Q1Medicare.com 2013 Medicare Part D or Medicare Advantage Plan Formulary Browser

2013 Medicare Part D Plan Formulary Information
WellCare Classic (PDP) (S5967-169-0) Benefit Details
The WellCare Classic (PDP) (S5967-169-0) Formulary Drugs Starting with the Letter A in CMS PDP Region 32 which includes: CA
Drugs Starting with Letter A Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter A Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ABACAVIR 300 MG TABLET	2	Preferred Brand	$45.00	$90.00	None
ABILIFY 10MG TABLET	3	Non-Preferred Brand	$95.00	$190.00	Q:31 /31Days
ABILIFY 15MG TABLET	3	Non-Preferred Brand	$95.00	$190.00	Q:31 /31Days
ABILIFY 1MG/ML SOLUTION	3	Non-Preferred Brand	$95.00	$190.00	Q:1050 /31Days
ABILIFY 20MG TABLET	3	Non-Preferred Brand	$95.00	$190.00	Q:31 /31Days
ABILIFY 2MG TABLET	3	Non-Preferred Brand	$95.00	$190.00	Q:31 /31Days
ABILIFY 30MG TABLET	3	Non-Preferred Brand	$95.00	$190.00	Q:31 /31Days
ABILIFY 5MG TABLET (OTSUKA)	3	Non-Preferred Brand	$95.00	$190.00	Q:31 /31Days
ABILIFY DISCMELT 10MG TABLET	3	Non-Preferred Brand	$95.00	$190.00	P Q:93 /31Days
ABILIFY DISCMELT 15MG TABLET	3	Non-Preferred Brand	$95.00	$190.00	P Q:62 /31Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ABILIFY INJ 9.75MG	3	Non-Preferred Brand	$95.00	$190.00	P
ABILIFY MAINTENA ER 300 MG VL	4	Specialty Tier	33%	N/A	P Q:1 /26Days
Acarbose 100mg/1 1000 TABLET BOTTLE, PLASTIC	2	Preferred Brand	$45.00	$90.00	None
Acarbose 50mg/1 100 TABLET BOTTLE	2	Preferred Brand	$45.00	$90.00	None
ACARBOSE TABLETS	2	Preferred Brand	$45.00	$90.00	None
ACEBUTOLOL 200MG CAPSULE	1	Preferred Generic	$6.00	$0.00	None
ACEBUTOLOL 400MG CAPSULE	1	Preferred Generic	$6.00	$0.00	None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE	2	Preferred Brand	$45.00	$90.00	None
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET BOTTLE	1	Preferred Generic	$6.00	$0.00	Q:248 /31Days
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD	1	Preferred Generic	$6.00	$0.00	None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)	1	Preferred Generic	$6.00	$0.00	Q: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	Preferred Generic	$6.00	$0.00	Q:248 /31Days
ACETAZOLAMIDE 125MG TABLET	1	Preferred Generic	$6.00	$0.00	None
ACETAZOLAMIDE 250MG TABLET (100 CT)	1	Preferred Generic	$6.00	$0.00	None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT	3	Non-Preferred Brand	$95.00	$190.00	None
ACETAZOLAMIDE SOD 500MG VL	3	Non-Preferred Brand	$95.00	$190.00	None
ACETIC ACID 2% SOLUTION NON-ORAL	1	Preferred Generic	$6.00	$0.00	None
ACETYLCYSTEINE 10% VIAL	1	Preferred Generic	$6.00	$0.00	P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN	1	Preferred Generic	$6.00	$0.00	P
ACTHIB VACCINE VIAL 10-24UNT/5ML	2	Preferred Brand	$45.00	$90.00	None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG	4	Specialty Tier	33%	N/A	P
ACYCLOVIR 200 MG CAPSULE	1	Preferred Generic	$6.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE	3	Non-Preferred Brand	$95.00	$190.00	None
acyclovir 400mg/1	1	Preferred Generic	$6.00	$0.00	None
acyclovir 5% ointment	3	Non-Preferred Brand	$95.00	$190.00	None
ACYCLOVIR 800 MG TABLET	1	Preferred Generic	$6.00	$0.00	None
ACYCLOVIR SODIUM 500MG VIAL	2	Preferred Brand	$45.00	$90.00	None
ADACEL VIAL 2UNT/5UNT	2	Preferred Brand	$45.00	$90.00	None
