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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:
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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 V

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
VALACYCLOVIR HCL 1 GRAM TABLET   3 Preferred Brand $40.00$100.00None
VALACYCLOVIR HCL 500 MG TABLET   3 Preferred Brand $40.00$100.00None
VALCHLOR 0.016% GEL   5 Specialty Tier 25%N/AP
VALGANCICLOVIR 450 MG TABLET [Valcyte]   5 Specialty Tier 25%N/ANone
VALGANCICLOVIR HCL 50 MG/ML [Valcyte]   5 Specialty Tier 25%N/ANone
VALPROIC ACID 250 MG CAPSULE [Depakene]   3 Preferred Brand $40.00$100.00None
VALPROIC ACID 250 MG/5 ML SOLN Solution [Depakene]   3 Preferred Brand $40.00$100.00None
VALSARTAN 160 MG TABLET [Diovan]   1* Preferred Generic $0.00$0.00None
VALSARTAN 320 MG TABLET [Diovan]   1* Preferred Generic $0.00$0.00None
VALSARTAN 40 MG TABLET [Diovan]   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VALSARTAN 80 MG TABLET [Diovan]   1* Preferred Generic $0.00$0.00None
VALSARTAN-HCTZ 160-12.5 MG TAB [Diovan HCT]   1* Preferred Generic $0.00$0.00None
VALSARTAN-HCTZ 160-25 MG TAB [Diovan HCT]   1* Preferred Generic $0.00$0.00None
VALSARTAN-HCTZ 320-12.5 MG TAB [Diovan HCT]   1* Preferred Generic $0.00$0.00None
VALSARTAN-HCTZ 320-25 MG TAB [Diovan HCT]   1* Preferred Generic $0.00$0.00None
VALSARTAN-HCTZ 80-12.5 MG Tablet [Diovan HCT]   1* Preferred Generic $0.00$0.00None
VANCOMYCIN 500 MG VIAL   4 Non-Preferred Drug 46%46%None
VANCOMYCIN HCL 125 MG CAPSULE   4 Non-Preferred Drug 46%46%None
VANCOMYCIN HCL 250 MG CAPSULE   5 Specialty Tier 25%N/ANone
VANCOMYCIN HCL 750 MG VIAL   4 Non-Preferred Drug 46%46%None
VANCOMYCIN HCL INJECTION 10 X 1GM VIAL (STERILE )   4 Non-Preferred Drug 46%46%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VANCOMYCIN HYDROCHLORIDE 100MG/ML 1 VIAL, PHARMACY BULK PACKAGE in 1 CASE / 95 mL in 1 VIAL, PHARMA   4 Non-Preferred Drug 46%46%None
VANDAZOLE 0.75% GEL WITH APPLICATOR   4 Non-Preferred Drug 46%46%None
VAQTA 25 UNITS/0.5 ML SYRINGE   3 Preferred Brand $40.00$100.00None
VAQTA 50 UNITS/ML SYRINGE   3 Preferred Brand $40.00$100.00None
Vaqta Hepatitis A Vaccine Adult 50 Unit / mL Injection Single Dose Vial 1 mL   3 Preferred Brand $40.00$100.00None
Vaqta Hepatitis A Vaccine Pediatric / Adolescent 25 Unit / 0.5 mL Injection Single Dose Vial 0.5 mL   3 Preferred Brand $40.00$100.00None
VARIVAX VACCINE W/DILUENT   3 Preferred Brand $40.00$100.00None
VASCEPA 0.5 GM CAPSULE   4 Non-Preferred Drug 46%46%None
VASCEPA 1 GM CAPSULE   4 Non-Preferred Drug 46%46%None
VELIVET 28 DAY TABLET [Velivet]   3 Preferred Brand $40.00$100.00None
VEMLIDY 25 MG TABLET   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VENCLEXTA 10 MG TABLET   4 Non-Preferred Drug 46%46%P
VENCLEXTA 100 MG TABLET   5 Specialty Tier 25%N/AP
VENCLEXTA 50 MG TABLET   4 Non-Preferred Drug 46%46%P
VENCLEXTA STARTING PACK   5 Specialty Tier 25%N/AP
VENLAFAXINE HCL 100 MG TABLET [Effexor]   3 Preferred Brand $40.00$100.00None
