WellCare Signature (PDP) and WellCare Classic (PDP) Formulary Addendum
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1 WellCare Signature (PDP) and WellCare Classic (PDP) Formulary Addendum This is a listing of the changes that have occurred in our formulary. Please carefully review these changes and call WellCare if you have any questions. UPPER CASE = Brand Name Drugs Lower case italics = Generic Drugs LA = Limited Access Key PA = Prior Authorization QL = Quantity Limits ST = Step Therapy Date of Change: 01/01/2010 Formulary File Formulary Version 9 amoxicillin/clavulanate potassium 250mg/5ml; 62.5mg/5ml susr codeine sulfate 15mg tabs codeine sulfate 30mg tabs codeine sulfate 60mg tabs Beta-lactam, Penicillins COLCRYS 0.6MG TABS Antigout Tier 3 cytra-2 334mg/5ml; 500mg/5ml soln cytra-3 334mg/5ml; 550mg/5ml; 500mg/5ml syrp galantamine hydrobromide 4mg/ml soln gavilyte-g 236gm; 2.97gm; 6.74gm; 5.86gm; 22.74gm solr Alkalinizing Alkalinizing Cholinesterase Inhibitors Gastrointestinal, Other Page 1 of 9
2 HECTOROL 1MCG CAPS LOTRONEX 0.5MG TABS LOTRONEX 1MG TABS Metabolic Bone Disease Irritable Bowel Syndrome Irritable Bowel Syndrome Tier 4 PA Removed PA Removed malathion 0.5% lotn Pediculicides/ Scabicides naproxen 250mg tabs naproxen 500mg tabs nifedipine 10mg caps nifedipine 20mg caps PREZISTA 150MG TABS Analgesics and Antipyretics Analgesics and Antipyretics Calcium Channel Blocking Calcium Channel Blocking Anti-HIV, Protease Inhibitors PROTONIX 40MG SOLR Proton Pump Inhibitors Tier 3 PA Removed SABRIL 500MG TABS Gamma-aminobutyric Acid (GABA) Augmenting Tier 4 SAPHRIS 10MG SUBL Atypicals Tier 3 SAPHRIS 5MG SUBL Atypicals Tier 3 sumatriptan succinate 4mg/0.5ml kit sumatriptan succinate 4mg/0.5ml soln sumatriptan succinate 6mg/0.5ml kit sumatriptan succinate 6mg/0.5ml soln Abortive QL Increased Abortive QL Increased Abortive QL Increased Abortive QL Increased Date of Change: 03/01/2010 Formulary File Formulary Version 9 ADCIRCA 20MG TABLET Pulmonary Antihypertensives Page 2 of 9 Tier 4 ak-con 0.1% solution Ophthalmic, Other
3 AMINOSYN-RF 113MEQ/L; 600MG/100ML; 429MG/100ML; 462MG/100ML; 726MG/100ML; 535MG/100ML; 726MG/100ML; 726MG/100ML; 330MG/100ML; 165MG/100ML; 528MG/100ML SOLU- TION amoclan 200mg/5ml; 28.5mg/5ml suspension, reconstitutable amoclan 400mg/5ml; 57mg/5ml suspension, reconstitutable brimonidine tartrate 0.15% solution buprenorphine hcl 2mg sublingual buprenorphine hcl 8mg sublingual bupropion hcl xl 150mg 24 hour bupropion hcl xl 300mg 24 hour Electrolytes/Minerals Beta-lactam, Penicillins Beta-lactam, Penicillins Ophthalmic Antiglaucoma Page 3 of 9 Psychotherapeutic Psychotherapeutic CERVARIX SUSPENSION Vaccines citric acid/sodium citrate 334mg/5ml; 500mg/5ml solution cyclosporine modified 25mg capsule cyclosporine modified 50mg capsule DERMA-SMOOTHE/FS SCALP OIL 0.01% OIL Electrolytes/Minerals Immunosuppressive Immune Suppressants Anti-inflammatory FANAPT 10MG TABLET Atypicals Tier 3
4 FANAPT 12MG TABLET Atypicals Tier 3 FANAPT 1MG TABLET Atypicals Tier 3 FANAPT 2MG TABLET Atypicals Tier 3 FANAPT 4MG TABLET Atypicals Tier 3 FANAPT 6MG TABLET Atypicals Tier 3 FANAPT 8MG TABLET Atypicals Tier 3 FANAPT TITRATION PACK FLOVENT DISKUS 100MCG/BLIST POWDER FOR INHALATION FLOVENT DISKUS 250MCG/BLIST POWDER FOR INHALATION FLOVENT DISKUS 50MCG/BLIST POWDER FOR INHALATION FLOVENT HFA 110MCG/ ACT AEROSOL FLOVENT HFA 220MCG/ ACT AEROSOL FLOVENT HFA 44MCG/ ACT AEROSOL Atypicals Tier 3 gengraf 100mg capsule Immune Suppressants gengraf 100mg/ml solution Immune Suppressants gengraf 25mg capsule Immune Suppressants INTRON-A 10MU/ML SOLUTION Immunomodulators Tier 3 Page 4 of 9
