a list of preferred pharmacies. At these pharmacies, you may get your drugs at a lower co-pay or coinsurance.

A non-preferred pharmacy is still a network pharmacy, but you may have to pay more for your prescription drugs.

The pharmacies in our network can change at any time. You can ask for a Pharmacy Directory or visit us at www.wellcarepdp.com. Our Customer Service number is listed at the end of this introduction.

Does my plan cover Medicare Part B or Part D drugs?WellCare Signature (PDP) and WellCare Classic (PDP) do not cover drugs that are covered under Medicare Part B as prescribed and dispensed. Generally, we only cover drugs, vaccines, biological products and medical supplies that are covered under the Medicare Prescription Drug Benefit (Part D) and that are on our formulary.

What is a prescription drug formulary?WellCare Signature (PDP) and WellCare Classic (PDP) use a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove or make changes to coverage limitations on certain drugs, or change how much you pay for a drug. If we make any formulary change that limits our members’ ability to fill their prescriptions, we will notify the affected enrollees before the change is made. We will send a formulary to you and you can see our complete formulary on our website at www.wellcarepdp.com.

If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician’s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy.

What should I do if I have other insurance in addition to Medicare?If you have a Medigap (Medicare Supplement) policy that includes prescription drug coverage, you must contact your Medigap Issuer to let them know that you have joined a Medicare Prescription Drug Plan. If you decide to keep your current Medigap supplement policy, your Medigap Issuer will remove the prescription drug coverage portion of your policy. Call your Medigap Issuer for details.

If you or your spouse has, or is able to get, employer group coverage, you should talk to your employer to find out how your benefits will be affected if you join WellCare Signature (PDP) or WellCare Classic (PDP). Get this information before you decide to enroll in this plan.

Section I – Introduction to Summary of Benefits

Summary of Benefits | 3

How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs?You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs. To see if you qualify for getting extra help, call:

• 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day, 7 days a week and see www.medicare.gov ‘Programs for People with Limited Income and Resources’ in the publication Medicare and You

• The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778 or

• Your state Medicaid office

What are my protections in this plan?All Medicare Prescription Drug Plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue to participate with the Medicare Prescription Drug Plan Program. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Prescription Drug Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.

As a member of WellCare Signature (PDP) and WellCare Classic (PDP), you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost-utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information.

Section I – Introduction to Summary of Benefits

Summary of Benefits | 4

What is a Medication Therapy Management (MTM) program?A Medication Therapy Management (MTM) program is a free service we offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate, but it is recommended that you take full advantage of this covered service if you are selected. Contact WellCare Signature (PDP) and WellCare Classic (PDP) for more details.

Where can I find information on plan ratings?The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the Web, you may use the Web tools on www.medicare.gov and select “Health and Drug Plans” then “Compare Drug and Health Plans”to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our Customer Service number is listed below.

Please call WellCare for more information about WellCare Signature (PDP) or WellCare Classic (PDP).

Visit us at www.wellcarepdp.com or, call us:

Customer Service Hours: October 15–February 14 — 8:00 a.m. to 2:00 a.m. Eastern, 7 days a week February 15–October 14 — 8:00 a.m. to 2:00 a.m. Eastern, Monday through Friday

Current members should call toll-free and locally (888) 550-5252 (TTY/TDD (888) 816-5252).

Prospective members should call toll-free and locally (888) 293-5151 (TTY/TDD (888) 816-5252).

For more information about Medicare, please call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week. Or visit www.medicare.gov on the Web.

This document may be available in other formats such as Braille, large print or other alternate formats.

This document may be available in a non-English language. For additional information, call Customer Service at the phone number listed above.

Este documento puede estar disponible en un idioma diferente al inglés. Para información adicional, llame a Servicio al Cliente al número de teléfono indicado más arriba.

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uppl

y of

dru

gs in

thi

s

tier v

v

Plea

se re

fer t

o th

e C

o-pa

y/Pr

emiu

m T

able

aft

er t

his

sect

ion

to fi

nd o

ut t

he c

osts

in y

our a

rea.

Sum

ma

ry o

f Ben

efit

s |

9

WEL

LCA

RE S

IGN

ATU

RE (P

DP)

WEL

LCA

RE C

LASS

IC (P

DP)

ORI

GIN

AL

MED

ICA

REBE

NEF

IT

Out

patie

nt

Pres

crip

tion

Dru

gs

Tier

2: N

on-P

refe

rred

Gen

eric

Dru

gs•

$0-$

20 c

o-pa

y fo

r a o

ne-m

onth

(3

1-da

y) s

uppl

y of

dru

gs in

thi

s tie

r v

• $0

-$60

co-

pay

for a

thr

ee-

mon

th (9

3-da

y) s

uppl

y of

dru

gs

in t

his

tier v

Tier

3: P

refe

rred

Bra

nd D

rugs

• $4

0-$4

5 co

-pay

for a

one

-mon

th

(31-

day)

sup

ply

of d

rugs

in t

his

tier v

• $1

20-$

135

co-p

ay fo

r a t

hree

-m

onth

(93-

day)

sup

ply

of d

rugs

in

thi

s tie

r v

Tier

4: N

on-P

refe

rred

Bra

nd D

rugs

•$

70-$

95 c

o-pa

y fo

r a o

ne-m

onth

(3

1-da

y) s

uppl

y of

dru

gs in

thi

s tie

r v

•$

210-

$285

co-

pay

for a

thr

ee-

mon

th (9

3-da

y) s

uppl

y of

dru

gs

in t

his

tier v

Tier

2: P

refe

rred

Bra

nd D

rugs

•$

38-$

45 c

o-pa

y fo

r a o

ne-

mon

th (3

1-da

y) s

uppl

y of

dr

ugs

in t

his

tier v

• $1

14-$

135

co-p

ay fo

r a t

hree

-m

onth

(93-

day)

sup

ply

of

drug

s in

thi

s tie

r v

Tier

3: N

on-P

refe

rred

Bra

nd

Dru

gs•

$89

-$95

co-

pay

for a

one

-m

onth

(31-

day)

sup

ply

of

drug

s in

thi

s tie

r v

• $2

67-$

285

co-p

ay fo

r a t

hree

-m

onth

(93-

day)

sup

ply

of

drug

s in

thi

s tie

r v

Tier

4: S

peci

alty

Tie

r D

rugs

• 25

%-3

3% c

oins

uran

ce fo

r a

one-

mon

th (3

1-da

y) s

uppl

y

of d

rugs

in t

his

tier v

v

Plea

se re

fer t

o th

e C

o-pa

y/Pr

emiu

m T

able

aft

er t

his

sect

ion

to fi

nd o

ut t

he c

osts

in y

our a

rea.

