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WellCare Signature (S5967-061-0)
Tier 1 (1666)
Tier 2 (652)
Tier 3 (264)
Tier 4 (136)

Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2009 Medicare Part D Plan Formulary Information
WellCare Signature (S5967-061-0)
Sanctioned Plan  
The WellCare Signature (S5967-061-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 27 which includes: CO
Drugs Starting with Letter A

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
ABILIFY 10MG TABLET   3 Tier 3 $79.00$237.00P Q:31
/31Days
ABILIFY 15MG TABLET   3 Tier 3 $79.00$237.00P Q:31
/31Days
ABILIFY 1MG/ML SOLUTION   3 Tier 3 $79.00$237.00P Q:960
/31Days
ABILIFY 20MG TABLET   3 Tier 3 $79.00$237.00P Q:31
/31Days
ABILIFY 2MG TABLET   3 Tier 3 $79.00$237.00P Q:31
/31Days
ABILIFY 30MG TABLET   3 Tier 3 $79.00$237.00P Q:31
/31Days
ABILIFY 5MG TABLET (OTSUKA)   3 Tier 3 $79.00$237.00P Q:31
/31Days
ABILIFY DISCMELT 10MG TABLET   3 Tier 3 $79.00$237.00P Q:93
/31Days
ABILIFY DISCMELT 15MG TABLET   3 Tier 3 $79.00$237.00P Q:62
/31Days
ABILIFY INJ 9.75MG   3 Tier 3 $79.00$237.00P Q:121
/31Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACARBOSE 100MG TABLET S   1 Tier 1 $0.00$0.00None
ACARBOSE 25MG TABLET S   1 Tier 1 $0.00$0.00None
ACARBOSE 50MG TABLET S   1 Tier 1 $0.00$0.00None
ACCOLATE 10MG TABLET   2 Tier 2 $39.00$117.00P
ACCOLATE 20MG TABLET   2 Tier 2 $39.00$117.00P
ACEBUTOLOL 200MG CAPSULE   1 Tier 1 $0.00$0.00None
ACEBUTOLOL 400MG CAPSULE   1 Tier 1 $0.00$0.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-15MG (1000 CT)   1 Tier 1 $0.00$0.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Tier 1 $0.00$0.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Tier 1 $0.00$0.00Q:248
/31Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Tier 1 $0.00$0.00Q:248
/31Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Tier 1 $0.00$0.00None
ACETAMINOPHEN/COD SOLUTION   1 Tier 1 $0.00$0.00None
ACETAZOLAMIDE 125MG TABLET   1 Tier 1 $0.00$0.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Tier 1 $0.00$0.00None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 Tier 1 $0.00$0.00None
ACETIC ACID 2% SOLUTION NON-ORAL   1 Tier 1 $0.00$0.00None
ACETIC ACID-HYDROCORTISONE 2%-1% DROPS   1 Tier 1 $0.00$0.00None
ACETYLCYSTEINE 10% VIAL   1 Tier 1 $0.00$0.00None
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Tier 1 $0.00$0.00None
ACTHIB VACCINE VIAL 10-24UNT/5ML   2 Tier 2 $39.00$117.00None
ACTICIN 5% CREAM   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   4 Tier 4 33%33%P
ACTONEL 150MG TABLET   3 Tier 3 $79.00$237.00P
ACTONEL 30MG TABLET   3 Tier 3 $79.00$237.00P
ACTONEL 35MG TABLET   3 Tier 3 $79.00$237.00P
ACTONEL 5MG TABLET   3 Tier 3 $79.00$237.00P
ACTONEL 75MG TABLET   3 Tier 3 $79.00$237.00P
ACTONEL WITH CALCIUM TABLET   3 Tier 3 $79.00$237.00P
ACTOPLUS MET 15MG/500MG TABLET   3 Tier 3 $79.00$237.00None
ACTOPLUS MET 15MG/850MG TABLET   3 Tier 3 $79.00$237.00None
ACTOS 15MG TABLET   3 Tier 3 $79.00$237.00None
ACTOS 30MG TABLET (500 CT)   3 Tier 3 $79.00$237.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTOS 45MG TABLET   3 Tier 3 $79.00$237.00None
ACULAR 0.5% EYE DROPS   2 Tier 2 $39.00$117.00None
ACULAR LS 0.4% OPHTH SOL   2 Tier 2 $39.00$117.00None
ACULAR PF 0.5% EYE DROPS   2 Tier 2 $39.00$117.00None
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Tier 1 $0.00$0.00None
