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WellCare Wellness Rx (PDP) (S4802-180-0)
Tier 1 (414)
Tier 2 (491)
Tier 3 (939)
Tier 4 (961)
Tier 5 (664)
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Uses Step Therapy:
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Has Quantity Limits:
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Cick on the first letter of your drug name to browse the formulary:

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2020 Medicare Part D Plan Formulary Information
WellCare Wellness Rx (PDP) (S4802-180-0)
Benefit Details           
The WellCare Wellness Rx (PDP) (S4802-180-0)
Formulary Drugs Starting with the Letter P

in CMS PDP Region 11 which includes: FL
Plan Monthly Premium: $13.20 Deductible: $435 Qualifies for LIS: No
Drugs Starting with Letter P

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
PACERONE 100MG TABLET   4 Non-Preferred Drug 46%46%None
PACERONE 200 MG TABLET   1* Preferred Generic $0.00$0.00None
PACERONE 400MG TABLET   4 Non-Preferred Drug 46%46%None
PALIPERIDONE ER 1.5 MG TABLET [INVEGA]   4 Non-Preferred Drug 46%46%Q:30
/30Days
PALIPERIDONE ER 3 MG TABLET [INVEGA]   4 Non-Preferred Drug 46%46%Q:30
/30Days
PALIPERIDONE ER 6 MG TABLET [INVEGA]   4 Non-Preferred Drug 46%46%Q:60
/30Days
PALIPERIDONE ER 9 MG TABLET [INVEGA]   4 Non-Preferred Drug 46%46%Q:30
/30Days
PANRETIN 0.1% GEL 60GM TUBE   5 Specialty Tier 25%N/AQ:60
/30Days
PANTOPRAZOLE SOD DR 20 MG TAB   1* Preferred Generic $0.00$0.00None
PANTOPRAZOLE SOD DR 40 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
PANZYGA 10% (1 G/10 ML) VIAL   5 Specialty Tier 25%N/AP
PANZYGA 10% (10 G/100 ML) VIAL   5 Specialty Tier 25%N/AP
PANZYGA 10% (2.5 G/25 ML) VIAL   5 Specialty Tier 25%N/AP
PANZYGA 10% (20G/200ML) VIAL   5 Specialty Tier 25%N/AP
PANZYGA 10% (30 G/300 ML) VIAL   5 Specialty Tier 25%N/AP
PANZYGA 10% (5 G/50 ML) VIAL   5 Specialty Tier 25%N/AP
PARICALCITOL 1 MCG CAPSULE [Zemplar]   4 Non-Preferred Drug 46%46%P
PARICALCITOL 2 MCG CAPSULE [Zemplar]   4 Non-Preferred Drug 46%46%P
PARICALCITOL 4 MCG CAPSULE [Zemplar]   4 Non-Preferred Drug 46%46%P
PAROMOMYCIN 250 MG CAPSULE   4 Non-Preferred Drug 46%46%None
PAROXETINE ER 12.5 MG TABLET 24H [Paxil CR]   4 Non-Preferred Drug 46%46%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PAROXETINE ER 25 MG TABLET 24H [Paxil CR]   4 Non-Preferred Drug 46%46%Q:60
/30Days
PAROXETINE ER 37.5 MG TABLET ER 24H [Paxil CR]   4 Non-Preferred Drug 46%46%Q:60
/30Days
PAROXETINE HCL 10 MG TABLET   2* Generic $6.00$15.00None
PAROXETINE HCL 20 MG TABLET   2* Generic $6.00$15.00None
PAROXETINE HCL 30 MG TABLET   2* Generic $6.00$15.00None
PAROXETINE HCL 40 MG TABLET   2* Generic $6.00$15.00None
PASER GRANULES 4GM PACKET   4 Non-Preferred Drug 46%46%None
PAXIL ORAL SUSPENSION 10 MG/5ML   4 Non-Preferred Drug 46%46%Q:900
/30Days
PAZEO 0.7% EYE DROPS   3 Preferred Brand $42.00$105.00None
PEDVAXHIB VACCINE VIAL   3 Preferred Brand $42.00$105.00None
PEG 3350-ELECTROLYTE SOLUTION RECON [TriLyte]   2* Generic $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PEG-3350 AND ELECTROLYTES SOLN SOLN RECON   2* Generic $6.00$15.00None
