Q1Medicare.com 2011 Medicare Part D or Medicare Advantage Plan Formulary Browser

2011 Medicare Part D Plan Formulary Information
WellCare Classic (PDP) (S5967-149-0) Benefit Details
The WellCare Classic (PDP) (S5967-149-0) Formulary Drugs Starting with the Letter C in CMS PDP Region 12 which includes: AL TN
Drugs Starting with Letter C Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter C Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CALCIPOTRIENE OINTMENT	2	Generic and Preferred Brand	$42.00	$105.00	None
CALCIPOTRIENE TOPICAL SOLUTION	2	Generic and Preferred Brand	$42.00	$105.00	None
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY	2	Generic and Preferred Brand	$42.00	$105.00	None
CALCITRIOL 0.25MCG CAPSULE	2	Generic and Preferred Brand	$42.00	$105.00	P
CALCITRIOL 0.5MCG CAPSULE	2	Generic and Preferred Brand	$42.00	$105.00	P
CALCITRIOL 1MCG/ML SOLUTION ORAL	3	Generic and Non-Preferred Brand	$88.00	$220.00	P
CALCITRIOL 2 MCG/ML VIAL	3	Generic and Non-Preferred Brand	$88.00	$220.00	P
CALCITRIOL INJECTION SOLUTION 1MCG 50 X 01ML AMP	3	Generic and Non-Preferred Brand	$88.00	$220.00	P
CALCIUM ACETATE CAPSULE 667 MG	2	Generic and Preferred Brand	$42.00	$105.00	None
CALCIUM CHLORIDE 0.0014 MEQ/ML / POTASSIUM CHLORIDE 0.004 MEQ/ML / SODIUM CHLORIDE 0.103 MEQ/ML / SO	2	Generic and Preferred Brand	$42.00	$105.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CAMILA 0.35MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
CAMPATH 30MG/ML VIAL	4	Specialty Tier	25%	N/A	P
CAMPRAL 333MG DOSE PAK	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CAPREOMYCIN 500 MG/ML INJECTABLE SOLUTION [CAPASTAT]	4	Specialty Tier	25%	N/A	None
CAPTOPRIL 100MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CAPTOPRIL 12.5MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CAPTOPRIL 25MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CAPTOPRIL 50MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CAPTOPRIL/HCTZ 25/15 TABLET	1	Preferred Generic	$0.00	$0.00	None
CAPTOPRIL/HCTZ 25/25 TABLET	1	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CAPTOPRIL/HCTZ 50/15 TABLET	1	Preferred Generic	$0.00	$0.00	None
CAPTOPRIL/HCTZ 50/25 TABLET	1	Preferred Generic	$0.00	$0.00	None
CARAC CRE 0.5%	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CARAFATE SUS 1GM/10ML	2	Generic and Preferred Brand	$42.00	$105.00	None
CARBAMAZEPINE ORAL SUSPENSION 200 MG	2	Generic and Preferred Brand	$42.00	$105.00	None
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT)	1	Preferred Generic	$0.00	$0.00	None
CARBAMAZEPINE TABLET USP 200MG (1000 CT)	1	Preferred Generic	$0.00	$0.00	None
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA	2	Generic and Preferred Brand	$42.00	$105.00	None
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA	2	Generic and Preferred Brand	$42.00	$105.00	None
CARBIDOPA/LEVO 10/100 TABLET	1	Preferred Generic	$0.00	$0.00	None
CARBIDOPA/LEVO 25/100 TABLET	1	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CARBIDOPA/LEVO 25/250 TABLET	1	Preferred Generic	$0.00	$0.00	None
CARIMUNE NF 3GM VIAL	4	Specialty Tier	25%	N/A	P
CARISOPRODOL TABLET USP 350MG (100 CT)	2	Generic and Preferred Brand	$42.00	$105.00	Q:124 /31Days
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT	1	Preferred Generic	$0.00	$0.00	None
CARTIA XT 120MG CAPSULE SA	1	Preferred Generic	$0.00	$0.00	None
CARTIA XT 180MG CAPSULE SA	1	Preferred Generic	$0.00	$0.00	None
CARTIA XT 240MG CAPSULE SA	1	Preferred Generic	$0.00	$0.00	None
CARTIA XT 300MG CAPSULE SR 24 HR	1	Preferred Generic	$0.00	$0.00	None
CARVEDILOL 12.5MG TABLET (100 CT)	1	Preferred Generic	$0.00	$0.00	None
CARVEDILOL 25MG TABLET (500 CT)	1	Preferred Generic	$0.00	$0.00	None
CARVEDILOL 3.125MG TABLET (100 CT)	1	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CARVEDILOL 6.25MG TABLET (500 CT)	1	Preferred Generic	$0.00	$0.00	None
CEENU 100MG CAPSULE	2	Generic and Preferred Brand	$42.00	$105.00	None
CEENU 10MG CAPSULE	2	Generic and Preferred Brand	$42.00	$105.00	None
