WyoBlue Prescription Drug Coverage Information & Resources
Essential PPO and Enhanced PPO plans include Part D prescription drug coverage. Part D benefits have their own deductible, cost share and yearly out-of-pocket maximum. Read on to learn more about this built-in benefit.
Part D Cost Sharing
Your Part D coverage is included with your monthly plan premium. Here is an overview of the costs you may pay throughout the year.
Drugs that are in Tiers 2 – 5 are subject to a yearly deductible, which is the amount that the member pays out-of-pocket before WyoBlue begins to pay a portion of the cost.
After the deductible is met, you will pay either a flat co-pay or a portion of the cost of the drug, which is called co-insurance, until you meet the 2026 maximum out-of-pocket cost of $2,100.
You enter the Catastrophic Coverage Stage when your out-of-pocket costs reach the $2,100 limit for the calendar year. Once you’re in the Catastrophic Coverage Stage, you’ll stay in this payment stage until the end of the calendar year and will pay nothing for covered drugs.
| Annual Deductible | Tiers | Description |
| $615 | 2 – 5 | Members pay the full cost for drugs on Tiers 2 – 5 until the $615 deductible is met. |
| Drug Tier | 30-day fill Preferred retail/Standard retail pharmacy | 100-day mail order |
| Tier 1 | $4/$9 | $0 |
| Tier 2 | $9/$14 | $22.50 |
| Tier 3 | 20% | 20% |
| Tier 4 | 35% | 35% |
| Tier 5 | 25% | 25% |
Understanding Drug Tiers
Drug tiers are groups of covered prescription drugs on the formulary. Each tier may have a different cost-sharing amount. In general, drugs on lower tiers may cost less than drugs on higher tiers. Check the Comprehensive Formulary here to see the tier for your medication and what you may pay.
| Drug Tier | Includes | Description |
| Tier 1 | Preferred Generic | A broad selection of generic drugs available at a low or no cost-sharing tier. |
| Tier 2 | Generic | Generic drugs that are not in the lowest cost-sharing tier. |
| Tier 3 | Preferred Brand | Mostly brand-name drugs, some high-cost generic drugs, and select insulins. |
| Tier 4 | Non-preferred | Brand and generic drugs that are not in a preferred tier. |
| Tier 5 | Specialty Tier | This contains high-cost generic and brand-name drugs. |
Part B and Part D formulary insulins are covered at $35 per 30-day supply, $70 per 60-day supply, and $105 per 100-day supply regardless of the cost sharing tier.
Learn more about the difference between a copay, coinsurance and deductible in the FAQ section by clicking here.
Drug Formulary, Prior Authorization, Step Therapy, and Quantity Limits
WyoBlue Advantage PPO has a comprehensive drug formulary covering over 3,000 medications. There are strict CMS guidelines over what can and cannot be included on a drug formulary. CMS does not allow Part D coverage on certain drug categories including: some pain medications, some benzodiazepines, weight loss, elective medications like for hair loss or erectile dysfunction, off-label use, and over the counter drugs.
Some covered drugs may have special rules before the plan will pay for them. These rules are used to help make sure medications are prescribed safely and appropriately and are covered according to Medicare and plan requirements
If you want to see if the prescription drugs you’re taking are covered by your plan or have a coverage rule, use our online tool or download and print the list for the respective coverage year by clicking here.
This list shows all the drugs that require prior authorization or are part of our step therapy program. If your prescription has a coverage rule, your pharmacist or prescriber may let you know that more information is needed before the drug can be covered. You can review the prior authorization and step therapy materials to understand what may be required and what options are available by clicking here.
Learn more about how prior authorizations work by clicking here.
Learn more about how step therapies work by visiting the Step Therapy Page here.
Requesting a Coverage Decision
You, your representative, or your prescriber may ask WyoBlue Advantage PPO to make a coverage decision about a prescription drug. This is also called a coverage determination. You may also request an exception, such as asking the plan to cover a drug that is not on the drug list or to waive a coverage rule when allowed by Medicare rules.
Use this form to ask for a decision about Part D prescription drug coverage. Click here to download.
Use this form if you disagree with a coverage decision and want to ask the plan to review it again. Click here to download the form.
Learn how to ask the plan to cover or share the cost of a prescription drug by visiting the Coverage Decisions page here.
Learn how to tell us about a concern related to service, quality of care, wait times, or another issue by clicking here.