PEGANONE 250 MG TABLET   4 Non-Preferred Drug 46%46%None
Pegasys 180ug/0.5mL 1 PACKET in 1 BOX / 4 SYRINGE, GLASS in 1 PACKET / 0.5 mL in 1 SYRINGE, GLASS   5 Specialty Tier 25%N/AP
PEGASYS INJECTION   5 Specialty Tier 25%N/AP
PEGASYS PROCLICK 180 MCG/0.5   5 Specialty Tier 25%N/AP
PEMAZYRE 13.5 MG TABLET   5 Specialty Tier 25%N/AP
PEMAZYRE 4.5 MG TABLET   5 Specialty Tier 25%N/AP
PEMAZYRE 9 MG TABLET   5 Specialty Tier 25%N/AP
PENICILLAMINE 250 MG TABLET [Depen]   5 Specialty Tier 25%N/ANone
PENICILLIN G POTASSIUM 2MMUNITS/50ML ISO-OSM   4 Non-Preferred Drug 46%46%None
PENICILLIN G POTASSIUM 3MMUNITS/50ML ISO-OSM   4 Non-Preferred Drug 46%46%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PENICILLIN G PROCAINE 1200000UNT 2ML CTG   4 Non-Preferred Drug 46%46%None
Penicillin G Sodium 5000000[iU]/1 10 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL   4 Non-Preferred Drug 46%46%None
PENICILLIN GK 20 MILLION UNIT   4 Non-Preferred Drug 46%46%None
PENICILLIN V POTASSIUM 250MG/5ML LIQUID   2* Generic $6.00$15.00None
PENICILLIN VK 125 MG/5 ML SOLN   2* Generic $6.00$15.00None
PENICILLIN VK 250 MG TABLET   1* Preferred Generic $0.00$0.00None
PENICILLIN VK 500 MG TABLET [Veetids]   1* Preferred Generic $0.00$0.00None
PENNSAID 2% PUMP   5 Specialty Tier 25%N/AP Q:224
/28Days
PENTAMIDINE 300 MG INHAL POWDER VIAL-NEB [NebuPent]   4 Non-Preferred Drug 46%46%P
PENTAMIDINE 300 MG VIAL [Pentam]   4 Non-Preferred Drug 46%46%None
PENTOXIFYLLINE 400MG TABLET SA   2* Generic $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PERFOROMIST 20MCG/2ML VIAL NEBULIZER   5 Specialty Tier 25%N/AP
PERINDOPRIL ERBUMINE 2 MG TAB   1* Preferred Generic $0.00$0.00None
PERINDOPRIL ERBUMINE 4 MG TAB   1* Preferred Generic $0.00$0.00None
PERINDOPRIL ERBUMINE 8 MG TAB   1* Preferred Generic $0.00$0.00None
Permethrin 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   3 Preferred Brand $42.00$105.00None
PERPHENAZINE 16 MG TABLET [Trilafon]   3 Preferred Brand $42.00$105.00None
PERPHENAZINE 2 MG TABLET [Trilafon]   3 Preferred Brand $42.00$105.00None
PERPHENAZINE 4 MG TABLET [Trilafon]   3 Preferred Brand $42.00$105.00None
PERPHENAZINE 8 MG TABLET [Trilafon]   3 Preferred Brand $42.00$105.00None
PERSERIS ER 120 MG SYRINGE KIT SUSER SYKT   5 Specialty Tier 25%N/AQ:1
/30Days
PERSERIS ER 90 MG SYRINGE KIT SUSER SYKT   5 Specialty Tier 25%N/AQ:1
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE   3 Preferred Brand $42.00$105.00None
Phenobarbital 100mg/1   3 Preferred Brand $42.00$105.00P
PHENOBARBITAL 15 MG TABLET   3 Preferred Brand $42.00$105.00P
PHENOBARBITAL 16.2 MG TABLET   3 Preferred Brand $42.00$105.00P
PHENOBARBITAL 20 MG/5 ML ELIX   4 Non-Preferred Drug 46%46%P
PHENOBARBITAL 30 MG TABLET   3 Preferred Brand $42.00$105.00P
PHENOBARBITAL 32.4 MG TABLET   3 Preferred Brand $42.00$105.00P
Phenobarbital 60mg/1   3 Preferred Brand $42.00$105.00P
PHENOBARBITAL 64.8 MG TABLET   3 Preferred Brand $42.00$105.00P
PHENOBARBITAL 97.2 MG TABLET   3 Preferred Brand $42.00$105.00P
PHENYTEK 200 MG CAPSULE   3 Preferred Brand $42.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PHENYTEK 300 MG CAPSULE   3 Preferred Brand $42.00$105.00None
