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Wellcare Medicare Rx Value Plus (PDP) (S4802-214-0)
Tier 1 (358)
Tier 2 (428)
Tier 3 (1051)
Tier 4 (957)
Tier 5 (692)
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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 T

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
TABLOID 40 MG TABLET   4 Non-Preferred Drug 50%50%None
TABRECTA 150 MG TABLET   5 Specialty Tier 33%N/AP
TABRECTA 200 MG TABLET   5 Specialty Tier 33%N/AP
TACROLIMUS 0.03% OINTMENT [Protopic]   4 Non-Preferred Drug 50%50%Q:100
/30Days
TACROLIMUS 0.1% OINTMENT [Protopic]   4 Non-Preferred Drug 50%50%Q:100
/30Days
TACROLIMUS 0.5 MG CAPSULE (IR) [Prograf]   4 Non-Preferred Drug 50%50%P
TACROLIMUS 1 MG CAPSULE (IR) [Prograf]   4 Non-Preferred Drug 50%50%P
TACROLIMUS 5 MG CAPSULE (IR) [Prograf]   4 Non-Preferred Drug 50%50%P
TADALAFIL 20 MG TABLET [Cialis]   5 Specialty Tier 33%N/AP Q:60
/30Days
TAFINLAR 50 MG CAPSULE   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAFINLAR 75 MG CAPSULE   5 Specialty Tier 33%N/AP
TAGRISSO 40 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
TAGRISSO 80 MG TABLET   5 Specialty Tier 33%N/AP Q:30
/30Days
TALZENNA 0.25 MG CAPSULE   5 Specialty Tier 33%N/AP Q:90
/30Days
TALZENNA 0.5 MG CAPSULE   5 Specialty Tier 33%N/AP Q:30
/30Days
TALZENNA 0.75 MG CAPSULE   5 Specialty Tier 33%N/AP Q:30
/30Days
TALZENNA 1 MG CAPSULE   5 Specialty Tier 33%N/AP Q:30
/30Days
TAMOXIFEN 10 MG TABLET [Nolvadex]   2 Generic $4.00$10.00None
TAMOXIFEN 20 MG TABLET [Nolvadex]   2 Generic $4.00$10.00None
TAMSULOSIN HCL 0.4 MG CAPSULE [Flomax]   2 Generic $4.00$10.00None
TARGRETIN 1% GEL   5 Specialty Tier 33%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TARINA FE 1-20 EQ TABLET   2 Generic $4.00$10.00None
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK   5 Specialty Tier 33%N/AP
TASIGNA 200 MG CAPSULE   5 Specialty Tier 33%N/AP
TASIGNA 50 MG CAPSULE   5 Specialty Tier 33%N/AP
TAZAROTENE 0.1% CREAM [Tazorac]   3 Preferred Brand $47.00$117.50P Q:60
/30Days
TAZICEF 1GM VIAL   4 Non-Preferred Drug 50%50%None
TAZICEF 2 GRAM VIAL   4 Non-Preferred Drug 50%50%None
TAZICEF 6 GRAM VIAL   4 Non-Preferred Drug 50%50%None
TAZORAC 0.05% CREAM (G)   4 Non-Preferred Drug 50%50%P Q:60
/30Days
TAZTIA XT 120 MG CAPSULE SA 24H [Tiazac]   2 Generic $4.00$10.00None
TAZTIA XT 180 MG CAPSULE SA 24H [Tiazac]   2 Generic $4.00$10.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAZTIA XT 240 MG CAPSULE SA 24H [Tiazac]   2 Generic $4.00$10.00None
TAZTIA XT 300 MG CAPSULE SA 24H [Tiazac]   2 Generic $4.00$10.00None
TAZTIA XT 360 MG CAPSULE SA 24H [Tiazac]   2 Generic $4.00$10.00None
TAZVERIK 200 MG TABLET   5 Specialty Tier 33%N/AP