Using Your WyoBlue Advantage Medicare Part B Benefits at the Pharmacy
Your WyoBlue Advantage plan includes Medicare Part A and Part B benefits. You can use your Medicare Part B medical benefits for certain drugs and supplies at a retail pharmacy or through home delivery.
Part B covers certain medically necessary drugs and supplies, such as diabetes testing supplies, continuous glucose monitors (CGMs) and blood glucose monitors (BGMs), some oral cancer drugs, nebulizer medications, and immunosuppressant drugs after certain transplants.
Just bring your WyoBlue Advantage Member ID Card to the pharmacy and show it to your pharmacist
Part B Diabetes Supplies: Up to a 100-Day Supply
Most diabetic supplies are $0 cost to you when covered under Part B. Insulin used with an insulin pump is no more than $35 per month.
- CGMs: Dexcom and FreeStyle Libre; prior authorization required; $0 cost
- BGMs and test strips: Preferred brands include Contour and Accu-Chek with no approval needed; other brands may need approval; $0 cost
- Lancets, lancet devices, and glucose control solution: $0 cost
Vaccines Covered Under Part B
You pay $0 at the pharmacy for Part B vaccines, including the flu shot each year, pneumonia shots as recommended by your doctor, and COVID-19 vaccines or boosters each season.
What Part B does not cover
Most prescription drugs are not covered under Part B. They are usually covered under Medicare Part D prescription drug coverage.
Fill your prescriptions at pharmacies nationwide
The retail pharmacy network consists of retail pharmacies that work with WyoBlue Advantage to fill covered prescriptions under your Part D plan benefit. Using a network pharmacy helps make sure your prescription claim is processed correctly.
Some pharmacies in the WyoBlue Advantage network may be preferred pharmacies. You may pay less for certain covered prescription drugs when you use a preferred pharmacy.
- Search for a network pharmacy before you fill a prescription or at the pharmacy, show your WyoBlue Advantage member ID card and ask if they are network
- Review your Evidence of Coverage for information about using out-of-network pharmacies.
To find a participating in-network pharmacy use our online tool by clicking here or download and print the list below.
Click here to download a print version of our 2027 Essential and Enhanced PPO provider and pharmacy directory or click here to download a print version of our 2027 Entrust PPO provider directory.
- Preferred pharmacies will be indicated with a (P) and Standard pharmacies will be indicated with an (S).
Did you know that your plan allows you to fill an extended days’ supply of up to 100 days at both retail and mail order pharmacies for the same cost as a 90-day supply? Talk to your doctor about writing a prescription for an extended days’ supply.
Home delivery pharmacy may be a convenient option for medications you take regularly allowing you to receive certain covered prescription drugs by mail instead of picking them up at a retail pharmacy.
You can choose to get your drugs delivered by mail through Optum pharmacy through one of the actions below.
- Call Optum Home Delivery at 1-855-205-4426. A member of the team will work with your provider to get a new prescription.
- Log into your WyoBlue Advantage secure member account by going to WyoBlueAdvantage.com/account and clicking on “Log in,” clicking on “Optum Pharmacy,” and then clicking on “My Prescriptions.” Next, find the prescription you would like to transfer to home delivery and click on “Transfer to Home Delivery.” Ask your doctor to send your prescription directly to Optum Home Delivery.
- Complete and mail the order form yourself. You can download the Home Delivery Pharmacy Form by clicking here. Mail your completed form to the address listed on the form.
Remember to allow enough time for your medication to be processed and delivered before your current supply runs out. Once Optum receives the prescription it can take up to 5 days to process the order and then 10-15 days for USPS to deliver to your home.
Need Help with Your Pharmacy Benefits?
If you have questions about your prescription drug coverage, covered medications, pharmacy options, or how to request a coverage decision, call WyoBlue Advantage Customer Service at 1-855-205-4426. TTY users call 711. Agents are available 24 hours a day, 7 days a week, 365 days a year to help.
Frequently Asked Questions
Check the Comprehensive Formulary, also called the drug list. The formulary shows covered Part D prescription drugs and may include information about drug tiers and coverage rules.
A network pharmacy is a pharmacy that works with WyoBlue Advantage to fill covered prescriptions under your plan benefits. Using a network pharmacy helps make sure your prescription claim is processed correctly.
The pharmacy network may change at any time. You will receive notice when necessary.
A preferred pharmacy is in your network and saves you money on your copays. A standard pharmacy is also in your network but has slightly higher copays.
These are coverage rules that may apply to some drugs. Prior authorization means more information may be needed before the drug is covered. Step therapy means you may need to try another covered drug first. Quantity limits mean the plan may limit how much of a drug is covered during a certain time period.
