PDP Classic Formulary Addendum The following medications have been added to the WellCare formulary as of March 2009. Drug Name Therapeutic Class Drug Tier Requirements/Limits Changes Made acetazolamide 500mg cp12 ALBENZA 200MG ALOCRIL 2% SOLN amantadine hcl 50mg/5ml syrp atropine sulfate 0.4mg/ml Diuretics Anthelmintics Ophthalmic Anti-allergy Agents Antiparkinson Agents atropine sulfate 1% oint Ophthalmic Agents, Other atropine sulfate 1% Ophthalmic Agents, Other atropine sulfate 1mg/ml AZASITE 1% SOLN Macrolides BANZEL 200MG Anticonvulsants, Other Non- BANZEL 400MG Anticonvulsants, Other Non- BICILLIN C-R 300000UNIT/ML; 300000UNIT/ML SUSP Beta-lactam, Penicillins BICILLIN C-R 900000UNIT/ML; 300000UNIT/ML SUSP Beta-lactam, Penicillins Page 1 of 12
BICILLIN L-A 1200000UNIT/2ML SUSP BICILLIN L-A 2400000UNIT/4ML SUSP Beta-lactam, Penicillins Beta-lactam, Penicillins BICILLIN L-A 600000UNIT/ML SUSP Beta-lactam, Penicillins BONIVA 150MG Metabolic Bone Disease Agents BONIVA 2.5MG Metabolic Bone Disease Agents BONIVA 3MG/3ML KIT Metabolic Bone Disease Agents Non- budeprion xl 150mg tb24 Antidepressants, Other calcitonin-salmon 200unit/act calcium acetate 667mg caps Metabolic Bone Disease Agents Phosphate Binders CEFAZOLIN SODIUM/DEXTROSE 1GM; 4% SOLR Beta-lactam, Cephalosporins cefdinir 125mg/5ml susr Beta-lactam, Cephalosporins cefdinir 250mg/5ml susr Beta-lactam, Cephalosporins cefdinir 300mg caps Beta-lactam, Cephalosporins chlorthalidone 100mg Diuretics ciclopirox 0.77% gel Antifungals CRESTOR 10MG CRESTOR 20MG CRESTOR 40MG CRESTOR 5MG Page 2 of 12
cyclophosphamide 1gm solr cyclophosphamide 25mg cyclophosphamide 2gm solr cyclophosphamide 500mg solr cyclophosphamide 50mg Alkylating Agents Alkylating Agents Alkylating Agents Alkylating Agents Alkylating Agents CYTOXAN 1GM SOLR Alkylating Agents Non- CYTOXAN 2GM SOLR Alkylating Agents Non- CYTOXAN 500MG SOLR Alkylating Agents Non- didanosine 125mg cpdr didanosine 200mg cpdr didanosine 250mg cpdr didanosine 400mg cpdr divalproex sodium 125mg cpsp divalproex sodium 125mg tbec divalproex sodium 250mg tb24 divalproex sodium 250mg tbec Page 3 of 12
divalproex sodium 500mg tb24 divalproex sodium 500mg tbec doxycycline monohydrate 25mg/5ml susr endocet 650mg; 10mg 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 generlac 10gm/15ml Tetracyclines Opioid Analgesics Anti-inflammatories, Inhaled Corticosteroids Anti-inflammatories, Inhaled Corticosteroids Anti-inflammatories, Inhaled Corticosteroids Metabolic Bone Disease Agents Specialty Cholinesterase Inhibitors Cholinesterase Inhibitors Cholinesterase Inhibitors Cholinesterase Inhibitors Cholinesterase Inhibitors Cholinesterase Inhibitors Agents, Other HALFLYTELY BOWEL PREP 5MG; 210GM; 0.74GM; 2.86GM; 5.6GM KIT Agents, Other Page 4 of 12
HALFLYTELY BOWEL PREP/FLAVOR CKS 5MG; 210GM; 0.74GM; 2.86GM; 5.6GM KIT Agents, Other 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 hyoscyamine 0.15mg hyoscyamine sulfate 0.125mg hyoscyamine sulfate 0.125mg tbdp hyoscyamine sulfate 0.125mg/5ml elix hyoscyamine sulfate er 0.375mg cp12 hyoscyamine sulfate er 0.375mg tb12 hyoscyamine sulfate ir/hyoscyamine sulfate sr 0.375mg tbcr hyoscyamine sulfate sl 0.125mg subl Page 5 of 12
hyosyne 0.125mg/ml 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 levetiracetam 250mg levetiracetam 500mg levetiracetam 750mg levetiracetam 1000mg levetiracetam 100mg/ml Cardiovascular Agents, Other Cardiovascular Agents, Other Cardiovascular Agents, Other Cardiovascular Agents, Other Anticonvulsants, Other Anticonvulsants, Other Anticonvulsants, Other Anticonvulsants, Other Anticonvulsants, Other MAXIPIME 1GM SOLR Beta-lactam, Cephalosporins MIRAPEX 0.75MG morphine sulfate 10mg/5ml morphine sulfate 20mg/5ml Antiparkinson Agents Opioid Analgesics Opioid Analgesics omeprazole 40mg cpdr Proton Pump Inhibitors oxycodone / acetaminophen 325mg; 2.5mg Opioid Analgesics Page 6 of 12