TDVAX VIAL   3 Preferred Brand $47.00$117.50P
TECFIDERA DR 120 MG CAPSULE   5 Specialty Tier 33%N/AP Q:14
/7Days
TECFIDERA DR 240 MG CAPSULE   5 Specialty Tier 33%N/AP Q:60
/30Days
TECFIDERA STARTER PACK   5 Specialty Tier 33%N/AP
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 33%N/ANone
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 33%N/ANone
TELMISARTAN 20 MG TABLET [Micardis]   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
TELMISARTAN 40 MG TABLET [Micardis]   1 Preferred Generic $0.00$0.00Q:30
/30Days
TELMISARTAN 80 MG TABLET [Micardis]   1 Preferred Generic $0.00$0.00Q:30
/30Days
TELMISARTAN-AMLODIPINE 40-10 TABLET [Twynsta]   1 Preferred Generic $0.00$0.00Q:30
/30Days
TELMISARTAN-AMLODIPINE 40-5 MG TABLET [Twynsta]   1 Preferred Generic $0.00$0.00Q:30
/30Days
TELMISARTAN-AMLODIPINE 80-10 TABLET [Twynsta]   1 Preferred Generic $0.00$0.00Q:30
/30Days
TELMISARTAN-AMLODIPINE 80-5 MG TABLET [Twynsta]   1 Preferred Generic $0.00$0.00Q:30
/30Days
TELMISARTAN-HCTZ 40-12.5 MG TABLET [Micardis HCT]   1 Preferred Generic $0.00$0.00Q:30
/30Days
TELMISARTAN-HCTZ 80-12.5 MG TABLET [Micardis HCT]   1 Preferred Generic $0.00$0.00Q:60
/30Days
TELMISARTAN-HCTZ 80-25 MG TABLET [Micardis HCT]   1 Preferred Generic $0.00$0.00Q:30
/30Days
TEMAZEPAM 15 MG CAPSULE [Restoril]   4 Non-Preferred Drug 50%50%P Q:60
/30Days
TEMAZEPAM 30 MG CAPSULE [Restoril]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TEMAZEPAM 7.5 MG CAPSULE [Restoril]   4 Non-Preferred Drug 50%50%P Q:30
/30Days
TENIVAC SYRINGE   3 Preferred Brand $47.00$117.50P
TENOFOVIR DISOP FUM 300 MG TABLET [Viread]   3 Preferred Brand $47.00$117.50None
TEPMETKO 225 MG TABLET   5 Specialty Tier 33%N/AP
TERAZOSIN 1 MG CAPSULE   2 Generic $4.00$10.00None
TERAZOSIN 10 MG CAPSULE [Hytrin]   2 Generic $4.00$10.00None
TERAZOSIN 2 MG CAPSULE   2 Generic $4.00$10.00None
TERAZOSIN 5 MG CAPSULE [Hytrin]   2 Generic $4.00$10.00None
TERBINAFINE HCL 250 MG TABLET [Terbinex]   1 Preferred Generic $0.00$0.00Q:90
/365Days
TERBUTALINE SULFATE 2.5 MG TABLET [Brethine]   4 Non-Preferred Drug 50%50%None
TERBUTALINE SULFATE 5 MG TABLET [Brethine]   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TERCONAZOLE 0.4% CREAM WITH APPLICATOR   3 Preferred Brand $47.00$117.50None
TERCONAZOLE 0.8% CREAM   3 Preferred Brand $47.00$117.50None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL   3 Preferred Brand $47.00$117.50None
TESTOSTERON CYP 2,000 MG/10 ML VIAL [Virilon]   3 Preferred Brand $47.00$117.50None
TESTOSTERON ENAN 1,000 MG/5 ML VIAL [Delatestryl]   3 Preferred Brand $47.00$117.50None
TESTOSTERONE 1.62% GEL MD PUMP [AndroGel]   4 Non-Preferred Drug 50%50%P Q:150
/30Days