ADAGEN 250U/ML VIAL	4	Specialty Tier	33%	N/A	P
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]	4	Specialty Tier	33%	N/A	P
ADCIRCA TABLETS 20MG 60 BOT	4	Specialty Tier	33%	N/A	P Q:62 /31Days
ADVAIR DISKUS MIS 100/50	2	Preferred Brand	$45.00	$90.00	Q:60 /30Days
ADVAIR DISKUS MIS 250/50	2	Preferred Brand	$45.00	$90.00	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ADVAIR DISKUS MIS 500/50	2	Preferred Brand	$45.00	$90.00	Q:60 /30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER	2	Preferred Brand	$45.00	$90.00	Q:12 /30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL	2	Preferred Brand	$45.00	$90.00	Q:12 /30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL	2	Preferred Brand	$45.00	$90.00	Q:12 /30Days
Afinitor 7.5mg/1 28 BLISTER PACK in 1 CARTON / 1 TABLET in 1 BLISTER PACK	4	Specialty Tier	33%	N/A	P Q:31 /31Days
AFINITOR TABLETS 10 MG	4	Specialty Tier	33%	N/A	P Q:31 /31Days
AFINITOR TABLETS 2.5 MG	4	Specialty Tier	33%	N/A	P Q:31 /31Days
AFINITOR TABLETS 5 MG	4	Specialty Tier	33%	N/A	P Q:31 /31Days
AGGRENOX 25-200MG CAPSULE	3	Non-Preferred Brand	$95.00	$190.00	None
AK-CON 0.1% EYE DROPS	1	Preferred Generic	$6.00	$0.00	None
ALBENZA 200 MG TABLET	2	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH in 1 CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL	1	Preferred Generic	$6.00	$0.00	P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER	1	Preferred Generic	$6.00	$0.00	P
ALBUTEROL SULFATE 4MG TABLET SR 12HR	3	Non-Preferred Brand	$95.00	$190.00	None
ALBUTEROL SULFATE 8MG TABLET SR 12HR	3	Non-Preferred Brand	$95.00	$190.00	None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR	1	Preferred Generic	$6.00	$0.00	P
ALBUTEROL SULFATE SOLUTION FOR INHALATION	1	Preferred Generic	$6.00	$0.00	P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT	1	Preferred Generic	$6.00	$0.00	None
ALBUTEROL SULFATE TABLET 2MG (500 CT)	1	Preferred Generic	$6.00	$0.00	None
ALBUTEROL TABLET 4MG (500 CT)	1	Preferred Generic	$6.00	$0.00	None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM	2	Preferred Brand	$45.00	$90.00	None
Alclometasone Dipropionate 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE	2	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALDURAZYME 2.9MG/5ML VIAL	4	Specialty Tier	33%	N/A	P
ALENDRONATE SODIUM 10MG TABLET	1	Preferred Generic	$6.00	$0.00	None
ALENDRONATE SODIUM 40MG TABLET	2	Preferred Brand	$45.00	$90.00	None
ALENDRONATE SODIUM 5MG TABLET	1	Preferred Generic	$6.00	$0.00	None
ALENDRONATE SODIUM 70mg/1	1	Preferred Generic	$6.00	$0.00	Q:4 /28Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN	1	Preferred Generic	$6.00	$0.00	Q:4 /28Days
ALIMTA 500MG VIAL	4	Specialty Tier	33%	N/A	P
ALINIA 100MG/5ML SUSPENSION	3	Non-Preferred Brand	$95.00	$190.00	P
ALINIA 500 MG TABLET	3	Non-Preferred Brand	$95.00	$190.00	P
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK	1	Preferred Generic	$6.00	$0.00	None
ALLOPURINOL TABLETS	1	Preferred Generic	$6.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ALOCRIL 2% EYE DROPS	2	Preferred Brand	$45.00	$90.00	None
ALPHAGAN P 0.1% DROPS	3	Non-Preferred Brand	$95.00	$190.00	None
ALPHAGAN P 0.15% EYE DROPS	3	Non-Preferred Brand	$95.00	$190.00	None
ALPRAZOLAM 0.25 MG TABLET	1	Preferred Generic	$6.00	$0.00	None
ALPRAZOLAM 0.5 MG TABLET	1	Preferred Generic	$6.00	$0.00	None