CEENU 40MG CAPSULE	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFACLOR 250MG/5ML ORAL SUSP	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFACLOR 375MG/5ML ORAL SUSP	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFACLOR CAPSULES	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFACLOR CAPSULES	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFACLOR POWDER FOR ORAL SUSPENSION USP 125MG 75ML BOT	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFADROXIL 1G TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFADROXIL 500MG CAPSULE	2	Generic and Preferred Brand	$42.00	$105.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CEFADROXIL 500MG/5ML SUSPENSION RECONSTITUTED ORAL	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFAZOLIN 1 GM VIAL	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFAZOLIN 1GM/D5W BAG	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFAZOLIN 20GM BULK VIAL	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFAZOLIN FOR INJECTION	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFDINIR CAPSULES 300MG (60 CT)	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT)	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFEPIME HCL 2 GRAM VIAL	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CEFOTAXIME FOR INJECTION	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CEFOTAXIME FOR INJECTION 1GM 50 BOX VIALGL	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CEFOTAXIME FOR INJECTION 2GM 25 VIAL	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CEFOTAXIME FOR INJECTION 500MG 10 VIAL	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CEFOXITIN 180 MG/ML INJECTABLE SOLUTION	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CEFOXITIN 95 MG/ML INJECTABLE SOLUTION	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CEFOXITIN FOR INJECTION SOLUTION	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CEFPODOXIME PROXETIL 200MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT)	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 100MG 50ML BOT	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 50MG 50ML BOT	2	Generic and Preferred Brand	$42.00	$105.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CEFPROZIL 250MG TABLET (100 CT)	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFPROZIL FOR ORAL SUSPENSION 125MG/5ML 75ML BOT	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFPROZIL TABLETS 500MG 100 BOT	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFTAZIDIME FOR INJECTION 1GM/VIAL 1 SINGLE VIAL VIAL	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CEFTRIAXONE 10GM VIAL	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFTRIAXONE FOR INJECTION	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFTRIAXONE FOR INJECTION	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL	2	Generic and Preferred Brand	$42.00	$105.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CEFTRIAXONE FOR INJECTION 500MG BOX OF 10 VIALGL	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFUROXIME 250MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL	2	Generic and Preferred Brand	$42.00	$105.00	None
CEFUROXIME AXETIL 500MG TABLET (20 CT)	1	Preferred Generic	$0.00	$0.00	None
CEFUROXIME FOR INJECTION	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CEFUROXIME FOR INJECTION	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CELLCEPT 200MG/ML ORAL SUSP	3	Generic and Non-Preferred Brand	$88.00	$220.00	P
CELONTIN 300MG KAPSEAL	2	Generic and Preferred Brand	$42.00	$105.00	None
CENESTIN 0.3MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
CENESTIN 0.45MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
CENESTIN 0.625MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CENESTIN 0.9MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
CENESTIN 1.25MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
CEPHALEXIN 250MG CAPSULE	1	Preferred Generic	$0.00	$0.00	None
CEPHALEXIN 250MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CEPHALEXIN 250MG/5ML ORAL SUSP	1	Preferred Generic	$0.00	$0.00	None
CEPHALEXIN 500MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CEPHALEXIN CAPSULES 500MG (500 CT)	1	Preferred Generic	$0.00	$0.00	None
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT	1	Preferred Generic	$0.00	$0.00	None
CEREDASE 80UNITS/ML VIAL	4	Specialty Tier	25%	N/A	P
CEREZYME INJ 200UNIT	4	Specialty Tier	25%	N/A	P