VENLAFAXINE HCL 25 MG TABLET [Effexor]   3 Preferred Brand $40.00$100.00None
VENLAFAXINE HCL 37.5 MG TABLET [Effexor]   3 Preferred Brand $40.00$100.00None
VENLAFAXINE HCL 50 MG TABLET [Effexor]   3 Preferred Brand $40.00$100.00None
VENLAFAXINE HCL 75 MG TABLET [Effexor]   3 Preferred Brand $40.00$100.00None
VENLAFAXINE HCL ER 150 MG CAPSULE 24H [Effexor XR]   2* Generic $5.00$12.50None
VENLAFAXINE HCL ER 37.5 MG CAPSULE 24H [Effexor XR]   2* Generic $5.00$12.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VENLAFAXINE HCL ER 75 MG CAPSULE 24H [Effexor XR]   2* Generic $5.00$12.50None
Ventavis 0.01mg/mL   5 Specialty Tier 25%N/AP
Ventavis 0.02mg/mL   5 Specialty Tier 25%N/AP
VENTOLIN HFA 90MCG INHALER   3 Preferred Brand $40.00$100.00Q:36
/30Days
VERAPAMIL 120 MG TABLET   1* Preferred Generic $0.00$0.00None
VERAPAMIL 120MG CAP PELLET   3 Preferred Brand $40.00$100.00None
VERAPAMIL 180MG CAP PELLET   3 Preferred Brand $40.00$100.00None
VERAPAMIL 240MG CAP PELLET   3 Preferred Brand $40.00$100.00None
VERAPAMIL 40MG TABLET   1* Preferred Generic $0.00$0.00None
VERAPAMIL 80 MG TABLET   1* Preferred Generic $0.00$0.00None
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS   3 Preferred Brand $40.00$100.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VERAPAMIL ER 120 MG TABLET   2* Generic $5.00$12.50None
VERAPAMIL ER 180 MG TABLET   2* Generic $5.00$12.50None
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT)   3 Preferred Brand $40.00$100.00None
VERAPAMIL ER 240 MG TABLET   2* Generic $5.00$12.50None
VERAPAMIL ER PM 300 MG CAPSULE 24H PCT [Verelan PM]   3 Preferred Brand $40.00$100.00None
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE   4 Non-Preferred Drug 46%46%None
VERSACLOZ 50 MG/ML ORAL SUSPENSION   5 Specialty Tier 25%N/AP Q:600
/30Days
VERZENIO 100 MG TABLET   5 Specialty Tier 25%N/AP
VERZENIO 150 MG TABLET   5 Specialty Tier 25%N/AP
VERZENIO 200 MG TABLET   5 Specialty Tier 25%N/AP
VERZENIO 50 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
VICTOZA 3-PAK 18 MG/3 ML PEN   3 Preferred Brand $40.00$100.00Q:9
/30Days
VIDEX 4 GM PEDIATRIC SOLN   4 Non-Preferred Drug 46%46%None
VIDEX EC 125MG CAPSULE SA   4 Non-Preferred Drug 46%46%None
VIENVA-28 TABLET   2* Generic $5.00$12.50None
VIGABATRIN 500 MG POWDER PACKET [SABRIL]   5 Specialty Tier 25%N/AP Q:180
/30Days
VIGABATRIN 500 MG TABLET [Sabril]   5 Specialty Tier 25%N/AP Q:180
/30Days
VIGADRONE 500 MG POWDER PACKET   5 Specialty Tier 25%N/AP Q:180
/30Days
VIIBRYD 10-20 MG STARTER PACK   4 Non-Preferred Drug 46%46%None
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 46%46%Q:30
/30Days
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 46%46%Q:30
/30Days
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 46%46%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VIMPAT 10 MG/ML SOLUTION   5 Specialty Tier 25%N/AQ:1200
/30Days
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 25%N/AQ:60
/30Days
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 25%N/AQ:60
