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2013 Medicare Part D Plan Formulary Information
WellCare Classic (PDP) (S5967-155-0) Benefit Details
The WellCare Classic (PDP) (S5967-155-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 18 which includes: MO
Drugs Starting with Letter P Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter P Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PACERONE 200MG TABLET	1	Preferred Generic	$5.00	$0.00	None
PAMIDRONATE DISODIUM INJECTION 3MG 10ML VIALSD	3	Non-Preferred Brand	$92.00	$184.00	P
PAMIDRONATE DISODIUM INJECTION 9MG 10ML VIALSD	3	Non-Preferred Brand	$92.00	$184.00	P
PANRETIN 0.1% GEL 60GM TUBE	4	Specialty Tier	33%	N/A	None
Pantoprazole 40mg/1 90 TABLET, DELAYED RELEASE in 1 BOTTLE	1	Preferred Generic	$5.00	$0.00	None
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE	1	Preferred Generic	$5.00	$0.00	None
pantoprazole sodium 40 mg vial	1	Preferred Generic	$5.00	$0.00	None
PAROMOMYCIN 250MG CAPSULE	2	Preferred Brand	$41.00	$82.00	None
Paroxetine 40mg/1 500 FILM COATED TABLETS in BOTTLE	1	Preferred Generic	$5.00	$0.00	Q:62 /31Days
PAROXETINE FILM COATED 20MG TABLET (100 CT)	1	Preferred Generic	$5.00	$0.00	Q:62 /31Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PAROXETINE HYDROCHLORIDE TABLETS 10 MG	1	Preferred Generic	$5.00	$0.00	Q:62 /31Days
PAROXETINE TABLETS 30MG 90 BOT	1	Preferred Generic	$5.00	$0.00	Q:62 /31Days
PASER GRANULES 4GM PACKET	3	Non-Preferred Brand	$92.00	$184.00	None
PATADAY 0.2% DROPS	3	Non-Preferred Brand	$92.00	$184.00	None
PATANOL 0.1% EYE DROPS	3	Non-Preferred Brand	$92.00	$184.00	None
PAXIL ORAL SUSPENSION 10 MG/5ML	3	Non-Preferred Brand	$92.00	$184.00	None
PEDI-DRI TOPICAL POWDER	2	Preferred Brand	$41.00	$82.00	None
PEDVAXHIB VACCINE VIAL	2	Preferred Brand	$41.00	$82.00	None
PEGANONE 250MG TABLET	3	Non-Preferred Brand	$92.00	$184.00	None
PEGASYS 180MCG/0.5ML CONV.PK	4	Specialty Tier	33%	N/A	P
PEGASYS INJECTION	4	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PEGASYS PROCLICK 135 MCG/0.5	4	Specialty Tier	33%	N/A	P
PENICILLIN G POTASSIUM FOR INJECTION 5000000UNIT/VIAL	2	Preferred Brand	$41.00	$82.00	None
PENICILLIN G PROCAINE 1200000UNT 2ML CTG	2	Preferred Brand	$41.00	$82.00	None
Penicillin V Potassium 125mg/5mL 200 mL in 1 BOTTLE	1	Preferred Generic	$5.00	$0.00	None
Penicillin V Potassium 250mg/1 1000 TABLET BOTTLE	1	Preferred Generic	$5.00	$0.00	None
PENICILLIN V POTASSIUM 250MG/5ML LIQUID	1	Preferred Generic	$5.00	$0.00	None
PENICILLIN V POTASSIUM 500MG TABLET	1	Preferred Generic	$5.00	$0.00	None
PENTAM 300 INJ 300MG	3	Non-Preferred Brand	$92.00	$184.00	P
PENTOSTATIN FOR INJECTION 10MG/VIAL	1	Preferred Generic	$5.00	$0.00	P
PENTOXIFYLLINE 400MG TABLET SA	2	Preferred Brand	$41.00	$82.00	None
PERIOGARD 0.12% ORAL RINSE	1	Preferred Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Permethrin 50mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE	1	Preferred Generic	$5.00	$0.00	None
