2017 Formulary Addendum Notice of Change (Medicare Advantage Plans)
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1 2017 Formulary Addendum Notice of Change (Medicare Advantage Plans) Easy Choice Health Plan Easy Choice Best Plan (HMO) H This is a listing of the changes that have occurred in our formulary. Please carefully review these changes and call Easy Choice 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_07 CMS Approved WellCare 2017 CA7RMRFOR06838E_NV07
2 Formulary ID: Effective Date:4/1/2017 Formulary Version: 10 Medication Name A-HYDROCORT INJECTION SOLUTION RECONSTITUTED 100MG ALTABAX EXTERNAL OINTMENT 1% ASACOL HD TABLET DELAYED RELEASE 800MG AZILECT TABLET 0.5MG AZILECT TABLET 1MG AZOR TABLET 10-20MG AZOR TABLET 10-40MG AZOR TABLET 5-20MG AZOR TABLET 5-40MG 03/01/2017. ALTERNATIVE DRUG(S): SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 250MG on Tier 4 Drug Removed / Medicare will no longer cover / Brand name 03/01/2017. ALTERNATIVE DRUG(S): mupirocin external ointment 2% on Tier ALTERNATIVE DRUG(S): mesalamine tablet delayed release 800mg on Tier 2 ALTERNATIVE DRUG(S): rasagiline mesylate tablets on Tier 2 ALTERNATIVE DRUG(S): rasagiline mesylate tablets on Tier 2 ALTERNATIVE DRUG(S): amlodipine-olmesartan tablets on Tier ALTERNATIVE DRUG(S): amlodipine-olmesartan tablets on Tier ALTERNATIVE DRUG(S): amlodipine-olmesartan tablets on Tier ALTERNATIVE DRUG(S): amlodipine-olmesartan tablets on Tier 2
3 Medication Name BENICAR HCT TABLET MG BENICAR HCT TABLET MG BENICAR HCT TABLET 40-25MG BENICAR TABLET 20MG BENICAR TABLET 40MG BENICAR TABLET 5MG CAFERGOT TABLET 1-100MG CERVARIX INTRAMUSCULAR SUSPENSION EPZICOM TABLET MG NILANDRON TABLET 150MG ALTERNATIVE DRUG(S): olmesartan medoxomil-hctz oral tablets on Tier ALTERNATIVE DRUG(S): olmesartan medoxomil-hctz oral tablets on Tier ALTERNATIVE DRUG(S): olmesartan medoxomil-hctz oral tablets on Tier ALTERNATIVE DRUG(S): olmesartan medoxomil tablets on Tier ALTERNATIVE DRUG(S): olmesartan medoxomil tablets on Tier ALTERNATIVE DRUG(S): olmesartan medoxomil tablets on Tier ALTERNATIVE DRUG(S): ergotamine-caffeine tablet 1-100mg on Tier 2 03/01/2017. ALTERNATIVE DRUG(S): GARDASIL 9 INTRAMUSCULAR SUSPENSION on Tier 3; NM ALTERNATIVE DRUG(S): abacavir sulfate-lamivudine tablet mg on Tier 5^ ALTERNATIVE DRUG(S): nilutamide tablet 150mg on Tier 5^ 3
4 Medication Name NITROSTAT SUBLINGUAL TABLET 0.3MG ALTERNATIVE DRUG(S): nitroglycerin sublingual tablets on Tier 2 NITROSTAT SUBLINGUAL TABLET 0.4MG ALTERNATIVE DRUG(S): nitroglycerin sublingual tablets on Tier 2 NITROSTAT SUBLINGUAL TABLET 0.6MG ALTERNATIVE DRUG(S): nitroglycerin sublingual tablets on Tier 2 OMECLAMOX-PAK MG PLASMA-LYTE-56 IN D5W INTRAVENOUS SOLUTION SEROQUEL XR TABLET EXTENDED RELEASE 150MG SEROQUEL XR TABLET EXTENDED RELEASE 200MG SEROQUEL XR TABLET EXTENDED RELEASE 300MG SEROQUEL XR TABLET EXTENDED RELEASE 400MG Drug Removed / Medicare will no longer cover / Brand name 03/01/2017. ALTERNATIVE DRUG(S): amoxicill-clarithrolansopraz on Tier 2 03/01/2017. ALTERNATIVE DRUG(S): NORMOSOL-R IN D5W INTRAVENOUS SOLUTION on Tier 4 ALTERNATIVE DRUG(S): quetiapine fumarate tablet extended release 150mg on Tier 2; QL (30 tablets per 30 days) ALTERNATIVE DRUG(S): quetiapine fumarate tablet extended release 200mg on Tier 2; QL (30 tablets per 30 days) ALTERNATIVE DRUG(S): quetiapine fumarate tablet extended release 300mg on Tier 2; QL (60 tablets per 30 days) ALTERNATIVE DRUG(S): quetiapine fumarate tablet extended release 400mg on Tier 2; QL (60 tablets per 30 days) 4