Sum

ma

ry o

f Ben

efit

s |

10

WEL

LCA

RE S

IGN

ATU

RE (P

DP)

WEL

LCA

RE C

LASS

IC (P

DP)

ORI

GIN

AL

MED

ICA

REBE

NEF

IT

Out

patie

nt

Pres

crip

tion

Dru

gs

Tier

5: S

peci

alty

Tie

r D

rugs

• 33%

coi

nsur

ance

for a

one

-m

onth

(31-

day)

sup

ply

of d

rugs

in

thi

s tie

r

Long

-Ter

m C

are

Phar

mac

y

Tier

1: P

refe

rred

Gen

eric

Dru

gs•

$0-

$6 c

o-pa

y fo

r a o

ne-m

onth

(3

1-da

y) s

uppl

y of

dru

gs in

thi

s tie

r v

Tier

2: P

refe

rred

Bra

nd D

rugs

•$

38-$

45 c

o-pa

y fo

r a o

ne-

mon

th (3

1-da

y) s

uppl

y of

dru

gs

in t

his

tier v

Tier

3: N

on-P

refe

rred

Bra

nd

Dru

gs•

$89

-$95

co-

pay

for a

one

-m

onth

(31-

day)

sup

ply

of d

rugs

in

thi

s tie

r v

v

Plea

se re

fer t

o th

e C

o-pa

y/Pr

emiu

m T

able

aft

er t

his

sect

ion

to fi

nd o

ut t

he c

osts

in y

our a

rea.

Long

-Ter

m C

are

Phar

mac

y

Tier

1: P

refe

rred

Gen

eric

Dru

gs•

$0

co-p

ay fo

r a o

ne-m

onth

(3

1-da

y) s

uppl

y of

dru

gs in

th

is tie

r

Tier

2: N

on-P

refe

rred

Gen

eric

D

rugs

•$

0-$2

0 co

-pay

for a

one

-mon

th

(31-

day)

sup

ply

of d

rugs

in t

his

tier v

Tier

3: P

refe

rred

Bra

nd D

rugs

•$

40-$

45 c

o-pa

y fo

r a o

ne-

mon

th (3

1-da

y) s

uppl

y of

dru

gs

in t

his

tier v

Sum

ma

ry o

f Ben

efit

s |

11

WEL

LCA

RE S

IGN

ATU

RE (P

DP)

WEL

LCA

RE C

LASS

IC (P

DP)

ORI

GIN

AL

MED

ICA

REBE

NEF

IT

Out

patie

nt

Pres

crip

tion

Dru

gs

Tier

4: S

peci

alty

Tie

r D

rugs

• 25

%-3

3% c

oins

uran

ce fo

r a o

ne-

mon

th (3

1-da

y) s

uppl

y of

dru

gs

in t

his

tier v

Tier

4: N

on-P

refe

rred

Bra

nd D

rugs

•$

70-$

95 c

o-pa

y fo

r a o

ne-

mon

th (3

1-da

y) s

uppl

y of

dru

gs

in t

his

tier v

Tier

5: S

peci

alty

Tie

r D

rugs

• 33%

coi

nsur

ance

for a

one

-m

onth

(31-

day)

sup

ply

of d

rugs

in

thi

s tie

r v

Mai

l-Ord

er

Tier

1: P

refe

rred

Gen

eric

Dru

gs•

$0 c

o-pa

y fo

r a o

ne-m

onth

(3

1-da

y) s

uppl

y of

dru

gs in

thi

s tie

r fro

m a

pre

ferr

ed m

ail-

orde

r pha

rmac

y

• $0

co-

pay

for a

thr

ee-m

onth

(9

3-da

y) s

uppl

y of

dru

gs in

thi

s tie

r fro

m a

pre

ferr

ed m

ail-

orde

r pha

rmac

y

Mai

l-Ord

er

Tier

1: P

refe

rred

Gen

eric

Dru

gs•

$0-

$6 c

o-pa

y fo

r a o

ne-m

onth

(3

1-da

y) s

uppl

y of

dru

gs in

thi

s tie

r fro

m a

pre

ferr

ed m

ail-o

rder

ph

arm

acy

v

•$

0-$1

5 co

-pay

for a

thr

ee-

mon

th (9

3-da

y) s

uppl

y of

dru

gs

in t

his

tier f

rom

a p

refe

rred

m

ail-o

rder

pha

rmac

y v

v

Plea

se re

fer t

o th

e C

o-pa

y/Pr

emiu

m T

able

aft

er t

his

sect

ion

to fi

nd o

ut t

he c

osts

in y

our a

rea.

Sum

ma

ry o

f Ben

efit

s |

12

WEL

LCA

RE S

IGN

ATU

RE (P

DP)

WEL

LCA

RE C

LASS

IC (P

DP)

