2016 FORMULARY ADDENDUM NOTICE OF CHANGE

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1 2016 FORMULARY ADDENDUM NOTICE OF CHANGE (PRESCRIPTION DRUG PLANS) WELLCARE PRESCRIPTION INSURANCE, INC. WellCare Simple (PDP) WellCare Classic (PDP) WellCare Extra (PDP) This is a listing of the changes that have occurred in our formulary. Please carefully review these changes and call WellCare 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_01 CMS Approved WellCare 2016 NA_09_16 PD6V01FOR78490E_0916

2 Formulary File: Effective Date:4/1/2016 Formulary Version: 9 AVODART CAPSULE 0.5 MG foscarnet sodium intravenous solution 24 mg/ml GLEEVEC TABLET 100 MG GLEEVEC TABLET 400 MG JALYN CAPSULE MG MEGACE ES SUSPENSION 625 MG/5ML NAMENDA SOLUTION 10 MG/5ML NAMENDA TABLET 10 MG ALTERNATIVE DRUG(S): dutasteride capsule 0.5 MG on Tier 4 with QL (30 capsules per 30 days) 03/01/2016. ALTERNATIVE DRUG(S): valganciclovir tablet 450 MG on Tier 5^ ALTERNATIVE DRUG(S): imatinib mesylate tablet 100 MG on Tier 5^ with PA ALTERNATIVE DRUG(S): imatinib mesylate tablet 400 MG on Tier 5^ with PA ALTERNATIVE DRUG(S): dutasteride-tamsulosin hcl capsule MG on Tier 4 with QL (30 capsules per 30 days) ALTERNATIVE DRUG(S): megestrol acetate suspension 625 MG/5ML on Tier 5^ with PA ALTERNATIVE DRUG(S): memantine hcl solution 2 MG/ML on Tier 3 with PA ALTERNATIVE DRUG(S): memantine tablet 10 MG on Tier 4 with PA 2

3 NAMENDA TABLET 5 MG ORAP TABLET 1 MG ORAP TABLET 2 MG TARGRETIN CAPSULE 75 MG XENAZINE TABLET 12.5 MG XENAZINE TABLET 25 MG ZYVOX SUSPENSION RECONSTITUTED 100 MG/5ML ALTERNATIVE DRUG(S): memantine tablet 5 MG on Tier 4 with PA ALTERNATIVE DRUG(S): pimozide tablet 1 MG on Tier 4 ALTERNATIVE DRUG(S): pimozide tablet 2 MG on Tier 4 ALTERNATIVE DRUG(S): bexarotene capsule 75 MG on Tier 5^ with PA ALTERNATIVE DRUG(S): tetrabenazine tablet 12.5 MG on Tier 5^ with PA, QL (240 tablets per 30 days) ALTERNATIVE DRUG(S): tetrabenazine tablet 25 MG on Tier 5^ with PA, QL (120 tablets per 30 days) ALTERNATIVE DRUG(S): linezolid suspension reconstituted 100 MG/5ML on Tier 5^ Brand drugs- UPPERCASE, Generics- lowercase, LA=Limited Access, NM=Not Available by Mail Service, PA=Prior Authorization, B/D=Covered under Medicare B or D, QL=Quantity Limits, ST=Step Therapy, ^ = Drug may be available for up to a 30-day supply only 3

4 Formulary File: Effective Date:5/1/2016 Formulary Version: 10 ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 800 MG AUVI-Q INJECTION 0.15 MG/0.15ML AUVI-Q INJECTION 0.3 MG/0.3ML 04/01/2016. ALTERNATIVE DRUG(S): ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG, 500 MG on Tier 5^ with PA; LA 05/01/2016. ALTERNATIVE DRUG(S): EPIPEN on Tier 3 05/01/2016. ALTERNATIVE DRUG(S): EPIPEN on Tier 3 diltzac capsule extended release 120 mg 03/01/2016. ALTERNATIVE DRUG(S): taztia xt capsule extended release 120 MG, diltiazem hcl beads capsule extended release 120 MG, on Tier 3 diltzac capsule extended release 180 mg 03/01/2016. ALTERNATIVE DRUG(S): taztia xt capsule extended release 180 MG, diltiazem hcl beads capsule extended release 180 MG, on Tier 3 diltzac capsule extended release 240 mg 03/01/2016. ALTERNATIVE DRUG(S): taztia xt capsule extended release 240 MG, diltiazem hcl beads capsule extended release 240 MG, on Tier 3 diltzac capsule extended release 300 mg 03/01/2016. ALTERNATIVE DRUG(S): taztia xt capsule extended release 300 MG, diltiazem hcl beads capsule extended release 300 MG, on Tier 3 4