TESTOSTERONE 12.5 MG/1.25 GRAM GEL MD PMP [Vogelxo]   4 Non-Preferred Drug 50%50%P Q:300
/30Days
TESTOSTERONE 25 MG/2.5 GM GEL PACKET [Vogelxo]   4 Non-Preferred Drug 50%50%P Q:300
/30Days
TESTOSTERONE 50 MG/5 GRAM GEL PACKET [Vogelxo]   4 Non-Preferred Drug 50%50%P Q:300
/30Days
Testosterone cyp 100 mg/ml   3 Preferred Brand $47.00$117.50None
TESTOSTERONE CYP 200 MG/ML   3 Preferred Brand $47.00$117.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TETRABENAZINE 12.5 MG TABLET [XENAZINE]   5 Specialty Tier 33%N/AP Q:90
/30Days
TETRABENAZINE 25 MG TABLET [XENAZINE]   5 Specialty Tier 33%N/AP Q:120
/30Days
TETRACYCLINE 250 MG CAPSULE [Panmycin]   4 Non-Preferred Drug 50%50%P
TETRACYCLINE 500 MG CAPSULE [Sumycin]   4 Non-Preferred Drug 50%50%P
THALOMID 100 MG CAPSULE   5 Specialty Tier 33%N/AP Q:28
/28Days
THALOMID 150 MG CAPSULE   5 Specialty Tier 33%N/AP Q:56
/28Days
THALOMID 200 MG CAPSULE   5 Specialty Tier 33%N/AP Q:56
/28Days
THALOMID 50 MG CAPSULE   5 Specialty Tier 33%N/AP Q:28
/28Days
THEO-24 ER 100 MG CAPSULE   4 Non-Preferred Drug 50%50%None
THEO-24 ER 200 MG CAPSULE   4 Non-Preferred Drug 50%50%None
THEO-24 ER 300 MG CAPSULE   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THEO-24 ER 400 MG CAPSULE   4 Non-Preferred Drug 50%50%None
THEOPHYLLINE 80 MG/15 ML SOLUTION   4 Non-Preferred Drug 50%50%None
THEOPHYLLINE ER 300 MG TAB   4 Non-Preferred Drug 50%50%None
THEOPHYLLINE ER 400 MG TABLET ER 24H [Uniphyl]   3 Preferred Brand $47.00$117.50None
THEOPHYLLINE ER 450 MG TABLET ER 12H   4 Non-Preferred Drug 50%50%None
THEOPHYLLINE ER 600 MG TABLET ER 24H [Uniphyl]   3 Preferred Brand $47.00$117.50None
THIORIDAZINE 10 MG TABLET   3 Preferred Brand $47.00$117.50None
THIORIDAZINE 100MG TABLET   3 Preferred Brand $47.00$117.50None
THIORIDAZINE 25 MG TABLET   3 Preferred Brand $47.00$117.50None
THIORIDAZINE 50 MG TABLET   3 Preferred Brand $47.00$117.50None
THIOTHIXENE 1 MG CAPSULE [Navane]   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THIOTHIXENE 10 MG CAPSULE [Navane]   4 Non-Preferred Drug 50%50%None
THIOTHIXENE 2 MG CAPSULE [Navane]   4 Non-Preferred Drug 50%50%None
THIOTHIXENE 5 MG CAPSULE [Navane]   4 Non-Preferred Drug 50%50%None
TIADYLT ER 120 MG CAPSULE SA 24H [Tiazac]   2 Generic $4.00$10.00None
TIADYLT ER 180 MG CAPSULE SA 24H [Tiazac]   2 Generic $4.00$10.00None
TIADYLT ER 240 MG CAPSULE SA 24H [Tiazac]   2 Generic $4.00$10.00None
TIADYLT ER 300 MG CAPSULE SA 24H [Tiazac]   2 Generic $4.00$10.00None
TIADYLT ER 360 MG CAPSULE SA 24H [Tiazac]   2 Generic $4.00$10.00None
TIADYLT ER 420 MG CAPSULE SA 24H [Tiazac]   2 Generic $4.00$10.00None
TIAGABINE HCL 12 MG TABLET [Gabitril]   4 Non-Preferred Drug 50%50%None