CESIA 7 DAYS X 3 TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CHANTIX 0.5MG TABLET	3	Generic and Non-Preferred Brand	$88.00	$220.00	Q:340 /365Days
CHANTIX 1MG TABLET	3	Generic and Non-Preferred Brand	$88.00	$220.00	Q:340 /365Days
CHANTIX STARTING MONTH PAK	3	Generic and Non-Preferred Brand	$88.00	$220.00	Q:106 /365Days
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT)	2	Generic and Preferred Brand	$42.00	$105.00	None
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH	1	Preferred Generic	$0.00	$0.00	None
CHLOROQUINE PH 500MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT)	2	Generic and Preferred Brand	$42.00	$105.00	None
CHLOROTHIAZIDE 250MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CHLOROTHIAZIDE 500MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CHLOROTHIAZIDE SODIUM FOR INJECTION 500MG/VIAL	2	Generic and Preferred Brand	$42.00	$105.00	None
CHLORPROMAZINE 100MG TABLET	1	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CHLORPROMAZINE 10MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CHLORPROMAZINE 25MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CHLORPROMAZINE 25MG/ML AMP	2	Generic and Preferred Brand	$42.00	$105.00	None
CHLORPROMAZINE 50MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CHLORPROMAZINE HCL 200MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CHLORPROPAMIDE 100MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CHLORPROPAMIDE 250MG TABLET (1000 CT)	1	Preferred Generic	$0.00	$0.00	None
CHLORTHALIDONE 25MG TABLET (100 CT)	1	Preferred Generic	$0.00	$0.00	None
CHLORTHALIDONE 50MG TABLET (1000 CT)	1	Preferred Generic	$0.00	$0.00	None
CHLORZOXAZONE 500MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION	2	Generic and Preferred Brand	$42.00	$105.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CHORIONIC GONAD 10000U VIAL	3	Generic and Non-Preferred Brand	$88.00	$220.00	P
CICLOPIROX 0.77% CREAM	2	Generic and Preferred Brand	$42.00	$105.00	None
CICLOPIROX 0.77% TOPICAL SUSPENSION	2	Generic and Preferred Brand	$42.00	$105.00	None
CICLOPIROX 1% SHAMPOO	2	Generic and Preferred Brand	$42.00	$105.00	None
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT	2	Generic and Preferred Brand	$42.00	$105.00	None
CICLOPIROX GEL	2	Generic and Preferred Brand	$42.00	$105.00	None
CILOSTAZOL 50MG TABLET (60 CT)	2	Generic and Preferred Brand	$42.00	$105.00	None
CILOSTAZOL TABLET 100MG (60 CT)	2	Generic and Preferred Brand	$42.00	$105.00	None
CIMETIDINE 200MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CIMETIDINE HCL 300MG/5ML SOL	1	Preferred Generic	$0.00	$0.00	None
CIMETIDINE TABLETS	1	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CIMETIDINE TABLETS	1	Preferred Generic	$0.00	$0.00	None
CIMETIDINE TABLETS USP	1	Preferred Generic	$0.00	$0.00	None
CIPROFLOXACIN 250MG TABLET (100 CT)	1	Preferred Generic	$0.00	$0.00	None
CIPROFLOXACIN 400 MG/40 ML VL	1	Preferred Generic	$0.00	$0.00	None
CIPROFLOXACIN 500MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CIPROFLOXACIN HCL 0.3% DROPS	1	Preferred Generic	$0.00	$0.00	None
CIPROFLOXACIN TABLETS 750MG 100 BOT	1	Preferred Generic	$0.00	$0.00	None
CITALOPRAM HBR 20 MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL	2	Generic and Preferred Brand	$42.00	$105.00	None
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT	1	Preferred Generic	$0.00	$0.00	None
CITOLOPRAM HBR 10MG TABLET (100 CT)	1	Preferred Generic	$0.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CLARITHROMYCIN 250MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CLARITHROMYCIN 500MG TABLET	1	Preferred Generic	$0.00	$0.00	None
CLARITHROMYCIN FOR ORAL SUSPENSION	2	Generic and Preferred Brand	$42.00	$105.00	None
CLARITHROMYCIN FOR ORAL SUSPENSION	2	Generic and Preferred Brand	$42.00	$105.00	None
CLINDAMYCIN 150MG/ML ADDVAN	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CLINDAMYCIN HCL 150MG CAPSULE	1	Preferred Generic	$0.00	$0.00	None
CLINDAMYCIN HYDROCHLORIDE CAPSULES	1	Preferred Generic	$0.00	$0.00	None
CLINDAMYCIN PHOSP 1% LOTION	2	Generic and Preferred Brand	$42.00	$105.00	None
CLINDAMYCIN PHOSPHATE 1% SOLUTION NON-ORAL	2	Generic and Preferred Brand	$42.00	$105.00	None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE	2	Generic and Preferred Brand	$42.00	$105.00	None
