2019 Medicare Part D Stand Alone Prescription Drug Plans

2019 Medicare Part D Stand Alone Prescription Drug Plans Massachusetts Updated 10/12/18- This chart is not approved by CMS Monthly Prescription Cost/Tiers Prescription Cost/Tiers Organization Name Plan Name /Plan ID # Preferred Pharmacies include: Monthly Premium Deductible Premium 30 Day Supply - Preferred PA Mail Order 90 Day Supply - Mail After Full LIS Pharmacy Aetna Medicare (1-855-338-7030) Big Y, Costco, CVS, Osco, Price Chopper, Aetna Medicare RX Select (S5810-276) $17.20 $385** $4.80 $0/$2/$47/40%/25% $0/$6/$141/40% NO www.aetnamedicare.com Wegmans Big Y, Costco, CVS, Osco, Price Chopper, Aetna Medicare RX Saver (S5810-036) $33.20 $300** $0.00 $1/$2/$30/35%/27% $3/$6/$90/35% NO Walmart, Wegmans Big Y, Costco, CVS, Osco, Price Chopper, Aetna Medicare Rx Value Plus (S5768-126 ) $58.80 $0 $22.60 $1/$2/$47/47%/33% $3/$6/$141/47% NO Walmart, Wegmans Blue MedicareRx (1-877-479-2227) Big Y, Costco, CVS, Osco, Price Chopper, Stop Blue Medicare Rx-Value Plus (S2893-001)*** $37.80 $350** $1.60 $2/$8/$35/40%/26% $2/$16/$70/40% YES www.rxmedicareplans.com & Shop, Walmart Big Y, Costco, CVS, Osco, Price Chopper, Stop Blue Medicare Rx-Premier (S2893-003)*** $127.90 $0 $91.70 $1/$7/$30/$70/33% $1/$14/$60/$140 YES & Shop, Walmart Cigna HealthSpring (1-800-735-1459) Big Y, Hannaford, Osco, Price Chopper, Cigna-HealthSpring Rx Secure-Essential (S5617-281) $21.80 $415** $7.70 $1/$3/20%/49%/25% $2/$6/20%/49% YES www.cignahealthspring.com Walgreens/Rite Aid, Walmart , Wegmans Big Y, Hannaford, Osco, Price Chopper, Cigna-HealthSpring Rx Secure-Xtra (S5617-247) $52.40 $100 $16.20 $4/$10/$42/50%/31%/$6 $10/$25/$105/50%/$15 YES Walgreens/Rite Aid, Walmart , Wegmans Big Y, Hannaford, Osco, Price Chopper, Cigna-HealthSpring Rx Secure (S5617-008) $54.70 $415 $18.50 $1/$3/$30/36%/25% $3/$9/$90/36% YES Walgreens/Rite Aid, Walmart , Wegmans

Envision Rx Plus (1-866-250-2005) EnvisionRx Plus (S7694-002) Costo, CVS, Hannaford,Osco, Stop & Shop $14.50 $365** $0.00 $1/$6/$34/37%/25% $0/$6/$102/37% YES www.envisionrxplus.com Express Scripts Medicare (866-477-5704) Express Scripts Medicare Saver (S5660-219) CVS, Walmart $24.00 $415** $5.50 $1/$4/18%/34%/25% $2/$8/ 18% NO www.express-scriptsmedicare.com Express Scripts Medicare Value (S5660-105) Walgreen's/Rite Aid $35.20 $415 $0.00 $1/$3/$26/38%/25% $2/$6/$78 NO

Express Scripts Medicare Choice (S5660-206) Walgreen's/Rite Aid $94.80 $350** $58.60 $2/$7/$42/48%/26% $0/$4/$126 NO

Humana (1-800-706-0872) Humana Walmart Rx Plan (S5884-149) Walmart $30.70 $415** $7.50 $1/$4/20%/35%/25% $0/$8/15%/35% NO www.humana-medicare.com NO PREFERRED PHARMACIES $34.80 $415 $0.00 $0/$1/25%/35%/25% $0/$0/15%/30% NO Humana Preferred Rx Plan (S5884-102) NO PREFERRED PHARMACIES $73.80 $0 $37.60 $5/$10/$47/50%/33% $0/$0/$116/44% NO Humana Enhanced (S5884-002) Mutual of Omaha ( 1-800-961-9006) CVS, CVS/Target, Sam’s Club, Walmart $26.40 $415** $5.80 $1/$4/15%/37%/25% $2/$8/18%/40%/25% www.mutualofomaharx.com Mutual of Omaha Rx Value (S7126-035) CVS, CVS/Target, Sam’s Club, Walmart $41.20 $415 $5.00 $3/$7/$34/48%/25% $8/$18/$97/48% Mutual of Omaha Rx Plus (S7126-002) SilverScript ( 1-866-552-6106) SilverScript Choice (S5601-004) Big Y, CVS,Price Chopper, Wegmans $34.20 $0 $0.00 $3/$12/$38/38%/33% $0/$30/$95/38% YES www.silverscript.com Big Y, CVS, Price Chopper, Walgreens, SilverScript Plus (S5601-005) $65.50 $0 $29.30 $1/$5/$35/40%/33% $0/$0/$87.50/40% YES Wegmans Big Y, CVS, Price Chopper, Walgreens, SilverScript Allure (S5601-144) $80.00 $0 $43.80 $1/$5/20%/40%/33% $0/$12.50/20%/40% YES Wegmans UnitedHealthcare (1-800-753-8004) YES- Set up aact AARP Medicare Rx Walgreens (S5921-385) Walgreens/ Rite Aid $28.10 $415** $20.40 $0/$5/$30/32%/25% $0/$15/$90/32%/25% www.aarpmedicarerx.com with Optum Rx Hannaford, Stop & Shop, Walgreens/Rite Aid, AARP MedicareRx Saver Plus (S5921-348) $34.90 $415 $0.00 $1/$5/$25/33%/25% $3/$15/$75/33%/25% YES- Set up aact Walmart, Wegmans (1-888-867-5564) with Optum Rx Hannaford, Stop & Shop, Walgreens/Rite Aid, $72.10 $0 $35.90 $5/$10/$40/40%/33% $0/$0/$105/40%/33% YES- Set up aact (1-888-867-5564) AARP MedicareRx Preferred (S5820-002) Walmart, Wegmans with Optum Rx WellCare (1-888-293-5151) Big Y, CVS, Price Chopper, Wegmans YES www.wellcarepdp.com WellCare Value Script (S4802-137) $14.00 $415** $14.00 $0/$8/$40/46%/25% $0/$20/$100/46% Big Y, CVS, Price Chopper, Wegmans $35.10 $415* $0.00 $0/$15/$37/41%/25% $0/$37.50/$92.50/41% YES WellCare Classic (S4802-076) Big Y, CVS, Price Chopper, Wegmans $68.20 $0 $32.00 $0/$5/$40/46%/33% $0/$12.50/$100/46% YES WellCare Extra (S4802-099) Pink highlighted basic plans have a premium below 2019 benchmark of $36.20 All plans are National except Blue Cross plans Plan copayments listed above are for preferred pharmacies where applicable. Otherwise, standard rates are shown. Contact plan for more details. *Tier 1 or **Tier 1 and 2: Medications not subject to plan deductible. Most plans have 5 tiers: preferred generic / non-preferred generic / preferred brand / non-preferred brand / specialty ***Plan has received 5 star rating from Medicare for 2019 Late enrollment penalty based on 2019 National Base Beneficiary Premium of $33.19 - (Penalty is 1% each month one did not have creditable coverage)