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WellCare Value Script (PDP) (S4802-146-0)
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A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2019 Medicare Part D Plan Formulary Information
WellCare Value Script (PDP) (S4802-146-0)
Benefit Details           
The WellCare Value Script (PDP) (S4802-146-0)
Formulary Drugs Starting with the Letter L

in CMS PDP Region 11 which includes: FL
Plan Monthly Premium: $13.40 Deductible: $415 Qualifies for LIS: No
Drugs Starting with Letter L

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
LABETALOL HCL 100 MG TABLET   3 Preferred Brand $42.00$105.00None
LABETALOL HCL 200 MG TABLET   3 Preferred Brand $42.00$105.00None
LABETALOL HCL 300 MG TABLET   3 Preferred Brand $42.00$105.00None
LACTULOSE 10 GM/15 ML SOLUTION [Constulose]   2* Generic $6.00$15.00None
Lamivudine 10 mg/ml oral soln   3 Preferred Brand $42.00$105.00None
LAMIVUDINE 150 MG TABLET   3 Preferred Brand $42.00$105.00None
LAMIVUDINE 300 MG TABLET   3 Preferred Brand $42.00$105.00None
Lamivudine hbv 100 mg tablet   4 Non-Preferred Drug 46%46%None
LAMIVUDINE-ZIDOVUDINE TABLET   4 Non-Preferred Drug 46%46%None
LAMOTRIGINE 150MG TABLET (60 CT)   2* Generic $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LAMOTRIGINE 200MG TABLET (60 CT)   2* Generic $6.00$15.00None
LAMOTRIGINE 25 MG DISPER TAB CHW DSP [Lamictal CD]   3 Preferred Brand $42.00$105.00None
LAMOTRIGINE 25 MG TABLET [Subvenite]   2* Generic $6.00$15.00None
LAMOTRIGINE 5 MG DISPER TABLET CHW DSP [Lamictal CD]   3 Preferred Brand $42.00$105.00None
LAMOTRIGINE ER 100 MG TABLET   4 Non-Preferred Drug 46%46%None
LAMOTRIGINE ER 200 MG TABLET   4 Non-Preferred Drug 46%46%None
LAMOTRIGINE ER 25 MG TABLET   4 Non-Preferred Drug 46%46%None
LAMOTRIGINE ER 250 MG TABLET   4 Non-Preferred Drug 46%46%None
LAMOTRIGINE ER 300 MG TABLET   4 Non-Preferred Drug 46%46%None
LAMOTRIGINE ER 50 MG TABLET   4 Non-Preferred Drug 46%46%None
LAMOTRIGINE ODT 100 MG TABLET RAPDIS [Lamictal ODT]   4 Non-Preferred Drug 46%46%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LAMOTRIGINE ODT 200 MG TABLET RAPDIS [Lamictal ODT]   4 Non-Preferred Drug 46%46%None
LAMOTRIGINE ODT 25 MG TABLET   4 Non-Preferred Drug 46%46%None
LAMOTRIGINE ODT 50 MG TABLET RAPDIS [Lamictal ODT]   4 Non-Preferred Drug 46%46%None
LAMOTRIGINE TABLET 100MG (100 CT)   2* Generic $6.00$15.00None
LANSOPRAZOL-AMOXICIL-CLARITHRO   4 Non-Preferred Drug 46%46%None
LANSOPRAZOLE DR 15 MG CAPSULE DR [Prevacid]   3 Preferred Brand $42.00$105.00None
LANSOPRAZOLE DR 30 MG CAPSULE [Prevacid]   3 Preferred Brand $42.00$105.00None
LANSOPRAZOLE ODT 15 MG TABLET RAP DR [Prevacid]   4 Non-Preferred Drug 46%46%None
LANSOPRAZOLE ODT 30 MG TABLET RAP DR [Prevacid]   4 Non-Preferred Drug 46%46%None
LARIN 1.5 MG-30 MCG TABLET   2* Generic $6.00$15.00None
LARIN 21 1-20 TABLET   2* Generic $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LARIN FE 1-20 TABLET   2* Generic $6.00$15.00None
LARIN FE 1.5-30 TABLET   2* Generic $6.00$15.00None
Larissia-28 tablet   2* Generic $6.00$15.00None