Perphenazine 16mg/1 100 FILM COATED TABLETS in BOTTLE	1	Preferred Generic	$5.00	$0.00	None
PERPHENAZINE TABLETS 4MG 100 BOXUD	1	Preferred Generic	$5.00	$0.00	None
PERPHENAZINE TABLETS 8MG 100 BOT	1	Preferred Generic	$5.00	$0.00	None
PERPHENAZINE TABLETS USP 2MG 100 BOT	1	Preferred Generic	$5.00	$0.00	None
PERTZYE DR 16,000 UNITS CAPS	3	Non-Preferred Brand	$92.00	$184.00	None
PERTZYE DR 8,000 UNITS CAPSULE	3	Non-Preferred Brand	$92.00	$184.00	None
PFIZERPEN 20MMU VIAL	2	Preferred Brand	$41.00	$82.00	None
Phenadoz 12.5 mg Suppository	2	Preferred Brand	$41.00	$82.00	None
PHENADOZ 25MG SUPPOSITORY	2	Preferred Brand	$41.00	$82.00	None
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE	3	Non-Preferred Brand	$92.00	$184.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Phenobarbital 100mg/1	1	Preferred Generic	$5.00	$0.00	None
Phenobarbital 15mg/1	1	Preferred Generic	$5.00	$0.00	None
PHENOBARBITAL 16.2 MG TABLET	1	Preferred Generic	$5.00	$0.00	None
PHENOBARBITAL 20 MG/5 ML ELIX	1	Preferred Generic	$5.00	$0.00	None
Phenobarbital 30mg/1	1	Preferred Generic	$5.00	$0.00	None
PHENOBARBITAL 32.4 MG TABLET	1	Preferred Generic	$5.00	$0.00	None
Phenobarbital 60mg/1	1	Preferred Generic	$5.00	$0.00	None
PHENOBARBITAL 64.8 MG TABLET	1	Preferred Generic	$5.00	$0.00	None
PHENOBARBITAL 97.2 MG TABLET	1	Preferred Generic	$5.00	$0.00	None
phenytoin 50 mg tablet chew	2	Preferred Brand	$41.00	$82.00	None
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT	2	Preferred Brand	$41.00	$82.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PHENYTOIN SOD EXT 200 MG CAP	1	Preferred Generic	$5.00	$0.00	None
PHENYTOIN SODIUM 50mg/mL 25 VIAL, SINGLE-DOSE in 1 CARTON / 2 mL in 1 VIAL, SINGLE-DOSE	2	Preferred Brand	$41.00	$82.00	None
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT)	1	Preferred Generic	$5.00	$0.00	None
Phoslyra 667mg/5mL 1 BOTTLE in 1 CARTON / 473 mL in 1 BOTTLE	3	Non-Preferred Brand	$92.00	$184.00	None
PHYSIOLYTE SOLUTION FOR IRRIGATION	2	Preferred Brand	$41.00	$82.00	None
PILOCARPINE HCL 5MG TABLET (100 CT)	3	Non-Preferred Brand	$92.00	$184.00	None
Pilocarpine Hydrochloride 7.5mg/1 100 FILM COATED TABLETS in BOTTLE	3	Non-Preferred Brand	$92.00	$184.00	None
PILOPINE HS 4% EYE GEL	2	Preferred Brand	$41.00	$82.00	None
PINDOLOL 10MG TABLET	1	Preferred Generic	$5.00	$0.00	None
PINDOLOL 5MG TABLET	1	Preferred Generic	$5.00	$0.00	None
pioglitaz-glimepir 30-2 mg tab	3	Non-Preferred Brand	$92.00	$184.00	Q:31 /31Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
pioglitaz-glimepir 30-4 mg tab	3	Non-Preferred Brand	$92.00	$184.00	Q:31 /31Days
pioglitazone hcl 15 mg tablet	3	Non-Preferred Brand	$92.00	$184.00	Q:31 /31Days
pioglitazone hcl 30 mg tablet	3	Non-Preferred Brand	$92.00	$184.00	Q:31 /31Days