ORI

GIN

AL

MED

ICA

REBE

NEF

IT

Out

patie

nt

Pres

crip

tion

Dru

gs

• $0

co-

pay

for a

thr

ee-m

onth

(9

3-da

y) s

uppl

y of

dru

gs in

th

is tie

r fro

m a

non

-pre

ferr

ed

mai

l-ord

er p

harm

acy

Tier

2: N

on-P

refe

rred

Gen

eric

D

rugs

•$

0-$2

0 co

-pay

for a

one

-m

onth

(31-

day)

sup

ply

of d

rugs

in t

his

tier f

rom

a

pref

erre

d m

ail-o

rder

ph

arm

acy

v

•$

0-$5

0 co

-pay

for a

thr

ee-

mon

th (9

3-da

y) s

uppl

y of

dru

gs in

thi

s tie

r fro

m

a pr

efer

red

mai

l-ord

er

phar

mac

y v

•$

0-$6

0 co

-pay

for a

thr

ee-

mon

th (9

3-da

y) s

uppl

y of

dr

ugs

in t

his

tier f

rom

a

non-

pref

erre

d m

ail-o

rder

ph

arm

acy

v

•$

0-$1

8 co

-pay

for a

thr

ee-

mon

th (9

3-da

y) s

uppl

y of

dru

gs

in t

his

tier f

rom

a n

on-p

refe

rred

m

ail-o

rder

pha

rmac

y v

Tier

2: P

refe

rred

Bra

nd D

rugs

•$

38-$

45 c

o-pa

y fo

r a o

ne-

mon

th (3

1-da

y) s

uppl

y of

dru

gs

in t

his

tier f

rom

a p

refe

rred

mai

l-or

der p

harm

acy

v

•$

95-$

112.5

0 co

-pay

for a

thr

ee-

mon

th (9

3-da

y) s

uppl

y of

dru

gs

in t

his

tier f

rom

a p

refe

rred

mai

l-or

der p

harm

acy

v

•$

114-$

135

co-p

ay fo

r a t

hree

-m

onth

(93-

day)

sup

ply

of d

rugs

in

thi

s tie

r fro

m a

non

-pre

ferr

ed

mai

l-ord

er p

harm

acy

v

v

Plea

se re

fer t

o th

e C

o-pa

y/Pr

emiu

m T

able

aft

er t

his

sect

ion

to fi

nd o

ut t

he c

osts

in y

our a

rea.

Sum

ma

ry o

f Ben

efit

s |

13

WEL

LCA

RE S

IGN

ATU

RE (P

DP)

WEL

LCA

RE C

LASS

IC (P

DP)

ORI

GIN

AL

MED

ICA

REBE

NEF

IT

Out

patie

nt

Pres

crip

tion

Dru

gs

Tier

3: P

refe

rred

Bra

nd D

rugs

• $4

0-$4

5 co

-pay

for a

one

-m

onth

(31-

day)

sup

ply

of d

rugs

in

thi

s tie

r fro

m a

pre

ferr

ed

mai

l-ord

er p

harm

acy

v

• $1

00-$

112.5

0 co

-pay

for a

thr

ee-

mon

th (9

3-da

y) s

uppl

y of

dru

gs

in t

his

tier f

rom

a p

refe

rred

m

ail-o

rder

pha

rmac

y v

• $1

20-$

135

co-p

ay fo

r a t

hree

-m

onth

(93-

day)

sup

ply

of d

rugs

in

thi

s tie

r fro

m a

non

-pre

ferr

ed

mai

l-ord

er p

harm

acy

v

Tier

4: N

on-P

refe

rred

Bra

nd

Dru

gs•

$70-

$95

co-p

ay fo

r a o

ne-

mon

th (3

1-da

y) s

uppl

y of

dru

gs

in t

his

tier f

rom

a p

refe

rred

m

ail-o

rder

pha

rmac

y v

• $1

75-$

237.5

0 co

-pay

for a

thr

ee-

mon

th (9

3-da

y) s

uppl

y of

dru

gs

in t

his

tier f

rom

a p

refe

rred

m

ail-o

rder

pha

rmac

y v

Tier

3: N

on-P

refe

rred

Bra

nd

Dru

gs•

$89-

$95

co-p

ay fo

r a o

ne-

mon

th (3

1-da

y) s

uppl

y of

dru

gs

in t

his

tier f

rom

a p

refe

rred

m

ail-o

rder

pha

rmac

y v

• $2

22.5

0-$2

37.5

0 co

-pay

for a

th

ree-

mon

th (9

3-da

y) s

uppl

y of

dru

gs in

thi

s tie

r fro

m a

pr

efer

red

mai

l-ord

er

phar

mac

y v

• $2

67-$

285

co-p

ay fo

r a t

hree

-m

onth

(93-

day)

sup

ply

of

drug

s in

thi

s tie

r fro

m a

non

-pr

efer

red

mai

l-ord

er

phar

mac

y v

Tier

4: S

peci

alty

Tie

r D

rugs

• 25

%-3

3% c

oins

uran

ce fo

r a

one-

mon

th (3

1-da

y) s

uppl

y of

dru

gs in

thi

s tie

r fro

m a

pr

efer

red

mai

l-ord

er

phar

mac

y v

v

Plea

se re

fer t

o th

e C

o-pa

y/Pr

emiu

m T

able

aft

er t

his

sect

ion

to fi

nd o

ut t

he c

osts

in y

our a

rea.

Sum

ma

ry o

f Ben

efit

s |

14

WEL

LCA

RE S

IGN

ATU

RE (P

DP)

WEL

LCA

RE C

LASS

IC (P

DP)

ORI

GIN

AL

MED

ICA

REBE

NEF

IT

Out

patie

nt

Pres

crip

tion

Dru

gs

• $2

10-$

285

co-p

ay fo

r a t

hree

-m

onth

(93-

day)

sup

ply

of d

rugs

in

thi

s tie

r fro

m a

non

-pre

ferr

ed

mai

l-ord

er p

harm

acy

Tier

5: S

peci

alty

Tie

r D

rugs

• 33

% c

oins

uran

ce fo

r a o

ne-

mon

th (3

1-da

y) s

uppl

y of

dru

gs

in t

his

tier f

rom

a p

refe

rred

m

ail-o

rder

pha

rmac

y

• 33

% c

oins

uran

ce fo

r a o

ne-

mon

th (3

1-da

y) s

uppl

y of

dru

gs

in t

his

tier f

rom

a n

on-p

refe

rred

m

ail-o

rder

pha

rmac

y

Cov

erag

e G

apA

fter

you

r tot

al y

early

dru

g co

sts

reac

h $2

,930

, you

rece

ive

a di

scou

nt o

n br

and-

nam

e dr

ugs

an

d pa

y 86

% o

f the

pla

n’s

cost

s

for a

ll ge

neric

dru

gs u

ntil

your

ye

arly

out

-of-

pock

et d

rug

cost

s re

ach

$4,7

00.