5 Medication Name SEROQUEL XR TABLET EXTENDED RELEASE 50MG stavudine solution reconstituted 1mg/ml TAMIFLU CAPSULE 30MG TAMIFLU CAPSULE 45MG TAMIFLU CAPSULE 75MG TRETIN-X EXTERNAL CREAM % TRIBENZOR TABLET MG TRIBENZOR TABLET MG TRIBENZOR TABLET MG ALTERNATIVE DRUG(S): quetiapine fumarate tablet extended release 50mg on Tier 2; QL (120 tablets per 30 days) Drug Removed / Manufacturer Discontinuation / Generic name 03/01/2017. ALTERNATIVE DRUG(S): ZERIT SOLUTION RECONSTITUTED 1MG/ML on Tier 5^ ALTERNATIVE DRUG(S): oseltamivir phosphate capsules on Tier 2 ALTERNATIVE DRUG(S): oseltamivir phosphate capsules on Tier 2 ALTERNATIVE DRUG(S): oseltamivir phosphate capsules on Tier 2 03/01/2017. ALTERNATIVE DRUG(S): tretinoin external cream 0.025% on Tier 2; PA ALTERNATIVE DRUG(S): olmesartan-amlodipine-hctz tablets on Tier ALTERNATIVE DRUG(S): olmesartan-amlodipine-hctz tablets on Tier ALTERNATIVE DRUG(S): olmesartan-amlodipine-hctz tablets on Tier 5
6 Medication Name TRIBENZOR TABLET MG TRIBENZOR TABLET MG VAGIFEM VAGINAL TABLET 10MCG XOPENEX HFA INHALATION AEROSOL 45MCG/ACT ZETIA TABLET 10MG ALTERNATIVE DRUG(S): olmesartan-amlodipine-hctz tablets on Tier ALTERNATIVE DRUG(S): olmesartan-amlodipine-hctz tablets on Tier ALTERNATIVE DRUG(S): yuvafem vaginal tablet 10mcg on Tier 2 ALTERNATIVE DRUG(S): levalbuterol tartrate inhalation aerosol 45mcg/act on Tier 2; QL (30gm per 30 days) ALTERNATIVE DRUG(S): ezetimibe tablet 10mg on Tier 2 Brand drugs- UPPERCASE, Generics- lowercase, PA=Prior Authorization, B/D=Covered under Medicare B or D, QL=Quantity Limits, ST=Step Therapy, ED=Excluded Drug, GC=Gap Coverage, LA=Limited Access, NM=Not Available by Mail Service, ^ =Drug may be available for up to a 30-day supply only 6
7 Formulary ID: Effective Date:5/1/2017 Formulary Version: 11 Medication Name ammonium chloride intravenous solution 5meq/ml CAPITAL/CODEINE ORAL SUSPENSION MG/5ML CLAFORAN IN D5W INTRAVENOUS SOLUTION 2GM/50ML CLAFORAN INTRAVENOUS SOLUTION RECONSTITUTED 1GM CLAFORAN INTRAVENOUS SOLUTION RECONSTITUTED 2GM docetaxel intravenous concentrate 140mg/7ml Drug Removed / Manufacturer Discontinuation / Generic name 04/01/2017. ALTERNATIVE DRUG(S): sodium chloride intravenous solution 0.9% on Tier 2 04/01/2017. ALTERNATIVE DRUG(S): acetaminophen-codeine oral solution mg/5ml on Tier 2; QL (5000ml per 30 days) 04/01/2017. ALTERNATIVE DRUG(S): cefotaxime sodium injection solution reconstituted 2gm on Tier 2 04/01/2017. ALTERNATIVE DRUG(S): cefotaxime sodium injection solution reconstituted 1gm on Tier 2 04/01/2017. ALTERNATIVE DRUG(S): cefotaxime sodium injection solution reconstituted 2gm on Tier 2 Drug Removed / Manufacturer Discontinuation / Generic name 05/01/2017. ALTERNATIVE DRUG(S): DOCETAXEL INTRAVENOUS CONCENTRATE 80MG/4ML on Tier 5^; B/D Brand drugs- UPPERCASE, Generics- lowercase, PA=Prior Authorization, B/D=Covered under Medicare B or D, QL=Quantity Limits, ST=Step Therapy, ED = Excluded Drug, GC = Gap Coverage, LA=Limited Access, NM=Not Available by Mail Service, ^ =Drug may be available for up to a 30-day supply only 7