CLINDAMYCIN PHOSPHATE VAGINAL CREAM	2	Generic and Preferred Brand	$42.00	$105.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CLINIMIX 2.75%/5% INJECTION 1000ML BAG	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CLINIMIX 4.25/10 SOLUTION	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CLINIMIX 4.25/20 SOLUTION	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CLINIMIX 4.25/25 SOLUTION	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CLINIMIX 4.25/5 SOLUTION	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CLINIMIX 5/15 SOLUTION	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CLINIMIX 5/20 SOLUTION	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CLINISOL 15% SOLUTION	2	Generic and Preferred Brand	$42.00	$105.00	None
CLOBETASOL 0.05% OINTMENT	2	Generic and Preferred Brand	$42.00	$105.00	None
CLOBETASOL 0.05% SOLUTION	2	Generic and Preferred Brand	$42.00	$105.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CLOBETASOL E 0.05% CREAM	2	Generic and Preferred Brand	$42.00	$105.00	None
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE	2	Generic and Preferred Brand	$42.00	$105.00	None
CLODERM 0.1% CREAM	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CLOMIPRAMINE HCL 25MG CAPSULE	1	Preferred Generic	$0.00	$0.00	None
CLOMIPRAMINE HCL 50MG CAPSULE	1	Preferred Generic	$0.00	$0.00	None
CLOMIPRAMINE HCL 75MG CAPSULE	1	Preferred Generic	$0.00	$0.00	None
CLONIDINE HCL 0.2MG TABLET (500 CT)	1	Preferred Generic	$0.00	$0.00	None
CLONIDINE HCL TABLET 0.1MG (500 CT)	1	Preferred Generic	$0.00	$0.00	None
CLONIDINE HCL TABLET 0.3MG (100 CT)	1	Preferred Generic	$0.00	$0.00	None
CLORPRES 0.1-15 TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
CLORPRES 0.2-15 TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CLORPRES 0.3-15 TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
CLOTRIMAZOLE 1% CREAM	1	Preferred Generic	$0.00	$0.00	None
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION	1	Preferred Generic	$0.00	$0.00	None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREAM USP .5MG-10GM 45GM TUBE	1	Preferred Generic	$0.00	$0.00	None
CLOZAPINE 100 MG ORAL TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
CLOZAPINE 12.5 MG DISINTEGRATING TABLET [FAZACLO]	3	Generic and Non-Preferred Brand	$88.00	$220.00	P
CLOZAPINE 200MG TABLET (500 CT)	2	Generic and Preferred Brand	$42.00	$105.00	None
CLOZAPINE 25MG TABLET (100 CT)	2	Generic and Preferred Brand	$42.00	$105.00	None
CLOZAPINE 50MG TABLET (500 CT)	2	Generic and Preferred Brand	$42.00	$105.00	None
CO-GESIC 5/500 TABLET	1	Preferred Generic	$0.00	$0.00	Q:248 /31Days
CODEINE 60 MG ORAL TABLET	2	Generic and Preferred Brand	$42.00	$105.00	Q:248 /31Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CODEINE SULFATE 30 MG TABLET 3100	2	Generic and Preferred Brand	$42.00	$105.00	Q:248 /31Days
CODEINE SULFATE TABLETS	2	Generic and Preferred Brand	$42.00	$105.00	Q:248 /31Days
COLCHICINE 0.6 MG ORAL TABLET [COLCRYS]	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
COLESTIPOL HCL 1G TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
COLESTIPOL HCL 5G GRANULES	2	Generic and Preferred Brand	$42.00	$105.00	None
COLISTIMETHATE 150MG VIAL	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
COLOCORT 100MG ENEMA	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
COMBIPATCH 0.05/0.14MG PTCH	2	Generic and Preferred Brand	$42.00	$105.00	None
COMBIPATCH 0.05/0.25MG PTCH	2	Generic and Preferred Brand	$42.00	$105.00	None
COMBIVENT INHALER	2	Generic and Preferred Brand	$42.00	$105.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
COMBIVIR TABLETS	2	Generic and Preferred Brand	$42.00	$105.00	None
COMPRO 25MG SUPPOSITORY	2	Generic and Preferred Brand	$42.00	$105.00	None
COMTAN 200MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
COMVAX VACCINE VIAL	2	Generic and Preferred Brand	$42.00	$105.00	None
CONDYLOX GEL 0.5% 3.5 GM CRTN	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN	4	Specialty Tier	25%	N/A	P
CORDRAN 0.05% LOTION	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR	2	Generic and Preferred Brand	$42.00	$105.00	None