Cov

erag

e G

apA

fter

you

r tot

al y

early

dru

g co

sts

reac

h $2

,930

, you

rece

ive

a di

scou

nt

on b

rand

-nam

e dr

ugs

and

pay

86%

of

the

pla

n’s

cost

s fo

r all

gene

ric

drug

s un

til y

our y

early

out

-of-

pock

et d

rug

cost

s re

ach

$4,7

00.

• 25

%-3

3% c

oins

uran

ce fo

r a o

ne-

mon

th (3

1-da

y) s

uppl

y of

dru

gs

in t

his

tier f

rom

a n

on-p

refe

rred

m

ail-o

rder

pha

rmac

y v

Sum

ma

ry o

f Ben

efit

s |

15

WEL

LCA

RE S

IGN

ATU

RE (P

DP)

WEL

LCA

RE C

LASS

IC (P

DP)

ORI

GIN

AL

MED

ICA

REBE

NEF

IT

Out

patie

nt

Pres

crip

tion

Dru

gs

Cat

astr

ophi

c C

over

age

Aft

er y

our y

early

out

-of-

pock

et

drug

cos

ts re

ach

$4,7

00, y

ou p

ay

the

grea

ter o

f:

• 5%

coi

nsur

ance

, or

• $2

.60

co-p

ay fo

r gen

eric

(in

clud

ing

bran

d dr

ugs

trea

ted

as g

ener

ic) a

nd a

$6.

50 c

o-pa

y fo

r all

othe

r dru

gs.

Cat

astr

ophi

c C

over

age

Aft

er y

our y

early

out

-of-

pock

et

drug

cos

ts re

ach

$4,7

00, y

ou p

ay

the

grea

ter o

f:

• 5%

coi

nsur

ance

, or

• $2

.60

co-p

ay fo

r gen

eric

(in

clud

ing

bran

d dr

ugs

trea

ted

as g

ener

ic) a

nd a

$6.

50 c

o-pa

y fo

r all

othe

r dru

gs.

Out

-of-

Net

wor

kPl

an d

rugs

may

be

cove

red

in

spec

ial c

ircum

stan

ces,

for i

nsta

nce,

ill

ness

whi

le t

rave

ling

outs

ide

of t

he p

lan’

s se

rvic

e ar

ea w

here

th

ere

is no

net

wor

k ph

arm

acy.

Yo

u m

ay h

ave

to p

ay m

ore

than

yo

ur n

orm

al c

ost-

shar

ing

amou

nt

if yo

u ge

t yo

ur d

rugs

at

an o

ut-

of-n

etw

ork

phar

mac

y. In

add

ition

, yo

u w

ill li

kely

hav

e to

pay

the

ph

arm

acy’

s fu

ll ch

arge

for t

he

drug

and

sub

mit

docu

men

tatio

n to

rece

ive

reim

burs

emen

t fr

om

Wel

lCar

e Si

gnat

ure

(PD

P).

Out

-of-

Net

wor

kPl

an d

rugs

may

be

cove

red

in

spec

ial c

ircum

stan

ces,

for i

nsta

nce,

ill

ness

whi

le t

rave

ling

outs

ide

of t

he p

lan’

s se

rvic

e ar

ea w

here

th

ere

is no

net

wor

k ph

arm

acy.

Yo

u m

ay h

ave

to p

ay m

ore

than

yo

ur n

orm

al c

ost-

shar

ing

amou

nt

if yo

u ge

t you

r dru

gs a

t an

out-

of-

netw

ork

phar

mac

y. In

add

ition

, yo

u w

ill li

kely

hav

e to

pay

the

ph

arm

acy’

s fu

ll ch

arge

for t

he

drug

and

sub

mit

docu

men

tatio

n to

rece

ive

reim

burs

emen

t fro

m

Wel

lCar

e C

lass

ic (P

DP)

.

Sum

ma

ry o

f Ben

efit

s |

16

WEL

LCA

RE S

IGN

ATU

RE (P

DP)

WEL

LCA

RE C

LASS

IC (P

DP)

ORI

GIN

AL

MED

ICA

REBE

NEF

IT

Out

patie

nt

Pres

crip

tion

Dru

gs

Out

-of-

Net

wor

k In

itial

C

over

age

You

will

be

reim

burs

ed u

p to

the

pl

an’s

cost

of t

he d

rug

min

us t

he

follo

win

g fo

r dru

gs p

urch

ased

out

-of

-net

wor

k un

til t

otal

yea

rly d

rug

cost

s re

ach

$2,9

30:

Tier

1: P

refe

rred

Gen

eric

Dru

gs•

$0 c

o-pa

y fo

r a o

ne-m

onth

(3

1-da

y) s

uppl

y of

dru

gs in

thi

s tie

r

Tier

2: N

on-P

refe

rred

Gen

eric

D

rugs

• $0

-$20

co-

pay

for a

one

-m

onth

(31-

day)

sup

ply

of d

rugs

in

thi

s tie

r v

Tier

3: P

refe

rred

Bra

nd D

rugs

• $4

0-$4

5 co

-pay

for a

one

-m

onth

(31-

day)

sup

ply

of d

rugs

in

thi

s tie

r v

Out

-of-

Net

wor

k In

itial

C

over

age

Aft

er y

ou p

ay y

our y

early

de

duct

ible

, you

will

be

reim

burs

ed

up to

the

plan

’s co

st o

f the

dru

g m

inus

the

follo

win

g fo

r dru

gs

purc

hase

d ou

t-of

-net

wor

k un

til

tota

l yea

rly d

rug

cost

s re

ach

$2,9

30:

Tier

1: P

refe

rred

Gen

eric

Dru

gs•

$0-$

6 co

-pay

for a

one

-mon

th

(31-

day)

sup

ply

of d

rugs

in t

his

tier v

Tier

2: P

refe

rred

Bra

nd D

rugs

• $3

8-$4

5 co

-pay

for a

one

-m

onth

(31-

day)

sup

ply

of d

rugs

in

thi

s tie

r v

v

Plea

se re

fer t

o th

e C

o-pa

y/Pr

emiu

m T

able

aft

er t

his

sect

ion

to fi

nd o

ut t

he c

osts

in y

our a

rea.