5 INVEGA 1.5MG 24 HOUR TABLET 117MG/0.75ML SUSPEN- SION 156MG/ML SUSPENSION 234MG/1.5ML SUSPEN- SION 39MG/0.25ML SUSPEN- SION 78MG/0.5ML SUSPEN- SION ketorolac tromethamine 0.4% solution ketorolac tromethamine 0.5% solution lansoprazole 15mg delayed release capsule lansoprazole 30mg delayed release capsule LIPOSYN II 2.5%; 10%; 10% EMULSION LIPOSYN II 2.5%; 5%; 5% EMULSION LIPOSYN III 1.2%; 2.5%; 10% EMULSION LIPOSYN III 1.2%; 2.5%; 20% EMULSION LIPOSYN III 1.8%; 2.5%; 30% EMULSION Atypicals Tier 3 QL Added Atypicals Tier 4 Atypicals Tier 4 Atypicals Tier 4 Atypicals Tier 3 Atypicals Tier 3 Ophthalmic Anti-inflammatories Ophthalmic Anti-inflammatories Page 5 of 9 Proton Pump Inhibitors Proton Pump Inhibitors nateglinide 120mg Antidiabetic nateglinide 60mg Antidiabetic oxcarbazepine 300mg/5ml suspension Sodium Channel Inhibitors
6 piperacillin sodium/ tazobactam sodium 3gm; 0.375gm solution, reconstitutable Beta-lactam, Penicillins RENAGEL 400MG TABLET Phosphate Binders Tier 3 RENAGEL 800MG TABLET Phosphate Binders Tier 3 RENVELA 2.4GM PACKET Phosphate Binders Tier 3 RENVELA 800MG TABLET Phosphate Binders Tier 3 SEREVENT DISKUS 50MCG/DOSE POWDER FOR INHALATION sotalol hcl (af) 120mg sotalol hcl (af) 160mg sotalol hcl (af) 80mg Bronchodilators, Sympathomimetic Antiarrhythmics Antiarrhythmics Antiarrhythmics tacrolimus 0.5mg capsule Immune Suppressants tacrolimus 1mg capsule Immune Suppressants tacrolimus 5mg capsule Immune Suppressants TAZORAC 0.05% CREAM Dermatological Tier 3 PA Removed TAZORAC 0.05% GEL Dermatological Tier 3 PA Removed TAZORAC 0.1% CREAM Dermatological Tier 3 PA Removed TAZORAC 0.1% GEL Dermatological Tier 3 PA Removed timolol maleate ophthalmic gel forming 0.25% timolol maleate ophthalmic gel forming 0.5% TREANDA 25MG SOLU- TION, RECONSTITUT- ABLE valacyclovir hcl 1000mg Ophthalmic Antiglaucoma Ophthalmic Antiglaucoma Alkylating Tier 4 Antiherpetic QL Added Page 6 of 9
7 valacyclovir hcl 500mg VOTRIENT 200MG TAB- LET ZENPEP UNIT; 20000UNIT; 68000UNIT CAPSULE ZENPEP 27000UNIT; 5000UNIT; 17000UNIT CAPSULE ZENPEP 55000UNIT; 10000UNIT; 34000UNIT CAPSULE ZENPEP 82000UNIT; 15000UNIT; 51000UNIT CAPSULE Antiherpetic QL Added Antiangiogenic Tier 4 Enzyme Replacements/ Modifiers Enzyme Replacements/ Modifiers Enzyme Replacements/ Modifiers Enzyme Replacements/ Modifiers Date of Change: 04/01/2010 Formulary File Formulary Version 11 CARAC 0.5% CREAM Dermatological chlorothiazide sodium 500mg reconstitutable solution Diuretics CIMZIA 200MG/ML KIT Immune Suppressants Tier 4 IXIARO SUSPENSION Vaccines lamotrigine starter/taking valproate 25mg kit Bipolar OFORTA 10MG TABLETS Antimetabolites Tier 4 Page 7 of 9
8 piperacillin sodium/ tazobactam sodium 2gm; 0.25gm solution piperacillin sodium/ tazobactam sodium 36gm; 4.5gm solution piperacillin sodium/ tazobactam sodium 4gm; 0.5gm solution 0.125mg s 0.25mg s 0.5mg s 1.5mg s 1mg s SORIATANE 10MG CAP- SULES Penicillins Penicillins Penicillins Antiparkinson Antiparkinson Antiparkinson Antiparkinson Antiparkinson Dermatological Tier 3 QL Added SORIATANE 17.5MG CAP- SULES SORIATANE 22.5MG CAP- SULES SORIATANE 25MG CAP- SULES ZYPREXA RELPREVV 210MG RECONSTITUT- ABLE SUSPENSION ZYPREXA RELPREVV 300MG RECONSTITUT- ABLE SUSPENSION ZYPREXA RELPREVV 405MG RECONSTITUT- ABLE SUSPENSION Dermatological Tier 4 Dermatological Tier 4 Dermatological Tier 4 Atypicals Tier 3 Atypicals Tier 4 Atypicals Tier 4 Page 8 of 9
