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Wellcare Medicare Rx Value Plus (PDP) (S4802-214-0)
Tier 1 (358)
Tier 2 (428)
Tier 3 (1051)
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Cick on the first letter of your drug name to browse the formulary:

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2022 Medicare Part D Plan Formulary Information
Wellcare Medicare Rx Value Plus (PDP) (S4802-214-0)
Benefit Details           
This plan covers select insulin pay $35 copay.
See individual insulin cost-sharing below.
The Wellcare Medicare Rx Value Plus (PDP) (S4802-214-0)
Formulary Drugs Starting with the Letter N

in CMS PDP Region 11 which includes: FL
Drugs Starting with Letter N

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
NABUMETONE 500 MG TABLET [Relafen]   2 Generic $4.00$10.00None
NABUMETONE 750 MG TABLET [Relafen]   2 Generic $4.00$10.00None
NADOLOL 20 MG TABLET   2 Generic $4.00$10.00None
NADOLOL 40 MG TABLET [Corgard]   2 Generic $4.00$10.00None
NADOLOL 80 MG TABLET   2 Generic $4.00$10.00None
NAFCILLIN 1 GM VIAL   4 Non-Preferred Drug 50%50%None
NAFCILLIN 10 GM BULK VIAL   5 Specialty Tier 33%N/ANone
NAFCILLIN 2 GM VIAL   4 Non-Preferred Drug 50%50%None
NALOXONE 0.4 MG/ML CARPUJECT CARTRIDGE [Narcan]   2 Generic $4.00$10.00None
NALOXONE 0.4 MG/ML VIAL [Narcan]   2 Generic $4.00$10.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
naloxone 1 mg/ml syringe   2 Generic $4.00$10.00None
NALOXONE HCL 4 MG NASAL SPRAY [Narcan]   3 Preferred Brand $47.00$117.50None
NALTREXONE 50 MG TABLET [ReVia]   3 Preferred Brand $47.00$117.50None
NAMZARIC 14 MG-10 MG CAPSULE   4 Non-Preferred Drug 50%50%None
NAMZARIC 21 MG-10 MG CAPSULE   4 Non-Preferred Drug 50%50%None
NAMZARIC 28 MG-10 MG CAPSULE   4 Non-Preferred Drug 50%50%None
NAMZARIC 7 MG-10 MG CAPSULE   4 Non-Preferred Drug 50%50%None
NAMZARIC TITRATION PACK   4 Non-Preferred Drug 50%50%None
NAPROXEN 250 MG TABLET [Naprosyn]   1 Preferred Generic $0.00$0.00None
NAPROXEN 375 MG TABLET   1 Preferred Generic $0.00$0.00None
NAPROXEN 500 MG 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
NAPROXEN DR 375 MG TABLET DR [EC-Naprosyn]   2 Generic $4.00$10.00Q:120
/30Days
NAPROXEN DR 500 MG TABLET DR [EC-Naprosyn]   4 Non-Preferred Drug 50%50%Q:90
/30Days
NAPROXEN SODIUM 275 MG TABLET [Anaprox]   3 Preferred Brand $47.00$117.50None
NAPROXEN SODIUM 550 MG TABLET [Anaprox DS]   3 Preferred Brand $47.00$117.50None
NARATRIPTAN HCL 1 MG TABLET   3 Preferred Brand $47.00$117.50Q:12
/30Days
NARATRIPTAN HCL 2.5 MG TABLET   3 Preferred Brand $47.00$117.50Q:12
/30Days
NATACYN 5% EYE DROPS/EYE DROPPER   4 Non-Preferred Drug 50%50%None
NATEGLINIDE 120 MG TABLET [Starlix]   1 Preferred Generic $0.00$0.00Q:90
/30Days
NATEGLINIDE 60 MG TABLET [Starlix]   1 Preferred Generic $0.00$0.00Q:90
/30Days
NATPARA 100 MCG DOSE CARTRIDGE   5 Specialty Tier 33%N/AP
NATPARA 25 MCG DOSE CARTRIDGE   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NATPARA 50 MCG DOSE CARTRIDGE   5 Specialty Tier 33%N/AP
NATPARA 75 MCG DOSE CARTRIDGE   5 Specialty Tier 33%N/AP
NAYZILAM 5 MG NASAL SPRAY   4 Non-Preferred Drug 50%50%None
NEBIVOLOL 10 MG TABLET [Bystolic]   3 Preferred Brand $47.00$117.50Q:30
/30Days
NEBIVOLOL 2.5 MG TABLET [Bystolic]   3 Preferred Brand $47.00$117.50Q:30
/30Days
NEBIVOLOL 20 MG TABLET [Bystolic]   3 Preferred Brand $47.00$117.50Q:60
/30Days
NEBIVOLOL 5 MG TABLET [Bystolic]   3 Preferred Brand $47.00$117.50Q:30
/30Days