LASTACAFT 2.5mg/mL 1 BOTTLE, PLASTIC per CARTON / 3 mL in 1 BOTTLE, PLASTIC   4 Non-Preferred Drug 46%46%None
LATANOPROST 0.005% EYE DROPS   2* Generic $6.00$15.00None
LATUDA 120 MG TABLET   4 Non-Preferred Drug 46%46%Q:30
/30Days
LATUDA 20 MG TABLET   4 Non-Preferred Drug 46%46%Q:60
/30Days
LATUDA 40 MG TABLET   4 Non-Preferred Drug 46%46%Q:30
/30Days
LATUDA 60 MG TABLET   4 Non-Preferred Drug 46%46%Q:60
/30Days
LATUDA 80 MG TABLET   4 Non-Preferred Drug 46%46%Q:60
/30Days
LEENA 28 TABLET [Tri-Norinyl]   3 Preferred Brand $42.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEFLUNOMIDE 10 MG TABLET   3 Preferred Brand $42.00$105.00None
LEFLUNOMIDE 20 MG TABLET   3 Preferred Brand $42.00$105.00None
LENVIMA 10 MG DAILY DOSE   5 Specialty Tier 25%N/AP
LENVIMA 12 MG DAILY DOSE Capsule   5 Specialty Tier 25%N/AP
LENVIMA 14 MG DAILY DOSE   5 Specialty Tier 25%N/AP
LENVIMA 18 MG DAILY DOSE   5 Specialty Tier 25%N/AP
LENVIMA 20 MG DAILY DOSE   5 Specialty Tier 25%N/AP
LENVIMA 24 MG DAILY DOSE   5 Specialty Tier 25%N/AP
LENVIMA 4 MG CAPSULE   5 Specialty Tier 25%N/AP
LENVIMA 8 MG DAILY DOSE   5 Specialty Tier 25%N/AP
Lessina 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK   2* Generic $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LETROZOLE 2.5 MG TABLET   2* Generic $6.00$15.00None
LEUCOVORIN CALCIUM 10MG TABLET   3 Preferred Brand $42.00$105.00None
Leucovorin Calcium 15mg/1 24 TABLET BOTTLE   3 Preferred Brand $42.00$105.00None
LEUCOVORIN CALCIUM 25MG TABLET   3 Preferred Brand $42.00$105.00None
LEUCOVORIN CALCIUM 5 MG TAB   3 Preferred Brand $42.00$105.00None
LEUKERAN 2 MG TABLET   5 Specialty Tier 25%N/ANone
LEUPROLIDE 2WK 14 MG/2.8 ML KT   3 Preferred Brand $42.00$105.00P
LEVALBUTEROL 0.31 MG/3 ML SOL VIAL-NEB [Xopenex Pediatric]   4 Non-Preferred Drug 46%46%P
LEVALBUTEROL 0.63 MG/3 ML SOL VIAL-NEB [Xopenex]   4 Non-Preferred Drug 46%46%P
LEVALBUTEROL 1.25 MG/0.5 ML   4 Non-Preferred Drug 46%46%P
LEVALBUTEROL 1.25 MG/3 ML SOL VIAL-NEB [Xopenex]   4 Non-Preferred Drug 46%46%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVALBUTEROL TAR HFA 45MCG INH [Xopenex]   3 Preferred Brand $42.00$105.00Q:30
/30Days
LEVEMIR 100UNITS/ML VIAL   3 Preferred Brand $42.00$105.00None
LEVEMIR FLEXTOUCH 100 UNITS/ML   3 Preferred Brand $42.00$105.00None
LEVETIRACETAM 1,000 MG TABLET   3 Preferred Brand $42.00$105.00None
LEVETIRACETAM 100 MG/ML SOLN   3 Preferred Brand $42.00$105.00None
LEVETIRACETAM 250 MG TABLET   3 Preferred Brand $42.00$105.00None
LEVETIRACETAM 500 MG TABLET   3 Preferred Brand $42.00$105.00None
LEVETIRACETAM 750 MG TABLET   3 Preferred Brand $42.00$105.00None
LEVETIRACETAM ER 500 MG TABLET   3 Preferred Brand $42.00$105.00None
LEVETIRACETAM ER 750 MG TABLET   3 Preferred Brand $42.00$105.00None