TIAGABINE HCL 16 MG TABLET [Gabitril]   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIAGABINE HCL 2 MG TABLET [Gabitril]   4 Non-Preferred Drug 50%50%None
TIAGABINE HCL 4 MG TABLET [Gabitril]   4 Non-Preferred Drug 50%50%None
TIBSOVO 250 MG TABLET   5 Specialty Tier 33%N/AP
TICOVAC 2.4 MCG/0.5 ML SYRINGE   3 Preferred Brand $47.00$117.50None
TIGECYCLINE 50 MG VIAL [Tygacil]   5 Specialty Tier 33%N/ANone
TILIA FE 28 TABLET [Tri-Legest Fe]   4 Non-Preferred Drug 50%50%None
TIMOLOL 0.25% GFS GEL-SOLUTION SOL-GEL [Timoptic-XE]   4 Non-Preferred Drug 50%50%None
TIMOLOL 0.5% EYE DROPS   4 Non-Preferred Drug 50%50%None
TIMOLOL 0.5% GFS GEL-SOLUTION SOL-GEL [Timoptic-XE]   4 Non-Preferred Drug 50%50%None
TIMOLOL MALEATE 0.25% EYE DROPS [Timoptic Ocumeter]   1 Preferred Generic $0.00$0.00None
TIMOLOL MALEATE 0.5% EYE DROPS [Timoptic Ocumeter]   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIMOLOL MALEATE 10MG TABLET   4 Non-Preferred Drug 50%50%None
TIMOLOL MALEATE 20MG TABLET   4 Non-Preferred Drug 50%50%None
TIMOLOL MALEATE 5MG TABLET   4 Non-Preferred Drug 50%50%None
TIVICAY 10 MG TABLET   3 Preferred Brand $47.00$117.50None
TIVICAY 25 MG TABLET   5 Specialty Tier 33%N/ANone
TIVICAY 50 MG TABLET   5 Specialty Tier 33%N/ANone
TIVICAY PD 5 MG TABLET FOR SUSPENSION   3 Preferred Brand $47.00$117.50None
TIZANIDINE HCL 2 MG CAPSULE   4 Non-Preferred Drug 50%50%None
TIZANIDINE HCL 2 MG TABLET   2 Generic $4.00$10.00None
TIZANIDINE HCL 4 MG CAPSULE [Zanaflex]   4 Non-Preferred Drug 50%50%None
TIZANIDINE HCL 4 MG TABLET   2 Generic $4.00$10.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIZANIDINE HCL 6 MG CAPSULE [Zanaflex]   4 Non-Preferred Drug 50%50%None
TOBRADEX EYE OINTMENT   3 Preferred Brand $47.00$117.50None
TOBRADEX ST 0.3-0.05% EYE DROP EYE DROPPER   3 Preferred Brand $47.00$117.50None
TOBRAMYCIN 0.3% EYE DROPS [Tobrex]   1 Preferred Generic $0.00$0.00None
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   3 Preferred Brand $47.00$117.50None
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   5 Specialty Tier 33%N/AP
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   3 Preferred Brand $47.00$117.50None
TOBRAMYCIN-DEXAMETH OPTH SUSP   4 Non-Preferred Drug 50%50%None
TOLTERODINE TART ER 2 MG CAPSULE ER 24H [Detrol LA]   4 Non-Preferred Drug 50%50%S Q:30
/30Days
TOLTERODINE TART ER 4 MG CAPSULE ER 24H [Detrol LA]   4 Non-Preferred Drug 50%50%S Q:30
/30Days
TOLTERODINE TARTRATE 1 MG TABLET [Detrol]   4 Non-Preferred Drug 50%50%S Q:60
/30Days
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 50%50%S Q:60
/30Days
TOLVAPTAN 15 MG TABLET [Samsca]   5 Specialty Tier 33%N/AP
TOLVAPTAN 30 MG TABLET [Samsca]   5 Specialty Tier 33%N/AP
