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Wellcare Classic (PDP) (S4802-083-0)
Tier 1 (123)
Tier 2 (458)
Tier 3 (1095)
Tier 4 (869)
Tier 5 (592)
Requires Prior Authorization:
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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 Classic (PDP) (S4802-083-0)
Benefit Details           
The Wellcare Classic (PDP) (S4802-083-0)
Formulary Drugs Starting with the Letter V

in CMS PDP Region 11 which includes: FL
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 [Valtrex]   3 Preferred Brand $36.00$108.00None
VALACYCLOVIR HCL 500 MG TABLET [Valtrex]   3 Preferred Brand $36.00$108.00None
VALCHLOR 0.016% GEL   5 Specialty Tier 25%N/AP Q:60
/30Days
VALGANCICLOVIR 450 MG TABLET [Valcyte]   3 Preferred Brand $36.00$108.00None
VALGANCICLOVIR HCL 50 MG/ML [Valcyte]   5 Specialty Tier 25%N/ANone
VALPROIC ACID 250 MG CAPSULE [Depakene]   3 Preferred Brand $36.00$108.00None
VALPROIC ACID 250 MG/5 ML SOLUTION [Depakene]   3 Preferred Brand $36.00$108.00None
VALSARTAN 160 MG TABLET [Diovan]   3 Preferred Brand $36.00$108.00Q:60
/30Days
VALSARTAN 320 MG TABLET [Diovan]   3 Preferred Brand $36.00$108.00Q:30
/30Days
VALSARTAN 40 MG TABLET [Diovan]   3 Preferred Brand $36.00$108.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VALSARTAN 80 MG TABLET [Diovan]   3 Preferred Brand $36.00$108.00Q:60
/30Days
VALSARTAN-HCTZ 160-12.5 MG TABLET [Diovan HCT]   3 Preferred Brand $36.00$108.00Q:30
/30Days
VALSARTAN-HCTZ 160-25 MG TABLET [Diovan HCT]   3 Preferred Brand $36.00$108.00Q:30
/30Days
VALSARTAN-HCTZ 320-12.5 MG TABLET [Diovan HCT]   3 Preferred Brand $36.00$108.00Q:30
/30Days
VALSARTAN-HCTZ 320-25 MG TABLET [Diovan HCT]   3 Preferred Brand $36.00$108.00Q:30
/30Days
VALSARTAN-HCTZ 80-12.5 MG TABLET [Diovan HCT]   3 Preferred Brand $36.00$108.00Q:30
/30Days
VALTOCO 10 MG NASAL SPRAY   4 Non-Preferred Drug 40%40%None
VALTOCO 15 MG NASAL SPRAY   4 Non-Preferred Drug 40%40%None
VALTOCO 20 MG NASAL SPRAY   4 Non-Preferred Drug 40%40%None
VALTOCO 5 MG NASAL SPRAY   4 Non-Preferred Drug 40%40%None
VANCOMYCIN 1 GM VIAL [Vancocin]   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VANCOMYCIN 500 MG VIAL   4 Non-Preferred Drug 40%40%None
VANCOMYCIN HCL 10 GM VIAL [Vancocin]   4 Non-Preferred Drug 40%40%None
VANCOMYCIN HCL 125 MG CAPSULE [Vancocin]   4 Non-Preferred Drug 40%40%Q:80
/180Days
VANCOMYCIN HCL 250 MG CAPSULE [Vancocin]   4 Non-Preferred Drug 40%40%Q:160
/180Days
VANCOMYCIN HCL 750 MG VIAL   4 Non-Preferred Drug 40%40%None
VANDAZOLE 0.75% GEL WITH APPLICATOR   3 Preferred Brand $36.00$108.00None
VAQTA 25 UNITS/0.5 ML SYRINGE   3 Preferred Brand $36.00$108.00None
VAQTA 50 UNITS/ML SYRINGE   3 Preferred Brand $36.00$108.00None
VAQTA 50 UNITS/ML VIAL   3 Preferred Brand $36.00$108.00None
Vaqta Hepatitis A Vaccine Pediatric / Adolescent 25 Unit / 0.5 mL Injection Single Dose Vial 0.5 mL   3 Preferred Brand $36.00$108.00None