Sum

ma

ry o

f Ben

efit

s |

17

WEL

LCA

RE S

IGN

ATU

RE (P

DP)

WEL

LCA

RE C

LASS

IC (P

DP)

ORI

GIN

AL

MED

ICA

REBE

NEF

IT

Out

patie

nt

Pres

crip

tion

Dru

gs

v

Plea

se re

fer t

o th

e C

o-pa

y/Pr

emiu

m T

able

aft

er t

his

sect

ion

to fi

nd o

ut t

he c

osts

in y

our a

rea.

Tier

4: N

on-P

refe

rred

Bra

nd

Dru

gs•

$70-

$95

co-p

ay fo

r a o

ne-

mon

th (3

1-da

y) s

uppl

y of

dru

gs

in t

his

tier v

Tier

5: S

peci

alty

Tie

r D

rugs

• 33

% c

oins

uran

ce fo

r a o

ne-

mon

th (3

1-da

y) s

uppl

y of

dru

gs

in t

his

tier

You

will

not

be

reim

burs

ed fo

r th

e di

ffer

ence

bet

wee

n th

e ou

t-of

-net

wor

k ph

arm

acy

char

ge a

nd

the

plan

’s in

-net

wor

k al

low

able

am

ount

.

Add

ition

al O

ut-o

f-N

etw

ork

Cov

erag

e G

apYo

u w

ill b

e re

imbu

rsed

up

to 14

%

of t

he p

lan’

s al

low

able

cos

t fo

r ge

neric

dru

gs p

urch

ased

out

-of-

netw

ork

until

tot

al y

early

out

-of-

pock

et d

rug

cost

s re

ach

$4,7

00.

Add

ition

al O

ut-o

f-N

etw

ork

Cov

erag

e G

apYo

u w

ill b

e re

imbu

rsed

up

to 14

%

of t

he p

lan’

s al

low

able

cos

t fo

r ge

neric

dru

gs p

urch

ased

out

-of-

netw

ork

until

tot

al y

early

out

-of-

pock

et d

rug

cost

s re

ach

$4,7

00.

Tier

3: N

on-P

refe

rred

Bra

nd

Dru

gs•

$89-

$95

co-p

ay fo

r a o

ne-

mon

th (3

1-da

y) s

uppl

y of

dru

gs

in t

his

tier v

Tier

4: S

peci

alty

Tie

r D

rugs

• 25

%-3

3% c

oins

uran

ce fo

r a o

ne-

mon

th (3

1-da

y) s

uppl

y of

dru

gs

in t

his

tier v

You

will

not

be

reim

burs

ed fo

r the

di

ffer

ence

bet

wee

n th

e ou

t-of

- ne

twor

k ph

arm

acy

char

ge a

nd t

he

plan

’s in

-net

wor

k al

low

able

am

ount

.

Sum

ma

ry o

f Ben

efit

s |

18

WEL

LCA

RE S

IGN

ATU

RE (P

DP)

WEL

LCA

RE C

LASS

IC (P

DP)

ORI

GIN

AL

MED

ICA

REBE

NEF

IT

Out

patie

nt

Pres

crip

tion

Dru

gs

You

will

be

reim

burs

ed u

p to

the

di

scou

nted

pric

e fo

r bra

nd-n

ame

drug

s pu

rcha

sed

out-

of-n

etw

ork

until

tot

al y

early

out

-of-

pock

et d

rug

cost

s re

ach

$4,7

00.

You

will

not

be

reim

burs

ed fo

r the

di

ffer

ence

bet

wee

n th

e ou

t-of

-ne

twor

k ph

arm

acy

char

ge a

nd t

he

plan

’s in

-net

wor

k al

low

able

am

ount

.

Out

-of-

Net

wor

k C

atas

trop

hic

Cov

erag

eA

fter

you

r yea

rly o

ut-o

f-po

cket

dr

ug c

osts

reac

h $4

,700

, you

will

be

reim

burs

ed fo

r dru

gs p

urch

ased

ou

t-of

-net

wor

k up

to

the

plan

’s co

st o

f the

dru

g, m

inus

you

r cos

t-sh

are,

whi

ch is

the

gre

ater

of:

• 5%

coi

nsur

ance

, or

• $2

.60

co-p

ay fo

r gen

eric

(in

clud

ing

bran

d dr

ugs

trea

ted

as g

ener

ic) a

nd a

$6.

50 c

o-pa

y fo

r all

othe

r dru

gs.

You

will

be

reim

burs

ed u

p to

the

di

scou

nted

pric

e fo

r bra

nd-n

ame

drug

s pu

rcha

sed

out-

of-n

etw

ork

until

tot

al y

early

out

-of-

pock

et

drug

cos

ts re

ach

$4,7

00.

You

will

not

be

reim

burs

ed fo

r the

di

ffer

ence

bet

wee

n th

e ou

t-of

-ne

twor

k ph

arm

acy

char

ge a

nd t

he

plan

’s in

-net

wor

k al

low

able

am

ount

.

Out

-of-

Net

wor

k C

atas

trop

hic

Cov

erag

eA

fter

you

r yea

rly o

ut-o

f-po

cket

dr

ug c

osts

reac

h $4

,700

, you

will

be

reim

burs

ed fo

r dru

gs p

urch

ased

ou

t-of

-net

wor

k up

to

the

plan

’s co

st o

f the

dru

g, m

inus

you

r cos

t-sh

are,

whi

ch is

the

gre

ater

of:

• 5%

coi

nsur

ance

, or

• $2

.60

co-p

ay fo

r gen

eric

(in

clud

ing

bran

d dr

ugs

trea

ted

as g

ener

ic) a

nd a

$6.

50 c

o-pa

y fo

r all

othe

r dru

gs.