NECON 0.5-35-28 TABLET [WERA]   2 Generic $4.00$10.00None
NEFAZODONE HCL 150MG TABLET (60 CT)   4 Non-Preferred Drug 50%50%None
NEFAZODONE HCL 250MG TABLET   4 Non-Preferred Drug 50%50%None
NEFAZODONE HCL 50MG TABLET   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT   4 Non-Preferred Drug 50%50%None
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT   4 Non-Preferred Drug 50%50%None
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT   3 Preferred Brand $47.00$117.50None
NEOMYC-POLYM-DEXAMET EYE OINTMENT [Poly-Dex]   2 Generic $4.00$10.00None
NEOMYC-POLYM-DEXAMETH EYE DROP   2 Generic $4.00$10.00None
NEOMYCIN SULFATE 500MG TABLET   2 Generic $4.00$10.00None
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT   3 Preferred Brand $47.00$117.50None
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS   4 Non-Preferred Drug 50%50%None
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M   3 Preferred Brand $47.00$117.50None
NEOMYCIN/POLYMY/HYDRO OTIC SUS   3 Preferred Brand $47.00$117.50None
NERLYNX 40 MG TABLET   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NEUPRO 1 MG/24 HR PATCH   4 Non-Preferred Drug 50%50%None
NEUPRO 2 MG/24 HR PATCH   4 Non-Preferred Drug 50%50%None
NEUPRO 3 MG/24 HR PATCH   4 Non-Preferred Drug 50%50%None
NEUPRO 4 MG/24 HR PATCH   4 Non-Preferred Drug 50%50%None
NEUPRO 6 MG/24 HR PATCH   4 Non-Preferred Drug 50%50%None
NEUPRO 8 MG/24 HR PATCH   4 Non-Preferred Drug 50%50%None
NEVIRAPINE 200 MG TABLET   2 Generic $4.00$10.00None
NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION [Viramune]   4 Non-Preferred Drug 50%50%None
NEVIRAPINE ER 100 MG TABLET ER 24H [Viramune XR]   4 Non-Preferred Drug 50%50%None
NEVIRAPINE ER 400 MG TABLET ER 24H [Viramune XR]   4 Non-Preferred Drug 50%50%None
NEXAVAR TABLETS 200MG 120 BOT   5 Specialty Tier 33%N/AP Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NIACIN ER 1,000 MG TABLET ER 24H [Niaspan]   3 Preferred Brand $47.00$117.50Q:60
/30Days
NIACIN ER 500 MG TABLET [Niaspan ER]   3 Preferred Brand $47.00$117.50Q:60
/30Days
NIACIN ER 750 MG TABLET [Niaspan ER]   3 Preferred Brand $47.00$117.50Q:60
/30Days
Nicardipine hydrochloride 20 MG Oral Capsule   4 Non-Preferred Drug 50%50%None
Nicardipine hydrochloride 30 MG Oral Capsule   4 Non-Preferred Drug 50%50%None
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL   4 Non-Preferred Drug 50%50%None
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL   4 Non-Preferred Drug 50%50%None
NIFEDIPINE ER 30 MG TABLET ER [Nifediac CC]   3 Preferred Brand $47.00$117.50None
NIFEDIPINE ER 30 MG TABLET ER [Procardia XL]   3 Preferred Brand $47.00$117.50None
NIFEDIPINE ER 60 MG TABLET ER [Nifediac CC]   3 Preferred Brand $47.00$117.50None
NIFEDIPINE ER 60 MG TABLET ER [Procardia XL]   3 Preferred Brand $47.00$117.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NIFEDIPINE ER 90 MG TABLET ER [Nifediac CC]   3 Preferred Brand $47.00$117.50None
NIFEDIPINE ER 90 MG TABLET ER [Procardia XL]   3 Preferred Brand $47.00$117.50None
NIKKI 3 MG-0.02 MG TABLET [Yaz]   3 Preferred Brand $47.00$117.50None
NILUTAMIDE 150 MG TABLET [Nilandron]   5 Specialty Tier 33%N/ANone
NIMODIPINE 30 MG CAPSULE [Nimotop]   4 Non-Preferred Drug 50%50%None
NINLARO 2.3 MG CAPSULE   5 Specialty Tier 33%N/AP Q:3
/28Days
NINLARO 3 MG CAPSULE   5 Specialty Tier 33%N/AP Q:3
/28Days
NINLARO 4 MG CAPSULE   5 Specialty Tier 33%N/AP Q:3
/28Days
NISOLDIPINE ER 17 MG TABLET ER 24H [Sular]   4 Non-Preferred Drug 50%50%None
