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WellCare Value Script (PDP) (S4802-147-0)
Tier 1 (378)
Tier 2 (463)
Tier 3 (947)
Tier 4 (959)
Tier 5 (649)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
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Cick on the first letter of your drug name to browse the formulary:

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2019 Medicare Part D Plan Formulary Information
WellCare Value Script (PDP) (S4802-147-0)
Benefit Details           
The WellCare Value Script (PDP) (S4802-147-0)
Formulary Drugs Starting with the Letter E

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $15.50 Deductible: $415 Qualifies for LIS: No
Drugs Starting with Letter E

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
E.E.S. 400 FILMTAB   4 Non-Preferred Drug 46%46%None
EDARBI 40 MG TABLET   4 Non-Preferred Drug 46%46%None
EDARBI 80 MG TABLET   4 Non-Preferred Drug 46%46%None
EDURANT 27.5mg/1   5 Specialty Tier 25%N/ANone
EFAVIRENZ 200 MG CAPSULE [Sustiva]   5 Specialty Tier 25%N/ANone
EFAVIRENZ 50 MG CAPSULE [Sustiva]   4 Non-Preferred Drug 46%46%None
EFAVIRENZ 600 MG TABLET [Sustiva]   5 Specialty Tier 25%N/ANone
ELETRIPTAN HBR 20 MG TABLET [Relpax]   4 Non-Preferred Drug 46%46%Q:12
/30Days
ELETRIPTAN HBR 40 MG TABLET [Relpax]   4 Non-Preferred Drug 46%46%Q:12
/30Days
ELIQUIS 2.5 MG TABLET   3 Preferred Brand $40.00$100.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ELIQUIS 5 MG STARTER PACK   3 Preferred Brand $40.00$100.00None
ELIQUIS 5 MG TABLET   3 Preferred Brand $40.00$100.00None
EMCYT 140MG CAPSULE   4 Non-Preferred Drug 46%46%None
EMEND 125 MG POWDER PACKET   4 Non-Preferred Drug 46%46%P
EMGALITY 120 MG/ML PEN INJCTR   3 Preferred Brand $40.00$100.00P Q:2
/30Days
EMGALITY 120 MG/ML SYRINGE   3 Preferred Brand $40.00$100.00P Q:2
/30Days
EMOQUETTE 28 DAY TABLET [Solia]   2* Generic $5.00$12.50None
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy]   3 Preferred Brand $40.00$100.00Q:120
/30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H   5 Specialty Tier 25%N/AP Q:30
/30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H   5 Specialty Tier 25%N/AP Q:30
/30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H   5 Specialty Tier 25%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EMTRIVA 10MG/ML SOLUTION   3 Preferred Brand $40.00$100.00None
EMTRIVA 200MG CAPSULE   3 Preferred Brand $40.00$100.00None
EMVERM 100 MG TABLET CHEW   5 Specialty Tier 25%N/ANone
ENALAPRIL MALEATE 10 MG TAB   1* Preferred Generic $0.00$0.00None
ENALAPRIL MALEATE 2.5 MG TAB   1* Preferred Generic $0.00$0.00None
ENALAPRIL MALEATE 20 MG TAB   1* Preferred Generic $0.00$0.00None
ENALAPRIL MALEATE 5 MG TABLET   1* Preferred Generic $0.00$0.00None
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC   1* Preferred Generic $0.00$0.00None
ENALAPRIL-HCTZ 5-12.5 MG TAB   1* Preferred Generic $0.00$0.00None
ENDARI 5 GRAM POWDER PACKET   5 Specialty Tier 25%N/AP
ENDOCET 10MG-325MG TABLET   3 Preferred Brand $40.00$100.00Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENDOCET 5/325 TABLET   3 Preferred Brand $40.00$100.00Q:360
/30Days
ENDOCET 7.5-325MG TABLET   3 Preferred Brand $40.00$100.00Q:240
/30Days
ENGERIX B INJECTION   3 Preferred Brand $40.00$100.00P
ENGERIX-B 20 MCG/ML SYRN   3 Preferred Brand $40.00$100.00P
ENOXAPARIN 100 MG/ML SYRINGE   4 Non-Preferred Drug 46%46%None
ENOXAPARIN 120 MG/0.8 ML SYRINGE   4 Non-Preferred Drug 46%46%None
ENOXAPARIN 150 MG/ML SYRINGE   4 Non-Preferred Drug 46%46%None
ENOXAPARIN 30 MG/0.3 ML SYR   4 Non-Preferred Drug 46%46%None
