Ask your coverage questions weekdays from 8 a.m. to 5 p.m. CT.
The coverage gap (also called the "donut hole") begins after your total yearly drug costs (including what our plan has paid and what you have paid) reach $4,430. Not everyone will enter the coverage gap, but if you do, the chart below explains what you'll pay.
Unless otherwise noted, copay and coinsurance amounts shown below are what you pay for a 30-day supply.
Please refer to the Summary of Benefits and Evidence of Coverage listed below each column for complete plan details.
Multi-Language Insert
Multi-language Interpreter Services
| WPS MedicareRx Plan 1 | WPS MedicareRx Plan 2 | |||
|---|---|---|---|---|
| Monthly premium | $85.30 | $133.30 | ||
| Annual deductible | $480 | $0 | ||
| Preferred Retail Rx 30-day supply | Standard Retail Rx 30-day supply |
Preferred Retail Rx 30-day supply |
Standard Retail Rx 30-day supply |
|
| Tier 1 Preferred generic drugs |
$3 | $8 | $0 | $5 |
| Tier 2 Generic drugs |
$15 | $20 | $11 | $16 |
| Tier 3 Preferred brand drugs |
$42 | $47 | $42 | $47 |
| Tier 4 Non-preferred drugs |
49% | 50% | 45% | 50% |
| Tier 5 Specialty drugs |
25% | 33% | ||
| Initial coverage limit | $4,430 | $4,430 | ||
| Coverage Gap | You pay 25% for all generics, for all others you pay 25% (after a 70% manufacturer discount and a 5% plan payment on covered brand drugs) | For preferred generics you pay $0 for Preferred Retail and $5 for Standard Retail. For non-preferred generics you pay $11 for Preferred Retail and $16 for Standard Retail. For all other generic drugs you pay 25%. For all brand drugs, you pay no more than 25% (after a 70% manufacturer discount and a 5% plan payment on covered brand drugs) | ||
| Catastrophic coverage (After your yearly out-of-pocket costs reach $7,050) |
The greater of $3.95 for generics* and $9.85 for all others, or 5%. | The greater of $3.95 for generics* and $9.85 for all others, or 5%. | ||
| State and national pharmacy network | Yes | Yes | ||
| Mail-order drugs (90-day supply) |
2.5 times a 30-day copay** | 2.5 times a 30-day copay** | ||
*Including covered brand-name drugs treated as generic.
**When you use our network mail-order pharmacy.
This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year.
The formulary and/or pharmacy network may change at any time. You will receive notice when necessary.
You must continue to pay your Medicare Part B premium.
