2012 WellCare Choice (Dade County)
|Name||CYCLOBENZAPRINE 10 MG TABLET|
|Tier||Tier 1 - Generic|
|Coverage||This drug is covered by your Plan.|
|GAP Coverage||We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.|
|Mail Order||This drug is available through mail order.|
Quantity Limit: 93/31 days
Prior Authorization (PA) required
Click here for the Prior Authorization Protocol for CYCLOBENZAPRINE HCL TABLET
*See applicable explanation(s) below
Note: This is not a complete list of all formulary alternatives covered by the Part D plan for the drug you have selected.
Please verify formulary status including tier information and any applicable utilization management edits associated with the alternative listed by clicking on the alternative drug as coverage may vary depending on strength and dosage form.
Quantity Limits (QL): For this drug, WellCare limits the amount of the drug that WellCare will cover.
Prior Authorization (PA): WellCare requires you to get prior authorization for this drug. (You may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for coverage through our exception process.) This means that you will need to get approval from WellCare before you fill your prescriptions. If you don't get approval, WellCare may not cover the drug.
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Last Modified: 10/01/2012