2011 Formulary Addendum
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1 2011 Formulary Addendum This is a listin of the chanes that have occurred in our formulary. Please carefully review these chanes and call WellCare if you have any questions. Date of Chane: 03/01/2011 Formulary File #11212 Formulary Version #7 NAME a-methapred solution 125m Glucocorticoids/ Mineralocorticoids a-methapred solution 40m Glucocorticoids/ Mineralocorticoids anaspaz orally disinteratin Antispasmodics, tablets 0.125m Gastrointestinal ASMANEX 7 METERED DOS- Anti-inflammatories, ES 110MCG/INHALATION Inhaled Corticosteroids ROMDAY SOLUTION 0.09% Ophthalmic Antiinflammatories calcipotriene ointment 0.005% Dermatoloical calcitriol capsules 0.25mc Metabolic one Disease calcitriol capsules 0.5mc Metabolic one Disease 2 Dru Added 2 Dru Added 1 Tier Decreased to Tier 1 2 Dru Added 3 Dru Added 2 Dru Added RAND NAME Pae 1 of 7
2 NAME calcitriol solution 1mc/ml Metabolic one Disease calcitriol solution 1mc/ml Metabolic one Disease calcitriol solution 2mc/ml Metabolic one Disease carisoprodol tablets 250m Skeletal Muscle Relaxants 3 Dru Added 3 PA Removed 3 PA Removed 2 Dru Added 1 Dru Added cimetidine hcl solution 300m/5ml Histamine2 (H2) lockin ciprofloxacin solution 400m Quinolones 1 Tier Decreased to Tier 1 dexamethasone sodium Glucocorticoids/ 1 Dru Added phosphate solution 4m/ml Mineralocorticoids donepezil hcl tablets 10m Cholinesterase Inhibitors donepezil hcl tablets 5m Cholinesterase Inhibitors donepezil hcl orally disinteratin tablets10m donepezil hcl orally disinteratin tablets 5m DULERA AEROSOL 5MCG/ ACTUATION; 100MCG/AC- TUATION DULERA AEROSOL 5MCG/ ACTUATION; 200MCG/AC- TUATION Cholinesterase Inhibitors Cholinesterase Inhibitors Anti-inflammatories, Inhaled Corticosteroids Anti-inflammatories, Inhaled Corticosteroids 3 Dru Added 3 Dru Added 3 Dru Added 3 Dru Added 2 Dru Added 2 Dru Added eliphos tablets 667m Phosphate inders RAND NAME Pae 2 of 7
3 NAME 100m/ml 120m/0.8ml 150m/ml 30m/0.3ml 40m/0.4ml 60m/0.6ml 80m/0.8ml epinephrine device 0.15m/0.15ml epinephrine device 0.3m/0.3ml HECTOROL CAPSULES 0.5MCG Anticoaulants 4 Dru Added Anticoaulants 4 Dru Added Anticoaulants 4 Dru Added Anticoaulants 2 Dru Added Anticoaulants 2 Dru Added Anticoaulants 4 Dru Added Anticoaulants 4 Dru Added ronchodilators, Sympathomimetic ronchodilators, Sympathomimetic Metabolic one Disease HECTOROL CAPSULES 1MCG Metabolic one Disease 1 Dru Added 1 Dru Added RAND NAME Pae 3 of 7
4 NAME HECTOROL CAPSULES 2.5MCG HECTOROL SOLUTION 4MCG/2ML HUMAPEN LUXURA HD DE- VICE Metabolic one Disease Metabolic one Disease Miscellaneous Therapeutic HUMAPEN MEMOIR DEVICE Miscellaneous Therapeutic INTRALIPID EMULSION 2.25%; 20% JALYN CAPSULES 0.5MG; 0.4MG Miscellaneous Therapeutic enin Prostatic Hypertrophy 2 Dru Added 2 Dru Added 2 Dru Added 2 Dru Added LATUDA TALETS 40MG Atypicals 3 Dru Added LATUDA TALETS 80MG Atypicals 3 Dru Added LUMIGAN SOLUTION 0.01% Ophthalmic Prostalandin and Prostamide Analos LUMIZYME SOLUTION 50MG Enzyme Replacements/ Modifiers np thyroid 30 tablets 30m Hormonal, Stimulant/ Replacement/ Modifyin (Thyroid) 2 Dru Added 4 Dru Added LA Added 1 Dru Added RAND NAME Pae 4 of 7
5 NAME np thyroid 60 tablets 60m Hormonal, Stimulant/ Replacement/ Modifyin (Thyroid) np thyroid 90 tablets 90m Hormonal, Stimulant/ Replacement/ Modifyin (Thyroid) 1 Dru Added 1 Dru Added oxycodone hcl capsules 5m Opioid Analesics 2 Dru Added phenelzine sulfate tablets 15m pramipexole dihydrochloride tablets 0.75m Monoamine Oxidase Inhibitors Antiparkinson 3 Dru Added 2 Dru Added RENVELA PACKET 0.8GM Phosphate inders 3 Dru Added RENVELA PACKET 2.4GM Phosphate inders 3 Dru Added RENVELA TAETS 800MG Phosphate inders 3 Dru Added SUOXONE SULINGUAL FILM 2MG; 0.5MG SUOXONE SULINGUAL FILM 8MG; 2MG Toxicoloic 3 Dru Added Toxicoloic 3 Dru Added tretinoin capsules 10m Retinoids 2 Tier Decreased to Tier 2 RAND NAME Pae 5 of 7
6 NAME verapamil hcl solution 2.5m/ml Calcium Channel lockin verapamil hcl sr capsules 240m verapamil hcl sr capsules 360m Calcium Channel lockin Calcium Channel lockin 1 Dru Added 1 Dru Added 1 Dru Added zafirlukast tablets 10m Antileukotrienes 3 Dru Added zafirlukast tablets 20m Antileukotrienes 3 Dru Added RAND NAME Pae 6 of 7
7 For Prescription Dru Plans (PDP), call toll-free: For all states: TTY/TDD: Monday Sunday, 8am to 2am Eastern. Or visit us anytime at This document is available in alternate formats or lanuaes. For information on the availability of alternate formats or lanuaes in your service area, please call Customer Service at the number listed in this document. Este documento se encuentra disponible en diferentes formatos o idiomas. Para obtener información sobre la disponibilidad de los formatos o idiomas alternativos en su área de servicio, por favor llame a Servicio al Cliente al número indicado en este documento. WellCare is a health plan with a Medicare contract. A Medicare-approved Part D sponsor. WellCare uses a formulary. You may be able to et Extra Help to pay for your prescription dru premiums and costs. To see if you qualify for ettin Extra Help, call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users can call You can also call the Social Security Administration at (TTY ) between 7am and 7pm, Monday Friday; or call your state Medicaid office. eneficiaries must use network pharmacies to access their prescription dru benefit, except in non-routine circumstances, and quantity limitations and restrictions may apply. enefits, formulary, pharmacy network, premium and/or co-payments/coinsurance may chane on January 1, P.O. ox Tampa, FL Pae 7 of 7
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