pioglitazone hcl 45 mg tablet	3	Non-Preferred Brand	$92.00	$184.00	Q:31 /31Days
PIOGLITAZONE-METFORMIN 15-500	3	Non-Preferred Brand	$92.00	$184.00	Q:93 /31Days
PIOGLITAZONE-METFORMIN 15-850	3	Non-Preferred Brand	$92.00	$184.00	Q:93 /31Days
PIPERACILLIN 200 MG/ML / TAZOBACTAM 25 MG/ML INJECTABLE SOLUTION	3	Non-Preferred Brand	$92.00	$184.00	None
Piperacillin and Tazobactam 4; 0.5g/1; g/1 10 VIAL, SINGLE-USE in 1 CARTON / 1 INJECTION, POWDER, L	3	Non-Preferred Brand	$92.00	$184.00	None
PIROXICAM 10 MG CAPSULE	2	Preferred Brand	$41.00	$82.00	None
Piroxicam 20mg/1 500 CAPSULE in 1 BOTTLE	2	Preferred Brand	$41.00	$82.00	None
PLASMA-LYTE 148 IV SOLUTION	3	Non-Preferred Brand	$92.00	$184.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PLASMA-LYTE 56/DEXTROSE 5%	3	Non-Preferred Brand	$92.00	$184.00	None
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML;	3	Non-Preferred Brand	$92.00	$184.00	None
PODOFILOX 0.5% TOPICAL TUBEX	2	Preferred Brand	$41.00	$82.00	None
POLYETH GLYC NF POWDER FOR ORAL SOLUTION 17GM (527 CT)	1	Preferred Generic	$5.00	$0.00	None
POLYETHYLENE GLYCOL 3350 105 MG/ML / POTASSIUM CHLORIDE 0.00497 MEQ/ML / SODIUM BICARBONATE 1.43 MG/	1	Preferred Generic	$5.00	$0.00	None
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1%	1	Preferred Generic	$5.00	$0.00	None
POMALYST 1 MG CAPSULE	4	Specialty Tier	33%	N/A	P
POMALYST 2 MG CAPSULE	4	Specialty Tier	33%	N/A	P
POMALYST 3 MG CAPSULE	4	Specialty Tier	33%	N/A	P
POMALYST 4 MG CAPSULE	4	Specialty Tier	33%	N/A	P
PORTIA 0.15-0.03 TABLET	2	Preferred Brand	$41.00	$82.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45%	3	Non-Preferred Brand	$92.00	$184.00	None
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.9% 1000ML	3	Non-Preferred Brand	$92.00	$184.00	None
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG	3	Non-Preferred Brand	$92.00	$184.00	None
POTASSIUM CHLORIDE 10MEQ/100ML SOL	3	Non-Preferred Brand	$92.00	$184.00	None
POTASSIUM CHLORIDE 10MEQ/50ML SOL	3	Non-Preferred Brand	$92.00	$184.00	None
POTASSIUM CHLORIDE 149mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 5 mL in 1 VIAL, SINGLE-DOSE	1	Preferred Generic	$5.00	$0.00	None
Potassium Chloride 20.000000meq/1	1	Preferred Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225%	3	Non-Preferred Brand	$92.00	$184.00	None
POTASSIUM CHLORIDE 20MEQ/50ML SOL	3	Non-Preferred Brand	$92.00	$184.00	None
POTASSIUM CHLORIDE 30MEQ/100ML SOL	3	Non-Preferred Brand	$92.00	$184.00	None
POTASSIUM CHLORIDE 40MEQ/NS 1000ML IV SOLUTION	3	Non-Preferred Brand	$92.00	$184.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POTASSIUM CHLORIDE ER CAPSULES 10MEQ	1	Preferred Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE ER CPCR 8MEQ	1	Preferred Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE EXTENDED RELEASE TABLETS	1	Preferred Generic	$5.00	$0.00	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE	3	Non-Preferred Brand	$92.00	$184.00	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA	3	Non-Preferred Brand	$92.00	$184.00	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION	3	Non-Preferred Brand	$92.00	$184.00	None