TOPIRAMATE 100 MG TABLET [Topiragen]   2 Generic $4.00$10.00None
TOPIRAMATE 15 MG SPRINKLE CAP   3 Preferred Brand $47.00$117.50None
TOPIRAMATE 200 MG TABLET [Topiragen]   2 Generic $4.00$10.00None
TOPIRAMATE 25 MG TABLET [Topiragen]   2 Generic $4.00$10.00None
Topiramate 25mg/1   3 Preferred Brand $47.00$117.50None
TOPIRAMATE 50 MG TABLET [Topiragen]   2 Generic $4.00$10.00None
TOREMIFENE CITRATE 60 MG TABLET [Fareston]   5 Specialty Tier 33%N/ANone
TORSEMIDE 10 MG TABLET   2 Generic $4.00$10.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TORSEMIDE 100 MG TABLET   2 Generic $4.00$10.00None
TORSEMIDE 20 MG TABLET [Demadex]   2 Generic $4.00$10.00None
TORSEMIDE 5 MG TABLET [Demadex]   2 Generic $4.00$10.00None
TOVIAZ TABLETS 4MG EXTENDED RELEASE   3 Preferred Brand $47.00$117.50Q:30
/30Days
TOVIAZ TABLETS 8MG EXTENDED RELEASE   3 Preferred Brand $47.00$117.50Q:30
/30Days
TPN ELECTROLYTES16.5/25.4 VIAL   4 Non-Preferred Drug 50%50%P
TRADJENTA 5 MG TABLET   3 Preferred Brand $47.00$117.50Q:30
/30Days
TRAMADOL HCL 50 MG TABLET [Ultram]   2 Generic $4.00$10.00Q:240
/30Days
TRAMADOL-ACETAMINOPHN 37.5-325 TABLET [Ultracet]   3 Preferred Brand $47.00$117.50Q:240
/30Days
TRANDOLAPRIL 1 MG TABLET   1 Preferred Generic $0.00$0.00None
TRANDOLAPRIL 2 MG TABLET [Mavik]   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRANDOLAPRIL 4 MG TABLET [Mavik]   1 Preferred Generic $0.00$0.00None
TRANEXAMIC ACID 650 MG TABLET [Lysteda]   3 Preferred Brand $47.00$117.50None
TRANYLCYPROMINE SULF 10 MG TABLET [Parnate]   4 Non-Preferred Drug 50%50%None
TRAVASOL 10% SOLUTION VIAFLEX   4 Non-Preferred Drug 50%50%P
TRAVOPROST 0.004% EYE DROPS [Travatan]   4 Non-Preferred Drug 50%50%None
TRAZODONE 100 MG TABLET [Desyrel]   2 Generic $4.00$10.00None
TRAZODONE 150 MG TABLET [Desyrel]   2 Generic $4.00$10.00None
TRAZODONE 300 MG TABLET [Desyrel]   2 Generic $4.00$10.00None
TRAZODONE 50 MG TABLET [Desyrel]   2 Generic $4.00$10.00None
TRECATOR 250MG TABLET   4 Non-Preferred Drug 50%50%None
TRELEGY ELLIPTA 100-62.5-25   3 Preferred Brand $47.00$117.50Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRELEGY ELLIPTA 200-62.5-25 BLST W/DEV   3 Preferred Brand $47.00$117.50Q:60
/30Days
TRELSTAR 11.25 MG VIAL   5 Specialty Tier 33%N/AP
TRELSTAR 3.75 MG VIAL   5 Specialty Tier 33%N/AP
TRESIBA 100 UNIT/ML VIAL   3 Preferred Brand $35.00$117.50None
TRESIBA FLEXTOUCH 100 UNITS/ML   3 Preferred Brand $35.00$117.50None
TRESIBA FLEXTOUCH 200 UNITS/ML   3 Preferred Brand $35.00$117.50None
TRETINOIN 0.01% GEL [Tretin-X]   4 Non-Preferred Drug 50%50%P Q:45
/30Days
TRETINOIN 0.025% CREAM (G) [Tretin-X]   4 Non-Preferred Drug 50%50%P Q:45
/30Days
TRETINOIN 0.025% GEL [Tretin-X]   4 Non-Preferred Drug 50%50%P Q:45
