WellCare Classic Formulary Addendum The following medications have been added to the WellCare formulary as of September 2009. Drug Name Therapeutic Class Drug Tier Requirements/Limits Changes Made acetazolamide 500mg cp12 Diuretics AFINITOR 10MG Molecular Target Specialty AFINITOR 5MG Molecular Target Specialty ALBENZA 200MG Anthelmintics ALOCRIL 2% SOLN Ophthalmic Anti-allergy amantadine hcl 50mg/5ml syrp Antiparkinson anaspaz 0.125mg Antispasmodics, Gastrointestinal APTIVUS 100MG/ML SOLN atropine sulfate 1% oint atropine sulfate 0.4mg/ml atropine sulfate 1% atropine sulfate 1mg/ml AZASITE 1% SOLN BANZEL 200MG Anti-HIV, Protease Ophthalmic, Antispasmodics, Gastrointestinal Ophthalmic, Antispasmodics, Gastrointestinal Macrolides Anticonvulsants, Page 1 of 17
BANZEL 400MG bicalutamide 50mg BICILLIN C-R 300000UNIT/ML; 300000UNIT/ML SUSP BICILLIN C-R 900000UNIT/ML; 300000UNIT/ML SUSP BICILLIN L-A 1200000UNIT/2ML SUSP BICILLIN L-A 2400000UNIT/4ML SUSP BICILLIN L-A 600000UNIT/ML SUSP BONIVA 150MG BONIVA 2.5MG BONIVA 3MG/3ML KIT budeprion xl 150mg tb24 calcitonin-salmon 200unit/act calcium acetate 667mg caps CEFAZOLIN SODIUM/DEXTROSE 1GM; 4% SOLR cefdinir 125mg/5ml susr cefdinir 250mg/5ml susr Anticonvulsants, Antiandrogens Beta-lactam, Penicillins Beta-lactam, Penicillins Beta-lactam, Penicillins Beta-lactam, Penicillins Beta-lactam, Penicillins Metabolic Bone Disease Metabolic Bone Disease Metabolic Bone Disease Antidepressants, Metabolic Bone Disease Phosphate Binders Beta-lactam, Cephalosporins Beta-lactam, Cephalosporins Beta-lactam, Cephalosporins Page 2 of 17
cefdinir 300mg caps Beta-lactam, Cephalosporins chlorthalidone 100mg Diuretics ciclopirox 0.77% gel Antifungals colestipol hcl for oral suspension 5gm pack Dyslipidemics CRESTOR 10MG Dyslipidemics CRESTOR 20MG Dyslipidemics CRESTOR 40MG Dyslipidemics CRESTOR 5MG Dyslipidemics cyclophosphamide 1gm solr Alkylating cyclophosphamide 25mg Alkylating cyclophosphamide 2gm solr Alkylating cyclophosphamide 500mg solr Alkylating cyclophosphamide 50mg Alkylating CYTOXAN 1GM Alkylating SOLR CYTOXAN 2GM SOLR CYTOXAN 500MG SOLR didanosine 125mg cpdr didanosine 200mg cpdr Alkylating Alkylating Anti-HIV, Nucleoside Transcriptase Anti-HIV, Nucleoside Transcriptase Page 3 of 17
didanosine 250mg cpdr Anti-HIV, Nucleoside Transcriptase didanosine 400mg cpdr diltzac 120mg cp24 diltzac 180mg cp24 diltzac 240mg cp24 diltzac 300mg cp24 diltzac 360mg cp24 divalproex sodium 125mg cpsp divalproex sodium 125mg tbec divalproex sodium 250mg tb24 divalproex sodium 250mg tbec divalproex sodium 500mg tb24 divalproex sodium 500mg tbec dorzolamide hcl 2% dorzolamide hcl/timolol maleate 2%; 0.5% doxycycline monohydrate 25mg/5ml susr Anti-HIV, Nucleoside Transcriptase Calcium Channel Blocking Calcium Channel Blocking Calcium Channel Blocking Calcium Channel Blocking Calcium Channel Blocking (GABA) Augmenting (GABA) Augmenting (GABA) Augmenting (GABA) Augmenting (GABA) Augmenting (GABA) Augmenting Ophthalmic Antiglaucoma Ophthalmic Antiglaucoma Tetracyclines eliphos 667mg Electrolytes/Minerals endocet 325mg; 10mg Opioid Analgesics Page 4 of 17