POTASSIUM CHLORIDE IN DEXTROSE 5; 0.3g/100mL; g/100mL 12 CONTAINER in 1 CASE / 1000 mL in 1 CONTAIN	3	Non-Preferred Brand	$92.00	$184.00	None
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG	2	Preferred Brand	$41.00	$82.00	None
Potassium Chloride in Dextrose 5; 224g/100mL; mg/100mL 1000 mL in 1 BAG	3	Non-Preferred Brand	$92.00	$184.00	None
Potassium Chloride in Dextrose and Sodium Chloride 5; 0.15; 0.33g/100mL; g/100mL; g/100mL 12 CONTAI	3	Non-Preferred Brand	$92.00	$184.00	None
Potassium Chloride in Dextrose and Sodium Chloride 5; 300; 900g/100mL; mg/100mL; mg/100mL 1000 mL i	3	Non-Preferred Brand	$92.00	$184.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL	3	Non-Preferred Brand	$92.00	$184.00	None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION	3	Non-Preferred Brand	$92.00	$184.00	None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG	3	Non-Preferred Brand	$92.00	$184.00	None
POTIGA 200 MG TABLET	4	Specialty Tier	33%	N/A	P
POTIGA 300 MG TABLET	4	Specialty Tier	33%	N/A	P
POTIGA 400 MG TABLET	4	Specialty Tier	33%	N/A	P
POTIGA 50 MG TABLET	3	Non-Preferred Brand	$92.00	$184.00	P
PRADAXA 150mg/1 1 BOTTLE in 1 CARTON / 60 CAPSULE in 1 BOTTLE	3	Non-Preferred Brand	$92.00	$184.00	Q:62 /31Days
PRADAXA 75mg/1 1 BOTTLE in 1 CARTON / 60 CAPSULE in 1 BOTTLE	3	Non-Preferred Brand	$92.00	$184.00	Q:62 /31Days
Pramipexole Dihydrochloride 0.125mg/1 500 TABLET BOTTLE, PLASTIC	3	Non-Preferred Brand	$92.00	$184.00	None
Pramipexole Dihydrochloride 0.25mg/1 500 TABLET BOTTLE, PLASTIC	3	Non-Preferred Brand	$92.00	$184.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Pramipexole Dihydrochloride 0.5mg/1 500 TABLET BOTTLE, PLASTIC	3	Non-Preferred Brand	$92.00	$184.00	None
Pramipexole Dihydrochloride 1.5mg/1 500 TABLET BOTTLE, PLASTIC	3	Non-Preferred Brand	$92.00	$184.00	None
Pramipexole Dihydrochloride 1mg/1 500 TABLET BOTTLE, PLASTIC	3	Non-Preferred Brand	$92.00	$184.00	None
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS	3	Non-Preferred Brand	$92.00	$184.00	None
PRANDIMET TABLET	3	Non-Preferred Brand	$92.00	$184.00	None
PRANDIMET TABLET	3	Non-Preferred Brand	$92.00	$184.00	None
Prandin 0.5mg/1 100 TABLET BOTTLE, PLASTIC	3	Non-Preferred Brand	$92.00	$184.00	None
Prandin 1mg/1 100 TABLET BOTTLE, PLASTIC	3	Non-Preferred Brand	$92.00	$184.00	None
Prandin 2mg/1 100 TABLET BOTTLE, PLASTIC	3	Non-Preferred Brand	$92.00	$184.00	None
PRAVASTATIN SODIUM 20MG TABLET 500 BOT	1	Preferred Generic	$5.00	$0.00	Q:31 /31Days
PRAVASTATIN SODIUM 40MG TABLET (500 CT)	1	Preferred Generic	$5.00	$0.00	Q:31 /31Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Pravastatin Sodium 80 mg tab	1	Preferred Generic	$5.00	$0.00	Q:31 /31Days