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION [Dilantin]   3 Preferred Brand $42.00$105.00None
PHENYTOIN 50 MG CHEWABLE TABLET [Dilantin]   3 Preferred Brand $42.00$105.00None
PHENYTOIN SOD EXT 100 MG CAP   3 Preferred Brand $42.00$105.00None
PHENYTOIN SOD EXT 200 MG CAP   3 Preferred Brand $42.00$105.00None
PHENYTOIN SOD EXT 300 MG CAPSULE [Phenytek]   3 Preferred Brand $42.00$105.00None
PHOSPHOLINE IODIDE 0.125% 6.25MG   4 Non-Preferred Drug 46%46%None
PICATO 0.015% GEL   4 Non-Preferred Drug 46%46%Q:3
/30Days
PICATO 0.05% GEL   4 Non-Preferred Drug 46%46%Q:2
/30Days
PIFELTRO 100 MG TABLET   5 Specialty Tier 25%N/ANone
PILOCARPINE 1% EYE DROPS [Pilocar]   3 Preferred Brand $42.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PILOCARPINE 2% EYE DROPS [Pilocar]   3 Preferred Brand $42.00$105.00None
PILOCARPINE 4% EYE DROPS [Pilocar]   3 Preferred Brand $42.00$105.00None
PILOCARPINE HCL 5 MG TABLET [Salagen]   4 Non-Preferred Drug 46%46%None
PILOCARPINE HCL 7.5 MG TABLET [Salagen]   4 Non-Preferred Drug 46%46%None
PIMOZIDE 1 MG TABLET [Orap]   4 Non-Preferred Drug 46%46%None
PIMOZIDE 2 MG TABLET [Orap]   4 Non-Preferred Drug 46%46%None
PIMTREA 28 DAY TABLET   3 Preferred Brand $42.00$105.00None
PINDOLOL 10 MG TABLET   3 Preferred Brand $42.00$105.00None
PINDOLOL 5 MG TABLET [Visken]   3 Preferred Brand $42.00$105.00None
PIOGLITAZONE HCL 15 MG TABLET [Actos]   1* Preferred Generic $0.00$0.00Q:30
/30Days
PIOGLITAZONE HCL 30 MG TABLET [Actos]   1* Preferred Generic $0.00$0.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PIOGLITAZONE HCL 45 MG TABLET [Actos]   1* Preferred Generic $0.00$0.00Q:30
/30Days
PIPERACIL-TAZOBACT 2.25 GM VIAL [Zosyn]   4 Non-Preferred Drug 46%46%None
PIPERACIL-TAZOBACT 3.375 GM VIAL [Zosyn]   4 Non-Preferred Drug 46%46%None
PIPERACIL-TAZOBACT 4.5 GM VIAL   4 Non-Preferred Drug 46%46%None
PIPERACIL-TAZOBACT 40.5 GRAM VIAL [Zosyn]   4 Non-Preferred Drug 46%46%None
PIQRAY 200 MG DAILY DOSE TABLET   5 Specialty Tier 25%N/AP
PIQRAY 250 MG DAILY DOSE TABLET   5 Specialty Tier 25%N/AP
PIQRAY 300 MG DAILY DOSE TABLET   5 Specialty Tier 25%N/AP
PIRMELLA 1-35 28 TABLET   2* Generic $6.00$15.00None
PIROXICAM 10 MG CAPSULE   3 Preferred Brand $42.00$105.00None
PIROXICAM 20 MG CAPSULE   3 Preferred Brand $42.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PLASMA-LYTE 148 IV SOLUTION   4 Non-Preferred Drug 46%46%None
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML;   4 Non-Preferred Drug 46%46%None
PLENVU POWDER PACKETS SQ   4 Non-Preferred Drug 46%46%None
PODOFILOX 0.5% TOPICAL TUBEX   3 Preferred Brand $42.00$105.00None
POLYMYXIN B-TMP EYE DROPS   2* Generic $6.00$15.00None
POMALYST 1 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/21Days
POMALYST 2 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/21Days
POMALYST 3 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/28Days
POMALYST 4 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/28Days
PORTIA 0.15-0.03 TABLET   2* Generic $6.00$15.00None
POSACONAZOLE DR 100 MG TABLET [Noxafil]   5 Specialty Tier 25%N/AQ:93
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Potassium Chloride 2 MEQ/ML Injectable Solution   2* Generic $6.00$15.00None