LEVO-T 100 MCG TABLET   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVO-T 112 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVO-T 125 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVO-T 137 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVO-T 150 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVO-T 175 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVO-T 200 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVO-T 25 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVO-T 300 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVO-T 50 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVO-T 75 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVO-T 88 MCG TABLET   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION   2* Generic $6.00$15.00None
LEVOCARNITINE 1 G/10 ML SOLN   4 Non-Preferred Drug 46%46%P
LEVOCARNITINE 330 MG TABLET   4 Non-Preferred Drug 46%46%P
LEVOCETIRIZINE 2.5 MG/5 ML SOL   4 Non-Preferred Drug 46%46%None
LEVOCETIRIZINE 5 MG TABLET   2* Generic $6.00$15.00None
LEVOFLOXACIN 25 MG/ML SOLUTION [LEVAQUIN]   4 Non-Preferred Drug 46%46%None
LEVOFLOXACIN 250 MG TABLET [LEVAQUIN]   1* Preferred Generic $0.00$0.00None
LEVOFLOXACIN 500 MG TABLET [LEVAQUIN]   1* Preferred Generic $0.00$0.00None
LEVOFLOXACIN 500 MG/20 ML VIAL [Levaquin]   4 Non-Preferred Drug 46%46%None
Levofloxacin 5mg/mL 24 POUCH per CARTON / 1 BAG in 1 POUCH / 100 mL in 1 BAG [LEVAQUIN]   3 Preferred Brand $42.00$105.00None
LEVOFLOXACIN 750 MG TABLET [LEVAQUIN]   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOFLOXACIN 750 MG/150 ML-D5W [LEVAQUIN]   3 Preferred Brand $42.00$105.00None
LEVONEST-28 TABLET   2* Generic $6.00$15.00None
LEVONOR-ETH ESTRAD 0.1-0.02 MG   2* Generic $6.00$15.00None
LEVONOR-ETH ESTRAD 0.15-0.03   2* Generic $6.00$15.00None
LEVONOR-ETH ESTRAD 0.15-0.03   3 Preferred Brand $42.00$105.00None
LEVONOR-ETH ESTRAD TRIPHASIC   2* Generic $6.00$15.00None
Levora-28 tablet   2* Generic $6.00$15.00None
LEVOTHYROXINE 100 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOTHYROXINE 112 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOTHYROXINE 125 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOTHYROXINE 137 MCG TABLET   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOTHYROXINE 150 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOTHYROXINE 175 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOTHYROXINE 200 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOTHYROXINE 25 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOTHYROXINE 300 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOTHYROXINE 50 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOTHYROXINE 75 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOTHYROXINE 88 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOXYL 100 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOXYL 112 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOXYL 125 MCG TABLET   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LEVOXYL 137 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOXYL 150 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOXYL 175 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOXYL 200 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOXYL 25 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOXYL 50 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOXYL 75 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEVOXYL 88 MCG TABLET   1* Preferred Generic $0.00$0.00None
