Prescriptions

Wellfleet Rx Member Information
Rx Bin Number	003858
Rx PCN	A4
Rx Group Number	WFLEET1
Member ID Number	Your member ID is on your Wellfleet ID card. Follow the instructions on this Wellfleet flyer to obtain your member ID.

Prescription Cost-Sharing (up to a 30-day supply)
	UHS Tang Pharmacy	Participating Retail Pharmacy (Outside UHS)	Non-Participating Retail Pharmacy
Tier 1 (Preferred Generics)	$0	$20 co-pay	$20 co-pay; then 50% up to $250 plus all charges in excess of the participating pharmacy’s negotiated charge
Tier 2 (Preferred Brand, High Cost Generics)	$25 co-pay	$40 co-pay	$40 co-pay; then 50% up to $250 plus all charges in excess of the participating pharmacy’s negotiated charge
Tier 3 (Non-Preferred)	$40 co-pay	$60 co-pay	$60 co-pay; then 50% up to $250 plus all charges in excess of the participating pharmacy’s negotiated charge
Specialty Medications	$75 co-pay	20%, up to $250	50% up to $250 plus all charges in excess of the participating pharmacy’s negotiated charge

Note: Outpatient prescriptions are not subject to the deductible.

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