Potassium Chloride 8 MEQ Extended Release Oral Tablet   2* Generic $6.00$15.00None
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG   2* Generic $6.00$15.00None
Potassium Chloride in Dextrose and Sodium Chloride 5; 300; 900g/100mL; mg/100mL; mg/100mL 1000 mL i   4 Non-Preferred Drug 46%46%None
POTASSIUM CITRATE ER 10 MEQ TB   4 Non-Preferred Drug 46%46%None
POTASSIUM CITRATE ER 15 MEQ TABLET   4 Non-Preferred Drug 46%46%None
POTASSIUM CITRATE ER 5 MEQ TAB   4 Non-Preferred Drug 46%46%None
POTASSIUM CL 10 MEQ/100 ML SOL PIGGYBACK   2* Generic $6.00$15.00None
POTASSIUM CL 10% (20 MEQ/15ML) Liquid [Kay Ciel]   4 Non-Preferred Drug 46%46%None
POTASSIUM CL 20 MEQ PACKET [Klor-Con]   4 Non-Preferred Drug 46%46%None
POTASSIUM CL 20 MEQ-0.45% NACL IV SOLN   2* Generic $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
POTASSIUM CL 20 MEQ/100 ML SOL PIGGYBACK   2* Generic $6.00$15.00None
POTASSIUM CL 20% (40 MEQ/15ML) Liquid [Kaon-CL]   4 Non-Preferred Drug 46%46%None
POTASSIUM CL 40 MEQ/100 ML SOL PIGGYBACK   2* Generic $6.00$15.00None
POTASSIUM CL 40 MEQ/20 ML CONC VIAL [PROAMP]   2* Generic $6.00$15.00None
POTASSIUM CL ER 10 MEQ CAPSULE   3 Preferred Brand $42.00$105.00None
POTASSIUM CL ER 10 MEQ TABLET   2* Generic $6.00$15.00None
POTASSIUM CL ER 10 MEQ TABLET [Klotrix]   2* Generic $6.00$15.00None
Potassium cl er 20 meq tablet   2* Generic $6.00$15.00None
POTASSIUM CL ER 20 MEQ TABLET   2* Generic $6.00$15.00None
POTASSIUM CL ER 8 MEQ CAPSULE ER [Micro-K Extencaps]   3 Preferred Brand $42.00$105.00None
PRADAXA 110 MG CAPSULE   4 Non-Preferred Drug 46%46%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PRADAXA 150 MG CAPSULE   4 Non-Preferred Drug 46%46%Q:60
/30Days
PRADAXA 75 MG CAPSULE   4 Non-Preferred Drug 46%46%Q:60
/30Days
PRALUENT 150 MG/ML PEN INJCTR   4 Non-Preferred Drug 46%46%P
PRALUENT 75 MG/ML PEN INJCTR   4 Non-Preferred Drug 46%46%P
PRAMIPEXOLE 0.125 MG TABLET   1* Preferred Generic $0.00$0.00None
PRAMIPEXOLE 0.25 MG TABLET   1* Preferred Generic $0.00$0.00None
PRAMIPEXOLE 0.5 MG TABLET   1* Preferred Generic $0.00$0.00None
PRAMIPEXOLE 0.75 MG TABLET   1* Preferred Generic $0.00$0.00None
PRAMIPEXOLE 1 MG TABLET   1* Preferred Generic $0.00$0.00None
PRAMIPEXOLE 1.5 MG TABLET [Mirapex]   1* Preferred Generic $0.00$0.00None
PRAMIPEXOLE ER 0.375 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
PRAMIPEXOLE ER 0.75 MG TABLET   4 Non-Preferred Drug 46%46%None
PRAMIPEXOLE ER 1.5 MG TABLET   4 Non-Preferred Drug 46%46%None
PRAMIPEXOLE ER 2.25 MG TABLET ER 24H [Mirapex ER]   4 Non-Preferred Drug 46%46%None
PRAMIPEXOLE ER 3 MG TABLET   4 Non-Preferred Drug 46%46%None
PRAMIPEXOLE ER 3.75 MG TABLET   4 Non-Preferred Drug 46%46%None
PRAMIPEXOLE ER 4.5 MG TABLET   4 Non-Preferred Drug 46%46%None
PRASUGREL 10 MG TABLET [Effient]   3 Preferred Brand $42.00$105.00None
PRASUGREL 5 MG TABLET [Effient]   3 Preferred Brand $42.00$105.00None
PRAVASTATIN SODIUM 10 MG TABLET [Pravachol]   1* Preferred Generic $0.00$0.00None
PRAVASTATIN SODIUM 20 MG TAB   1* Preferred Generic $0.00$0.00None