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR	2	Generic and Preferred Brand	$42.00	$105.00	None
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR	2	Generic and Preferred Brand	$42.00	$105.00	None
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR	2	Generic and Preferred Brand	$42.00	$105.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CORTIFOAM RECTAL FOAM	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CORTISONE ACETATE 25MG TABLET (100 CT)	2	Generic and Preferred Brand	$42.00	$105.00	None
CORTOMYCIN EAR SOLUTION	1	Preferred Generic	$0.00	$0.00	None
CORTOMYCIN EAR SUSPENSION	1	Preferred Generic	$0.00	$0.00	None
COUMADIN 10MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
COUMADIN 1MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
COUMADIN 2.5MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
COUMADIN 2MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
COUMADIN 3MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
COUMADIN 4MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
COUMADIN 5MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
COUMADIN 5MG VIAL	2	Generic and Preferred Brand	$42.00	$105.00	None
COUMADIN 6MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
COUMADIN 7.5MG TABLET	2	Generic and Preferred Brand	$42.00	$105.00	None
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT	3	Generic and Non-Preferred Brand	$88.00	$220.00	None
CRIXIVAN 100MG CAPSULE	2	Generic and Preferred Brand	$42.00	$105.00	None
CRIXIVAN 200MG CAPSULE	2	Generic and Preferred Brand	$42.00	$105.00	None
CRIXIVAN 333MG CAPSULE	2	Generic and Preferred Brand	$42.00	$105.00	None
CRIXIVAN 400MG CAPSULE (120 CT)	2	Generic and Preferred Brand	$42.00	$105.00	None
CROMOLYN NEBULIZER SOLUTION	2	Generic and Preferred Brand	$42.00	$105.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CROMOLYN SODIUM 4% 40MG 10ML BOT	1	Preferred Generic	$0.00	$0.00	None
CUPRIMINE CAPSULES 250MG (100 CT)	2	Generic and Preferred Brand	$42.00	$105.00	None
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT)	2	Generic and Preferred Brand	$42.00	$105.00	Q:93 /31Days
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT)	2	Generic and Preferred Brand	$42.00	$105.00	Q:93 /31Days
CYCLOPHOSPHAMIDE 25MG TABLET	3	Generic and Non-Preferred Brand	$88.00	$220.00	P
CYCLOPHOSPHAMIDE 50MG TABLET	3	Generic and Non-Preferred Brand	$88.00	$220.00	P
CYCLOSPORINE 100MG CAPSULE	3	Generic and Non-Preferred Brand	$88.00	$220.00	P
CYCLOSPORINE 100MG CAPSULE	3	Generic and Non-Preferred Brand	$88.00	$220.00	P
CYCLOSPORINE 25MG CAPSULE	3	Generic and Non-Preferred Brand	$88.00	$220.00	P
CYCLOSPORINE 50MG CAPSULE	3	Generic and Non-Preferred Brand	$88.00	$220.00	P
CYCLOSPORINE 50MG/ML AMP	3	Generic and Non-Preferred Brand	$88.00	$220.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT	3	Generic and Non-Preferred Brand	$88.00	$220.00	P
CYKLOKAPRON 100MG/ML AMPUL	2	Generic and Preferred Brand	$42.00	$105.00	None
CYMBALTA 20MG CAPSULE	3	Generic and Non-Preferred Brand	$88.00	$220.00	S
CYMBALTA 60MG CAPSULE	3	Generic and Non-Preferred Brand	$88.00	$220.00	S
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT)	3	Generic and Non-Preferred Brand	$88.00	$220.00	S
CYPROHEPTADINE HCL 4 MG	1	Preferred Generic	$0.00	$0.00	None
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL	1	Preferred Generic	$0.00	$0.00	None
CYSTADANE POWDER FOR ORAL SOLUTION 180GM	2	Generic and Preferred Brand	$42.00	$105.00	P
CYSTAGON 150MG CAPSULE	3	Generic and Non-Preferred Brand	$88.00	$220.00	P
CYSTAGON 50MG CAPSULE	3	Generic and Non-Preferred Brand	$88.00	$220.00	P
CYTOVENE IV INJECTION	3	Generic and Non-Preferred Brand	$88.00	$220.00	P

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D WellCare Classic (PDP) 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 standard $310 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 with 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 the drug’s tier. 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $(2840)) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, on the 2011 Humana Walmart-Preferred Rx Plan the pricing 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 2011 )

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.