oxycodone / acetaminophen 650mg; 10mg oxycodone hcl 10mg oxycodone hcl 20mg Opioid Analgesics Opioid Analgesics Opioid Analgesics NCREASE MT 10 30000UNIT; 10000UNIT; 30000UNIT CPEP Enzyme Replacements/ Modifiers Non- NCREASE MT 16 48000UNIT; 16000UNIT; 48000UNIT CPEP Enzyme Replacements/ Modifiers Non- NCREASE MT 20 56000UNIT; 20000UNIT; 44000UNIT CPEP Enzyme Replacements/ Modifiers Non- NCREASE MT 4 12000UNIT; 4000UNIT; 12000UNIT CPEP Enzyme Replacements/ Modifiers Non- REGORIC 2MG/5ML TINC phenazopyridine hcl 100mg phenazopyridine hcl 200mg polyethylene glycol 3350 0 powd PRANDIMET 500MG; 1MG PRANDIMET 500MG; 2MG PREZISTA 400MG PREZISTA 600MG PREZISTA 75MG Agents, Other Local Anesthetics Local Anesthetics Agents, Other Anti-HIV Agents, Protease Inhibitors Anti-HIV Agents, Protease Inhibitors Anti-HIV Agents, Protease Inhibitors Specialty Specialty Page 7 of 12
PRISTIQ 100MG TB24 PRISTIQ 50MG TB24 protriptyline hcl 10mg Serotonin/ Norepinephrine Reuptake Inhibitors Serotonin/ Norepinephrine Reuptake Inhibitors Non- Non- Tricyclics protriptyline hcl 5mg Tricyclics ramipril 1.25mg caps ramipril 10mg caps ramipril 2.5mg caps ramipril 5mg caps reprexain 10mg; 200mg Renin-angiotensin-aldosterone System Inhibitors Renin-angiotensin-aldosterone System Inhibitors Renin-angiotensin-aldosterone System Inhibitors Renin-angiotensin-aldosterone System Inhibitors Opioid Analgesics QL risperidone 1mg/ml Atypicals QL SEROQUEL XR 150MG TB24 Atypicals QL SEROQUEL XR 50MG TB24 Atypicals QL stavudine 15mg caps stavudine 20mg caps stavudine 30mg caps stavudine 40mg caps STAVZOR 125MG CPDR Non- Page 8 of 12
STAVZOR 250MG CPDR STAVZOR 500MG CPDR sulfacetamide sodium 10% sumatriptan 20mg/act Non- Non- Sulfonamides Abortive QL sumatriptan 5mg/act Abortive QL 100mg 25mg 4mg/0.5ml kit 50mg 6mg/0.5ml kit 6mg/0.5ml refill 4mg/0.5ml kit refill 6mg/0.5ml kit Abortive QL Abortive QL Abortive Abortive QL Abortive Abortive Abortive Abortive tobramycin / dexamethasone 0.1%; 0.3% susp Ophthalmic Anti-inflammatories URECHOLINE 10MG Genitourinary Agents, Other URECHOLINE 25MG Genitourinary Agents, Other URECHOLINE 50MG Genitourinary Agents, Other URECHOLINE 5MG Genitourinary Agents, Other Page 9 of 12
VOLTAREN 1% GEL Nonsteroidal Anti-inflammatory Drugs The following medications have been removed from the WellCare formulary as of March 2009. Drug Name Therapeutic Class Drug Tier Requirements/Limits Changes Made ketotifen fumarate 0.025% Ophthalmic Anti-allergy Agents Drug Removed MINTEZOL 500MG CHEW Anthelmintics Drug Removed MINTEZOL 500MG/5ML SUSP Anthelmintics Drug Removed The tier levels or requirements/limits on the following medications have changed as of March 2009. Drug Name Therapeutic Class Drug Tier Requirements/Limits Changes Made amikacin sulfate 250mg/ml amikacin sulfate 50mg/ml desmopressin acetate 0.01% desmopressin acetate 0.1mg desmopressin acetate 0.2mg desmopressin acetate 4mcg/ml fluconazole in dextrose 0; 400mg/200ml fluconazole in nacl 200mg/100ml; 0.9% fluconazole in nacl 400mg/200ml; 0.9% Aminoglycosides Removed Aminoglycosides Removed Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) QL Removed Removed Removed QL Removed Antifungals Removed Antifungals Removed Antifungals Removed Page 10 of 12
MATULANE 50MG CAPS Alkylating Agents Non- Removed nalbuphine hcl 10mg/ml nalbuphine hcl 20mg/ml Opioid Analgesics Removed Opioid Analgesics Removed NILANDRON 150MG Antiandrogens Non- Removed terbinafine hcl 250mg Antifungals Removed ZOLINZA 100MG CAPS Antineoplastics, Other Specialty Removed fluconazole 150mg Antifungals QL Decreased ondansetron hcl 4mg Antiemetics QL QL Increased ondansetron hcl 8mg Antiemetics QL QL Increased 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 JANUMET 1000MG; 50MG Non- ST Removed JANUMET 500MG; 50MG Non- ST Removed JANUVIA 100MG Non- ST Removed JANUVIA 25MG Non- ST Removed JANUVIA 50MG Non- ST Removed ATROVENT HFA 17MCG/ACT AERS Bronchodilators, Anticholinergic Tier Changed to NIACOR 500MG Tier Changed to Page 11 of 12
VYTORIN 10MG; 10MG Tier Changed to VYTORIN 10MG; 20MG Tier Changed to VYTORIN 10MG; 40MG Tier Changed to VYTORIN 10MG; 80MG Tier Changed to 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: 03/01/2009 WellCare 2008 NA_02_09 Page 12 of 12