ACYCLOVIR 200MG/5ML SUSP   1 Tier 1 $0.00$0.00None
ACYCLOVIR 400MG TABLET (100 CT)   1 Tier 1 $0.00$0.00None
ACYCLOVIR SOD 50MG/ML VIAL   1 Tier 1 $0.00$0.00None
ACYCLOVIR SODIUM 1GM VIAL   1 Tier 1 $0.00$0.00None
ACYCLOVIR SODIUM 500MG VIAL   1 Tier 1 $0.00$0.00None
ACYCLOVIR TABLET USP 800MG (100 CT)   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADACEL VIAL 2UNT/5UNT   2 Tier 2 $39.00$117.00None
ADAGEN 250U/ML VIAL   4 Tier 4 33%33%P
ADVAIR DISKU MIS 100/50   2 Tier 2 $39.00$117.00None
ADVAIR DISKU MIS 250/50   2 Tier 2 $39.00$117.00None
ADVAIR DISKU MIS 500/50   2 Tier 2 $39.00$117.00None
ADVAIR HFA 115/21MCG INHALER   2 Tier 2 $39.00$117.00None
ADVAIR HFA 230/21MCG INHALER   2 Tier 2 $39.00$117.00None
ADVAIR HFA 45/21MCG INHALER   2 Tier 2 $39.00$117.00None
AFINITOR TABLETS   4 Tier 4 33%33%P
AFINITOR TABLETS 5 MG   4 Tier 4 33%33%P
AGGRENOX 25-200MG CAPSULE   3 Tier 3 $79.00$237.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBENZA 200MG TABLET   2 Tier 2 $39.00$117.00None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER   1 Tier 1 $0.00$0.00P
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER   1 Tier 1 $0.00$0.00P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 Tier 1 $0.00$0.00None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Tier 1 $0.00$0.00None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Tier 1 $0.00$0.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Tier 1 $0.00$0.00None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Tier 1 $0.00$0.00None
ALBUTEROL TABLET 4MG (500 CT)   1 Tier 1 $0.00$0.00None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Tier 1 $0.00$0.00None
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALCOHOL ANTISEPTIC PADS   1 Tier 1 $0.00$0.00None
ALDARA 5% CREAM   2 Tier 2 $39.00$117.00P
ALDURAZYME 2.9MG/5ML VIAL   4 Tier 4 33%33%P
ALENDRONATE SODIUM 10MG TABLET   1 Tier 1 $0.00$0.00None
ALENDRONATE SODIUM 40MG TABLET   1 Tier 1 $0.00$0.00None
ALENDRONATE SODIUM 5MG TABLET   1 Tier 1 $0.00$0.00None
ALENDRONATE SODIUM 70MG TABLET 4 BLPK   1 Tier 1 $0.00$0.00None
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Tier 1 $0.00$0.00None
ALLOPURINOL TABLET 300MG (1000 CT)   1 Tier 1 $0.00$0.00None
ALLOPURINOL TABLET USP 100MG (1000 CT)   1 Tier 1 $0.00$0.00None
ALOCRIL 2% EYE DROPS   2 Tier 2 $39.00$117.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALPHAGAN P 0.1% DROPS   1 Tier 1 $0.00$0.00None
ALPHAGAN P 0.15% EYE DROPS   1 Tier 1 $0.00$0.00None
AMANTADINE 100MG CAPSULE   1 Tier 1 $0.00$0.00None
AMANTADINE 100MG TABLET   1 Tier 1 $0.00$0.00None
AMCINONIDE 0.1% CREAM   1 Tier 1 $0.00$0.00None
AMCINONIDE 0.1% LOTION   1 Tier 1 $0.00$0.00None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Tier 1 $0.00$0.00None
AMIKACIN 250MG/ML VIAL   1 Tier 1 $0.00$0.00None
AMIKACIN 50MG/ML VIAL   1 Tier 1 $0.00$0.00None
AMILORIDE HCL 5MG TABLET   1 Tier 1 $0.00$0.00None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINESS 5.2% IV SOLUTION   2 Tier 2 $39.00$117.00None
AMINOPHYLLINE 100MG TABLET (100 CT)   1 Tier 1 $0.00$0.00None
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Tier 1 $0.00$0.00None
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   1 Tier 1 $0.00$0.00None
AMINOSYN 10% IV SOLUTION   2 Tier 2 $39.00$117.00None
AMINOSYN 3.5% IV SOLUTION   2 Tier 2 $39.00$117.00None
AMINOSYN 5% IV SOLUTION   2 Tier 2 $39.00$117.00None