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT	1	Preferred Generic	$5.00	$0.00	Q:31 /31Days
PRAZOSIN 5MG CAPSULE	1	Preferred Generic	$5.00	$0.00	None
PRAZOSIN HCL 1MG CAPSULE	1	Preferred Generic	$5.00	$0.00	None
PRAZOSIN HCL 2MG CAPSULE	1	Preferred Generic	$5.00	$0.00	None
PREDNICARBATE 0.1% OINTMENT	2	Preferred Brand	$41.00	$82.00	None
PREDNICARBATE 1 MG/ML TOPICAL CREAM	2	Preferred Brand	$41.00	$82.00	None
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR	1	Preferred Generic	$5.00	$0.00	None
PREDNISOLONE SOD 1% EYE DROP	1	Preferred Generic	$5.00	$0.00	None
PREDNISOLONE SOD PH 25 MG/5 ML	1	Preferred Generic	$5.00	$0.00	None
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL	1	Preferred Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION	1	Preferred Generic	$5.00	$0.00	None
PREDNISONE 10MG TABLET (100 CT)	1	Preferred Generic	$5.00	$0.00	None
PREDNISONE 1MG TABLET	1	Preferred Generic	$5.00	$0.00	None
PREDNISONE 2.5MG TABLET	1	Preferred Generic	$5.00	$0.00	None
PREDNISONE 20MG TABLET (1000 CT)	1	Preferred Generic	$5.00	$0.00	None
PREDNISONE 5 MG TABLET	1	Preferred Generic	$5.00	$0.00	None
PREDNISONE 50MG TABLET	1	Preferred Generic	$5.00	$0.00	None
PREDNISONE 5MG/5ML SOLUTION	2	Preferred Brand	$41.00	$82.00	None
PREMARIN 0.3MG (100 CT)	2	Preferred Brand	$41.00	$82.00	Q:31 /31Days
PREMARIN 0.45MG TABLET	2	Preferred Brand	$41.00	$82.00	Q:31 /31Days
PREMARIN 0.625MG (100 CT)	2	Preferred Brand	$41.00	$82.00	Q:31 /31Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Premarin 0.625mg/g	2	Preferred Brand	$41.00	$82.00	None
PREMARIN 0.9MG TABLET	2	Preferred Brand	$41.00	$82.00	Q:31 /31Days
PREMARIN 1.25MG (100 CT)	2	Preferred Brand	$41.00	$82.00	Q:31 /31Days
PREMARIN 25MG VIAL	2	Preferred Brand	$41.00	$82.00	None
PREMASOL 10% IV SOLUTION	3	Non-Preferred Brand	$92.00	$184.00	None
PREMASOL 6% IV SOLUTION	3	Non-Preferred Brand	$92.00	$184.00	None
PREMPHASE 0.625-5 MG TABLET	2	Preferred Brand	$41.00	$82.00	None
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA	2	Preferred Brand	$41.00	$82.00	None
PREMPRO 0.45-1.5 MG TABLET 28 EA	2	Preferred Brand	$41.00	$82.00	None
PREMPRO 0.625-5 MG TABLET	2	Preferred Brand	$41.00	$82.00	None
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK in 1 CARTON / 28 TABLET, SUGAR COATED in 1 BLISTER PACK	2	Preferred Brand	$41.00	$82.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PREVALITE POW 4GM	2	Preferred Brand	$41.00	$82.00	None
Previfem 6 BLISTER PACK in 1 BLISTER PACK / 1 KIT in 1 BLISTER PACK	2	Preferred Brand	$41.00	$82.00	None
PREZISTA 100 MG/ML SUSPENSION	4	Specialty Tier	33%	N/A	Q:372 /31Days
PREZISTA 800 MG TABLET	4	Specialty Tier	33%	N/A	Q:62 /31Days
PREZISTA TABLET 600MG	4	Specialty Tier	33%	N/A	Q:62 /31Days
PREZISTA TABLET 75MG	2	Preferred Brand	$41.00	$82.00	Q:62 /31Days
PREZISTA TABLETS	2	Preferred Brand	$41.00	$82.00	None