ALPRAZOLAM 1 MG TABLET	1	Preferred Generic	$6.00	$0.00	None
ALPRAZOLAM 2 MG TABLET	1	Preferred Generic	$6.00	$0.00	None
ALREX 0.2% EYE DROPS	3	Non-Preferred Brand	$95.00	$190.00	None
AMANTADINE 100MG CAPSULE	2	Preferred Brand	$45.00	$90.00	None
AMANTADINE 100MG TABLET	2	Preferred Brand	$45.00	$90.00	None
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE	2	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMCINONIDE 0.1% CREAM	2	Preferred Brand	$45.00	$90.00	None
AMCINONIDE 0.1% LOTION	2	Preferred Brand	$45.00	$90.00	None
AMCINONIDE 0.1% OINTMENT 60GM TUBE	2	Preferred Brand	$45.00	$90.00	None
Amethia 2 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK	2	Preferred Brand	$45.00	$90.00	None
Amethyst 20; 90ug/1; ug/1 1 BLISTER PACK in 1 CARTON / 28 TABLET in 1 BLISTER PACK	2	Preferred Brand	$45.00	$90.00	None
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE in 1 CARTON / 10 mL in 1 VIAL, SINGLE-USE	3	Non-Preferred Brand	$95.00	$190.00	P
AMIKACIN 50MG/ML VIAL	2	Preferred Brand	$45.00	$90.00	None
AMIKACIN Sulfate 1g/4mL 10 VIAL, SINGLE-DOSE in 1 CARTON / 4 mL in 1 VIAL, SINGLE-DOSE	2	Preferred Brand	$45.00	$90.00	None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET	1	Preferred Generic	$6.00	$0.00	None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT	1	Preferred Generic	$6.00	$0.00	None
Aminophylline 25mg/mL 5 TRAY in 1 CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE	2	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMINOSYN HBC INJECTION SULFITE FREE 7%	2	Preferred Brand	$45.00	$90.00	None
AMINOSYN II 10% IV SOLUTION	2	Preferred Brand	$45.00	$90.00	None
AMINOSYN II 7% IV SOLUTION	2	Preferred Brand	$45.00	$90.00	None
AMINOSYN II 8.5% ELECTROLYT	2	Preferred Brand	$45.00	$90.00	None
AMINOSYN II 8.5% IV SOLUTION	2	Preferred Brand	$45.00	$90.00	None
Aminosyn II Sulfite-Free 1490; 1527; 1050; 1107; 750; 450; 990; 1500; 1575; 258; 405; 447; 1083; 79	2	Preferred Brand	$45.00	$90.00	None
AMINOSYN M 3.5% IV SOLUTION	2	Preferred Brand	$45.00	$90.00	None
AMINOSYN PF INJECTION	2	Preferred Brand	$45.00	$90.00	None
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%	2	Preferred Brand	$45.00	$90.00	None
AMINOSYN-PF 7% IV SOLUTION	2	Preferred Brand	$45.00	$90.00	None
AMIODARONE HCL 200MG 60 TABLET BOTTLE	1	Preferred Generic	$6.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMIODARONE HCL 400MG TABLET	3	Non-Preferred Brand	$95.00	$190.00	None
AMITIZA 8MCG CAPSULE	3	Non-Preferred Brand	$95.00	$190.00	S
AMITIZA CAPSULES 24MCG 60 CAP BOT	3	Non-Preferred Brand	$95.00	$190.00	S
AMITRIP/CDP 25-10 TABLET	2	Preferred Brand	$45.00	$90.00	None
AMITRIP/PERPHEN 10-2 TABLET	2	Preferred Brand	$45.00	$90.00	None
AMITRIP/PERPHEN 10-4 TABLET	2	Preferred Brand	$45.00	$90.00	None
AMITRIP/PERPHEN 25-2 TABLET	2	Preferred Brand	$45.00	$90.00	None
AMITRIP/PERPHEN 25-4 TABLET	2	Preferred Brand	$45.00	$90.00	None
AMITRIP/PERPHEN 50-4 TABLET	2	Preferred Brand	$45.00	$90.00	None
AMITRIPTYLINE HCL 100MG TABLET	1	Preferred Generic	$6.00	$0.00	None