AMINOSYN 7% IV SOLUTION   2 Tier 2 $39.00$117.00None
AMINOSYN 7%-ELECTROLYTE SOL   2 Tier 2 $39.00$117.00None
AMINOSYN 8.5% IV SOLUTION   2 Tier 2 $39.00$117.00None
AMINOSYN II 10% IV SOLUTION   2 Tier 2 $39.00$117.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 15% IV SOLUTION   2 Tier 2 $39.00$117.00None
AMINOSYN II 3.5% IN D25W IV   2 Tier 2 $39.00$117.00None
AMINOSYN II 3.5% IN D5W IV   2 Tier 2 $39.00$117.00None
AMINOSYN II 3.5% M/D5W IV   2 Tier 2 $39.00$117.00None
AMINOSYN II 3.5% W/ELEC DEX   2 Tier 2 $39.00$117.00None
AMINOSYN II 4.25% IN D10W   2 Tier 2 $39.00$117.00None
AMINOSYN II 4.25% IN D20W   2 Tier 2 $39.00$117.00None
AMINOSYN II 4.25% M/D10W IV   2 Tier 2 $39.00$117.00None
AMINOSYN II 4.25% W/ELEC DW   2 Tier 2 $39.00$117.00None
AMINOSYN II 4.25%-D25W IV   2 Tier 2 $39.00$117.00None
AMINOSYN II 5% IN D25W IV   2 Tier 2 $39.00$117.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 7% IV SOLUTION   2 Tier 2 $39.00$117.00None
AMINOSYN II 8.5% ELECTROLYT   2 Tier 2 $39.00$117.00None
AMINOSYN II 8.5% IV SOLUTION   2 Tier 2 $39.00$117.00None
AMINOSYN M 3.5% IV SOLUTION   2 Tier 2 $39.00$117.00None
AMINOSYN PF INJECTION   2 Tier 2 $39.00$117.00None
AMINOSYN-HBC 7% IV SOLUTION   2 Tier 2 $39.00$117.00None
AMINOSYN-HF 8% IV SOLUTION   2 Tier 2 $39.00$117.00None
AMINOSYN-PF 7% IV SOLUTION   2 Tier 2 $39.00$117.00None
AMIODARONE HCL 200MG TABLET (60 CT)   1 Tier 1 $0.00$0.00None
AMIODARONE HCL 400MG TABLET   1 Tier 1 $0.00$0.00None
AMIODARONE HCL INJECTION   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIP/CDP 25-10 TABLET   1 Tier 1 $0.00$0.00None
AMITRIP/PERPHEN 10-2 TABLET   1 Tier 1 $0.00$0.00None
AMITRIP/PERPHEN 10-4 TABLET   1 Tier 1 $0.00$0.00None
AMITRIP/PERPHEN 25-2 TABLET   1 Tier 1 $0.00$0.00None
AMITRIP/PERPHEN 25-4 TABLET   1 Tier 1 $0.00$0.00None
AMITRIP/PERPHEN 50-4 TABLET   1 Tier 1 $0.00$0.00None
AMITRIPTYLINE HCL 100MG TABLET   1 Tier 1 $0.00$0.00None
AMITRIPTYLINE HCL 10MG TABLET   1 Tier 1 $0.00$0.00None
AMITRIPTYLINE HCL 150MG TABLET (100 CT)   1 Tier 1 $0.00$0.00None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Tier 1 $0.00$0.00None
AMITRIPTYLINE HCL 50MG TABLET   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Tier 1 $0.00$0.00None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Tier 1 $0.00$0.00None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Tier 1 $0.00$0.00None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Tier 1 $0.00$0.00None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 Tier 1 $0.00$0.00None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 Tier 1 $0.00$0.00None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 Tier 1 $0.00$0.00None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 Tier 1 $0.00$0.00None
AMMONIUM LACTATE 12% CREAM   1 Tier 1 $0.00$0.00None
AMMONIUM LACTATE 12% LOTION   1 Tier 1 $0.00$0.00None
AMMONIUM LACTATE 12% LOTION   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX TR-K CLV 200-28.5 CHEW   1 Tier 1 $0.00$0.00None
AMOX TR-K CLV 200-28.5/5 SU   1 Tier 1 $0.00$0.00None
AMOX TR-K CLV 400-57 CHW TABLET   1 Tier 1 $0.00$0.00None
AMOX TR-K CLV 400-57/5 SUSP   1 Tier 1 $0.00$0.00None
AMOX TR-K CLV 500-125MG TABLET   1 Tier 1 $0.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $0.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Tier 1 $0.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Tier 1 $0.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Tier 1 $0.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $0.00$0.00None