VARENICLINE 0.5 MG TABLET [Chantix]   4 Non-Preferred Drug 40%40%Q:56
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VARENICLINE 1 MG TABLET [Chantix]   4 Non-Preferred Drug 40%40%Q:56
/28Days
VARENICLINE STARTING MONTH BOX TABLET DS PK [Chantix]   4 Non-Preferred Drug 40%40%None
VARIVAX VACCINE W/DILUENT   3 Preferred Brand $36.00$108.00None
VASCEPA 0.5 GM CAPSULE   4 Non-Preferred Drug 40%40%None
VASCEPA 1 GM CAPSULE   4 Non-Preferred Drug 40%40%None
VELIVET 28 DAY TABLET   3 Preferred Brand $36.00$108.00None
VELPHORO 500 MG CHEWABLE TAB   4 Non-Preferred Drug 40%40%None
VELTASSA 16.8 GM POWDER PACKET   3 Preferred Brand $36.00$108.00None
VELTASSA 25.2 GM POWDER PACKET   3 Preferred Brand $36.00$108.00None
VELTASSA 8.4 GM POWDER PACKET   3 Preferred Brand $36.00$108.00None
VEMLIDY 25 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
VENCLEXTA 10 MG TABLET   4 Non-Preferred Drug 40%40%P Q:112
/28Days
VENCLEXTA 100 MG TABLET   5 Specialty Tier 25%N/AP Q:180
/30Days
VENCLEXTA 50 MG TABLET   5 Specialty Tier 25%N/AP Q:112
/28Days
VENCLEXTA STARTING PACK   5 Specialty Tier 25%N/AP Q:42
/28Days
VENLAFAXINE HCL 100 MG TABLET [Effexor]   3 Preferred Brand $36.00$108.00None
VENLAFAXINE HCL 25 MG TABLET [Effexor]   3 Preferred Brand $36.00$108.00None
VENLAFAXINE HCL 37.5 MG TABLET [Effexor]   3 Preferred Brand $36.00$108.00None
VENLAFAXINE HCL 50 MG TABLET [Effexor]   3 Preferred Brand $36.00$108.00None
VENLAFAXINE HCL 75 MG TABLET [Effexor]   3 Preferred Brand $36.00$108.00None
VENLAFAXINE HCL ER 150 MG CAPSULE ER 24H [Effexor XR]   2 Generic $4.00$12.00None
VENLAFAXINE HCL ER 37.5 MG CAPSULE ER 24H [Effexor XR]   2 Generic $4.00$12.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VENLAFAXINE HCL ER 75 MG CAPSULE ER 24H [Effexor XR]   2 Generic $4.00$12.00None
Ventavis 0.02mg/mL   5 Specialty Tier 25%N/AP
VENTAVIS 10 MCG/1 ML SOLUTION AMPUL-NEB   5 Specialty Tier 25%N/AP
VENTOLIN HFA 90MCG INHALER   3 Preferred Brand $36.00$108.00Q:36
/30Days
VERAPAMIL 120 MG TABLET [Calan]   2 Generic $4.00$12.00None
VERAPAMIL 40 MG TABLET [Isoptin SR]   2 Generic $4.00$12.00None
VERAPAMIL 80 MG TABLET   2 Generic $4.00$12.00None
VERAPAMIL ER 120 MG TABLET   2 Generic $4.00$12.00None
VERAPAMIL ER 180 MG TABLET   2 Generic $4.00$12.00None
VERAPAMIL ER 240 MG TABLET   2 Generic $4.00$12.00None
VERAPAMIL ER PM 100 MG CAPSULE 24H PCT [Verelan PM]   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VERAPAMIL ER PM 200 MG CAPSULE 24H PCT [Verelan PM]   4 Non-Preferred Drug 40%40%None
VERAPAMIL ER PM 300 MG CAPSULE 24H PCT [Verelan PM]   4 Non-Preferred Drug 40%40%None
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE   4 Non-Preferred Drug 40%40%None
VERAPAMIL SR 120 MG CAPSULE 24H PEL [Verelan]   3 Preferred Brand $36.00$108.00None
VERAPAMIL SR 180 MG CAPSULE 24H PEL [Verelan]   3 Preferred Brand $36.00$108.00None