Sum

ma

ry o

f Ben

efit

s |

19

WEL

LCA

RE S

IGN

ATU

RE (P

DP)

WEL

LCA

RE C

LASS

IC (P

DP)

ORI

GIN

AL

MED

ICA

REBE

NEF

IT

Out

patie

nt

Pres

crip

tion

Dru

gs

You

will

not

be

reim

burs

ed fo

r th

e di

ffer

ence

bet

wee

n th

e ou

t-of

-net

wor

k ph

arm

acy

char

ge a

nd

the

plan

’s in

-net

wor

k al

low

able

am

ount

.

You

will

not

be

reim

burs

ed fo

r th

e di

ffer

ence

bet

wee

n th

e ou

t-of

-net

wor

k ph

arm

acy

char

ge a

nd

the

plan

’s in

-net

wor

k al

low

able

am

ount

.

Sum

ma

ry o

f Ben

efit

s |

20

Co-

pa

y/Pr

emiu

m T

ab

le

S596

7

Stat

eM

onth

ly

Prem

ium

Ded

uctib

leTi

er 1

(P

refe

rred

Gen

eric

)Ti

er 2

(P

refe

rred

Bra

nd)

Tier

3

(Non

-Pre

ferr

ed B

rand

)Ti

er 4

(S

peci

alty

Ti

er)

31

Day

s93

Day

sPr

efer

red

Mai

l-Ord

er

93 D

ays

31

Day

s93

Day

sPr

efer

red

Mai

l-Ord

er

93 D

ays

31

Day

s93

Day

sPr

efer

red

Mai

l-Ord

er

93 D

ays

31 D

ays

AK

$37.

00$3

20$0

$0$0

$39

$117

$97.

50$8

9$2

67$2

22.5

025

%

AL

$34.

50$3

20$0

$0$0

$42

$126

$105

$90

$270

$225

25%

AR

$33.

10$3

20$0

$0$0

$41

$123

$102

.50

$95

$285

$237

.50

25%

AZ

$26.

40$3

20$0

$0$0

$45

$135

$112

.50

$95

$285

$237

.50

25%

CA

$31.5

0$3

20$0

$0$0

$42

$126

$105

$95

$285

$237

.50

25%

CO

$34.

00$3

20$0

$0$0

$42

$126

$105

$95

$285

$237

.50

25%

CT

$33.

70$3

20$0

$0$0

$41

$123

$102

.50

$94

$282

$235

25%

DC

$34.

30$3

20$0

$0$0

$42

$126

$105

$95

$285

$237

.50

25%

DE

$34.

30$3

20$0

$0$0

$42

$126

$105

$95

$285

$237

.50

25%

FL$2

7.00

$320

$0$0

$0$3

8$1

14$9

5$9

0$2

70$2

2525

%

GA

$32.

30$3

20$0

$0$0

$41

$123

$102

.50

$92

$276

$230

25%

HI

$32.

30$0

$6$1

8$1

5$4

1$1

23$1

02.5

0$9

5$2

85$2

37.5

033

%

IA$3

9.40

$320

$0$0

$0$4

5$1

35$1

12.5

0$9

5$2

85$2

37.5

025

%

ID$4

1.00

$320

$0$0

$0$4

5$1

35$1

12.5

0$9

5$2

85$2

37.5

025

%

IL$3

1.20

$320

$0$0

$0$4

2$1

26$1

05$9

5$2

85$2

37.5

025

%

IN$3

7.10

$320

$0$0

$0$4

3$1

29$1

07.5

0$9

5$2

85$2

37.5

025

%

KS$3

7.40

$320

$0$0

$0$4

1$1

23$1

02.5

0$9

5$2

85$2

37.5

025

%

KY$3

7.10

$320

$0$0

$0$4

3$1

29$1

07.5

0$9

5$2

85$2

37.5

025

%

LA$3

6.90

$320

$0$0

$0$4

0$1

20$1

00$9

1$2

73$2

27.5

025

%

WEL

LCA

RE C

LASS

IC (P

DP)

Sum

ma

ry o

f Ben

efit

s |

21

Co-

pa

y/Pr

emiu

m T

ab

le

S596

7

Stat

eM

onth

ly

Prem

ium

Ded

uctib

leTi

er 1

(P

refe

rred

Gen

eric

)Ti

er 2

(P

refe

rred

Bra

nd)

Tier

3

(Non

-Pre

ferr

ed B

rand

)Ti

er 4

(S

peci

alty

Ti

er)

31

Day

s93

Day

sPr

efer

red

Mai

l-Ord

er

93 D

ays

31

Day

s93

Day

sPr

efer

red

Mai

l-Ord

er

93 D

ays

31

Day

s93

Day

sPr

efer

red

Mai

l-Ord

er

93 D

ays

31 D

ays

MA

$33.

70$3

20$0

$0$0

$41

$123

$102

.50

$94

$282

$235

25%

MD

$34.

30$3

20$0

$0$0

$42

$126

$105

$95

$285

$237

.50

25%

ME

$31.0

0$3

20$0

$0$0

$42

$126

$105

$94

$282

$235

25%

MI

$35.

60$3

20$0

$0$0

$45

$135

$112

.50

$95

$285

$237

.50

25%

MN

$39.

40$3

20$0

$0$0

$45

$135

$112

.50

$95

$285

$237

.50

25%

MO

$35.

30$3

20$0

$0$0

$40

$120

$100

$90

$270

$225

25%

MS

$35.

60$3

20$0

$0$0

$39

$117

$97.

50$9

0$2

70$2

2525

%

MT

$39.

40$3

20$0

$0$0

$45

$135

$112

.50

$95

$285

$237

.50

25%

NC

$35.

40$0

$5$1

5$1

2.50

$44

$132

$110

$95

$285

$237

.50

33%

ND

$39.

40$3

20$0

$0$0

$45

$135

$112

.50

$95

$285

$237

.50

25%

NE

$39.

40$3

20$0

$0$0

$45

$135

$112

.50

$95

$285

$237

.50

25%

NH

$31.0

0$3

20$0

$0$0

$42

$126

$105

$94

$282

$235

25%

NJ

$37.4

0$0

$6$1

8$1

5$4

5$1

35$1

12.5

0$9

5$2

85$2

37.5

033

%

NM

$24.

10$3

20$0

$0$0

$45

$135

$112

.50

$95

$285

$237

.50

25%

NV

$28.