LEXIVA 50mg/mL 225 mL in 1 BOTTLE   4 Non-Preferred Drug 46%46%None
LIDOCAINE 2% VISCOUS SOLN   2* Generic $6.00$15.00None
LIDOCAINE 5% OINTMENT   4 Non-Preferred Drug 46%46%P Q:50
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Lidocaine 5% patch   3 Preferred Brand $42.00$105.00P Q:3
/1Days
LIDOCAINE HCL 2% JELLY 30ML TUBE   3 Preferred Brand $42.00$105.00P Q:30
/30Days
LIDOCAINE HCL IV 4% SOLUTION   2* Generic $6.00$15.00P Q:50
/30Days
LIDOCAINE-PRILOCAINE CREAM   3 Preferred Brand $42.00$105.00P Q:30
/30Days
Linezolid 20 MG/ML Oral Suspension [Zyvox]   5 Specialty Tier 25%N/ANone
LINEZOLID 600 MG TABLET [Zyvox]   5 Specialty Tier 25%N/ANone
LINEZOLID 600 MG/300 ML IV SOL [Zyvox]   4 Non-Preferred Drug 46%46%None
LINZESS 145 MCG CAPSULE   3 Preferred Brand $42.00$105.00Q:30
/30Days
LINZESS 290 MCG CAPSULE   3 Preferred Brand $42.00$105.00Q:30
/30Days
LINZESS 72 MCG CAPSULE   3 Preferred Brand $42.00$105.00Q:30
/30Days
LIOTHYRONINE SOD 25 MCG TAB   3 Preferred Brand $42.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LIOTHYRONINE SOD 5 MCG TAB   3 Preferred Brand $42.00$105.00None
LIOTHYRONINE SOD 50 MCG TABLET [Cytomel]   3 Preferred Brand $42.00$105.00None
LISINOPRIL 10 MG TABLET   1* Preferred Generic $0.00$0.00None
LISINOPRIL 2.5 MG TABLET   1* Preferred Generic $0.00$0.00None
LISINOPRIL 20 MG TABLET   1* Preferred Generic $0.00$0.00None
LISINOPRIL 30 MG TABLET   1* Preferred Generic $0.00$0.00None
LISINOPRIL 40 MG TABLET   1* Preferred Generic $0.00$0.00None
LISINOPRIL 5 MG TABLET   1* Preferred Generic $0.00$0.00None
LISINOPRIL-HCTZ 10-12.5 MG TAB   1* Preferred Generic $0.00$0.00None
LISINOPRIL-HCTZ 20-12.5 MG TAB   1* Preferred Generic $0.00$0.00None
LISINOPRIL-HCTZ 20-25 MG TAB   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LITHIUM CARBONATE 150 MG CAP   1* Preferred Generic $0.00$0.00None
LITHIUM CARBONATE 300 MG Capsule [Eskalith]   1* Preferred Generic $0.00$0.00None
Lithium Carbonate 300 mg tab   2* Generic $6.00$15.00None
Lithium Carbonate 450mg/1   2* Generic $6.00$15.00None
LITHIUM CARBONATE 600 MG CAP   1* Preferred Generic $0.00$0.00None
LITHIUM CARBONATE ER 300 MG TB   2* Generic $6.00$15.00None
LITHIUM CIT 8MEQ/5ML SYRUP   4 Non-Preferred Drug 46%46%None
LIVALO 1 MG TABLET   4 Non-Preferred Drug 46%46%S
LIVALO 2 MG TABLET   4 Non-Preferred Drug 46%46%S
LIVALO 4 MG TABLET   4 Non-Preferred Drug 46%46%S
LONSURF 15 MG-6.14 MG TABLET   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LONSURF 20 MG-8.19 MG TABLET   5 Specialty Tier 25%N/AP
LOPERAMIDE HCL 2MG CAPSULE   2* Generic $6.00$15.00None
LOPINAVIR-RITONAVIR 80-20MG/ML Solution [Kaletra]   4 Non-Preferred Drug 46%46%None
LORAZEPAM 0.5 MG TABLET   2* Generic $6.00$15.00Q:150
/30Days
LORAZEPAM 1 MG TABLET   2* Generic $6.00$15.00Q:150
/30Days
LORAZEPAM 2 MG TABLET   2* Generic $6.00$15.00Q:150
/30Days
LORAZEPAM 2 MG/ML ORAL CONCENT   3 Preferred Brand $42.00$105.00Q:150
/30Days
LORBRENA 100 MG TABLET   5 Specialty Tier 25%N/AP
LORBRENA 25 MG TABLET   5 Specialty Tier 25%N/AP
