2017 Formulary Addendum Notice of Change

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1 2017 Formulary Addendum Notice of Change (Medicare Advantage Plans) WellCare Health Plans WellCare Access (HMO SNP), WellCare Liberty (HMO SNP), WellCare Reserve (HMO), WellCare Rx (HMO), WellCare Select (HMO SNP), WellCare Value (HMO) 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_09 CMS Approved WellCare 2017 NA7WCMFOR05668E_NV09

2 Formulary ID: Effective Date:4/1/2017 Formulary Version: 11 Medication Name A-HYDROCORT INJECTION SOLUTION RECONSTITUTED 100MG ASACOL HD TABLET DELAYED RELEASE 800MG AZILECT TABLET 0.5MG AZILECT TABLET 1MG CAFERGOT TABLET 1-100MG CERVARIX INTRAMUSCULAR SUSPENSION EPZICOM TABLET MG NILANDRON TABLET 150MG 03/01/2017. ALTERNATIVE DRUG(S): SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 250MG on Tier 4 ALTERNATIVE DRUG(S): mesalamine tablet delayed release 800mg on Tier 4 ALTERNATIVE DRUG(S): rasagiline mesylate tablets on Tier 3 ALTERNATIVE DRUG(S): rasagiline mesylate tablets on Tier 3 ALTERNATIVE DRUG(S): ergotamine-caffeine tablet 1-100mg on Tier 4 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^ NITROSTAT SUBLINGUAL TABLET 0.3MG ALTERNATIVE DRUG(S): nitroglycerin sublingual tablets on Tier 3 2

3 Medication Name NITROSTAT SUBLINGUAL TABLET 0.4MG ALTERNATIVE DRUG(S): nitroglycerin sublingual tablets on Tier 3 NITROSTAT SUBLINGUAL TABLET 0.6MG ALTERNATIVE DRUG(S): nitroglycerin sublingual tablets on Tier 3 PLASMA-LYTE-56 IN D5W INTRAVENOUS SOLUTION RELEASE 150MG RELEASE 200MG RELEASE 300MG RELEASE 400MG RELEASE 50MG stavudine solution reconstituted 1mg/ml 03/01/2017. ALTERNATIVE DRUG(S): NORMOSOL-R IN D5W INTRAVENOUS SOLUTION on Tier 4 release 150mg on Tier 4; QL (30 tablets per 30 days) release 200mg on Tier 4; QL (30 tablets per 30 days) release 300mg on Tier 4; QL (60 tablets per 30 days) release 400mg on Tier 4; QL (60 tablets per 30 days) release 50mg on Tier 4; 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^ 3

4 Medication Name TAMIFLU CAPSULE 30MG TAMIFLU CAPSULE 45MG TAMIFLU CAPSULE 75MG VAGIFEM VAGINAL TABLET 10MCG XOPENEX HFA INHALATION AEROSOL 45MCG/ACT ZETIA TABLET 10MG ALTERNATIVE DRUG(S): oseltamivir phosphate capsules on Tier 3 ALTERNATIVE DRUG(S): oseltamivir phosphate capsules on Tier 3 ALTERNATIVE DRUG(S): oseltamivir phosphate capsules on Tier 3 ALTERNATIVE DRUG(S): yuvafem vaginal tablet 10mcg on Tier 4 ALTERNATIVE DRUG(S): levalbuterol tartrate inhalation aerosol 45mcg/act on Tier 3; QL (30gm per 30 days) ALTERNATIVE DRUG(S): ezetimibe tablet 10mg on Tier 3 Brand drugs- UPPERCASE, Generics- lowercase, PA=Prior Authorization, B/D=Covered under Medicare B or D, QL=Quantity Limits, ST=Step Therapy, LA=Limited Access, NM=Not Available by Mail Service, ^ =Drug may be available for up to a 30-day supply only 4

5 Formulary ID: Effective Date:5/1/2017 Formulary Version: 12 Medication Name docetaxel intravenous concentrate 140mg/7ml 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, LA=Limited Access, NM=Not Available by Mail Service, ^ =Drug may be available for up to a 30-day supply only 5

6 Formulary ID: Effective Date:7/1/2017 Formulary Version: 14 Medication Name ILOTYCIN OPHTHALMIC OINTMENT 5MG/GM VITEKTA TABLET 150MG VITEKTA TABLET 85MG 06/01/2017. ALTERNATIVE DRUG(S): erythromycin ophthalmic ointment 5mg/gm on Tier 2 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, 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:9/1/2017 Formulary Version: 16 Medication Name AMINOSYN II INTRAVENOUS SOLUTION 7 % 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): 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 4 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, LA=Limited Access, NM=Not Available by Mail Service, ^ =Drug may be available for up to a 30-day supply only 7

8 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: ). WellCare (HMO) is a Medicare Advantage organization with a Medicare contract. Enrollment in WellCare (HMO) depends on contract renewal. WellCare (HMO SNP) is a Medicare Advantage organization with a Medicare contract and a contract with the state Medicaid program. Enrollment in WellCare (HMO SNP) depends on contract renewal. Notice: TennCare is not responsible for payment for these benefits, except for appropriate cost-sharing amounts. TennCare is not responsible for guaranteeing the availability or quality of these benefits. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. 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. 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. 14 pt NA036143_WCM_INS_MLT_NA_11_16 NA7WCMINS79943M P.O. Box Tampa, FL

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