40$0

$6$1

8$1

5$4

2$1

26$1

05$9

2$2

76$2

3033

%

NY

$39.

40$0

$6$1

8$1

5$4

4$1

32$1

10$9

5$2

85$2

37.5

033

%

OH

$30.

40$3

20$0

$0$0

$43

$129

$107

.50

$95

$285

$237

.50

25%

OK

$34.

60$3

20$0

$0$0

$43

$129

$107

.50

$93

$279

$232

.50

25%

OR

$36.

00$3

20$0

$0$0

$44

$132

$110

$95

$285

$237

.50

25%

WEL

LCA

RE C

LASS

IC (P

DP)

Sum

ma

ry o

f Ben

efit

s |

22

Co-

pa

y/Pr

emiu

m T

ab

le

S596

7

Stat

eM

onth

ly

Prem

ium

Ded

uctib

leTi

er 1

(P

refe

rred

Gen

eric

)Ti

er 2

(P

refe

rred

Bra

nd)

Tier

3

(Non

-Pre

ferr

ed B

rand

)Ti

er 4

(S

peci

alty

Ti

er)

31

Day

s93

Day

sPr

efer

red

Mai

l-Ord

er

93 D

ays

31

Day

s93

Day

sPr

efer

red

Mai

l-Ord

er

93 D

ays

31

Day

s93

Day

sPr

efer

red

Mai

l-Ord

er

93 D

ays

31 D

ays

PA$3

4.90

$320

$0$0

$0$4

0$1

20$1

00$9

2$2

76$2

3025

%

RI$3

3.70

$320

$0$0

$0$4

1$1

23$1

02.5

0$9

4$2

82$2

3525

%

SC$3

9.60

$320

$0$0

$0$4

0$1

20$1

00$9

0$2

70$2

2525

%

SD$3

9.40

$320

$0$0

$0$4

5$1

35$1

12.5

0$9

5$2

85$2

37.5

025

%

TN$3

4.50

$320

$0$0

$0$4

2$1

26$1

05$9

0$2

70$2

2525

%

TX$3

0.70

$320

$0$0

$0$4

5$1

35$1

12.5

0$9

5$2

85$2

37.5

025

%

UT

$41.0

0$3

20$0

$0$0

$45

$135

$112

.50

$95

$285

$237

.50

25%

VA$3

3.20

$320

$0$0

$0$4

1$1

23$1

02.5

0$9

1$2

73$2

27.5

025

%

VT

$33.

70$3

20$0

$0$0

$41

$123

$102

.50

$94

$282

$235

25%

WA

$36.

00$3

20$0

$0$0

$44

$132

$110

$95

$285

$237

.50

25%

WV

$34.

90$3

20$0

$0$0

$40

$120

$100

$92

$276

$230

25%

WY

$39.

40$3

20$0

$0$0

$45

$135

$112

.50

$95

$285

$237

.50

25%

WEL

LCA

RE C

LASS

IC (P

DP)

Sum

ma

ry o

f Ben

efit

s |

23

S596

7

Stat

eM

onth

ly

Prem

ium

Tier

1

(Pre

ferr

ed

Gen

eric

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Tier

2

(Non

-Pre

ferr

ed G

ener

ic)

Tier

3

(Pre

ferr

ed B

rand

)Ti

er 4

(N

on-P

refe

rred

Bra

nd)

Tier

5

(Spe

cial

ty

Tier

)

31 D

ays

and

93

Day

s31

Day

s93

Day

sPr

efer

red

Mai

l-Ord

er

93 D

ays

31 D

ays

93 D

ays

Pref

erre

d M

ail-O

rder

93

Day

s31

Day

s93

Day

sPr

efer

red

Mai

l-Ord

er

93 D

ays

31 D

ays

Co-

pa

y/Pr

emiu

m T

ab

le

AK

$60.

00

$0$2

0$6

0$5

0$4

5$1

35$1

12.5

0$8

5$2

55$2

12.5

033

%

AL

$65.

90$0

$20

$60

$50

$45

$135

$112

.50

$85

$255

$212

.50

33%

AR

$63.

80$0

$20

$60

$50

$45

$135

$112

.50

$85

$255

$212

.50

33%

AZ

$55.

50$0

$20

$60

$50

$45

$135

$112

.50

$95

$285

$237

.50

33%

CA

$55.

40$0

$20

$60

$50

$45

$135

$112

.50

$90

$270

$225

33%

CO

$65.

10$0

$20

$60

$50

$45

$135

$112

.50

$90

$270

$225

33%

CT

$55.

90$0

$20

$60

$50

$45

$135

$112

.50

$90

$270

$225

33%

DC

$56.

40$0

$20

$60

$50

$45

$135

$112

.50

$90

$270

$225

33%

DE

$56.

40$0

$20

$60

$50

$45

$135

$112

.50

$90

$270

$225

33%

FL$5

5.00

$0$2

0$6

0$5

0$4

5$1

35$1

12.5

0$8

5$2

55$2

12.5

033

%

GA

$61.9

0$0

$20

$60

$50

$45

$135

$112

.50

$85

$255

$212

.50

33%

HI

$65.

90$0

$0$0

$0$4

0$1

20$1

00$7

0$2

10$1

7533

%

IA$7

2.00

$0

$20

$60

$50

$45

$135

$112

.50

$95

$285

$237

.50

33%

ID$7

8.20

$0$2

0$6

0$5

0$4

5$1

35$1

12.5

0$9

5$2

85$2

37.5

033

%

IL$6

0.00

$0

$20

$60

$50

$45

$135

$112

.50

$90

$270

$225

33%

IN$6

8.60

$0

$20

$60

$50

$45

$135

$112

.50

$90

$270

$225

33%

KS$6

6.00

$0

$20

$60

$50

$45

$135

$112

.50

$85

$255

$212

.50

33%

KY$6

8.60

$0

$20

$60

$50

$45

$135

$112

.50

$90

$270

$225

33%

LA$6

5.40

$0

$20

$60

$50

$45

$135

$112

.50

$85

$255

$212

.50

33%

MA

$55.