9 If you need more information, visit or call Customer Service at the toll-free number listed below TTY: Monday Sunday, 7am to 2am Eastern WellCare is a Medicare-approved Part D Sponsor. WellCare uses a formulary. You may be able to get extra help to pay for your Medicare prescription drug premiums and costs. To see if you qualify, call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users can call You can also call the Social Security Administration at between 7am and 7pm, Monday Friday, or call your state Medicaid office. TTY users can call Page 9 of 9
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Medi-Cal Managed Care L. A. Care Major Risk Medical Insurance Program Provider Bulletin The formulary changes listed in the table below were reviewed and approved at our first-quarter 2018 Pharmacy and
ALLERGIC CONJUNCTIVITIS AGENTS
2018 5 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: 18390 Last Updated: 04/2018 Effective Date: 05-01-2018 ALLERGIC CONJUNCTIVITIS AGENTS epinastine 0.05 % eye drops
Additional drug coverage
Additional drug coverage Bonus Drug List The North Carolina State Health Plan for Teachers and State Employees offers a bonus drug list. The prescription drugs in this list are covered in addition to the
Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18
Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18 Granite Alliance requires step therapy for certain drugs. This means prior to receiving a drug with a step therapy
Step Therapy Approval Criteria
Effective Date: 01/01/2018 This document contains Step Therapy Approval Criteria for the following medications: 1. Colcrys (colchicine) 2. Dovonex (calcipotriene) 3. Enbrel (etanercept) 4. Humira (adalimumab)
Step Therapy Criteria 2019
Step Therapy 2019 For information on obtaining an updated coverage determination or an exception to a coverage determination please call Freedom Health Member Services at 1-800-401-2740 or, for TTY/TDD
TN Cover Rx Tennessee CoverRx MAC Price Change List As of: 04/26/2018
1 Tennessee CoverRx List Run : 04/26/18 Dosage Form amiodarone HCl 200 MG TABLET ORAL 04/25/2018 0.16102 0.14405 11.8 hydralazine HCl 100 MG TABLET ORAL 04/25/2015 0.11390 0.10854 4.9 hydralazine HCl 25
ICP Formulary Updates
ICP Formulary Updates July 2017 TRADE NAME (generic name) adapalene cream 0.1% 2017-07-01 Removal adapalene gel 0.3% 2017-07-01 Removal adefovir dipivoxil tab 10 mg 2017-07-01 Removal ADVAIR DISKUS (fluticasone-salmeterol
STEP THERAPY CRITERIA
STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered under your medical or prescription
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary April 1, 2018 Updates. Formulary Alternatives
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select April 1, 2018 Updates Drug Name adapalene-benzoyl-peroxide Gel 0.1-2.5% (Brand = Epiduo ) prasugrel hcl (Brand = Effient ) vigabatrin pak 500 mg (Brand
VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 04/01/2019
VNSNY CHOICE FIDA Complete Step Therapy Requirements Effective: 04/01/2019 Updated 03/2019 AMANTADINE ER OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED
STEP THERAPY CRITERIA
STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered under your medical or prescription