/30Days
TRETINOIN 0.05% CREAM   4 Non-Preferred Drug 50%50%P Q:45
/30Days
TRETINOIN 0.1% CREAM   4 Non-Preferred Drug 50%50%P Q:45
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRETINOIN 10MG CAPSULE   5 Specialty Tier 33%N/ANone
TREXALL 10MG TABLET   4 Non-Preferred Drug 50%50%None
TREXALL 15MG TABLET   4 Non-Preferred Drug 50%50%None
TREXALL 5MG TABLET   4 Non-Preferred Drug 50%50%None
TREXALL 7.5MG TABLET   4 Non-Preferred Drug 50%50%None
TRI-ESTARYLLA TABLET [Trinessa]   2 Generic $4.00$10.00None
TRI-LEGEST FE 5-7-9-7 TABLET   4 Non-Preferred Drug 50%50%None
TRI-LO-ESTARYLLA TABLET [Trinessa Lo]   3 Preferred Brand $47.00$117.50None
TRI-LO-SPRINTEC TABLET   3 Preferred Brand $47.00$117.50None
TRI-MILI 28 TABLET [Trinessa]   2 Generic $4.00$10.00None
TRI-NYMYO 28 TABLET [Trinessa]   2 Generic $4.00$10.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRI-SPRINTEC 7DAYSX3 28 TABLET   2 Generic $4.00$10.00None
TRI-VYLIBRA 28 TABLET [Trinessa]   2 Generic $4.00$10.00None
TRI-VYLIBRA LO TABLET [Trinessa Lo]   3 Preferred Brand $47.00$117.50None
TRIAMCINOLONE 0.025% CREAM   2 Generic $4.00$10.00None
TRIAMCINOLONE 0.025% LOTION [Kenalog]   3 Preferred Brand $47.00$117.50None
TRIAMCINOLONE 0.025% OINT   2 Generic $4.00$10.00None
TRIAMCINOLONE 0.1% CREAM (G) [Triderm]   2 Generic $4.00$10.00Q:454
/30Days
TRIAMCINOLONE 0.1% LOTION [Kenalog]   3 Preferred Brand $47.00$117.50None
TRIAMCINOLONE 0.1% OINTMENT [Triderm]   2 Generic $4.00$10.00None
TRIAMCINOLONE 0.1% PASTE PASTE (G) [Oralone]   3 Preferred Brand $47.00$117.50None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE   2 Generic $4.00$10.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE   2 Generic $4.00$10.00None
TRIAMTERENE-HCTZ 37.5-25 MG CAPSULE [Dyazide]   1 Preferred Generic $0.00$0.00None
TRIAMTERENE-HCTZ 37.5-25 MG TABLET [Maxzide]   1 Preferred Generic $0.00$0.00None
TRIAMTERENE-HCTZ 75-50 MG TAB   1 Preferred Generic $0.00$0.00None
TRIDERM 0.5% CREAM (G)   2 Generic $4.00$10.00None
TRIENTINE HCL 250 MG CAPSULE [Syprine]   5 Specialty Tier 33%N/AP
TRIFLUOPERAZINE 1 MG TABLET   3 Preferred Brand $47.00$117.50None
TRIFLUOPERAZINE HCL 2MG TABLET   3 Preferred Brand $47.00$117.50None
TRIFLUOPERAZINE HCL 5MG TABLET   3 Preferred Brand $47.00$117.50None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)   3 Preferred Brand $47.00$117.50None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIHEXYPHENIDYL 2 MG TABLET   3 Preferred Brand $47.00$117.50P
TRIHEXYPHENIDYL 5 MG TABLET [Artane]   3 Preferred Brand $47.00$117.50P
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE   3 Preferred Brand $47.00$117.50P
TRIJARDY XR 10-5-1,000 MG TABLET BP 24H   3 Preferred Brand $47.00$117.50Q:30