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 100MG TABLET   1 Tier 1 $0.00$0.00None
AMOXAPINE 150MG TABLET   1 Tier 1 $0.00$0.00None
AMOXAPINE 25MG TABLET   1 Tier 1 $0.00$0.00None
AMOXAPINE 50MG TABLET   1 Tier 1 $0.00$0.00None
AMOXICIILIN CLAVULNATE POTASSIUM FOR ORAL SUSPENSION   1 Tier 1 $0.00$0.00None
AMOXICILLIN 250MG CAPSULE   1 Tier 1 $0.00$0.00None
AMOXICILLIN 500MG CAPSULE   1 Tier 1 $0.00$0.00None
AMOXICILLIN 500MG TABLET (100 CT)   1 Tier 1 $0.00$0.00None
AMOXICILLIN 875MG TABLET   1 Tier 1 $0.00$0.00None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Tier 1 $0.00$0.00None
AMOXICILLIN CLAVULANATE POTASSIUM TABLET 875-125MG 1 BLPK   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Tier 1 $0.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Tier 1 $0.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Tier 1 $0.00$0.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Tier 1 $0.00$0.00None
AMPHET ASP/ AMPHET/ D-AMPHET 10MG TABLET   1 Tier 1 $0.00$0.00None
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET   1 Tier 1 $0.00$0.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Tier 1 $0.00$0.00None
AMPHETAMINE SALT COMBO 15MG TABLET   1 Tier 1 $0.00$0.00None
AMPHETAMINE SALT COMBO 30MG TABLET   1 Tier 1 $0.00$0.00None
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Tier 1 $0.00$0.00None
AMPHETAMINE SALTS 20MG TABLET   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALTS 30MG TABLET   1 Tier 1 $0.00$0.00None
AMPHOTERICIN B FOR INJECTION 50 MG   1 Tier 1 $0.00$0.00None
AMPICILLIN AND SULBACTAM FOR INJECTION 1-0.5 10 VIAL VIAL   1 Tier 1 $0.00$0.00None
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   1 Tier 1 $0.00$0.00None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   1 Tier 1 $0.00$0.00None
AMPICILLIN FOR INJECTION 1GM VIAL   1 Tier 1 $0.00$0.00None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Tier 1 $0.00$0.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Tier 1 $0.00$0.00None
AMPICILLIN SODIUM STERILE 2 GM/VIAL   1 Tier 1 $0.00$0.00None
AMPICILLIN TR 250MG CAPSULE   1 Tier 1 $0.00$0.00None
AMPICILLIN TR 500MG CAPSULE   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANADROL-50 50MG TABLET (100 CT)   4 Tier 4 33%33%None
ANCOBON 250MG CAPSULE   3 Tier 3 $79.00$237.00P
ANCOBON 500MG CAPSULE   3 Tier 3 $79.00$237.00P
ANDROGEL 1%(25MG) GEL PACKET   2 Tier 2 $39.00$117.00None
ANDROGEL 1.25G (1%) GEL IN METERED-DOSE PUMP   2 Tier 2 $39.00$117.00None
ANDROGEL 1%(50MG) GEL PACKET   2 Tier 2 $39.00$117.00None
ANDROID 10MG CAPSULE   2 Tier 2 $39.00$117.00None
ANTABUSE 250MG TABLET   2 Tier 2 $39.00$117.00None
ANTABUSE 500MG TABLET   2 Tier 2 $39.00$117.00None
ANTIZOL INJECTION 1GM 4 X 1.5ML VIAL CRTN   4 Tier 4 33%33%None
APRI 0.15-0.03 TABLET   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APTIVUS 250MG CAPSULE   3 Tier 3 $79.00$237.00None
ARANELLE 7-9-5 TABLET   2 Tier 2 $39.00$117.00None
ARICEPT 10MG TABLET   3 Tier 3 $79.00$237.00None
ARICEPT 5MG TABLET   3 Tier 3 $79.00$237.00None
ARICEPT ODT 10MG TABLET   3 Tier 3 $79.00$237.00None
ARICEPT ODT 5MG TABLET   3 Tier 3 $79.00$237.00None
ARIMIDEX 1MG TABLET   3 Tier 3 $79.00$237.00None
ARIXTRA 10MG SYRINGE   4 Tier 4 33%33%Q:11
