2018 Formulary Notice of Change Medicare Advantage Plans
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1 2018 Formulary Notice of Change Medicare Advantage Plans WellCare/ Ohana Plans in the following state: IL WellCare Choice (HMO-POS), WellCare Plus (HMO), WellCare Rx (HMO) Plans in the following states: AR, CT, FL, IL, LA, KY, NJ, TN, TX WellCare Value (HMO), WellCare Value (HMO-POS) Plans in the following states: CT, FL, KY, MS, TN, TX WellCare Essential (HMO-POS), WellCare Preferred (HMO) WellCare Dividend (HMO), WellCare Dividend Prime (HMO) Plans in the following states: CT, HI, LA, NJ, TX WellCare Access (HMO SNP) WellCare/ Ohana may add or remove drugs Ohana Liberty (HMO SNP) from our formulary during the year. If we WellCare Liberty (HMO SNP) remove drugs from our formulary, or add Plans in the following state: FL prior authorization, quantity limits and/ WellCare Premier (PPO) or step therapy restrictions on a drug and/ WellCare Guardian (HMO SNP) 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_V04 NM WellCare 2018 NA8WCMFOR14367E_NV04
2 Formulary ID: Effective Date: 4/1/2018 Formulary Version: 7 Medication Name Aminosyn II Inj 7% Clindamax Gel 1% Discontinuation / Alternative Drug: Aminosyn-HBC Inj 7% on Tier 4 / Effective Date: 3/1/2018 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 Lortab Tab mg Menomune Inj A/C/Y/W 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 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 1
3 Medication Name Morphine Sulate Inj 15mg/mL Discontinuation / Alternative Drug: Morphine Sulfate IV Soln Pf 10mg/mL on Tier 4 / 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 / 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 Tier 3 / Zazole Cream 0.8% Discontinuation / Alternative Drug: Terconazole Vaginal Cream 0.8% on Tier 3 / Effective Date: 3/1/2018 2
4 Medication Name 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 Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare (HMO/PPO) 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/ Ohana 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 any time. You will receive notice when necessary. WellCare/ Ohana uses a formulary. Some plans are available to those who have medical assistance from both the state and Medicare. Some plans are available to anyone with Medicare who has been diagnosed with Cardiovascular Disorders, Chronic Heart Failure or Diabetes. 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
2018 Formulary Notice of Change Medicare Advantage Plans
2018 Formulary Notice of Change Medicare Advantage Plans WellCare/ Ohana Plans in the following state: IL WellCare Choice (HMO-POS), WellCare Plus (HMO), WellCare Rx (HMO) Plans in the following states:
2018 Formulary Notice of Change Medicare Advantage Plans
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