8 Formulary ID: Effective Date:7/1/2017 Formulary Version: 13 Medication Name AMETHYST ORAL TABLET 90-20MCG ILOTYCIN OPHTHALMIC OINTMENT 5MG/GM VITEKTA TABLET 150MG VITEKTA TABLET 85MG 06/01/2017. ALTERNATIVE DRUG(S): levonorgestrel-ethinyl estrad tablet on Tier 2 06/01/2017. ALTERNATIVE DRUG(S): erythromycin ophthalmic ointment 5mg/gm on Tier 05/01/2017. ALTERNATIVE DRUG(S): TIVICAY TABLET 25MG, 50MG on Tier 5^; ISENTRESS TABLET 400MG on Tier 5^ 05/01/2017. ALTERNATIVE DRUG(S): TIVICAY TABLET 25MG, 50MG on Tier 5^; ISENTRESS TABLET 400MG on Tier 5^ Brand drugs- UPPERCASE, Generics- lowercase, PA=Prior Authorization, B/D=Covered under Medicare B or D, QL=Quantity Limits, ST=Step Therapy, ED = Excluded Drug, GC=Gap Coverage, LA=Limited Access, NM=Not Available by Mail Service, ^ =Drug may be available for up to a 30-day supply only 8
9 Formulary ID: Effective Date:9/1/2017 Formulary Version: 15 Medication Name AMINOSYN II INTRAVENOUS SOLUTION 7 % atropine sulfate injection solution prefilled syringe 0.5 mg/5ml docetaxel intravenous concentrate 200 mg/20ml KLOR-CON ORAL PACKET 20 MEQ UVADEX INJECTION SOLUTION 20 MCG/ML 08/01/2017. ALTERNATIVE DRUG(S): AMINOSYN-HBC INTRAVENOUS SOLUTION 7 % on Tier 4; B/D; AMINOSYN-PF INTRAVENOUS SOLUTION 7 % on Tier 4; B/D Drug Removed / Manufacturer Discontinuation / Generic name 08/01/2017. ALTERNATIVE DRUG(S): ATROPINE SULFATE INJECTION SOLUTION PREFILLED SYRINGE 0.25 MG/5ML, 1 MG/10ML on Tier 2 Drug Removed / Manufacturer Discontinuation / Generic name 08/01/2017. ALTERNATIVE DRUG(S): DOCETAXEL INTRAVENOUS SOLUTION 160 MG/16ML on Tier 5^ with B/D 08/01/2017. ALTERNATIVE DRUG(S): POTASSIUM CHLORIDE ORAL PACKET 20 MEQ on Tier 2 Drug Removed / Medicare will no longer cover / Brand name 07/01/2017. ALTERNATIVE DRUG(S): Consult your Health Care Professional Brand drugs- UPPERCASE, Generics- lowercase, PA=Prior Authorization, B/D=Covered under Medicare B or D, QL=Quantity Limits, ST=Step Therapy, ED=Excluded Drug, GC=Gap Coverage, LA=Limited Access, NM=Not Available by Mail Service, ^ =Drug may be available for up to a 30-day supply only 9
10 Formulary ID: Effective Date:10/1/2017 Formulary Version: 16 Medication Name LOKARA EXTERNAL LOTION 0.05% LORTAB TABLET MG LORTAB TABLET 5-325MG LORTAB TABLET MG REPREXAIN TABLET MG ZAZOLE VAGINAL CREAM 0.8% 09/01/2017. ALTERNATIVE DRUG(S): desonide external lotion 0.05% on Tier 2 09/01/2017. ALTERNATIVE DRUG(S): hydrocodoneacetaminophen tablet mg on Tier 2 with QL (360 tablets per 30 days) 09/01/2017. ALTERNATIVE DRUG(S): hydrocodoneacetaminophen tablet 5-325mg on Tier 2 with QL (360 tablets per 30 days) 09/01/2017. ALTERNATIVE DRUG(S): hydrocodoneacetaminophen tablet mg on Tier 2 with QL (360 tablets per 30 days) 09/01/2017. ALTERNATIVE DRUG(S): hydrocodone-ibuprofen tablet mg on Tier 2 with QL (150 tablets per 30 days) 09/01/2017. ALTERNATIVE DRUG(S): terconazole vaginal cream 0.8% on Tier 2 Brand drugs- UPPERCASE, Generics- lowercase, PA=Prior Authorization, B/D=Covered under Medicare B or D, QL=Quantity Limits, ST=Step Therapy, ED = Excluded Drug, GC=Gap Coverage, LA=Limited Access, NM=Not Available by Mail Service, ^ =Drug may be available for up to a 30-day supply only 10
11 ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call (TTY: ). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Easy Choice Health Plan (HMO), a WellCare company, is a Medicare Advantage organization with a Medicare contract. Enrollment in Easy Choice (HMO) depends on contract renewal. The formulary, pharmacy network, and/ or provider network may change at any time. You will receive notice when necessary. 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. P.O. Box Tampa, FL
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