/30Days
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 25%N/AQ:60
/30Days
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Drug 46%46%Q:120
/30Days
VIRACEPT 250MG TABLET   5 Specialty Tier 25%N/ANone
VIRACEPT 625MG TABLET   5 Specialty Tier 25%N/ANone
VIRAMUNE 50MG/5ML SUSP   4 Non-Preferred Drug 46%46%None
VIREAD 150 MG TABLET   5 Specialty Tier 25%N/ANone
VIREAD 200 MG TABLET   5 Specialty Tier 25%N/ANone
VIREAD 250 MG TABLET   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VIREAD POWDER   5 Specialty Tier 25%N/ANone
VITRAKVI 100 MG CAPSULE   5 Specialty Tier 25%N/AP
VITRAKVI 20 MG/ML SOLUTION   5 Specialty Tier 25%N/AP
VITRAKVI 25 MG CAPSULE   5 Specialty Tier 25%N/AP
VIVITROL INJECTABLE SUSPENSION 380MG/VIAL   5 Specialty Tier 25%N/ANone
VIZIMPRO 15 MG TABLET   5 Specialty Tier 25%N/AP
VIZIMPRO 30 MG TABLET   5 Specialty Tier 25%N/AP
VIZIMPRO 45 MG TABLET   5 Specialty Tier 25%N/AP
VORICONAZOLE 200 MG TABLET [VFEND]   5 Specialty Tier 25%N/ANone
VORICONAZOLE 200 MG VIAL   4 Non-Preferred Drug 46%46%None
Voriconazole 40 MG/ML Oral Suspension   5 Specialty Tier 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VORICONAZOLE 50 MG TABLET [VFEND]   5 Specialty Tier 25%N/ANone
VOSEVI 400-100-100 MG TABLET   5 Specialty Tier 25%N/AP
VOTRIENT 200 MG TABLET   5 Specialty Tier 25%N/AP
VRAYLAR 1.5 MG CAP   5 Specialty Tier 25%N/AP Q:60
/30Days
VRAYLAR 1.5 MG-3 MG PACK   4 Non-Preferred Drug 46%46%P
VRAYLAR 3 MG CAP   5 Specialty Tier 25%N/AP Q:30
/30Days
VRAYLAR 4.5 MG CAP   5 Specialty Tier 25%N/AP Q:30
/30Days
VRAYLAR 6 MG CAP   5 Specialty Tier 25%N/AP Q:30
/30Days
Vyfemla 28 tablet   3 Preferred Brand $40.00$100.00None
VYLIBRA 28 TABLET   2* Generic $5.00$12.50None
VYTORIN 10-10 MG TABLET   4 Non-Preferred Drug 46%46%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VYTORIN 10-20 MG TABLET   4 Non-Preferred Drug 46%46%None
VYTORIN 10-40 MG TABLET   4 Non-Preferred Drug 46%46%None
VYTORIN 10-80 MG TABLET   4 Non-Preferred Drug 46%46%None
VYVANSE 10 MG CAPSULE   4 Non-Preferred Drug 46%46%Q:60
/30Days
VYVANSE 10 MG CHEWABLE TABLET   4 Non-Preferred Drug 46%46%Q:60
/30Days
VYVANSE 20 MG CHEWABLE TABLET   4 Non-Preferred Drug 46%46%Q:60
/30Days
VYVANSE 30 MG CHEWABLE TABLET   4 Non-Preferred Drug 46%46%Q:60
/30Days
VYVANSE 30MG CAPSULE   4 Non-Preferred Drug 46%46%Q:60
/30Days
VYVANSE 40 MG CHEWABLE TABLET   4 Non-Preferred Drug 46%46%Q:30
/30Days
VYVANSE 40MG CAPSULE 100 EA   4 Non-Preferred Drug 46%46%Q:30
/30Days
VYVANSE 50 MG CHEWABLE TABLET   4 Non-Preferred Drug 46%46%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VYVANSE 50MG CAPSULE   4 Non-Preferred Drug 46%46%Q:30
/30Days
VYVANSE 60 MG CHEWABLE TABLET   4 Non-Preferred Drug 46%46%Q:30
/30Days
VYVANSE 70MG CAPSULE   4 Non-Preferred Drug 46%46%Q:30
/30Days
VYVANSE CAPSULES 20MG 100 BOT   4 Non-Preferred Drug 46%46%Q:60
/30Days
VYVANSE CAPSULES 60MG 100 BOT   4 Non-Preferred Drug 46%46%Q:30
/30Days

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.