You, your representative, or your prescriber may ask for a coverage decision. You may also request an exception, such as asking the plan to cover a drug that is not on the drug list or to waive a coverage rule when allowed by Medicare rules.
If you disagree with a coverage decision, you may ask the plan to review the decision again. This is called a redetermination. Use the Request for Redetermination Form or follow the instructions provided with the coverage decision.
These terms all describe money you pay toward health care when you have a health insurance plan. A member’s final out-of-pocket cost depends on factors such as deductibles, co-insurance, and whether they receive supplemental government assistance.
- Part D Copay: A fixed amount of money you pay for a certain medication. Your plan pays the rest of the cost.
- Drugs on Tiers 1 & 2 are subject to a set copay
- Part D Coinsurance: A percentage of the cost you pay for a certain medication. Your plan pays the rest of the cost. Tiers 3, 4, and 5 are subject to coinsurance.
- Part D Annual Deductible: The amount of money you pay for care before your plan starts paying. Most Medicare Advantage plans have a prescription drug deductible. The deductible resets every calendar year. Drugs on Tiers 2-5 are subject to a deductible.
- Part D Annual Max out of pocket: This is the maximum out of pocket you will pay for your prescriptions in a calendar or plan year. This amount is determined by Medicare and resets every year. Learn more by visiting cms.gov or medicare.gov.
- In plan year 2026, the maximum out-of-pocket you will pay is $2,100
- In plan year 2027, the maximum out-of-pocket you will pay is $2,400
Each Medicare Part D has its own rules, formularies, and medical necessity criteria. You will need to have your healthcare provider submit a new prior authorization request to ensure ongoing coverage for your medications or treatments.
In the meantime, you might be eligible for a Transition Fill – see the next section for more information.
A transition fill or transition supply is a temporary supply of certain prescription medications that may be available in certain situations, such as during your first 108 days in the plan or when your drug coverage changes. This helps you avoid a gap in therapy while you and your doctor work on a long-term coverage solution.
- You can get multiple fills up to the 30-day supply within your transition period if your first fill is less than a 30-day supply.
- If you are a resident of a long-term care facility, you can receive a maximum single fill 31- day supply of a Part D drug during your transition period
The following applies to existing members who renew their Medicare coverage and are taking a Part D drug that is either:
- Removed from the formulary for the new plan year, or
- Subject to a new utilization requirement or new limitation at the beginning of the new plan year
The following applies to new members who are taking a Part D drug that is either:
- Not on the WyoBlue Comprehensive Formulary
- Subject to a utilization requirement or limitation
If you are a resident of a long-term care facility, you can receive a maximum single fill 31- day supply of a Part D drug during your transition period.
Learn more by visiting the WyoBlue Advantage Transition Policy page by clicking here or visit the Medicare.gov drug plan rules page by clicking here.
Call the WyoBlue Advantage plan customer service at 1-844-682-9966
TTY: 711, 8am – 8pm local time, Monday – Friday, with weekend hours Oct 1. – March 31.
Medicare Part B and D drug coverage does not include OTC drug items purchased at the pharmacy. Please review your Evidence of Coverage documents to determine if you have additional OTC benefits.
Filling a 100-day supply of maintenance medication offers significant benefits, including fewer pharmacy trips, greater medication adherence, and cost savings. It is the exact same copay as a 90-day supply, providing an extra 10 days of medication for free. Use this advantage at both retail and home delivery pharmacies.
Ask your prescriber or healthcare provider to write your prescriptions to allow for 100 days’ supply.
Call WyoBlue Advantage Customer Service at 1-855-205-4426. TTY users call 711.
Prescription Drug Coverage Resources
Find the pharmacy benefit documents, forms, and resources you need to understand and use your WyoBlue Advantage prescription drug coverage.
Learn how your medical and prescription drug benefits work, including costs, rights, and responsibilities by clicking here.
Learn about a program that may help members who take multiple medications manage their prescriptions by clicking here.
Understand how temporary supplies may be available when you are new to the plan or when coverage changes. Learn more by clicking here.
Learn about the Medicare Prescription Payment Program by clicking here.
Find Part B Drugs requiring Prior Authorizations by clicking here.
WyoBlue Advantage’s pharmacy network includes limited lower-cost, preferred pharmacies in Wyoming. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including whether there are any lower-cost preferred pharmacies in your area, please call 1-855-205-4426 TTY: 711 or consult the online pharmacy directory at WyoBlueAdvantage.com/pharmacies.
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