AMITRIPTYLINE HCL 10MG TABLET	1	Preferred Generic	$6.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMITRIPTYLINE HCL 150 MG TAB	1	Preferred Generic	$6.00	$0.00	None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)	1	Preferred Generic	$6.00	$0.00	None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)	1	Preferred Generic	$6.00	$0.00	None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT	1	Preferred Generic	$6.00	$0.00	None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)	1	Preferred Generic	$6.00	$0.00	None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)	1	Preferred Generic	$6.00	$0.00	None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)	1	Preferred Generic	$6.00	$0.00	None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES	2	Preferred Brand	$45.00	$90.00	Q:31 /31Days
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES	2	Preferred Brand	$45.00	$90.00	Q:31 /31Days
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE	2	Preferred Brand	$45.00	$90.00	Q:31 /31Days
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE	2	Preferred Brand	$45.00	$90.00	Q:31 /31Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE	2	Preferred Brand	$45.00	$90.00	Q:31 /31Days
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE	2	Preferred Brand	$45.00	$90.00	Q:31 /31Days
ammonium lactate 12% cream	2	Preferred Brand	$45.00	$90.00	None
AMMONIUM LACTATE 12% LOTION	2	Preferred Brand	$45.00	$90.00	None
amox tr-k clv 200-28.5/5 susp	2	Preferred Brand	$45.00	$90.00	None
AMOX TR-K CLV 500-125 MG TAB	2	Preferred Brand	$45.00	$90.00	None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE	2	Preferred Brand	$45.00	$90.00	None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET	2	Preferred Brand	$45.00	$90.00	None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE	2	Preferred Brand	$45.00	$90.00	None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL	2	Preferred Brand	$45.00	$90.00	None
AMOXAPINE 100MG TABLET	2	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMOXAPINE 150MG TABLET	2	Preferred Brand	$45.00	$90.00	None
AMOXAPINE 25MG TABLET	2	Preferred Brand	$45.00	$90.00	None
AMOXAPINE 50MG TABLET	2	Preferred Brand	$45.00	$90.00	None
AMOXICILLIN 125MG TABLET CHEW	1	Preferred Generic	$6.00	$0.00	None
AMOXICILLIN 250MG CAPSULE	1	Preferred Generic	$6.00	$0.00	None
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE	1	Preferred Generic	$6.00	$0.00	None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION	2	Preferred Brand	$45.00	$90.00	None
AMOXICILLIN 500MG TABLET (100 CT)	1	Preferred Generic	$6.00	$0.00	None
Amoxicillin 500mg/1 500 CAPSULE in 1 BOTTLE, PLASTIC	1	Preferred Generic	$6.00	$0.00	None
AMOXICILLIN 875MG TABLET	1	Preferred Generic	$6.00	$0.00	None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT	2	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT	2	Preferred Brand	$45.00	$90.00	None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT	1	Preferred Generic	$6.00	$0.00	None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL	1	Preferred Generic	$6.00	$0.00	None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT	1	Preferred Generic	$6.00	$0.00	None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL	1	Preferred Generic	$6.00	$0.00	None
AMPHETAMINE SALT COMBO 12.5MG TABLET	2	Preferred Brand	$45.00	$90.00	P
AMPHETAMINE SALT COMBO 15MG TABLET	2	Preferred Brand	$45.00	$90.00	P
AMPHETAMINE SALT COMBO 30MG TABLET	2	Preferred Brand	$45.00	$90.00	P
AMPHETAMINE SALT COMBO 7.5MG TABLET	2	Preferred Brand	$45.00	$90.00	P
AMPHETAMINE SALTS 20MG TABLET	2	Preferred Brand	$45.00	$90.00	P
