2015 Formulary Addendum Notice of Change
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1 2015 Formulary Addendum Notice of Change Prescription Drug Plans WellCare Prescription Insurance, Inc. WellCare Extra (PDP) This is a listing of the changes that have occurred in our formulary. Please carefully review these changes and call WellCare at the telephone number listed in your Comprehensive Formulary if you have any questions. You can obtain an updated coverage determination or an exception to a coverage determination by visiting our website at or by calling the telephone number listed in your Comprehensive Formulary. Please refer to your Evidence of Coverage for cost-sharing information. Y0070_NA028274_WCM_FOR_ENG_FINAL_08 CMS Approved PD5V08FOR63788E 0615 WellCare 2015 NA_06_15
2 Formulary File: Effective Date:5/1/2015 Formulary Version: 12 Medication Name BARACLUDE TABLET 0.5 MG BARACLUDE TABLET 1 MG CELLCEPT ORAL SUSPENSION 200 MG/ML EPIVIR ORAL SOLUTION 10 MG/ML ALTERNATIVE DRUG(S): entecavir tablets on Tier 5* with QL (30 tablets per 30 days), MS ALTERNATIVE DRUG(S): entecavir tablets on Tier 5* with QL (30 tablets per 30 days), MS ALTERNATIVE DRUG(S): mycophenolate mofetil oral suspension on Tier 5* with PA-BvsD, MS ALTERNATIVE DRUG(S): lamivudine oral solution on EXFORGE HCT TABLET MG EXFORGE HCT TABLET MG EXFORGE HCT TABLET MG EXFORGE HCT TABLET MG EXFORGE HCT TABLET MG 2
3 Medication Name EXFORGE TABLET 10 MG-160 MG EXFORGE TABLET 10 MG-320 MG EXFORGE TABLET 5 MG-160 MG EXFORGE TABLET 5 MG-320 MG FAZACLO TABLET, DISPERSIBLE 12.5 MG PATANASE NASAL SOLUTION 0.6 % RAPAMUNE TABLET 1 MG RAPAMUNE TABLET 2 MG STROMECTOL TABLET 3 MG VALCYTE TABLET 450 MG on on on on ALTERNATIVE DRUG(S): clozapine tablets, dispersible on Tier 2 with PA-NS, MS ALTERNATIVE DRUG(S): olopatadine hcl nasal solution on Tier 2, MS ALTERNATIVE DRUG(S): sirolimus tablets 0.5 mg, 1 mg on Tier 2 with PA-BvsD; 2 mg on Tier 5* with PA-BvsD, MS ALTERNATIVE DRUG(S): sirolimus tablets 0.5 mg, 1 mg on Tier 2 with PA-BvsD; 2 mg on Tier 5* with PA-BvsD, MS ALTERNATIVE DRUG(S): ivermectin tablets on ALTERNATIVE DRUG(S): valganciclovir hcl tablets on Tier 5*, MS 3
4 Medication Name VIRAMUNE XR TABLET, EXTENDED RELEASE 400 MG BIWEEKLY MG/24HR BIWEEKLY MG/24HR BIWEEKLY 0.05 MG/24HR BIWEEKLY MG/24HR BIWEEKLY 0.1 MG/24HR ZYVOX INTRAVENOUS SOLUTION 2 MG/ML ALTERNATIVE DRUG(S): nevirapine tablets, extended release 400 mg on biweekly on biweekly on biweekly on biweekly on biweekly on ALTERNATIVE DRUG(S): linezolid intravenous solution on Tier 5* with PA, MS Brand drugs- UPPERCASE/ BOLD, Generics- lowercase, PA=Prior Authorization, PA-NS=Prior Authorization New Starts, PA-BvsD=Prior Authorization-BvsD Only, QL=Quantity Limits, ST=Step Therapy, ST-NS=Step Therapy New Starts, LA=Limited Access, MS=Mail Service Available, *-Drug may be available for up to a 30 day supply only 4
5 Formulary File: Effective Date:6/1/2015 Formulary Version: 13 Medication Name hydromorphone hcl suppository 3 mg Drug Removed / Medication not covered under Part D / Generic name medication will be removed from the formulary effective 08/01/2015. ALTERNATIVE DRUG(S): Please consult your health care provider ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML ZEMPLAR INTRAVENOUS SOLUTION 5 MCG/ML will be removed from the formulary effective 08/01/2015. ALTERNATIVE DRUG(S): paricalcitol intravenous solution on will be removed from the formulary effective 08/01/2015. ALTERNATIVE DRUG(S): paricalcitol intravenous solution on Brand drugs- UPPERCASE/ BOLD, Generics- lowercase/italics, PA=Prior Authorization, PA-NS=Prior Authorization New Starts, PA-BvsD=Prior Authorization-BvsD Only, QL=Quantity Limits, ST=Step Therapy, ST-NS=Step Therapy New Starts, LA=Limited Access, MS=Mail Service Available, *-Drug may be available for up to a 30 day supply only 5
6 This information is available for free in other languages. Please call our Customer Service number at , Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are available Monday Sunday, 8 a.m. to 8 p.m. TTY users should call Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de Servicio al Cliente al , de lunes a viernes, de 8 a.m. a 8 p.m. Entre el 1 de octubre y el 14 de febrero, los representantes están disponibles de lunes a domingo de 8 a.m. a 8 p.m. Los usuarios de TTY deben llamar al WellCare (PDP) is a Medicare-approved Part D sponsor. Enrollment in WellCare (PDP) depends on contract renewal. WellCare uses a formulary. Some plans are available to those who have medical assistance from both the state and Medicare. Premiums, co-pays, coinsurance and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, co-payments and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/coinsurance may change on January 1 of each year. P.O. Box Tampa, FL
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