PREZISTA TABLETS 400MG 60 TABLETS BOT	4	Specialty Tier	33%	N/A	Q:62 /31Days
PRIFTIN 150MG TABLET	3	Non-Preferred Brand	$92.00	$184.00	None
Primidone 250mg/1 100 TABLET BOTTLE	2	Preferred Brand	$41.00	$82.00	None
Primidone 50mg/1 500 TABLET BOTTLE	2	Preferred Brand	$41.00	$82.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PRISTIQ 100MG TABLET SR 24HR	3	Non-Preferred Brand	$92.00	$184.00	P Q:31 /31Days
Pristiq Extended-Release 50mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	3	Non-Preferred Brand	$92.00	$184.00	P Q:31 /31Days
PROBENECID 500MG TABLET	1	Preferred Generic	$5.00	$0.00	None
PROCAINAMIDE 100MG/ML VIAL	1	Preferred Generic	$5.00	$0.00	None
PROCAINAMIDE 500MG/ML VIAL	1	Preferred Generic	$5.00	$0.00	None
ProcalAmine 0.21; 0.29; 0.026; 0.014; 3; 0.42; 0.085; 0.21; 0.27; 0.22; 0.054; 0.16; 0.17; 0.041; 0	3	Non-Preferred Brand	$92.00	$184.00	None
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN	2	Preferred Brand	$41.00	$82.00	None
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT)	1	Preferred Generic	$5.00	$0.00	None
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT)	1	Preferred Generic	$5.00	$0.00	None
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX	2	Preferred Brand	$41.00	$82.00	None
PROCRIT 10000U/ML VIAL	2	Preferred Brand	$41.00	$82.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL	2	Preferred Brand	$41.00	$82.00	P
PROCRIT 3000U/ML VIAL	2	Preferred Brand	$41.00	$82.00	P
PROCRIT 40000U/ML VIAL PR	4	Specialty Tier	33%	N/A	P
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL	2	Preferred Brand	$41.00	$82.00	P
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY	4	Specialty Tier	33%	N/A	P
Proctocream HC 25mg/g	1	Preferred Generic	$5.00	$0.00	None
Proglycem 50mg/mL 1 BOTTLE, DROPPER in 1 BOX / 30 mL in 1 BOTTLE, DROPPER	3	Non-Preferred Brand	$92.00	$184.00	None
PROGRAF 5MG/ML AMPULE	2	Preferred Brand	$41.00	$82.00	P
PROLASTIN-C 1 KIT in 1 CARTON	4	Specialty Tier	33%	N/A	P
PROLENSA 0.07% EYE DROPS	3	Non-Preferred Brand	$92.00	$184.00	None
PROLEUKIN 22 MILLION UNIT 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
PROLIA INJECTION	3	Non-Preferred Brand	$92.00	$184.00	P Q:1 /180Days
PROMACTA 12.5 MG TABLET	4	Specialty Tier	33%	N/A	P Q:31 /31Days
PROMACTA 25 MG TABLET	4	Specialty Tier	33%	N/A	P Q:31 /31Days
PROMACTA 50 MG TABLET	4	Specialty Tier	33%	N/A	P Q:31 /31Days
PROMACTA 75 MG TABLET	4	Specialty Tier	33%	N/A	P Q:31 /31Days
PROMETHAZINE 50MG/ML VIAL	2	Preferred Brand	$41.00	$82.00	P
PROMETHAZINE HCL 25MG TABLET (1000 CT)	2	Preferred Brand	$41.00	$82.00	P
PROMETHAZINE HCL 50MG TABLET (100 CT)	2	Preferred Brand	$41.00	$82.00	P
PROMETHAZINE HCL 6.25MG/5ML SYRUP	2	Preferred Brand	$41.00	$82.00	P
PROMETHAZINE HCL INJECTION 25MG 10 X 1ML VIAL	2	Preferred Brand	$41.00	$82.00	P
