10/7/2016
2017 North Carolina Stand-Alone Prescription Drug Plan Organizations
Beneficiary
Total Drug
Plan Premium
Organization Name/Plan Name
Deductible
Coverage During
Gap/Donut Hole
Contract ID
&
Plan ID
Aetna Life Insurance Company ~ 1-888-247-1051 ~ www.aetnamedicare.com
Aetna Medicare RX Saver (PDP) 1,2
$30.50
$350
No
S5810 - 042
Blue Cross and Blue Shield of NC ~ 1-800-661-5518 ~ www.bcbsnc.com/medicare
Blue Medicare Rx Standard (PDP)
Blue Medicare Rx Enhanced (PDP)
$67.00
$124.00
$290
$0
No
Yes
S5540 - 002
S5540 - 004
Cigna-HealthSpring Rx ~ 1-800-735-1459 (current members) ~ www.cignahealthspring.com
***CIGNA-HealthSpring Rx Secure (PDP) 1,2
***CIGNA-HealthSpring Rx Secure-Extra
(PDP) 1
$25.40
$400
No
S5617 - 217
$34.40
$50
Yes
S5617 - 253
EnvisionRxPlus ~ 1-866-250-2005 ~ www.envisionrxplus.com
EnvisionRxPlus (PDP) 1,2
$14.60
$260
No
S7694 - 008
Express Scripts Medicare ~ 1-866-477-5703 ~ www.Express-ScriptsMedicare.com
Express Scripts Medicare–Value (PDP) 1
Express Scripts Medicare–Choice (PDP)
1
$39.20
$86.40
$400
$350
No
No
S5660 - 110
S5660 - 209
First Health Part D from Coventry Health Care ~ 1-855-438-3513 ~ www.coventry-medicare.com
First Health Part D Value Plus (PDP) 1
First Health Part D Premier Plus) (PDP) 1
$39.20
$95.50
$0
$0
Yes
Yes
S5768 - 131
S5768 - 167
Humana Insurance Company ~ 1-800-706-0872 ~ www.humana-medicare.com
Humana Wal-Mart Rx Plan (PDP) 1
Humana Preferred Rx Plan (PDP) 1,2
Humana Enhanced (PDP) 1
$17.00
$25.90
$62.20
$400
$400
$0
No
No
Yes
S5884 - 154
S5884 - 133
S5884 - 066
Magellan Rx Medicare ~ 1-800-424-5870 ~ https://medicare.magellanrx.com
Magellan Rx Medicare Basic (PDP)
$41.40
$400
No
S4607-010
SilverScript ~ 1-866-362-6212 ~ www.silverscript.com
SilverScript Choice (PDP) 1,2
SilverScript Plus (PDP) 1
$29.30
$68.70
1
$0
$0
No
Yes
S5601 - 016
S5601 - 017
National Plan
For those people who are deemed eligible and approved for Extra Help, plan premium should be covered in full.
***Sanctioned Plan – Current members can remain in the plan but no new enrollments are allowed.
2
1 of 2
10/7/2016
2017 North Carolina Stand-Alone Prescription Drug Plan Organizations
Organization Name/Plan Name
Beneficiary
Total Drug
Plan
Premium
Deductible
Coverage During
Gap/Donut Hole
Contract ID
&
Plan ID
UnitedHealthcare Insurance Company ~ 1-888-867-5564 ~ www.uhcmedicaresolutions.com
AARP MedicareRx Saver Plus (PDP) 1
AARP MedicareRx Preferred (PDP) 1
AARP MedicareRx Walgreens (PDP) 1
Symphonix Value Rx (PDP) 1,2
$46.20
$69.40
$22.50
$30.10
$400
$0
$400
$400
No
No
No
No
S5921 - 353
S5820 - 007
S0522 - 053
S0522 - 010
WellCare Health Plans ~ 1-877-818-8744 ~ www.wellcarepdp.com
WellCare Classic (PDP) 1,2
WellCare Extra (PDP) 1
$29.40
$65.30
1
$400
$0
No
No
S4802 - 081
S4802 - 105
National Plan
For those people who are deemed eligible and approved for Extra Help, plan premium should be covered in full.
***Sanctioned Plan – Current members can remain in the plan but no new enrollments are allowed.
2
2 of 2