Q1Medicare.com 2019 Medicare Part D or Medicare Advantage Plan Formulary Browser

2019 Medicare Part D Plan Formulary Information
WellCare Classic (PDP) (S4802-071-0) Benefit Details
The WellCare Classic (PDP) (S4802-071-0) Formulary Drugs Starting with the Letter T in CMS PDP Region 12 which includes: AL TN Plan Monthly Premium: $29.90 Deductible: $415 Qualifies for LIS: Yes
Drugs Starting with Letter T Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter T Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TABLOID 40 MG TABLET	4	Non-Preferred Drug	42%	42%	None
Tacrolimus 0.03% ointment	4	Non-Preferred Drug	42%	42%	None
Tacrolimus 0.1% ointment	4	Non-Preferred Drug	42%	42%	None
TACROLIMUS 0.5 MG CAPSULE	4	Non-Preferred Drug	42%	42%	P
TACROLIMUS 1 MG CAPSULE	4	Non-Preferred Drug	42%	42%	P
TACROLIMUS 5 MG CAPSULE	4	Non-Preferred Drug	42%	42%	P
TAFINLAR 50 MG CAPSULE	5	Specialty Tier	25%	N/A	P
TAFINLAR 75 MG CAPSULE	5	Specialty Tier	25%	N/A	P
TAGRISSO 40 MG TABLET	5	Specialty Tier	25%	N/A	P
TAGRISSO 80 MG TABLET	5	Specialty Tier	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TALZENNA 0.25 MG CAPSULE	5	Specialty Tier	25%	N/A	P
TALZENNA 1 MG CAPSULE	5	Specialty Tier	25%	N/A	P
TAMOXIFEN 10 MG TABLET	1*	Preferred Generic	$0.00	$0.00	None
TAMOXIFEN CITRATE 20MG TABLET (30 CT)	1*	Preferred Generic	$0.00	$0.00	None
TAMSULOSIN HCL 0.4 MG CAPSULE	2	Generic	$1.00	$2.50	None
TARCEVA 100MG TABLET	5	Specialty Tier	25%	N/A	P Q:30 /30Days
TARCEVA 150MG TABLET	5	Specialty Tier	25%	N/A	P Q:30 /30Days
TARCEVA 25MG TABLET	5	Specialty Tier	25%	N/A	P Q:90 /30Days
TARGRETIN 1% GEL	5	Specialty Tier	25%	N/A	P
Tarina Fe 1-20 tablet	3	Preferred Brand	$37.00	$92.50	None
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK	5	Specialty Tier	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TASIGNA 200 MG CAPSULE	5	Specialty Tier	25%	N/A	P
TASIGNA 50 MG CAPSULE	5	Specialty Tier	25%	N/A	P
TAZAROTENE 0.1% CREAM [Tazorac]	3	Preferred Brand	$37.00	$92.50	P
TAZICEF 1GM VIAL	4	Non-Preferred Drug	42%	42%	None
TAZICEF 2 GRAM VIAL	4	Non-Preferred Drug	42%	42%	None
TAZICEF 6 GRAM VIAL	4	Non-Preferred Drug	42%	42%	None
TAZORAC 0.05% CREAM	4	Non-Preferred Drug	42%	42%	P
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG ER CAPSULES	3	Preferred Brand	$37.00	$92.50	None
TAZTIA XT 180 MG CAPSULE	3	Preferred Brand	$37.00	$92.50	None
TAZTIA XT 240MG CAPSULE SA	3	Preferred Brand	$37.00	$92.50	None
TAZTIA XT 300 MG CAPSULE	3	Preferred Brand	$37.00	$92.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TAZTIA XT 360MG CAPSULE SA	3	Preferred Brand	$37.00	$92.50	None
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE	5	Specialty Tier	25%	N/A	None
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE	5	Specialty Tier	25%	N/A	None
TEKTURNA 150 MG TABLET	4	Non-Preferred Drug	42%	42%	None
TEKTURNA 300 MG TABLET	4	Non-Preferred Drug	42%	42%	None
TEKTURNA HCT 300-25 MG TABLET	4	Non-Preferred Drug	42%	42%	None
TELMISARTAN 20 MG TABLET [Micardis]	2	Generic	$1.00	$2.50	None
