2018 Formulary Notice of Change Medicare Advantage Plans
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1 2018 Formulary Notice of Change Medicare Advantage Plans WellCare Health Plans Plans in the following states: AR, FL, GA, KY, MS, NC, NY, SC, TN WellCare Access (HMO SNP), WellCare Liberty (HMO SNP) WellCare Select (HMO SNP) Plan in the following states: AR, TN WellCare Rx (HMO) Plan in the following state: MS WellCare Value (HMO) WellCare may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug and/or move a drug to a higher cost-sharing tier, we will notify you of the change at least 60 days before the date the change becomes effective. However, if the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we may immediately remove the drug from our formulary and notify you as soon as possible. Y0070_WCM_10674E_V12 NM WellCare 2018 NA8WCMFOR14390E_NV12
2 Formulary ID: Effective Date: 4/1/2018 Formulary Version: 7 Medication Name Aminosyn II Inj 7% Bromfenac Ophth Soln 0.09% Discontinuation / Alternative Drug: Aminosyn-HBC Inj 7% on Tier 4 / Effective Date: 3/1/2018 Discontinuation / Alternative Drug: Bromfenac Sodium Ophth Soln 0.09% (Once-Daily) on Tier 4 / Effective Date: 3/1/2018 Buphenyl Tab 500mg Deletion of Drug From Formulary / Generic Available / Alternative Drug: Sodium Phenylbutyrate Tab 500mg on Tier 5 / Clindamax Gel 1% Discontinuation / Alternative Drug: Clindamycin Phosphate Gel 1% on Tier 3 / Effective Date: 3/1/2018 Copaxone Inj 40mg/mL Deletion of Drug From Formulary / Generic Available / Alternative Drug: Glatiramer Inj 40mg/mL on Tier 5 / Docefrez Inj 20mg Discontinuation / Alternative Drug: Docetaxel Inj 80mg/4mL on Tier 5 / Effective Date: 3/1/2018 Estrace Vaginal Cream 0.01% Deletion of Drug From Formulary / Generic Available / Alternative Drug: Estradiol Vaginal Cream 0.01% on Tier 4 / Gavilyte-H Kit Discontinuation / Alternative Drug: Gavilyte-G Sol on Tier 2 / Effective Date: 3/1/2018 Istalol Ophth Soln 0.5% Deletion of Drug From Formulary / Generic Available / Alternative Drug: Timolol Maleate Ophth Soln 0.5% (Once-Daily) on Tier 3 / Lortab Tab mg Lortab Tab 5-325mg Discontinuation / Alternative Drug: Hydrocodone- Acetaminophen Tab mg on Tier 3 / Effective Date: 3/1/2018 Discontinuation / Alternative Drug: Hydrocodone- Acetaminophen Tab 5-325mg on Tier 3 / Effective Date: 3/1/2018 1
3 Medication Name Lortab Tab mg Menomune Inj A/C/Y/W Morphine Sulate Inj 15mg/mL Necon Tab 10/11-28 Discontinuation / Alternative Drug: Hydrocodone- Acetaminophen Tab mg on Tier 3 / Effective Date: 3/1/2018 Discontinuation / Alternative Drug: Menactra Inj on Tier 3 / Effective Date: 3/1/2018 Discontinuation / Alternative Drug: Morphine Sulfate IV Soln Pf 10mg/mL on Tier 4 / Effective Date: 3/1/2018 Discontinuation / Alternative Drug: Necon Tab 7/7/7 on Tier 2 / Effective Date: 3/1/2018 Relpax Tab Deletion of Drug From Formulary / Generic Available / Alternative Drug: Eletriptan Tab on Tier 4 / Effective Date: 6/1/2018 Renvela Pak Deletion of Drug From Formulary / Generic Available / Alternative Drug: Sevelamer Carbonate Packet on Tier 3 / Renvela Tab 800mg Deletion of Drug From Formulary / Generic Available / Alternative Drug: Sevelamer Carbonate Tab 800mg on Tier 3 / Reyataz Cap Deletion of Drug From Formulary / Generic Available / Alternative Drug: Atazanavir Cap on Tier 5 / Effective Date: 6/1/2018 Sabril Pack 500mg Deletion of Drug From Formulary / Generic Available / Alternative Drug: Vigabatrin Powder Pack 500mg on Tier 5 / Sustiva Cap 200mg Deletion of Drug From Formulary / Generic Available / Alternative Drug: Efavirenz Cap 200mg on Tier 5 / Sustiva Cap 50mg Deletion of Drug From Formulary / Generic Available / Alternative Drug: Efavirenz Cap 50mg on Tier 4 / Tamiflu Susp 6mg/mL Deletion of Drug From Formulary / Generic Available / Alternative Drug: Oseltamivir Phosphate Susp 6 mg/ml on Tier 3 / 2
4 Medication Name Transderm-Sc Patch 1.5mg Deletion of Drug From Formulary / Generic Available / Alternative Drug: Scopolamine Patch on Tier 4 / Triklo Cap 1gm Discontinuation / Alternative Drug: Omega-3-Acid Ethyl Esters Cap 1 gm on Tier 4 / Effective Date: 3/1/2018 Vigamox Drops 0.5% Deletion of Drug From Formulary / Generic Available / Alternative Drug: Moxifloxacin Hcl Ophth Soln 0.5% on Zazole Cream 0.8% Tier 3 / Discontinuation / Alternative Drug: Terconazole Vaginal Cream 0.8% on Tier 3 / Effective Date: 3/1/2018 Ziagen Soln 20mg/mL Deletion of Drug From Formulary / Generic Available / Alternative Drug: Abacavir Soln 20mg/mL on Tier 3 / Zoledronic Inj 4mg Discontinuation / Alternative Drug: Zoledronic Inj 4mg/5mL on Tier 4 / Effective Date: 3/1/2018 3
5 Formulary ID: Formulary Version: 9 Medication Name Acetic Acid 2% In Aluminum Acetate Otic Soln Didanosine Cap 125 Mg Gengraf Cap 50mg Gentamicin Inj 10mg/Ml Nevirapine Susp 50mg/5ml Nyata Oxycodone W/ Acetaminophen Soln Mg/5ml Trisenox Sol 10mg/10ml Discontinuation / Alternative Drug: Acetic Acid Otic Soln 2% on Tier 3 / Discontinuation / Alternative Drug: Videx EC Cap 125mg on Tier 4 / Effective Date: 5/1/2018 Discontinuation / Alternative Drug: Cyclosporine Modified Cap 50 mg on Tier 4 / Effective Date: 6/1/2018 Discontinuation / Alternative Drug: Gentamicin Inj 40mg/mL on Tier 2 / Effective Date: 5/1/2018 Discontinuation / Alternative Drug: Viramune Susp 50mg/5mL on Tier 4 / Discontinuation / Alternative Drug: Nystatin Pow on Tier 3 / Effective Date: 4/1/2018 Discontinuation / Alternative Drug: Oxycodone Hcl Soln 5 Mg/5mL on Tier 4 / Discontinuation / Alternative Drug: Trisenox Inj 12mg/6mL on Tier 5 / Effective Date: 5/1/2018 4
6 WellCare (HMO) is a Medicare Advantage organization with a Medicare contract. WellCare (HMO SNP) is a Medicare Advantage organization with a Medicare contract and a contract with the state s Medicaid programs. Enrollment in WellCare depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments and restrictions may apply. Benefits, premiums and/or co-payments/coinsurance may change on January 1 of each year. The formulary, pharmacy network, and/ or provider network may change at anytime. You will receive notice when necessary. 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 P.O. Box Tampa, FL
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