5 LACLOTION EXTERNAL LOTION 12 % levobunolol hcl opthalmic solution 0.25 % lomustine capsule 10 mg lomustine capsule 100 mg lomustine capsule 40 mg MY WAY TABLET 1.5 MG 04/01/2016. ALTERNATIVE DRUG(S): ammonium lactate external lotion 12 % on Tier 2 04/01/2016. ALTERNATIVE DRUG(S): levobunolol hcl ophthalmic solution 0.5 % on Tier 3 04/01/2016. ALTERNATIVE DRUG(S): GLEOSTINE CAPSULE 10 MG on Tier 4 04/01/2016. ALTERNATIVE DRUG(S): GLEOSTINE CAPSULE 100 MG on Tier 4 04/01/2016. ALTERNATIVE DRUG(S): GLEOSTINE CAPSULE 40 MG on Tier 4 Drug Removed / Medicare will no longer cover / Brand name 03/01/2016. ALTERNATIVE DRUG(S): levonorgestrel tablet 1.5 MG on Tier 3 NEXT CHOICE ONE DOSE TABLET 1.5 MG Drug Removed / Medicare will no longer cover / Brand name 03/01/2016. ALTERNATIVE DRUG(S): levonorgestrel tablet 1.5 MG on Tier 3 tobramycin sulfate in saline intravenous solution mg/ml-% 04/01/2016. ALTERNATIVE DRUG(S): tobramycin sulfate injection solution 80 mg/2ml on Tier 3 Brand drugs- UPPERCASE, Generics- lowercase, LA=Limited Access, NM=Not Available by Mail Service, PA=Prior Authorization, B/D=Covered under Medicare B or D, QL=Quantity Limits, ST=Step Therapy,^ = Drug may be available for up to a 30-day supply only 5

6 Formulary File: Effective Date:8/1/2016 ZAZOLE VAGINAL CREAM 0.4 % Formulary Version: 13 06/01/2016. ALTERNATIVE DRUG(S): terconazole vaginal cream 0.4 % on Tier 3 Brand drugs- UPPERCASE, Generics- lowercase, LA=Limited Access, NM=Not Available by Mail Service, PA=Prior Authorization, B/D=Covered under Medicare B or D, QL=Quantity Limits, ST=Step Therapy,^ = Drug may be available for up to a 30-day supply only 6

7 Formulary File: Effective Date:9/1/2016 cefuroxime sodium intravenous solution reconstituted 7.5 gm Formulary Version: 14 08/01/2016. ALTERNATIVE DRUG(S): cefuroxime sodium injection solution reconstituted 7.5 GM on Tier 3 Brand drugs- UPPERCASE, Generics- lowercase, LA=Limited Access, NM=Not Available by Mail Service, PA=Prior Authorization, B/D=Covered under Medicare B or D, QL=Quantity Limits, ST=Step Therapy, ^ = Drug may be available for up to a 30-day supply only 7

8 This information is available for free in other languages. Please call our Customer Service number at , Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are available Monday Sunday, 8 a.m. to 8 p.m. TTY users should call Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de Servicio al Cliente al , de lunes a viernes, de 8 a.m. a 8 p.m. Entre el 1 de octubre y el 14 de febrero, los representantes están disponibles de lunes a domingo de 8 a.m. a 8 p.m. Los usuarios de TTY deben llamar al WellCare (PDP) is a Medicare-approved Part D sponsor. Enrollment in WellCare (PDP) depends on contract renewal. WellCare Simple (PDP) is offered by Windsor Health Plan, Inc., or WellCare Prescription Insurance, Inc. 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 uses a formulary. Some plans are available to those who have medical assistance from both the state and Medicare. 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

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