TELMISARTAN 40 MG TABLET [Micardis]	2	Generic	$1.00	$2.50	None
TELMISARTAN 80 MG TABLET [Micardis]	2	Generic	$1.00	$2.50	None
TEMAZEPAM 15 MG CAPSULE	3	Preferred Brand	$37.00	$92.50	P Q:60 /30Days
Temazepam 7.5mg/1 100 CAPSULE BOTTLE, PLASTIC	3	Preferred Brand	$37.00	$92.50	P Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TENIVAC SYRINGE	3	Preferred Brand	$37.00	$92.50	P
TENOFOVIR DISOP FUM 300 MG TABLET [Viread]	5	Specialty Tier	25%	N/A	None
TERAZOSIN 1 MG CAPSULE	1*	Preferred Generic	$0.00	$0.00	None
TERAZOSIN 10 MG CAPSULE [Hytrin]	1*	Preferred Generic	$0.00	$0.00	None
TERAZOSIN 2 MG CAPSULE	1*	Preferred Generic	$0.00	$0.00	None
TERAZOSIN 5 MG CAPSULE [Hytrin]	1*	Preferred Generic	$0.00	$0.00	None
TERBINAFINE HCL 250 MG TABLET	2	Generic	$1.00	$2.50	Q:90 /365Days
TERBUTALINE SULFATE 2.5 MG TAB	4	Non-Preferred Drug	42%	42%	None
TERBUTALINE SULFATE 5MG TABLET	4	Non-Preferred Drug	42%	42%	None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR	3	Preferred Brand	$37.00	$92.50	None
TERCONAZOLE 0.8% CREAM	3	Preferred Brand	$37.00	$92.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TERCONAZOLE 80MG SUPPOSITORY VAGINAL	3	Preferred Brand	$37.00	$92.50	None
TESTOSTERONE 12.5 MG/1.25 GRAM	4	Non-Preferred Drug	42%	42%	P Q:300 /30Days
Testosterone 2500 MG 0.01 MG/MG Topical Gel	4	Non-Preferred Drug	42%	42%	P Q:300 /30Days
Testosterone 5000 MG 0.01 MG/MG Topical Gel	4	Non-Preferred Drug	42%	42%	P Q:300 /30Days
Testosterone cyp 100 mg/ml	3	Preferred Brand	$37.00	$92.50	None
TESTOSTERONE CYP 200 MG/ML	3	Preferred Brand	$37.00	$92.50	None
TESTOSTERONE ENANTHATE 200MG/ML INJECTION	3	Preferred Brand	$37.00	$92.50	None
TETRABENAZINE 12.5 MG TABLET [XENAZINE]	5	Specialty Tier	25%	N/A	P Q:240 /30Days
TETRABENAZINE 25 MG TABLET [XENAZINE]	5	Specialty Tier	25%	N/A	P Q:120 /30Days
TETRACYCLINE 250 MG CAPSULE	4	Non-Preferred Drug	42%	42%	None
TETRACYCLINE 500 MG CAPSULE	4	Non-Preferred Drug	42%	42%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THALOMID 100 MG CAPSULE	5	Specialty Tier	25%	N/A	P Q:30 /30Days
THALOMID 150 MG CAPSULE	5	Specialty Tier	25%	N/A	P Q:60 /30Days
THALOMID 200 MG CAPSULE	5	Specialty Tier	25%	N/A	P Q:60 /30Days
THALOMID 50 MG CAPSULE	5	Specialty Tier	25%	N/A	P Q:30 /30Days
THEOPHYLLINE ER 100 MG TABLET	3	Preferred Brand	$37.00	$92.50	None
THEOPHYLLINE ER 200 MG TABLET	3	Preferred Brand	$37.00	$92.50	None
THEOPHYLLINE ER 300 MG TAB	3	Preferred Brand	$37.00	$92.50	None
THEOPHYLLINE ER 400 MG TABLET	3	Preferred Brand	$37.00	$92.50	None
THEOPHYLLINE ER 600 MG TABLET	3	Preferred Brand	$37.00	$92.50	None
THIORIDAZINE 10 MG TABLET	3	Preferred Brand	$37.00	$92.50	None
THIORIDAZINE 100MG TABLET	3	Preferred Brand	$37.00	$92.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
THIORIDAZINE 25 MG TABLET	3	Preferred Brand	$37.00	$92.50	None
THIORIDAZINE 50 MG TABLET	3	Preferred Brand	$37.00	$92.50	None
THIOTHIXENE 1 MG CAPSULE	4	Non-Preferred Drug	42%	42%	None
THIOTHIXENE 10MG CAPSULE	4	Non-Preferred Drug	42%	42%	None
THIOTHIXENE 2MG CAPSULE	4	Non-Preferred Drug	42%	42%	None