ENOXAPARIN 40 MG/0.4 ML SYR   4 Non-Preferred Drug 46%46%None
ENOXAPARIN 60 MG/0.6 ML SYRINGE   4 Non-Preferred Drug 46%46%None
ENOXAPARIN 80 MG/0.8 ML SYRINGE   4 Non-Preferred Drug 46%46%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENSKYCE 28 TABLET [Solia]   2* Generic $5.00$12.50None
ENSTILAR 0.005%-0.064% FOAM   4 Non-Preferred Drug 46%46%P
ENTACAPONE 200 MG TABLET [Comtan Entacapone]   4 Non-Preferred Drug 46%46%None
ENTECAVIR 0.5 MG TABLET [Baraclude]   5 Specialty Tier 25%N/ANone
ENTECAVIR 1 MG TABLET [Baraclude]   5 Specialty Tier 25%N/ANone
ENTRESTO 24 MG-26 MG TABLET   3 Preferred Brand $40.00$100.00None
ENTRESTO 49 MG-51 MG TABLET   3 Preferred Brand $40.00$100.00None
ENTRESTO 97 MG-103 MG TABLET   3 Preferred Brand $40.00$100.00None
ENULOSE 10 GM/15 ML SOLUTION   2* Generic $5.00$12.50None
EPCLUSA 400 MG-100 MG TABLET   5 Specialty Tier 25%N/AP
EPIDIOLEX 100 MG/ML SOLUTION   5 Specialty Tier 25%N/AP Q:600
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EPINEPHRINE 0.15 MG AUTO-INJECT   3 Preferred Brand $40.00$100.00None
EPINEPHRINE 0.3 MG AUTO-INJECT   3 Preferred Brand $40.00$100.00None
EPITOL 200MG TABLET   3 Preferred Brand $40.00$100.00None
EPIVIR HBV 25MG/5ML TUBEX   4 Non-Preferred Drug 46%46%None
Eplerenone 25mg/1 90 TABLET BOTTLE   3 Preferred Brand $40.00$100.00None
Eplerenone 50mg/1 90 TABLET BOTTLE   3 Preferred Brand $40.00$100.00None
Ergotamine-caffeine 1-100mg tb   4 Non-Preferred Drug 46%46%None
ERIVEDGE 150 MG CAPSULE   5 Specialty Tier 25%N/AP
ERLEADA 60 MG TABLET   5 Specialty Tier 25%N/AP
ERLOTINIB HCL 100 MG TABLET [Tarceva]   5 Specialty Tier 25%N/AP Q:30
/30Days
ERLOTINIB HCL 150 MG TABLET [Tarceva]   5 Specialty Tier 25%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ERLOTINIB HCL 25 MG TABLET [Tarceva]   5 Specialty Tier 25%N/AP Q:90
/30Days
Errin 0.35 mg tablet   2* Generic $5.00$12.50None
ERTAPENEM 1 GRAM VIAL [Invanz]   4 Non-Preferred Drug 46%46%None
ERY 2% PADS 2% 60 PADS JAR   3 Preferred Brand $40.00$100.00None
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE   4 Non-Preferred Drug 46%46%None
ERY-TAB TAB 250MG EC   4 Non-Preferred Drug 46%46%None
ERY-TAB TAB 333MG EC   4 Non-Preferred Drug 46%46%None
ERYTHROCIN 500MG ADDVNT VL   4 Non-Preferred Drug 46%46%None
ERYTHROCIN TAB 250MG   4 Non-Preferred Drug 46%46%None
ERYTHROMYCIN 0.5% EYE OINTMENT   2* Generic $5.00$12.50None
ERYTHROMYCIN 2% GEL   4 Non-Preferred Drug 46%46%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ERYTHROMYCIN 2% SOLUTION   3 Preferred Brand $40.00$100.00None
ERYTHROMYCIN 500 MG FILMTAB   4 Non-Preferred Drug 46%46%None
ERYTHROMYCIN EC 250 MG CAP   4 Non-Preferred Drug 46%46%None
ERYTHROMYCIN ES 400 MG TAB   4 Non-Preferred Drug 46%46%None
ERYTHROMYCIN TAB 250MG BS   4 Non-Preferred Drug 46%46%None
ERYTHROMYCIN-BENZOYL GEL   4 Non-Preferred Drug 46%46%None
ESBRIET 267 MG CAPSULE   5 Specialty Tier 25%N/AP
ESBRIET 267 MG TABLET   5 Specialty Tier 25%N/AP
ESBRIET 801 MG TABLET   5 Specialty Tier 25%N/AP
ESCITALOPRAM 10 MG TABLET [Lexapro]   1* Preferred Generic $0.00$0.00None
ESCITALOPRAM 20 MG TABLET [Lexapro]   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ESCITALOPRAM 5 MG TABLET [Lexapro]   1* Preferred Generic $0.00$0.00None
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro]   4 Non-Preferred Drug 46%46%None
ESOMEPRAZOLE MAG DR 20 MG CAP [Nexium]   4 Non-Preferred Drug 46%46%None
ESOMEPRAZOLE MAG DR 40 MG CAP [Nexium]   4 Non-Preferred Drug 46%46%None
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra]   2* Generic $5.00$12.50None
ESTRADIOL 0.01% CREAM   4 Non-Preferred Drug 46%46%None
