2018 Formulary Notice of Change Medicare Advantage Plans

Transcription

1 2018 Formulary Notice of Change Medicare Advantage Plans Easy Choice Health Plan Plan in the following state: CA Easy Choice Best Plan (HMO) H Easy Choice 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_V10 NM WellCare 2018 CA8RMRFOR12958E_NV10

2 Formulary ID: Effective Date: 4/1/2018 Formulary Version: 8 Medication Name Aminosyn II Inj 7% Bromfenac Ophth Soln 0.09% Discontinuation / Alternative Drug: Aminosyn-HBC Inj 7% on Tier 4 / Effective Discontinuation / Alternative Drug: Bromfenac Sodium Ophth Soln 0.09% (Once-Daily) on Tier 2 / Effective 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 2 / Effective Copaxone Inj 40mg/mL Deletion of Drug From Formulary / Generic Available / Alternative Drug: Glatiramer Inj 40mg/mL on Tier 5 / Coreg CR Cap Deletion of Drug From Formulary / Generic Available / Alternative Drug: Carvedilol Phosphate ER 24hr Cap on Tier 2 / Docefrez Inj 20mg Discontinuation / Alternative Drug: Docetaxel Inj 80mg/4mL on Tier 5 / Effective Estrace Vaginal Cream 0.01% Deletion of Drug From Formulary / Generic Available / Alternative Drug: Estradiol Vaginal Cream 0.01% on Tier 2 / Gavilyte-H Kit Discontinuation / Alternative Drug: Gavilyte-G Sol on Tier 2 / Effective Istalol Ophth Soln 0.5% Deletion of Drug From Formulary / Generic Available / Alternative Drug: Timolol Maleate Ophth Soln 0.5% (Once-Daily) on Tier 2 / Lortab Tab mg Acetaminophen Tab mg on Tier 3 / Effective 1

3 Medication Name Lortab Tab 5-325mg Lortab Tab mg Menomune Inj A/C/Y/W Morphine Sulate Inj 15mg/mL Necon Tab 10/11-28 Acetaminophen Tab 5-325mg on Tier 3 / Effective Date: 3/1/2018 Acetaminophen Tab mg on Tier 3 / Effective Discontinuation / Alternative Drug: Menactra Inj on Tier 3 / Effective Discontinuation / Alternative Drug: Morphine Sulfate IV Soln Pf 10mg/mL on Tier 4 / Effective Discontinuation / Alternative Drug: Necon Tab 7/7/7 on Tier 2 / Effective Relpax Tab Deletion of Drug From Formulary / Generic Available / Alternative Drug: Eletriptan Tab on Tier 2 / Effective Date: 6/1/2018 Renvela Pak Deletion of Drug From Formulary / Generic Available / Alternative Drug: Sevelamer Carbonate Packet on Tier 2 / Renvela Tab 800mg Deletion of Drug From Formulary / Generic Available / Alternative Drug: Sevelamer Carbonate Tab 800mg on Tier 2 / 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 2 / 2

4 Medication Name Tamiflu Susp 6mg/mL Deletion of Drug From Formulary / Generic Available / Alternative Drug: Oseltamivir Phosphate Susp 6 mg/ml on Tier 2 / 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 2 / Effective 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 2 / Discontinuation / Alternative Drug: Terconazole Vaginal Cream 0.8% on Tier 2 / Effective Ziagen Soln 20mg/mL Deletion of Drug From Formulary / Generic Available / Alternative Drug: Abacavir Soln 20mg/mL on Tier 2 / Zoledronic Inj 4mg Discontinuation / Alternative Drug: Zoledronic Inj 4mg/5mL on Tier 2 / Effective 3

5 Easy Choice Health Plan (HMO), a WellCare company, is a Medicare Advantage organization with a Medicare contract. Enrollment in Easy Choice 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. Easy Choice uses a formulary. P.O. Box Tampa, FL