/31Days
ARIXTRA 2.5MG SYRINGE   4 Tier 4 33%33%Q:16
/31Days
ARIXTRA 5MG SYRINGE   4 Tier 4 33%33%Q:5
/31Days
ARIXTRA 7.5MG SYRINGE   4 Tier 4 33%33%Q:8
/31Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AROMASIN 25MG TABLET   2 Tier 2 $39.00$117.00None
ASACOL 400MG TABLET EC   2 Tier 2 $39.00$117.00None
ASCOMP W/CODEINE 30-50-325 CAPSULE   1 Tier 1 $0.00$0.00None
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED   2 Tier 2 $39.00$117.00None
ASMANEX TWISTHALER 220MCG #120   2 Tier 2 $39.00$117.00None
ASMANEX TWISTHALER 220MCG #30   2 Tier 2 $39.00$117.00None
ASMANEX TWISTHALER 220MCG #60   2 Tier 2 $39.00$117.00None
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   3 Tier 3 $79.00$237.00None
ATENOLOL 25MG TABLET (100 CT)   1 Tier 1 $0.00$0.00None
ATENOLOL TABLET 100MG (100 CT)   1 Tier 1 $0.00$0.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Tier 1 $0.00$0.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Tier 1 $0.00$0.00None
ATRIPLA TABLET 600MG/200MG   4 Tier 4 33%33%None
ATROPINE 0.05MG/ML SYRINGE   1 Tier 1 $0.00$0.00None
ATROPINE 0.1MG/ML SYRINGE   1 Tier 1 $0.00$0.00None
ATROVENT HFA AER 17MCG   2 Tier 2 $39.00$117.00None
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   2 Tier 2 $39.00$117.00None
AVANDAMET 2MG/1000MG TABLET   2 Tier 2 $39.00$117.00None
AVANDAMET 2MG/500MG TABLET   2 Tier 2 $39.00$117.00None
AVANDAMET 4MG/500MG TABLET   2 Tier 2 $39.00$117.00None
AVANDAMET TABLET 4-1000MG   2 Tier 2 $39.00$117.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDARYL 4MG/1MG TABLET   2 Tier 2 $39.00$117.00None
AVANDARYL 4MG/2MG TABLET   2 Tier 2 $39.00$117.00None
AVANDARYL 4MG/4MG TABLET   2 Tier 2 $39.00$117.00None
AVANDARYL 8MG-2MG TABLET   2 Tier 2 $39.00$117.00None
AVANDARYL 8MG-4MG TABLET   2 Tier 2 $39.00$117.00None
AVANDIA 2MG TABLET   2 Tier 2 $39.00$117.00None
AVANDIA 4MG TABLET (90 CT)   2 Tier 2 $39.00$117.00None
AVANDIA 8MG TABLET (90 CT)   2 Tier 2 $39.00$117.00None
AVELOX 400MG TABLET   2 Tier 2 $39.00$117.00None
AVIANE 0.1-0.02 TABLET   1 Tier 1 $0.00$0.00None
AVODART 0.5MG SOFTGEL   2 Tier 2 $39.00$117.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZASAN 100MG TABLET   3 Tier 3 $79.00$237.00None
AZASAN 75MG TABLET   3 Tier 3 $79.00$237.00None
AZASITE 1% DROPS   2 Tier 2 $39.00$117.00None
AZATHIOPRINE 50MG TABLET   1 Tier 1 $0.00$0.00None
AZATHIOPRINE SOD 100MG VIAL   1 Tier 1 $0.00$0.00None
AZELEX 20% CREAM 30GM TUBE   2 Tier 2 $39.00$117.00None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $0.00$0.00None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $0.00$0.00None
AZITHROMYCIN 250MG TABLET (30 CT)   1 Tier 1 $0.00$0.00None
AZITHROMYCIN 500MG TABLET (30 CT)   1 Tier 1 $0.00$0.00None
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   1 Tier 1 $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN TABLET 600MG (30 CT)   1 Tier 1 $0.00$0.00None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   2 Tier 2 $39.00$117.00None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D WellCare Signature Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the the standard $295 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons wit the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on which tier the drug is in. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data October 2009 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.