/30Days
TRIJARDY XR 12.5-2.5-1,000 MG TAB BP 24H   3 Preferred Brand $47.00$117.50Q:60
/30Days
TRIJARDY XR 25-5-1,000 MG TABLET BP 24H   3 Preferred Brand $47.00$117.50Q:30
/30Days
TRIJARDY XR 5-2.5-1,000 MG TABLET BP 24H   3 Preferred Brand $47.00$117.50Q:60
/30Days
TRIKAFTA 100/50/75 MG-150 MG TABLET SEQ   5 Specialty Tier 33%N/AP Q:84
/28Days
TRIKAFTA 50-25-37.5 MG/75 MG TABLET SEQ   5 Specialty Tier 33%N/AP Q:84
/28Days
TRIMETHOPRIM 100 MG TABLET [Proloprim]   2 Generic $4.00$10.00None
TRIMIPRAMINE MALEATE 100 MG CP   4 Non-Preferred Drug 50%50%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIMIPRAMINE MALEATE 25 MG CAP   4 Non-Preferred Drug 50%50%Q:240
/30Days
TRIMIPRAMINE MALEATE 50 MG CAP   4 Non-Preferred Drug 50%50%Q:120
/30Days
TRINTELLIX 10 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
TRINTELLIX 20 MG TABLET   4 Non-Preferred Drug 50%50%Q:30
/30Days
TRINTELLIX 5 MG TABLET   4 Non-Preferred Drug 50%50%Q:120
/30Days
TRIUMEQ PD 60-5-30 MG TABLET SUSP   5 Specialty Tier 33%N/ANone
TRIUMEQ TABLET   5 Specialty Tier 33%N/ANone
TRIVORA-28 TABLET [Trivora]   2 Generic $4.00$10.00None
TRIZIVIR 300; 150; 300mg/1; mg/1; mg/1 60 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 33%N/ANone
TROPHAMINE INJECTION SOLUTION   4 Non-Preferred Drug 50%50%P
TROSPIUM CHLORIDE 20 MG TABLET [Sanctura]   3 Preferred Brand $47.00$117.50Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TROSPIUM CHLORIDE ER 60 MG CAP   2 Generic $4.00$10.00None
TRULICITY 0.75 MG/0.5 ML PEN   3 Preferred Brand $47.00$117.50Q:2
/28Days
TRULICITY 1.5 MG/0.5 ML PEN   3 Preferred Brand $47.00$117.50Q:2
/28Days
TRULICITY 3 MG/0.5 ML PEN INJECTOR   3 Preferred Brand $47.00$117.50Q:2
/28Days
TRULICITY 4.5 MG/0.5 ML PEN INJECTOR   3 Preferred Brand $47.00$117.50Q:2
/28Days
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe   3 Preferred Brand $47.00$117.50None
TRUSELTIQ 100 MG DAILY DOSE PK CAPSULE   5 Specialty Tier 33%N/AP
TRUSELTIQ 125 MG DAILY DOSE PK CAPSULE   5 Specialty Tier 33%N/AP
TRUSELTIQ 50 MG DAILY DOSE PK CAPSULE   5 Specialty Tier 33%N/AP
TRUSELTIQ 75 MG DAILY DOSE PK CAPSULE   5 Specialty Tier 33%N/AP
TUKYSA 150 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
TUKYSA 50 MG TABLET   5 Specialty Tier 33%N/AP
TURALIO 200 MG CAPSULE   5 Specialty Tier 33%N/AP
TWINRIX VACCINE SYRINGE   3 Preferred Brand $47.00$117.50None
TYBOST 150 MG TABLET   3 Preferred Brand $47.00$117.50None
TYMLOS 80 MCG DOSE PEN INJECTR   5 Specialty Tier 33%N/AP
TYPHIM VI 25 MCG/0.5 ML SYRINGE   3 Preferred Brand $47.00$117.50None
TYPHIM VI 25MCG/0.5ML VIAL   3 Preferred Brand $47.00$117.50None

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.