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Drug Details  
TierTier 1 - Generic
Coverage This drug is covered by your Plan.
GAP CoverageWe 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 OrderThis drug is available through mail order.
Restrictions* 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
Formulary Alternative(s)

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.

Click here for the Prior Authorization Protocol for CYCLOBENZAPRINE HCL TABLET

Updated: 05/02/2012


Last Modified: 10/01/2012

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