THIOTHIXENE 5MG CAPSULE	4	Non-Preferred Drug	42%	42%	None
TIAGABINE HCL 12 MG TABLET [Gabitril]	4	Non-Preferred Drug	42%	42%	None
TIAGABINE HCL 16 MG TABLET [Gabitril]	4	Non-Preferred Drug	42%	42%	None
tiagabine hcl 2 mg tablet [Gabitril]	4	Non-Preferred Drug	42%	42%	None
tiagabine hcl 4 mg tablet [Gabitril]	4	Non-Preferred Drug	42%	42%	None
TIBSOVO 250 MG TABLET	5	Specialty Tier	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TIGECYCLINE 50 MG VIAL [Tygacil]	5	Specialty Tier	25%	N/A	None
TIMOLOL 0.25% EYE DROPS	2	Generic	$1.00	$2.50	None
TIMOLOL 0.25% GFS GEL-SOLUTION	4	Non-Preferred Drug	42%	42%	None
TIMOLOL 0.5% EYE DROPS	4	Non-Preferred Drug	42%	42%	None
TIMOLOL 0.5% EYE DROPS	2	Generic	$1.00	$2.50	None
TIMOLOL 0.5% GFS GEL-SOLUTION	4	Non-Preferred Drug	42%	42%	None
TIMOLOL MALEATE 10MG TABLET	3	Preferred Brand	$37.00	$92.50	None
TIMOLOL MALEATE 20MG TABLET	3	Preferred Brand	$37.00	$92.50	None
TIMOLOL MALEATE 5MG TABLET	3	Preferred Brand	$37.00	$92.50	None
TIVICAY 10 MG TABLET	3	Preferred Brand	$37.00	$92.50	None
TIVICAY 25 MG TABLET	5	Specialty Tier	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TIVICAY 50 MG TABLET	5	Specialty Tier	25%	N/A	None
TIZANIDINE HCL 2 MG TABLET	2	Generic	$1.00	$2.50	None
TIZANIDINE HCL 4 MG TABLET	2	Generic	$1.00	$2.50	None
TOBRADEX EYE OINTMENT	3	Preferred Brand	$37.00	$92.50	None
TOBRADEX ST 0.5; 3mg/mL; mg/mL 5 mL in 1 BOTTLE	3	Preferred Brand	$37.00	$92.50	None
TOBRAMYCIN 0.3% EYE DROPS [Tobrex]	2	Generic	$1.00	$2.50	None
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]	4	Non-Preferred Drug	42%	42%	None
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]	5	Specialty Tier	25%	N/A	P
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]	4	Non-Preferred Drug	42%	42%	None
TOBRAMYCIN-DEXAMETH OPTH SUSP	4	Non-Preferred Drug	42%	42%	None
TOLTERODINE TARTRATE 1 MG TAB [Detrol LA]	4	Non-Preferred Drug	42%	42%	S
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TOLTERODINE TARTRATE 2 MG TABLET [Detrol]	4	Non-Preferred Drug	42%	42%	S
Tolterodine Tartrate 24 HR 4 MG Extended Release Oral Capsule [Detrol LA]	4	Non-Preferred Drug	42%	42%	S Q:30 /30Days
Tolterodine Tartrate ER 2 MG CAPSULE [Detrol LA]	4	Non-Preferred Drug	42%	42%	S Q:30 /30Days
TOPIRAMATE 100 MG TABLET	2	Generic	$1.00	$2.50	None
TOPIRAMATE 15 MG SPRINKLE CAP	3	Preferred Brand	$37.00	$92.50	None
TOPIRAMATE 200 MG TABLET	2	Generic	$1.00	$2.50	None
TOPIRAMATE 25 MG TABLET	2	Generic	$1.00	$2.50	None
Topiramate 25mg/1	3	Preferred Brand	$37.00	$92.50	None
TOPIRAMATE 50 MG TABLET	2	Generic	$1.00	$2.50	None
TOREMIFENE CITRATE 60 MG TABLET [Fareston]	5	Specialty Tier	25%	N/A	None
TORSEMIDE 10 MG TABLET	2	Generic	$1.00	$2.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TORSEMIDE 100 MG TABLET	2	Generic	$1.00	$2.50	None
TORSEMIDE 20 MG TABLET	2	Generic	$1.00	$2.50	None
TORSEMIDE 5 MG TABLET	2	Generic	$1.00	$2.50	None
TOVIAZ TABLETS 4MG EXTENDED RELEASE	3	Preferred Brand	$37.00	$92.50	Q:30 /30Days