LORCET HD 10-325 MG TABLET   3 Preferred Brand $42.00$105.00Q:180
/30Days
Lorcet plus 7.5-325 mg tablet   3 Preferred Brand $42.00$105.00Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LORYNA 3 MG-0.02 MG TABLET [Yaz]   3 Preferred Brand $42.00$105.00None
LOSARTAN POTASSIUM 100 MG TAB   1* Preferred Generic $0.00$0.00None
LOSARTAN POTASSIUM 25 MG TAB   1* Preferred Generic $0.00$0.00None
LOSARTAN POTASSIUM 50 MG TAB   1* Preferred Generic $0.00$0.00None
LOSARTAN-HCTZ 100-12.5 MG TAB   1* Preferred Generic $0.00$0.00None
LOSARTAN-HCTZ 100-25 MG TAB   1* Preferred Generic $0.00$0.00None
LOSARTAN-HCTZ 50-12.5 MG TAB   1* Preferred Generic $0.00$0.00None
LOTEMAX 0.5% EYE DROPS   3 Preferred Brand $42.00$105.00None
LOTEMAX 0.5% OPHTHALMIC GEL   3 Preferred Brand $42.00$105.00None
Lotemax 5mg/g 1 TUBE per CARTON / 3.5 g in 1 TUBE   3 Preferred Brand $42.00$105.00None
LOTEPREDNOL ETABONATE 0.5% EYE DROPPER [Lotemax]   3 Preferred Brand $42.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LOVASTATIN 10 MG TABLET   1* Preferred Generic $0.00$0.00None
LOVASTATIN 20 MG TABLET   1* Preferred Generic $0.00$0.00None
LOVASTATIN 40 MG TABLET   1* Preferred Generic $0.00$0.00None
LOW-OGESTREL-28 TABLET   2* Generic $6.00$15.00None
LOXAPINE 10 MG CAPSULE   3 Preferred Brand $42.00$105.00None
LOXAPINE 25MG CAPSULE (100 CT)   3 Preferred Brand $42.00$105.00None
LOXAPINE CAPSULES 50MG 100 BOT   3 Preferred Brand $42.00$105.00None
LOXAPINE CAPSULES 5MG 100 BOT   3 Preferred Brand $42.00$105.00None
LUMIGAN 0.01% EYE DROPS   3 Preferred Brand $42.00$105.00None
LUNESTA 2MG TABLET   4 Non-Preferred Drug 46%46%P Q:30
/30Days
LUNESTA 3MG TABLET   4 Non-Preferred Drug 46%46%P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LUNESTA TABLETS 1MG 30 BOT   4 Non-Preferred Drug 46%46%P Q:30
/30Days
LUPRON DEPOT 11.25 MG 3MO KIT   5 Specialty Tier 25%N/AP
LUPRON DEPOT 3.75 MG KIT   5 Specialty Tier 25%N/AP
LUTERA-28 TABLET   2* Generic $6.00$15.00None
LYNPARZA 100 MG TABLET   5 Specialty Tier 25%N/AP
LYNPARZA 150 MG TABLET   5 Specialty Tier 25%N/AP
LYRICA 100MG CAPSULE   3 Preferred Brand $42.00$105.00Q:120
/30Days
LYRICA 150MG CAPSULE   3 Preferred Brand $42.00$105.00Q:120
/30Days
LYRICA 20 MG/ML ORAL SOLUTION   3 Preferred Brand $42.00$105.00Q:946
/30Days
LYRICA 200MG CAPSULE   3 Preferred Brand $42.00$105.00Q:90
/30Days
LYRICA 225MG CAPSULE   3 Preferred Brand $42.00$105.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
LYRICA 25MG CAPSULE   3 Preferred Brand $42.00$105.00Q:120
/30Days
LYRICA 300MG CAPSULE   3 Preferred Brand $42.00$105.00Q:60
/30Days
LYRICA 50MG CAPSULE   3 Preferred Brand $42.00$105.00Q:120
/30Days
LYRICA 75MG CAPSULE   3 Preferred Brand $42.00$105.00Q:120
/30Days
LYRICA CR 165 MG TABLET ER 24H   3 Preferred Brand $42.00$105.00P Q:90
/30Days
LYRICA CR 330 MG TABLET ER 24H   3 Preferred Brand $42.00$105.00P Q:60
/30Days
LYRICA CR 82.5 MG TABLET ER 24H   3 Preferred Brand $42.00$105.00P Q:90
/30Days
LYSODREN 500MG TABLET   3 Preferred Brand $42.00$105.00None
LYZA 0.35 MG TABLET   2* Generic $6.00$15.00None

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.