AMPHETAMINE SALTS 5 MG TAB	2	Preferred Brand	$45.00	$90.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
amphotericin b 50mg/10mL 10 mL in 1 VIAL	3	Non-Preferred Brand	$95.00	$190.00	None
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS	3	Non-Preferred Brand	$95.00	$190.00	None
AMPICILLIN CAPSULES 250MG 100 BOT	1	Preferred Generic	$6.00	$0.00	None
AMPICILLIN CAPSULES 500MG 100 BOT	1	Preferred Generic	$6.00	$0.00	None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT	2	Preferred Brand	$45.00	$90.00	None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT	2	Preferred Brand	$45.00	$90.00	None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML	3	Non-Preferred Brand	$95.00	$190.00	None
ampicillin-sulbactam 15 gm vl	3	Non-Preferred Brand	$95.00	$190.00	None
ampicillin-sulbactam 3 gm vial	3	Non-Preferred Brand	$95.00	$190.00	None
AMPYRA ER 10 MG TABLET	4	Specialty Tier	33%	N/A	P Q:62 /31Days
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE in 1 BOTTLE	2	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Anagrelide Hydrochloride 1mg/1 100 CAPSULE in 1 BOTTLE	2	Preferred Brand	$45.00	$90.00	None
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC	2	Preferred Brand	$45.00	$90.00	Q:31 /31Days
ANTARA CAPSULES	2	Preferred Brand	$45.00	$90.00	None
ANTARA CAPSULES	2	Preferred Brand	$45.00	$90.00	None
APOKYN 30 MG/3 ML CARTRIDGE	4	Specialty Tier	33%	N/A	P Q:90 /30Days
APRI 0.15-0.03 TABLET	2	Preferred Brand	$45.00	$90.00	None
APRISO CP24	3	Non-Preferred Brand	$95.00	$190.00	None
APTIVUS 250MG CAPSULE	4	Specialty Tier	33%	N/A	Q:124 /31Days
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT	4	Specialty Tier	33%	N/A	Q:310 /31Days
ARANELLE 7-9-5 TABLET	2	Preferred Brand	$45.00	$90.00	None
ARCALYST INJECTION 220MG/VIAL	4	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Arcapta Neohaler 75ug/1 30 BLISTER PACK in 1 BOX / 1 CAPSULE in 1 BLISTER PACK	3	Non-Preferred Brand	$95.00	$190.00	None
ASACOL 400mg/1 12 BOTTLE CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE	2	Preferred Brand	$45.00	$90.00	None
ASMANEX 220ug/1 1 POUCH in 1 POUCH / 1 INHALER in 1 POUCH / 14 INHALANT in 1 INHALER	2	Preferred Brand	$45.00	$90.00	None
ASMANEX TWISTHALER 110 MCG #30	2	Preferred Brand	$45.00	$90.00	None
ASMANEX TWISTHALER 220MCG #120	2	Preferred Brand	$45.00	$90.00	None
ASMANEX TWISTHALER 220MCG #30	2	Preferred Brand	$45.00	$90.00	None
ASMANEX TWISTHALER 220MCG #60	2	Preferred Brand	$45.00	$90.00	None
ASTELIN 137MCG AEROSOL SPRAY W/PUMP	2	Preferred Brand	$45.00	$90.00	None
ASTEPRO 0.15% NASAL SPRAY 30 ML	2	Preferred Brand	$45.00	$90.00	None
ATENOLOL 100mg 100 TABLET BOTTLE	1	Preferred Generic	$6.00	$0.00	None
Atenolol 25mg 100 TABLET BOTTLE	1	Preferred Generic	$6.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ATENOLOL TABLET USP 50MG (100 CT)	1	Preferred Generic	$6.00	$0.00	None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)	1	Preferred Generic	$6.00	$0.00	None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)	1	Preferred Generic	$6.00	$0.00	None
ATORVASTATIN 10 MG TABLET	1	Preferred Generic	$6.00	$0.00	Q:31 /31Days
ATORVASTATIN 20 MG TABLET	1	Preferred Generic	$6.00	$0.00	Q:31 /31Days
ATORVASTATIN 40 MG TABLET	1	Preferred Generic	$6.00	$0.00	Q:31 /31Days
ATORVASTATIN 80 MG TABLET	1	Preferred Generic	$6.00	$0.00	Q:31 /31Days