endocet 325mg; 7.5mg endocet 500mg; 7.5mg endocet 650mg; 10mg FIRMAGON 120MG SOLR FIRMAGON 80MG SOLR FLOVENT DISKUS 100MCG/BLIST AEPB FLOVENT DISKUS 250MCG/BLIST AEPB FLOVENT DISKUS 50MCG/BLIST AEPB FORTEO 600MCG/2.4ML SOLN galantamine hydrobromide 12mg galantamine hydrobromide 16mg cp24 galantamine hydrobromide 24mg cp24 galantamine hydrobromide 4mg galantamine hydrobromide 8mg cp24 galantamine hydrobromide 8mg gavilyte-g 236gm; 2.97gm; 6.74gm; 5.86gm; 22.74gm solr Opioid Analgesics Opioid Analgesics Opioid Analgesics Antineoplastics, Antineoplastics, Anti-inflammatories, Inhaled Corticosteroids Anti-inflammatories, Inhaled Corticosteroids Anti-inflammatories, Inhaled Corticosteroids Metabolic Bone Disease, QL, QL Specialty Cholinesterase Cholinesterase Cholinesterase Cholinesterase Cholinesterase Cholinesterase Gastrointestinal, Page 5 of 17
generlac 10gm/15ml HALFLYTELY BOWEL PREP 5MG; 210GM; 0.74GM; 2.86GM; 5.6GM KIT HALFLYTELY BOWEL PREP/FLAVOR CKS 5MG; 210GM; 0.74GM; 2.86GM; 5.6GM KIT HUMALOG KWIKPEN 100UNIT/ML SOLN HUMALOG MIX 50/50 50%; 50% SUSP HUMALOG MIX 50/50 KWIKPEN 50%; 50% SUSP HUMALOG MIX 50/50 PEN 50%; 50% SUSP HUMALOG MIX 75/25 KWIKPEN 25%; 75% SUSP HUMULIN R U-500 (CONCENTRATED) 500UNIT/ML SOLN hydrocodone / acetaminophen 325mg; 10mg hydrocodone / acetaminophen 325mg; 5mg hydrocodone / acetaminophen 325mg; 7.5mg hydrocodone / acetaminophen 500mg; 10mg hyoscyamine 0.15mg Gastrointestinal, Gastrointestinal, Gastrointestinal, Opioid Analgesics QL Opioid Analgesics QL Opioid Analgesics QL Opioid Analgesics QL Antispasmodics, Gastrointestinal Page 6 of 17
hyoscyamine sulfate 0.125mg subl hyoscyamine sulfate 0.125mg/5ml elix hyoscyamine sulfate ir/ hyoscyamine sulfate sr 0.375mg tbcr hyosyne 0.125mg/ml ipratropium bromide/ albuterol sulfate 2.5mg/3ml; 0.5mg/3ml KAYEXALATE 0 POWD ketoprofen er 200mg cp24 Antispasmodics, Gastrointestinal Antispasmodics, Gastrointestinal Antispasmodics, Gastrointestinal Antispasmodics, Gastrointestinal Bronchodilators, Sympathomimetic Antidotes Nonsteroidal Antiinflammatory Drugs QL kionex 0 powd Antidotes klor-con 20meq pack Electrolytes/Minerals LANOXIN 0.125MG LANOXIN 0.1MG/ML SOLN LANOXIN 0.25MG LANOXIN 0.25MG/ML SOLN LANTUS FOR OPTICLIK 100UNIT/ML SOLN LEVEMIR 100UNIT/ML SOLN LEVEMIR FLEXPEN 100UNIT/ML SOLN levetiracetam 1000mg levetiracetam 100mg/ml Cardiovascular, Cardiovascular, Cardiovascular, Cardiovascular, QL QL Anticonvulsants, Anticonvulsants, Page 7 of 17
levetiracetam 250mg levetiracetam 500mg levetiracetam 750mg liothyronine sodium 25mcg liothyronine sodium 50mcg liothyronine sodium 5mcg MAXIPIME 1GM SOLR METHITEST 10MG micronized colestipol hcl 1gm MIRAPEX 0.75MG morphine sulfate 10mg/5ml morphine sulfate 20mg/5ml mycophenolate mofetil 250mg caps mycophenolate mofetil 500mg next choice 0.75mg nimodipine 30mg caps NITRO-BID 2% OINT NORCE CR 100MG CP12 Anticonvulsants, Anticonvulsants, Anticonvulsants, Hormonal, Stimulant/ Replacement/ Modifying (Thyroid) Hormonal, Stimulant/ Replacement/ Modifying (Thyroid) Hormonal, Stimulant/ Replacement/ Modifying (Thyroid) Beta-lactam, Cephalosporins Androgens Dyslipidemics Antiparkinson Opioid Analgesics Opioid Analgesics Immune Suppressants Immune Suppressants Progestins QL Calcium Channel Blocking Vasodilators Antiarrhythmics Page 8 of 17