NISOLDIPINE ER 20 MG TABLET 24H [Sular]   4 Non-Preferred Drug 50%50%None
NISOLDIPINE ER 25.5 MG TABLET 24H [Sular]   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NISOLDIPINE ER 30 MG TABLET 24H [Sular]   4 Non-Preferred Drug 50%50%None
NISOLDIPINE ER 34 MG TABLET ER 24H [Sular]   4 Non-Preferred Drug 50%50%None
NISOLDIPINE ER 40 MG TABLET 24H [Sular]   4 Non-Preferred Drug 50%50%None
NISOLDIPINE ER 8.5 MG TABLET ER 24H [Sular]   4 Non-Preferred Drug 50%50%None
NITAZOXANIDE 500 MG TABLET [Alinia]   5 Specialty Tier 33%N/AQ:6
/30Days
NITISINONE 10 MG CAPSULE [Orfadin]   5 Specialty Tier 33%N/AP
NITISINONE 2 MG CAPSULE [Orfadin]   5 Specialty Tier 33%N/AP
NITISINONE 5 MG CAPSULE [Orfadin]   5 Specialty Tier 33%N/AP
NITRO-BID 2% OINTMENT   3 Preferred Brand $47.00$117.50None
NITROFURANTOIN MCR 100 MG CAPSULE [Macrodantin]   3 Preferred Brand $47.00$117.50None
NITROFURANTOIN MCR 50 MG CAPSULE [Macrodantin]   3 Preferred Brand $47.00$117.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NITROFURANTOIN MONO-MCR 100 MG CAPSULE [Macrobid]   3 Preferred Brand $47.00$117.50None
NITROGLYCERIN 0.2 MG/HR PATCH [Nitrodisc]   3 Preferred Brand $47.00$117.50None
NITROGLYCERIN 0.3 MG TABLET SL   3 Preferred Brand $47.00$117.50None
NITROGLYCERIN 0.4 MG SUBLIGUAL TABLET [Nitrotab]   3 Preferred Brand $47.00$117.50None
NITROGLYCERIN 0.4 MG/HR PATCH [Transdermal-NTG]   3 Preferred Brand $47.00$117.50None
NITROGLYCERIN 0.6 MG SUBLIGUAL TABLET [Nitrotab]   3 Preferred Brand $47.00$117.50None
NITROGLYCERIN 0.6 MG/HR PATCH [Transdermal-NTG]   3 Preferred Brand $47.00$117.50None
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX   3 Preferred Brand $47.00$117.50None
NIZATIDINE 150 MG CAPSULE [Axid]   4 Non-Preferred Drug 50%50%None
NIZATIDINE 300 MG CAPSULE [Axid]   4 Non-Preferred Drug 50%50%None
NORA-BE 0.35MG TABLET   2 Generic $4.00$10.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NORETH-EE-FE 1-0.02(21)-75 TABLET [Tarina Fe 1/20]   2 Generic $4.00$10.00None
NORETHIN-ETH ESTRAD 1 MG-5 MCG   3 Preferred Brand $47.00$117.50None
NORETHIND-ETH ESTRAD 0.5-2.5 TABLET [Jevantique]   3 Preferred Brand $47.00$117.50None
NORETHIND-ETH ESTRAD 1-0.02 MG   2 Generic $4.00$10.00None
NORETHINDRONE 0.35 MG TABLET [Sharobel 28-Day]   2 Generic $4.00$10.00None
NORETHINDRONE 5MG TABLET   3 Preferred Brand $47.00$117.50None
NORG-EE 0.18-0.215-0.25/0.035   2 Generic $4.00$10.00None
NORG-ETHIN ESTRA 0.18-0.215-0.25/0.025   3 Preferred Brand $47.00$117.50None
NORG-ETHIN ESTRA 0.25-0.035 MG TABLET [VyLibra]   2 Generic $4.00$10.00None
NORPACE CR 100 MG CAPSULE   4 Non-Preferred Drug 50%50%None
NORPACE CR 150MG CAPSULE SA   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK   2 Generic $4.00$10.00None
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK   2 Generic $4.00$10.00None
NORTREL 1-0.035MG TABLET 28DAY   2 Generic $4.00$10.00None
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER   2 Generic $4.00$10.00None
NORTRIPTYLINE 10 MG/5 ML SOL   4 Non-Preferred Drug 50%50%None
NORTRIPTYLINE HCL 25MG CAP   2 Generic $4.00$10.00None
NORTRIPTYLINE HCL 50 MG CAP   2 Generic $4.00$10.00None
NORTRIPTYLINE HCL 75 MG CAPSULE [Pamelor]   2 Generic $4.00$10.00None
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE   2 Generic $4.00$10.00None
NORVIR 100 MG POWDER PACKET   4 Non-Preferred Drug 50%50%None