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC	4	Specialty Tier	33%	N/A	Q:31 /31Days
ATROPINE 0.05MG/ML SYRINGE	2	Preferred Brand	$45.00	$90.00	None
ATROPINE 0.1MG/ML SYRINGE	2	Preferred Brand	$45.00	$90.00	None
ATROVENT HFA AER 17MCG	2	Preferred Brand	$45.00	$90.00	Q:26 /31Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT	2	Preferred Brand	$45.00	$90.00	None
AVANDAMET 1000; 2mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$95.00	$190.00	Q:62 /31Days
AVANDAMET 1000; 4mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$95.00	$190.00	Q:62 /31Days
AVANDAMET 500; 2mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$95.00	$190.00	Q:62 /31Days
AVANDAMET 500; 4mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$95.00	$190.00	Q:62 /31Days
AVANDARYL 1; 4mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$95.00	$190.00	Q:31 /31Days
AVANDARYL 2; 4mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$95.00	$190.00	Q:31 /31Days
AVANDARYL 2; 8mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$95.00	$190.00	Q:31 /31Days
AVANDARYL 4; 4mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$95.00	$190.00	Q:31 /31Days
AVANDARYL 4; 8mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$95.00	$190.00	Q:31 /31Days
AVANDIA 2mg/1 60 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$95.00	$190.00	Q:31 /31Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AVANDIA 4mg/1 30 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$95.00	$190.00	Q:31 /31Days
AVANDIA 8mg/1 30 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$95.00	$190.00	Q:31 /31Days
AVASTIN 100MG/4ML VIAL	4	Specialty Tier	33%	N/A	P
AVIANE 0.1-0.02 TABLET	2	Preferred Brand	$45.00	$90.00	None
AVODART 0.5MG SOFTGEL	2	Preferred Brand	$45.00	$90.00	Q:31 /31Days
AVONEX ADMIN PACK 30MCG SYR	4	Specialty Tier	33%	N/A	P Q:4 /28Days
AVONEX ADMIN PACK 30MCG VL	4	Specialty Tier	33%	N/A	P Q:4 /28Days
AZASITE 1% DROPS	2	Preferred Brand	$45.00	$90.00	None
AZATHIOPRINE 50MG TABLET	1	Preferred Generic	$6.00	$0.00	P
AZATHIOPRINE SOD 100MG VIAL	1	Preferred Generic	$6.00	$0.00	P
AZELASTINE 137 MCG NASAL SPRAY	2	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
AZELEX 20% CREAM 30GM TUBE	2	Preferred Brand	$45.00	$90.00	None
AZILECT 0.5MG TABLET	3	Non-Preferred Brand	$95.00	$190.00	None
AZILECT 1MG TABLET	3	Non-Preferred Brand	$95.00	$190.00	None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL	2	Preferred Brand	$45.00	$90.00	None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL	2	Preferred Brand	$45.00	$90.00	None
AZITHROMYCIN 250 MG TABLET	1	Preferred Generic	$6.00	$0.00	None
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION	2	Preferred Brand	$45.00	$90.00	None
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE	1	Preferred Generic	$6.00	$0.00	None
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE	1	Preferred Generic	$6.00	$0.00	None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT	2	Preferred Brand	$45.00	$90.00	None

Chart Legend:

Below are a few notes to help you understand the above 2013 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 $325 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 $2970) 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 2013 )

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.