TOVIAZ TABLETS 8MG EXTENDED RELEASE	3	Preferred Brand	$37.00	$92.50	Q:30 /30Days
TPN ELECTROLYTES16.5/25.4 VIAL	4	Non-Preferred Drug	42%	42%	P
TRACLEER 125MG TABLET	5	Specialty Tier	25%	N/A	P Q:60 /30Days
TRACLEER 62.5MG TABLET	5	Specialty Tier	25%	N/A	P Q:120 /30Days
TRADJENTA 5 MG TABLET	3	Preferred Brand	$37.00	$92.50	Q:30 /30Days
TRAMADOL HCL 50 MG TABLET	2	Generic	$1.00	$2.50	Q:240 /30Days
TRANDOLAPRIL 1 MG TABLET	2	Generic	$1.00	$2.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRANDOLAPRIL 2 MG TABLET	2	Generic	$1.00	$2.50	None
TRANDOLAPRIL 4 MG TABLET	2	Generic	$1.00	$2.50	None
tranexamic acid 650 mg tablet	3	Preferred Brand	$37.00	$92.50	None
TRANSDERM-SCOP 1.5 MG/3 DAY	4	Non-Preferred Drug	42%	42%	P Q:10 /30Days
TRANYLCYPROMINE SULF 10 MG TABLET [Parnate]	4	Non-Preferred Drug	42%	42%	None
TRAVASOL 10% SOLUTION VIAFLEX	4	Non-Preferred Drug	42%	42%	P
TRAVATAN Z 0.04MG DROPS 2.5ML BOT	3	Preferred Brand	$37.00	$92.50	None
TRAZODONE 100 MG TABLET	2	Generic	$1.00	$2.50	None
TRAZODONE 50 MG TABLET	2	Generic	$1.00	$2.50	None
TRAZODONE HCL TABLET USP 150MG (100 CT)	2	Generic	$1.00	$2.50	None
TRECATOR 250MG TABLET	4	Non-Preferred Drug	42%	42%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRELEGY ELLIPTA 100-62.5-25	3	Preferred Brand	$37.00	$92.50	Q:60 /30Days
TRELSTAR 11.25 MG SYRINGE	5	Specialty Tier	25%	N/A	P
TRELSTAR 3.75 MG SYRINGE	5	Specialty Tier	25%	N/A	P
TRESIBA 100 UNIT/ML VIAL	3	Preferred Brand	$37.00	$92.50	None
TRESIBA FLEXTOUCH 100 UNITS/ML	3	Preferred Brand	$37.00	$92.50	None
TRESIBA FLEXTOUCH 200 UNITS/ML	3	Preferred Brand	$37.00	$92.50	None
TRETINOIN 0.01% GEL	4	Non-Preferred Drug	42%	42%	P
TRETINOIN 0.025% CREAM	4	Non-Preferred Drug	42%	42%	P
TRETINOIN 0.025% GEL	4	Non-Preferred Drug	42%	42%	P
TRETINOIN 0.05% CREAM	4	Non-Preferred Drug	42%	42%	P
TRETINOIN 0.1% CREAM	4	Non-Preferred Drug	42%	42%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRETINOIN 10MG CAPSULE	5	Specialty Tier	25%	N/A	None
TRI-ESTARYLLA TABLET [Trinessa]	3	Preferred Brand	$37.00	$92.50	None
TRI-LEGEST FE 5-7-9-7 TABLET	3	Preferred Brand	$37.00	$92.50	None
TRI-LO-ESTARYLLA TABLET [Trinessa Lo]	3	Preferred Brand	$37.00	$92.50	None
TRI-LO-SPRINTEC TABLET	3	Preferred Brand	$37.00	$92.50	None
TRI-MILI 28 TABLET [Trinessa]	3	Preferred Brand	$37.00	$92.50	None
TRI-PREVIFEM TABLET [Trinessa]	3	Preferred Brand	$37.00	$92.50	None
TRI-SPRINTEC 7DAYSX3 28 TABLET	3	Preferred Brand	$37.00	$92.50	None
TRI-VYLIBRA 28 TABLET [Trinessa]	3	Preferred Brand	$37.00	$92.50	None
TRI-VYLIBRA LO TABLET [Trinessa Lo]	3	Preferred Brand	$37.00	$92.50	None
TRIAMCINOLONE 0.025% CREAM	2	Generic	$1.00	$2.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIAMCINOLONE 0.025% LOTION	3	Preferred Brand	$37.00	$92.50	None
TRIAMCINOLONE 0.025% OINT	2	Generic	$1.00	$2.50	None
TRIAMCINOLONE 0.1% CREAM	2	Generic	$1.00	$2.50	None
TRIAMCINOLONE 0.1% LOTION [Kenalog]	3	Preferred Brand	$37.00	$92.50	None
TRIAMCINOLONE 0.1% OINTMENT	2	Generic	$1.00	$2.50	None