PRAVASTATIN SODIUM 40 MG TABLET [Pravachol]   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PRAVASTATIN SODIUM 80 MG TABLET [Pravachol]   1* Preferred Generic $0.00$0.00None
PRAZIQUANTEL 600 MG TABLET [Biltricide]   3 Preferred Brand $42.00$105.00None
PRAZOSIN 1 MG CAPSULE   3 Preferred Brand $42.00$105.00None
PRAZOSIN 2 MG CAPSULE   3 Preferred Brand $42.00$105.00None
PRAZOSIN 5MG CAPSULE   3 Preferred Brand $42.00$105.00None
PREDNISOLONE 15 MG/5 ML SOLN   2* Generic $6.00$15.00None
PREDNISOLONE AC 1% EYE DROP   3 Preferred Brand $42.00$105.00None
PREDNISOLONE ODT 10 MG TABLET RAPDIS [Orapred ODT]   2* Generic $6.00$15.00None
PREDNISOLONE ODT 15 MG TABLET RAPDIS [Orapred ODT]   2* Generic $6.00$15.00None
PREDNISOLONE ODT 30 MG TABLET RAPDIS [Orapred ODT]   2* Generic $6.00$15.00None
PREDNISOLONE SOD 1% EYE DROP   3 Preferred Brand $42.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREDNISOLONE SOD PH 25 MG/5 ML   4 Non-Preferred Drug 46%46%None
PREDNISOLONE SODIUM PHOSPHATE 5MG /5ML ORAL SOLUTION   4 Non-Preferred Drug 46%46%None
PREDNISONE 1 MG TABLET   1* Preferred Generic $0.00$0.00None
PREDNISONE 10 MG TABLET [Sterapred DS]   1* Preferred Generic $0.00$0.00None
PREDNISONE 10 MG TABLET DOSE PACK   3 Preferred Brand $42.00$105.00None
PREDNISONE 10 MG TABLET DOSE PACK   3 Preferred Brand $42.00$105.00None
PREDNISONE 2.5 MG TABLET   1* Preferred Generic $0.00$0.00None
PREDNISONE 20 MG TABLET [Predone]   1* Preferred Generic $0.00$0.00None
PREDNISONE 5 MG TABLET   3 Preferred Brand $42.00$105.00None
PREDNISONE 5 MG TABLET   3 Preferred Brand $42.00$105.00None
PREDNISONE 5 MG TABLET [Sterapred]   1* Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREDNISONE 5 MG/5 ML SOLUTION   4 Non-Preferred Drug 46%46%None
PREDNISONE 50MG TABLET   1* Preferred Generic $0.00$0.00None
PREDNISONE 5MG/ML SOLUTION   4 Non-Preferred Drug 46%46%None
PREGABALIN 100 MG CAPSULE [Lyrica]   3 Preferred Brand $42.00$105.00Q:120
/30Days
PREGABALIN 150 MG CAPSULE [Lyrica]   3 Preferred Brand $42.00$105.00Q:120
/30Days
PREGABALIN 20 MG/ML SOLUTION [Lyrica]   4 Non-Preferred Drug 46%46%Q:900
/30Days
PREGABALIN 200 MG CAPSULE [Lyrica]   3 Preferred Brand $42.00$105.00Q:90
/30Days
PREGABALIN 225 MG CAPSULE [Lyrica]   3 Preferred Brand $42.00$105.00Q:60
/30Days
PREGABALIN 25 MG CAPSULE [Lyrica]   3 Preferred Brand $42.00$105.00Q:120
/30Days
PREGABALIN 300 MG CAPSULE [Lyrica]   3 Preferred Brand $42.00$105.00Q:60
/30Days
PREGABALIN 50 MG CAPSULE [Lyrica]   3 Preferred Brand $42.00$105.00Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PREGABALIN 75 MG CAPSULE [Lyrica]   3 Preferred Brand $42.00$105.00Q:120
/30Days
PREMARIN 0.3 MG TABLET   3 Preferred Brand $42.00$105.00None
PREMARIN 0.45MG TABLET   3 Preferred Brand $42.00$105.00None
PREMARIN 0.625 MG TABLET   3 Preferred Brand $42.00$105.00None
Premarin 0.625mg/g   3 Preferred Brand $42.00$105.00None
PREMARIN 0.9MG TABLET   3 Preferred Brand $42.00$105.00None
PREMARIN 1.25 MG TABLET   3 Preferred Brand $42.00$105.00None
PREMASOL 10% IV SOLUTION   4 Non-Preferred Drug 46%46%P
PREMPRO 0.3 MG-1.5 MG TABLET #28 EA   3 Preferred Brand $42.00$105.00None
PREMPRO 0.45-1.5 MG TABLET 28 EA   3 Preferred Brand $42.00$105.00None