Promethazine Hydrochloride 12.5mg/1 100 TABLET BOTTLE	2	Preferred Brand	$41.00	$82.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX	2	Preferred Brand	$41.00	$82.00	P
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX	2	Preferred Brand	$41.00	$82.00	P
PROMETHAZINE VC PLAIN 6.25-5MG 16 FL OZ BOT	2	Preferred Brand	$41.00	$82.00	None
PROMETHEGAN 25MG SUPP	2	Preferred Brand	$41.00	$82.00	None
PROMETHEGAN 50MG SUPPOS	2	Preferred Brand	$41.00	$82.00	None
Propafenone HCl 150mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	2	Preferred Brand	$41.00	$82.00	None
PROPAFENONE HCL 225MG TABLET	2	Preferred Brand	$41.00	$82.00	None
PROPAFENONE HCL 300MG TABLET (100 CT)	2	Preferred Brand	$41.00	$82.00	None
Propantheline Bromide 15mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	2	Preferred Brand	$41.00	$82.00	None
Propranolol 1mg/mL 1 mL in 1 VIAL	2	Preferred Brand	$41.00	$82.00	None
PROPRANOLOL 20MG/5ML TUBEX	2	Preferred Brand	$41.00	$82.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROPRANOLOL 40MG/5ML TUBEX	2	Preferred Brand	$41.00	$82.00	None
PROPRANOLOL 60MG TABLET	1	Preferred Generic	$5.00	$0.00	None
PROPRANOLOL 80 MG TABLET	1	Preferred Generic	$5.00	$0.00	None
PROPRANOLOL HCL 20MG TABLET (1000 CT)	1	Preferred Generic	$5.00	$0.00	None
PROPRANOLOL HCL TABLET USP 10MG (1000 CT)	1	Preferred Generic	$5.00	$0.00	None
PROPRANOLOL HCL TABLET USP 40MG (1000 CT)	1	Preferred Generic	$5.00	$0.00	None
Propranolol Hydrochloride 120mg EXTENDED RELEASE 100 CAPSULE BOTTLE	2	Preferred Brand	$41.00	$82.00	None
Propranolol Hydrochloride 160mg EXTENDED RELEASE 100 CAPSULE BOTTLE	2	Preferred Brand	$41.00	$82.00	None
Propranolol Hydrochloride 60mg/1 1000 CAPSULE, EXTENDED RELEASE in 1 BOTTLE	2	Preferred Brand	$41.00	$82.00	None
Propranolol Hydrochloride 80mg EXTENDED RELEASE 100 CAPSULE BOTTLE	2	Preferred Brand	$41.00	$82.00	None
PROPRANOLOL/HCTZ 40/25 TABLET	1	Preferred Generic	$5.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROPRANOLOL/HCTZ 80/25 TABLET	1	Preferred Generic	$5.00	$0.00	None
PROPYLTHIOURACIL 50MG TABLET	1	Preferred Generic	$5.00	$0.00	None
PROQUAD VIAL	2	Preferred Brand	$41.00	$82.00	None
PROSOL 20% INJECTION	3	Non-Preferred Brand	$92.00	$184.00	None
PROTOPIC 0.03% OINTMENT 100GM TUBE	3	Non-Preferred Brand	$92.00	$184.00	P
PROTOPIC 0.1% OINTMENT 60GM TUBE	3	Non-Preferred Brand	$92.00	$184.00	P
PROTRIPTYLINE HYDROCHLORIDE TABLETS	2	Preferred Brand	$41.00	$82.00	None
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG	2	Preferred Brand	$41.00	$82.00	None
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED	3	Non-Preferred Brand	$92.00	$184.00	None
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED	3	Non-Preferred Brand	$92.00	$184.00	None
PULMOZYME 1MG/ML AMPUL	4	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
pyridostigmine br 60 mg tablet	2	Preferred Brand	$41.00	$82.00	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.