ofloxacin 0.3% Quinolones omeprazole 40mg cpdr Proton Pump oxycodone / acetaminophen 325mg; 2.5mg oxycodone / acetaminophen 650mg; 10mg oxycodone hcl 10mg oxycodone hcl 20mg NCREASE MT 10 30000UNIT; 10000UNIT; 30000UNIT CPEP NCREASE MT 16 48000UNIT; 16000UNIT; 48000UNIT CPEP NCREASE MT 20 56000UNIT; 20000UNIT; 44000UNIT CPEP NCREASE MT 4 12000UNIT; 4000UNIT; 12000UNIT CPEP pancrelipase 20000unit; 4500unit; 25000unit cpep pancrelipase 30000unit; 8000unit; 30000unit REGORIC 2MG/5ML TINC phenazopyridine hcl 100mg phenazopyridine hcl 200mg Opioid Analgesics Opioid Analgesics Opioid Analgesics Opioid Analgesics Enzyme Replacements/ Modifiers Enzyme Replacements/ Modifiers Enzyme Replacements/ Modifiers Enzyme Replacements/ Modifiers Enzyme Replacements/ Modifiers Enzyme Replacements/ Modifiers Gastrointestinal, Local Anesthetics Local Anesthetics Page 9 of 17
polyethylene glycol 3350 0 powd PRANDIMET 500MG; 1MG PRANDIMET 500MG; 2MG PREZISTA 150MG PREZISTA 400MG PREZISTA 600MG PREZISTA 75MG PRISTIQ 100MG TB24 PRISTIQ 50MG TB24 protriptyline hcl 10mg protriptyline hcl 5mg ramipril 1.25mg caps ramipril 10mg caps ramipril 2.5mg caps ramipril 5mg caps reprexain 10mg; 200mg reserpine 0.1mg Gastrointestinal, Antidiabetic Antidiabetic Anti-HIV, Protease Anti-HIV, Protease Anti-HIV, Protease Anti-HIV, Protease Serotonin/ Norepinephrine Reuptake Serotonin/ Norepinephrine Reuptake Specialty Specialty Specialty Tricyclics Tricyclics Opioid Analgesics QL Alpha-adrenergic Blocking Page 10 of 17
risperidone 1mg/ml risperidone m-tab 0.5mg risperidone m-tab 1mg risperidone m-tab 2mg risperidone m-tab 3mg risperidone m-tab 4mg risperidone odt 0.25mg risperidone odt 0.5mg risperidone odt 2mg risperidone odt 3mg risperidone odt 4mg SEROQUEL XR 150MG TB24 SEROQUEL XR 50MG TB24 SPRYCEL 100MG stavudine 15mg caps stavudine 1mg/ml solr stavudine 20mg caps Atypicals QL Atypicals QL Atypicals QL Atypicals QL Atypicals QL Atypicals QL Atypicals QL Atypicals QL Atypicals QL Atypicals QL Atypicals QL Atypicals Atypicals QL QL Molecular Target Specialty Anti-HIV, Nucleoside Transcriptase Anti-HIV, Nucleoside Transcriptase Anti-HIV, Nucleoside Transcriptase Page 11 of 17
stavudine 30mg caps stavudine 40mg caps STAVZOR 125MG CPDR STAVZOR 250MG CPDR STAVZOR 500MG CPDR sulfacetamide sodium 10% sumatriptan 20mg/act sumatriptan 5mg/act 100mg 25mg 4mg/0.5ml kit 4mg/0.5ml 50mg 6mg/0.5ml kit 6mg/0.5ml refill 4mg/0.5ml kit refill 6mg/0.5ml kit Anti-HIV, Nucleoside Transcriptase Anti-HIV, Nucleoside Transcriptase (GABA) Augmenting (GABA) Augmenting (GABA) Augmenting Sulfonamides Abortive QL Abortive QL Abortive QL Abortive QL Abortive Abortive Abortive QL Abortive Abortive Abortive Abortive Page 12 of 17
TEKTURNA 150MG TEKTURNA 300MG TEKTURNA HCT 150MG; 12.5MG TEKTURNA HCT 150MG; 25MG TEKTURNA HCT 300MG; 12.5MG TEKTURNA HCT 300MG; 25MG tobramycin / dexamethasone 0.1%; 0.3% susp Ophthalmic Antiinflammatories ST ST ST ST ST ST topiramate 100mg Glutamate Reducing topiramate 15mg cpsp Glutamate Reducing topiramate 200mg Glutamate Reducing topiramate 25mg cpsp Glutamate Reducing topiramate 25mg Glutamate Reducing topiramate 50mg Glutamate Reducing tri-lo-sprintec 0; 0 Estrogens trimipramine maleate 50mg caps Tricyclics urea 40% crea Dermatological urealac 50% crea Dermatological URECHOLINE 10MG URECHOLINE 25MG URECHOLINE 50MG URECHOLINE 5MG Genitourinary, Genitourinary, Genitourinary, Genitourinary, Page 13 of 17