PREMPRO 0.625-5 MG TABLET   3 Preferred Brand $42.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Prempro 0.625; 2.5mg/1; mg/1 1 BLISTER PACK per CARTON / 28 TABLET, SUGAR COATED per BLISTER PACK   3 Preferred Brand $42.00$105.00None
PREVALITE PACKET   4 Non-Preferred Drug 46%46%None
PREVIFEM TABLET [VyLibra]   2* Generic $6.00$15.00None
PREZCOBIX 800 MG-150 MG TABLET   5 Specialty Tier 25%N/ANone
PREZISTA 100 MG/ML SUSPENSION   5 Specialty Tier 25%N/AQ:400
/30Days
PREZISTA 150MG TABLETS   5 Specialty Tier 25%N/AQ:240
/30Days
PREZISTA 800 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
PREZISTA TABLET 600MG   5 Specialty Tier 25%N/AQ:60
/30Days
PREZISTA TABLET 75MG   4 Non-Preferred Drug 46%46%Q:480
/30Days
PRIFTIN 150 MG TABLET   4 Non-Preferred Drug 46%46%None
PRILOSEC DR 10 MG SUSPENSION   4 Non-Preferred Drug 46%46%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PRILOSEC DR 2.5 MG SUSPENSION   4 Non-Preferred Drug 46%46%None
Primaquine Phosphate 26.3 MG Oral Tablet   3 Preferred Brand $42.00$105.00None
PRIMIDONE 250 MG TABLET [Mysoline]   2* Generic $6.00$15.00None
PRIMIDONE 50 MG TABLET [Mysoline]   2* Generic $6.00$15.00None
PRIVIGEN 10% VIAL   5 Specialty Tier 25%N/AP
PROBENECID 500 MG TABLET   2* Generic $6.00$15.00None
PROBENECID-COLCHICINE TABLET   3 Preferred Brand $42.00$105.00None
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   4 Non-Preferred Drug 46%46%P
PROCHLORPERAZINE 10 MG TAB   2* Generic $6.00$15.00None
PROCHLORPERAZINE 5 MG TABLET   2* Generic $6.00$15.00None
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX   4 Non-Preferred Drug 46%46%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROCRIT 10000U/ML VIAL   3 Preferred Brand $42.00$105.00P
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL   3 Preferred Brand $42.00$105.00P
PROCRIT 3,000 UNITS/ML VIAL   3 Preferred Brand $42.00$105.00P
PROCRIT 4,000 UNITS/ML VIAL   3 Preferred Brand $42.00$105.00P
PROCRIT 40000U/ML VIAL PR   5 Specialty Tier 25%N/AP
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY   5 Specialty Tier 25%N/AP
PROCTO-MED HC 2.5% CREAM   3 Preferred Brand $42.00$105.00None
procto-pak 1% cream   3 Preferred Brand $42.00$105.00None
PROCTOSOL-HC 2.5% CREAM   3 Preferred Brand $42.00$105.00None
PROCTOZONE-HC 2.5% CREAM   3 Preferred Brand $42.00$105.00None
PROGLYCEM 50 MG/ML ORAL SUSP   4 Non-Preferred Drug 46%46%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROGRAF 0.2 MG GRANULE PACKET   4 Non-Preferred Drug 46%46%P
PROGRAF 1 MG GRANULE PACKET   4 Non-Preferred Drug 46%46%P
PROLASTIN C 1,000 MG VIAL   5 Specialty Tier 25%N/AP
PROLENSA 0.07% EYE DROPS   3 Preferred Brand $42.00$105.00None
PROLIA 60MG/ML INJECTION   4 Non-Preferred Drug 46%46%Q:1
/180Days
PROMACTA 12.5 MG SUSPEN PACKET POWDER PACK   5 Specialty Tier 25%N/AP Q:360
/30Days
PROMACTA 12.5 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
PROMACTA 25 MG SUSPENSION POWDER PACK   5 Specialty Tier 25%N/AP Q:180
/30Days
PROMACTA 25 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
PROMACTA 50 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
PROMACTA 75 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROMETHAZINE 12.5 MG TABLET   2* Generic $6.00$15.00P