TRIAMCINOLONE 0.1% PASTE	3	Preferred Brand	$37.00	$92.50	None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE	2	Generic	$1.00	$2.50	None
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE	2	Generic	$1.00	$2.50	None
TRIAMTERENE-HCTZ 37.5-25 MG CP	1*	Preferred Generic	$0.00	$0.00	None
TRIAMTERENE-HCTZ 37.5-25 MG TB	1*	Preferred Generic	$0.00	$0.00	None
TRIAMTERENE-HCTZ 75-50 MG TAB	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
TRIENTINE HCL 250 MG CAPSULE [Syprine]	5	Specialty Tier	25%	N/A	P
TRIFLUOPERAZINE 1 MG TABLET	3	Preferred Brand	$37.00	$92.50	None
TRIFLUOPERAZINE HCL 2MG TABLET	3	Preferred Brand	$37.00	$92.50	None
TRIFLUOPERAZINE HCL 5MG TABLET	3	Preferred Brand	$37.00	$92.50	None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)	3	Preferred Brand	$37.00	$92.50	None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT	3	Preferred Brand	$37.00	$92.50	None
TRIHEXYPHENIDYL 2 MG TABLET	3	Preferred Brand	$37.00	$92.50	P
TRIHEXYPHENIDYL 5 MG TABLET	3	Preferred Brand	$37.00	$92.50	P
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE	3	Preferred Brand	$37.00	$92.50	P
TRILYTE WITH FLAVOR PACKETS	2	Generic	$1.00	$2.50	None
TRIMETHOPRIM 100 MG TABLET	2	Generic	$1.00	$2.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRIMIPRAMINE MALEATE 100 MG CP	4	Non-Preferred Drug	42%	42%	Q:60 /30Days
TRIMIPRAMINE MALEATE 25 MG CAP	4	Non-Preferred Drug	42%	42%	Q:240 /30Days
TRIMIPRAMINE MALEATE 50 MG CAP	4	Non-Preferred Drug	42%	42%	Q:120 /30Days
TRINTELLIX 10 MG TABLET	4	Non-Preferred Drug	42%	42%	Q:60 /30Days
TRINTELLIX 20 MG TABLET	4	Non-Preferred Drug	42%	42%	Q:30 /30Days
TRINTELLIX 5 MG TABLET	4	Non-Preferred Drug	42%	42%	Q:120 /30Days
TRIUMEQ TABLET	5	Specialty Tier	25%	N/A	None
TRIVORA-28 TABLET	3	Preferred Brand	$37.00	$92.50	None
TROPHAMINE INJECTION SOLUTION	4	Non-Preferred Drug	42%	42%	P
TROSPIUM CHLORIDE 20 MG TABLET	3	Preferred Brand	$37.00	$92.50	Q:60 /30Days
TRULICITY 0.75 MG/0.5 ML PEN	3	Preferred Brand	$37.00	$92.50	Q:2 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TRULICITY 1.5 MG/0.5 ML PEN	3	Preferred Brand	$37.00	$92.50	Q:2 /28Days
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe	3	Preferred Brand	$37.00	$92.50	None
TRUVADA 100 MG-150 MG TABLET	5	Specialty Tier	25%	N/A	Q:60 /30Days
TRUVADA 133 MG-200 MG TABLET	5	Specialty Tier	25%	N/A	Q:30 /30Days
TRUVADA 167 MG-250 MG TABLET	5	Specialty Tier	25%	N/A	Q:30 /30Days
TRUVADA 200/300MG TABLET	5	Specialty Tier	25%	N/A	Q:30 /30Days
TWINRIX VACCINE SYRINGE	3	Preferred Brand	$37.00	$92.50	None
TYBOST 150 MG TABLET	4	Non-Preferred Drug	42%	42%	None
TYKERB 250 MG TABLET	5	Specialty Tier	25%	N/A	P
TYMLOS 80 MCG DOSE PEN INJECTR	5	Specialty Tier	25%	N/A	P
TYPHIM VI 25 MCG/0.5 ML SYRINGE	3	Preferred Brand	$37.00	$92.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
TYPHIM VI 25MCG/0.5ML VIAL	3	Preferred Brand	$37.00	$92.50	None

Chart Legend:

Below are a few notes to help you understand the above 2019 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). 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.