VERAPAMIL SR 240 MG CAPSULE 24H PEL [Verelan]   3 Preferred Brand $36.00$108.00None
VERSACLOZ 50 MG/ML ORAL SUSPENSION   4 Non-Preferred Drug 40%40%P Q:600
/30Days
VERZENIO 100 MG TABLET   5 Specialty Tier 25%N/AP Q:56
/28Days
VERZENIO 150 MG TABLET   5 Specialty Tier 25%N/AP Q:56
/28Days
VERZENIO 200 MG TABLET   5 Specialty Tier 25%N/AP Q:56
/28Days
VERZENIO 50 MG TABLET   5 Specialty Tier 25%N/AP Q:56
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VESTURA 3 MG-0.02 MG TABLET [Yaz]   3 Preferred Brand $36.00$108.00None
VICTOZA 3-PAK 18 MG/3 ML PEN   3 Preferred Brand $36.00$108.00Q:9
/30Days
VIENVA-28 TABLET [Vienva]   3 Preferred Brand $36.00$108.00None
VIGABATRIN 500 MG POWDER PACK [VIGADRONE]   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 40%40%None
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 40%40%Q:30
/30Days
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 40%40%Q:30
/30Days
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 40%40%Q:30
/30Days
VILAZODONE HCL 10 MG TABLET [VIIBRYD]   4 Non-Preferred Drug 40%40%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
VILAZODONE HCL 20 MG TABLET [VIIBRYD]   4 Non-Preferred Drug 40%40%Q:30
/30Days
VILAZODONE HCL 40 MG TABLET [VIIBRYD]   4 Non-Preferred Drug 40%40%Q:30
/30Days
VIMPAT 10 MG/ML SOLUTION   4 Non-Preferred Drug 40%40%Q:1200
/30Days
VIRACEPT 250MG TABLET   5 Specialty Tier 25%N/ANone
VIRACEPT 625MG TABLET   5 Specialty Tier 25%N/ANone
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
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
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
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
VONJO 100 MG CAPSULE   5 Specialty Tier 25%N/AP Q:120
/30Days
VORICONAZOLE 200 MG TABLET [VFEND]   4 Non-Preferred Drug 40%40%P Q:120
/30Days
VORICONAZOLE 200 MG VIAL [VFEND]   5 Specialty Tier 25%N/AP
VORICONAZOLE 40 MG/ML ORAL SUSPENSION [VFEND]   5 Specialty Tier 25%N/AP
VORICONAZOLE 50 MG TABLET [VFEND]   4 Non-Preferred Drug 40%40%P Q:480
/30Days
VOSEVI 400-100-100 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
VOTRIENT 200 MG TABLET   5 Specialty Tier 25%N/AP
VRAYLAR 1.5 MG CAP   4 Non-Preferred Drug 40%40%Q:60
/30Days
VRAYLAR 1.5 MG-3 MG PACK   4 Non-Preferred Drug 40%40%None
VRAYLAR 3 MG CAP   4 Non-Preferred Drug 40%40%Q:30
/30Days
VRAYLAR 4.5 MG CAP   4 Non-Preferred Drug 40%40%Q:30
/30Days
VRAYLAR 6 MG CAP   4 Non-Preferred Drug 40%40%Q:30
/30Days
VUMERITY DR 231 MG CAPSULE DR   5 Specialty Tier 25%N/AP Q:120
/30Days
VYFEMLA 0.4 MG-0.035 MG TABLET [Zenchent]   3 Preferred Brand $36.00$108.00None
VYLIBRA 28 TABLET   3 Preferred Brand $36.00$108.00None
VYZULTA 0.024% OPHTH SOLUTION DROPS   4 Non-Preferred Drug 40%40%None

Chart Legend:

Below are a few notes to help you understand the above 2022 Medicare Part D Wellcare Classic (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.