90

$0$2

0$6

0$5

0$4

5$1

35$1

12.5

0$9

0$2

70$2

2533

%

WEL

LCA

RE S

IGN

ATU

RE (P

DP)

Sum

ma

ry o

f Ben

efit

s |

24

S596

7

Stat

eM

onth

ly

Prem

ium

Tier

1

(Pre

ferr

ed

Gen

eric

)

Tier

2

(Non

-Pre

ferr

ed G

ener

ic)

Tier

3

(Pre

ferr

ed B

rand

)Ti

er 4

(N

on-P

refe

rred

Bra

nd)

Tier

5

(Spe

cial

ty

Tier

)

31 D

ays

and

93

Day

s31

Day

s93

Day

sPr

efer

red

Mai

l-Ord

er

93 D

ays

31 D

ays

93 D

ays

Pref

erre

d M

ail-O

rder

93

Day

s31

Day

s93

Day

sPr

efer

red

Mai

l-Ord

er

93 D

ays

31 D

ays

Co-

pa

y/Pr

emiu

m T

ab

le

WEL

LCA

RE S

IGN

ATU

RE (P

DP)

MD

$56.

40

$0$2

0$6

0$5

0$4

5$1

35$1

12.5

0$9

0$2

70$2

2533

%

ME

$45.

60$0

$20

$60

$50

$45

$135

$112

.50

$90

$270

$225

33%

MI

$58.

50

$0$2

0$6

0$5

0$4

5$1

35$1

12.5

0$9

5$2

85$2

37.5

033

%

MN

$72.

00$0

$20

$60

$50

$45

$135

$112

.50

$95

$285

$237

.50

33%

MO

$66.

50$0

$20

$60

$50

$45

$135

$112

.50

$85

$255

$212

.50

33%

MS

$71.9

0$0

$20

$60

$50

$45

$135

$112

.50

$85

$255

$212

.50

33%

MT

$72.

00$0

$20

$60

$50

$45

$135

$112

.50

$95

$285

$237

.50

33%

NC

$74.

40$0

$0$0

$0$4

0$1

20$1

00$7

0$2

10$1

7533

%

ND

$72.

00$0

$20

$60

$50

$45

$135

$112

.50

$95

$285

$237

.50

33%

NE

$72.

00$0

$20

$60

$50

$45

$135

$112

.50

$95

$285

$237

.50

33%

NH

$45.

60$0

$20

$60

$50

$45

$135

$112

.50

$90

$270

$225

33%

NJ

$67.

50$0

$0$0

$0$4

0$1

20$1

00$7

0$2

10$1

7533

%

NM

$48.

00$0

$20

$60

$50

$45

$135

$112

.50

$95

$285

$237

.50

33%

NV

$64.

30$0

$0$0

$0$4

0$1

20$1

00$7

0$2

10$1

7533

%

NY

$65.

90$0

$0$0

$0$4

0$1

20$1

00$7

0$2

10$1

7533

%

OH

$57.

00$0

$20

$60

$50

$45

$135

$112

.50

$85

$255

$212

.50

33%

OK

$69.

20$0

$20

$60

$50

$45

$135

$112

.50

$90

$270

$225

33%

OR

$70.

90$0

$20

$60

$50

$45

$135

$112

.50

$95

$285

$237

.50

33%

PA$5

8.80

$0$2

0$6

0$5

0$4

5$1

35$1

12.5

0$8

5$2

55$2

12.5

033

%

RI$5

5.90

$0$2

0$6

0$5

0$4

5$1

35$1

12.5

0$9

0$2

70$2

2533

%

Sum

ma

ry o

f Ben

efit

s |

25

S596

7

Stat

eM

onth

ly

Prem

ium

Tier

1

(Pre

ferr

ed

Gen

eric

)

Tier

2

(Non

-Pre

ferr

ed G

ener

ic)

Tier

3

(Pre

ferr

ed B

rand

)Ti

er 4

(N

on-P

refe

rred

Bra

nd)

Tier

5

(Spe

cial

ty

Tier

)

31 D

ays

and

93

Day

s31

Day

s93

Day

sPr

efer

red

Mai

l-Ord

er

93 D

ays

31 D

ays

93 D

ays

Pref

erre

d M

ail-O

rder

93

Day

s31

Day

s93

Day

sPr

efer

red

Mai

l-Ord

er

93 D

ays

31 D

ays

Co-

pa

y/Pr

emiu

m T

ab

le

SC$6

3.80

$0$2

0$6

0$5

0$4

5$1

35$1

12.5

0$8

5$2

55$2

12.5

033

%

SD$7

2.00

$0$2

0$6

0$5

0$4

5$1

35$1

12.5

0$9

5$2

85$2

37.5

033

%

TN$6

5.90

$0$2

0$6

0$5

0$4

5$1

35$1

12.5

0$8

5$2

55$2

12.5

033

%

TX$6

0.30

$0$2

0$6

0$5

0$4

5$1

35$1

12.5

0$9

5$2

85$2

37.5

033

%

UT

$78.

20$0

$20

$60

$50

$45

$135

$112

.50

$95

$285

$237

.50

33%

VA$6

2.00

$0$2

0$6

0$5

0$4

5$1

35$1

12.5

0$8

5$2

55$2

12.5

033

%

VT

$55.

90$0

$20

$60

$50

$45

$135

$112

.50

$90

$270

$225

33%

WA

$70.

90$0

$20

$60

$50

$45

$135

$112

.50

$95

$285

$237

.50

33%

WV

$58.

80$0

$20

$60

$50

$45

$135

$112

.50

$85

$255

$212

.50

33%

WY

$72.

00$0

$20

$60

$50

$45

$135

$112

.50

$95

$285

$237

.50

33%

WEL

LCA

RE S

IGN

ATU

RE (P

DP)

1-888-293-5151 | TTY: 1-888-816-5252Hours of operation are Monday–Sunday,

8 a.m. to 2 a.m. Eastern. Between 2/15/12 and 10/14/12, representatives are available Monday–Friday, 8 a.m. to 2 a.m. Eastern.

Or visit us anytime at www.wellcarepdp.com.

3890

0