VIMT 100MG VIMT 150MG VIMT 200MG VIMT 200MG/20ML SOLN VIMT 50MG VOLTAREN 1% GEL XIBROM 0.09% SOLN Anticonvulsants, Anticonvulsants, Anticonvulsants, Anticonvulsants, Anticonvulsants, Nonsteroidal Antiinflammatory Drugs Ophthalmic Antiinflammatories QL The following medications have been removed from the WellCare formulary as of September 2009. Drug Name Therapeutic Class Drug Tier Requirements/Limits Changes Made ketotifen fumarate 0.025% MINTEZOL 500MG CHEW MINTEZOL 500MG/5ML SUSP Ophthalmic Anti-allergy Anthelmintics Anthelmintics Drug Removed Drug Removed Drug Removed The tier levels or requirements/limits on the following medications have changed as of September 2009. Drug Name Therapeutic Class Drug Tier Requirements/Limits Changes Made amikacin sulfate 250mg/ml amikacin sulfate 50mg/ml balsalazide disodium 750mg caps Aminoglycosides Removed Aminoglycosides Removed Salicylates Removed Page 14 of 17
desmopressin acetate 0.01% desmopressin acetate 0.1mg desmopressin acetate 0.2mg desmopressin acetate 4mcg/ml FEMARA 2.5MG fluconazole in dextrose 0; 400mg/200ml fluconazole in nacl 200mg/100ml; 0.9% fluconazole in nacl 400mg/200ml; 0.9% MATULANE 50MG CAPS nalbuphine hcl 10mg/ml nalbuphine hcl 20mg/ml NILANDRON 150MG terbinafine hcl 250mg ZOLINZA 100MG CAPS ondansetron hcl 4mg ondansetron hcl 8mg Hormonal, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal, Stimulant/ Replacement/ Modifying (Pituitary) Aromatase, 3rd Generation QL Removed Removed Removed QL Removed Removed Antifungals Removed Antifungals Removed Antifungals Removed Alkylating Removed Opioid Analgesics Removed Opioid Analgesics Removed Antiandrogens Removed Antifungals Removed Antineoplastics, Specialty Removed Antiemetics QL QL Increased Antiemetics QL QL Increased Page 15 of 17
risperidone 0.25mg Atypicals QL QL Increased risperidone 0.5mg Atypicals QL QL Increased risperidone 1mg Atypicals QL QL Increased risperidone 2mg Atypicals QL QL Increased risperidone 3mg Atypicals QL QL Increased risperidone 4mg Atypicals QL QL Increased ZYVOX 600MG Antibacterials, Specialty, QL QL Increased fluconazole 150mg JANUMET 1000MG; 50MG JANUMET 500MG; 50MG JANUVIA 100MG JANUVIA 25MG JANUVIA 50MG ARIXTRA 2.5MG/0.5ML SOLN ATROVENT HFA 17MCG/ACT AERS NIACOR 500MG VYTORIN 10MG; 10MG VYTORIN 10MG; 20MG VYTORIN 10MG; 40MG VYTORIN 10MG; 80MG Antifungals QL Removed Antidiabetic Antidiabetic Antidiabetic Antidiabetic Antidiabetic Anticoagulants Bronchodilators, Anticholinergic Dyslipidemics Dyslipidemics Dyslipidemics Dyslipidemics Dyslipidemics QL ST Removed ST Removed ST Removed ST Removed ST Removed Tier Changed to Tier Changed to Tier Changed to Tier Changed to Tier Changed to Tier Changed to Tier Changed to Page 16 of 17
If you need more information, call us today! 1-888-517-5252 TTY/TDD: 1-888-816-5252 Monday Sunday, 7am to 2am Eastern WellCare is a prescription drug plan with a Medicare contract. WellCare uses a formulary. You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048. You can also call the Social Security Administration at 1-800-772-1213 (TTY/TDD: 1-800-325-0778) between 7am and 7pm Monday through Friday, or call your state Medicaid office. S5967_NA09250_PDP_FOR_ENG (11/08/2008) Last Updated: 09/01/2009 WellCare 2009 NA_CLA_09_09 Page 17 of 17