Prescription Drug Formulary

The Wellpoint Medicare Prescription Drug Formulary provides members with comprehensive access to affordable medications across multiple therapeutic categories. Drug tiers help determine how much you pay for your prescriptions, and additional limits such as Prior Authorization (PA), Step Therapy (ST), and Quantity Limits (QL) may apply.

Cost-Sharing Overview (30-Day Supply)

• Tier 1 — Preferred Generic: $0 preferred pharmacy / $0 standard pharmacy
• Tier 2 — Generic: $0 preferred pharmacy / $10 standard pharmacy
• Tier 3 — Preferred Brand:
  • 20% preferred pharmacy
  • 25% standard pharmacy
  • Covered insulin products: no more than $30 per month
• Tier 4 — Non-Preferred Drug:
  • 25% preferred & standard pharmacy
• Tier 5 — Specialty Tier:
  • 29% preferred & standard pharmacy
• Tier 6 — Select Care Drugs: $0 at all pharmacies

Please refer to the Evidence of Coverage for full details. Medication costs may vary if you qualify for Medicare’s Low-Income Subsidy (Extra Help).

Understanding Requirements & Limits

• QL – Quantity Limits: Restricts how much medication you can receive each fill.
• PA – Prior Authorization: Approval required from the plan before certain drugs are covered.
• ST – Step Therapy: You must try one or more preferred drugs before others are covered.
• B/D PA – Part B vs. Part D: Drug may fall under medical or prescription benefits.
• NEDS – Non-Extended Day Supply: Only available in 30-day fills.
• MO – Mail Order: Delivered directly to your home (allow up to 14 days).