PROMETHAZINE 25 MG TABLET   2* Generic $6.00$15.00P
PROMETHAZINE 50 MG TABLET   2* Generic $6.00$15.00P
PROMETHAZINE 6.25 MG/5 ML SYRUP [Prometh Plain]   2* Generic $6.00$15.00P
PROPAFENONE HCL 150 MG TABLET [Rythmol]   2* Generic $6.00$15.00None
PROPAFENONE HCL 225MG TABLET   2* Generic $6.00$15.00None
PROPAFENONE HCL 300 MG TAB   2* Generic $6.00$15.00None
PROPAFENONE HCL ER 225 MG CAP   4 Non-Preferred Drug 46%46%None
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE   4 Non-Preferred Drug 46%46%None
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE   4 Non-Preferred Drug 46%46%None
Proparacaine hydrochloride 5 MG/ML Ophthalmic Solution   3 Preferred Brand $42.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROPRANOLOL 10 MG TABLET   2* Generic $6.00$15.00None
PROPRANOLOL 20 MG TABLET   2* Generic $6.00$15.00None
PROPRANOLOL 20MG/5ML TUBEX   3 Preferred Brand $42.00$105.00None
PROPRANOLOL 40 MG TABLET   2* Generic $6.00$15.00None
PROPRANOLOL 40MG/5ML TUBEX   3 Preferred Brand $42.00$105.00None
PROPRANOLOL 60 MG TABLET   2* Generic $6.00$15.00None
PROPRANOLOL 80 MG TABLET [Inderal]   2* Generic $6.00$15.00None
PROPRANOLOL ER 120 MG CAPSULE   3 Preferred Brand $42.00$105.00None
PROPRANOLOL ER 160 MG CAPSULE   3 Preferred Brand $42.00$105.00None
PROPRANOLOL ER 60 MG CAPSULE   3 Preferred Brand $42.00$105.00None
PROPRANOLOL ER 80 MG CAPSULE   3 Preferred Brand $42.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PROPRANOLOL/HCTZ 40/25 TABLET   3 Preferred Brand $42.00$105.00None
PROPRANOLOL/HCTZ 80/25 TABLET   3 Preferred Brand $42.00$105.00None
PROPYLTHIOURACIL 50MG TABLET   3 Preferred Brand $42.00$105.00None
PROQUAD VIAL   3 Preferred Brand $42.00$105.00None
PROSOL 20% INJECTION   4 Non-Preferred Drug 46%46%P
PROTRIPTYLINE HCL 10 MG TABLET [Vivactil]   4 Non-Preferred Drug 46%46%None
PROTRIPTYLINE HCL 5 MG TABLET [Vivactil]   4 Non-Preferred Drug 46%46%None
PSORCON 0.05% CREAM   5 Specialty Tier 25%N/AQ:60
/30Days
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED   4 Non-Preferred Drug 46%46%Q:2
/30Days
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED   4 Non-Preferred Drug 46%46%Q:2
/30Days
PULMOZYME 1MG/ML AMPUL   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
PURIXAN 20 MG/ML ORAL SUSP   5 Specialty Tier 25%N/ANone
PYRAZINAMIDE 500 MG TABLET   4 Non-Preferred Drug 46%46%None
PYRIDOSTIGMINE BR 60 MG TABLET   3 Preferred Brand $42.00$105.00None

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D WellCare Wellness Rx (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage 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 $435 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.
    • Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s 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 - This is what you will pay for formulary drugs in 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 initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $4020) 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 2020 )

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 Medicare plan provider.