ESTRADIOL 0.5 MG TABLET   2* Generic $5.00$12.50None
ESTRADIOL 1 MG TABLET   2* Generic $5.00$12.50None
ESTRADIOL 10 MCG VAGINAL INSRT   3 Preferred Brand $40.00$100.00None
ESTRADIOL 2MG TABLET   2* Generic $5.00$12.50None
ESTRADIOL TDS 0.025 MG/DAY   3 Preferred Brand $40.00$100.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ESTRADIOL TDS 0.0375 MG/DAY   3 Preferred Brand $40.00$100.00None
ESTRADIOL TDS 0.05 MG/DAY   3 Preferred Brand $40.00$100.00None
ESTRADIOL TDS 0.06 MG/DAY   3 Preferred Brand $40.00$100.00None
ESTRADIOL TDS 0.075 MG/DAY   3 Preferred Brand $40.00$100.00None
ESTRADIOL TDS 0.1 MG/DAY   3 Preferred Brand $40.00$100.00None
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE   3 Preferred Brand $40.00$100.00None
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE   3 Preferred Brand $40.00$100.00None
ESZOPICLONE 1 MG TABLET [Lunesta]   4 Non-Preferred Drug 46%46%P Q:30
/30Days
ESZOPICLONE 2 MG TABLET [Lunesta]   4 Non-Preferred Drug 46%46%P Q:30
/30Days
ESZOPICLONE 3 MG TABLET [Lunesta]   4 Non-Preferred Drug 46%46%P Q:30
/30Days
ETHAMBUTOL HCL 400 MG TABLET   3 Preferred Brand $40.00$100.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Ethambutol Hydrochloride 100mg/1   3 Preferred Brand $40.00$100.00None
Ethinyl Estradiol 0.0025 MG / norethindrone acetate 0.5 MG Oral Tablet [Fyavolv]   3 Preferred Brand $40.00$100.00None
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6   2* Generic $5.00$12.50None
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21   2* Generic $5.00$12.50None
ETHOSUXIMIDE 250 MG CAPSULE   4 Non-Preferred Drug 46%46%None
ETHOSUXIMIDE 250 MG/5 ML SOLN   4 Non-Preferred Drug 46%46%None
ETHYNODIOL-ETH ESTRA 1MG-35MCG [ZOVIA]   3 Preferred Brand $40.00$100.00None
ethynodiol-eth estra 1mg-50mcg [ZOVIA]   3 Preferred Brand $40.00$100.00None
ETODOLAC 200 MG CAPSULE [LODINE]   2* Generic $5.00$12.50None
ETODOLAC 300 MG CAPSULE [LODINE]   2* Generic $5.00$12.50None
ETODOLAC 400 MG TABLET [LODINE]   2* Generic $5.00$12.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ETODOLAC 500 MG TABLET [LODINE]   2* Generic $5.00$12.50None
ETODOLAC ER 400 MG TABLET [LODINE]   2* Generic $5.00$12.50None
ETODOLAC ER 500 MG TABLET [LODINE]   2* Generic $5.00$12.50None
ETODOLAC ER 600 MG TABLET [LODINE]   2* Generic $5.00$12.50None
EVOTAZ 300 MG-150 MG TABLET   5 Specialty Tier 25%N/ANone
EXEMESTANE 25 MG TABLET   4 Non-Preferred Drug 46%46%None
EXJADE 125MG TABLET   5 Specialty Tier 25%N/AP
EXJADE 250MG TABLET   5 Specialty Tier 25%N/AP
EXJADE 500MG TABLET   5 Specialty Tier 25%N/AP
EZETIMIBE 10 MG TABLET [Zetia]   4 Non-Preferred Drug 46%46%None
Ezetimibe-Simvastatin 10-10 MG [Vytorin]   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Ezetimibe-Simvastatin 10-20 MG [Vytorin]   1* Preferred Generic $0.00$0.00None
Ezetimibe-Simvastatin 10-40 MG [Vytorin]   1* Preferred Generic $0.00$0.00None
Ezetimibe-Simvastatin 10-80 MG [Vytorin]   1* Preferred Generic $0.00$0.00None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D WellCare Value Script (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). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • 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 $415 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 five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier 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 $3820) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • 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 September 2019 )

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.