NORVIR 100 MG TABLET   3 Preferred Brand $47.00$117.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NORVIR 80MG/ML ORAL SOLUTION   4 Non-Preferred Drug 50%50%None
Novolin 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL   3 Preferred Brand $35.00$117.50None
Novolin 100[USP'U]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL   3 Preferred Brand $35.00$117.50None
NOVOLIN 70-30 FLEXPEN INSULN PEN   3 Preferred Brand $35.00$117.50None
NOVOLIN N 100 UNIT/ML FLEXPEN INSULN PEN   3 Preferred Brand $35.00$117.50None
NOVOLIN R 100 UNIT/ML FLEXPEN INSULN PEN   3 Preferred Brand $35.00$117.50None
Novolin R 100[iU]/mL 1 VIAL per CARTON / 10 mL in 1 VIAL   3 Preferred Brand $35.00$117.50None
NOVOLOG 100 UNIT/ML CARTRIDGE   3 Preferred Brand $35.00$117.50None
NOVOLOG 100U/ML VIAL   3 Preferred Brand $35.00$117.50None
NOVOLOG FLEXPEN SYRINGE   3 Preferred Brand $35.00$117.50None
NOVOLOG MIX 70/30 SYRINGE 70-30U/ML   3 Preferred Brand $35.00$117.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NOVOLOG MIX 70/30 VIAL   3 Preferred Brand $35.00$117.50None
NOXAFIL 200MG/5ML SUSPENSION ORAL   5 Specialty Tier 33%N/AP Q:630
/30Days
NUBEQA 300 MG TABLET   5 Specialty Tier 33%N/AP
NUCALA 100 MG VIAL   5 Specialty Tier 33%N/AP
NUCALA 100 MG/ML AUTO-INJECTOR AUTO INJCT   5 Specialty Tier 33%N/AP
NUCALA 100 MG/ML SYRINGE   5 Specialty Tier 33%N/AP
NUEDEXTA 20; 10mg/1; mg/1   4 Non-Preferred Drug 50%50%P Q:60
/30Days
NUPLAZID 10 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
NUPLAZID 34 MG CAPSULE   5 Specialty Tier 33%N/AP Q:30
/30Days
NURTEC ODT 75 MG TABLET RAPDIS   5 Specialty Tier 33%N/AP Q:16
/30Days
NUTRILIPID 20 % EMULSION   4 Non-Preferred Drug 50%50%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NUZYRA 100 MG VIAL   5 Specialty Tier 33%N/ANone
NUZYRA 150 MG TABLET   5 Specialty Tier 33%N/ANone
NYAMYC 100,000 UNIT/GM POWDER [Pedi-Dri]   3 Preferred Brand $47.00$117.50Q:60
/30Days
NYLIA 1-35 28 TABLET [Pirmella]   2 Generic $4.00$10.00None
NYLIA 7-7-7-28 TABLET [Pirmella]   2 Generic $4.00$10.00None
NYMALIZE 60 MG/10 ML ORAL SYRINGE   5 Specialty Tier 33%N/ANone
NYMYO 0.25-0.035 MG (28) TABLET [VyLibra]   2 Generic $4.00$10.00None
NYSTATIN 100,000 UNIT/GM CREAM (g) [Pediaderm AF]   3 Preferred Brand $47.00$117.50Q:30
/30Days
NYSTATIN 100,000 UNIT/GM OINTMENT [Nystex]   3 Preferred Brand $47.00$117.50Q:30
/30Days
NYSTATIN 100,000 UNIT/GM POWDER [Pedi-Dri]   3 Preferred Brand $47.00$117.50Q:60
/30Days
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [Nystex]   3 Preferred Brand $47.00$117.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
NYSTATIN 500,000 UNIT ORAL TAB   3 Preferred Brand $47.00$117.50None
NYSTOP 100,000 UNITS/GM POWDER   3 Preferred Brand $47.00$117.50Q:60
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2022 Medicare Part D Wellcare Medicare Rx Value Plus (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 $480 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 $4,430) 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.

      * When the insulin copay is in green, example: $35.00, this Part D plan may offer particular forms of insulin as part of the Senior Savings Model.  The Senior Savings Model stipulates that some insulin will cost no more than $35 in the deductible, initial coverage, and coverage gap phases of your Part D plan. Please contact the drug plan for more details.

    • 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 2022 )

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.