2016 formulary addendum notice of change€¦ · alternative drug(s): taztia xt capsule extended...
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2016 FORMULARY ADDENDUM NOTICE OF CHANGE
(MEDICARE ADVANTAGE PLANS) Easy Choice Best Plan (HMO)
H5087-005
This is a listing of the changes that have occurred in our formulary Please carefully review these changes and call Easy Choice 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 wwweasychoicehealthplancom 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_07 CMS Approved 12092014 EC6V07FOR79429E_1116 copyWellCare 2016 NA_11_16
Fomulary File 16186
Effective Date412016 Formulary Version 9Medication Name Change Description
AVODART CAPSULE 05 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) dutasteride capsule 05 MG capsule on Tier 2
CEDAX SUSPENSION RECONSTITUTED 90 MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) ceftibuten suspension reconstituted 180 MG5ML on Tier 2
foscarnet sodium intravenous solution 24 mgml
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) valganciclovir hcl tablet 450 MG on Tier 5^
GLEEVEC TABLET 100 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) imatinib mesylate tablet 100 MG on Tier 5^ with PA
GLEEVEC TABLET 400 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) imatinib mesylate tablet 400 MG on Tier 5^ with PA
JALYN CAPSULE 05-04 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) dutasteride-tamsulosin hcl capsule 05-04 MG on Tier 2
LIPTRUZET TABLET 10-10 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) VYTORIN TABLET on Tier 4 with ST
LIPTRUZET TABLET 10-20 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) VYTORIN TABLET on Tier 4 with ST
2
Medication Name Change Description
LIPTRUZET TABLET 10-40 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) VYTORIN TABLET on Tier 4 with ST
LIPTRUZET TABLET 10-80 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) VYTORIN TABLET on Tier 4 with ST
MEGACE ES SUSPESION 625 MG5ML Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) megestrol acetate suspension 625 MG5ML on Tier 5^ with PA
NAMENDA SOLUTION 10MG5ML Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) memantine hcl solution 2 MGML on Tier 2 with PA
NAMENDA TABLET 10 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) memantine tablet 10 MG on Tier 2 with PA
NAMENDA TABLET 5 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) memantine tablet 5 MG on Tier 2 with PA
ORAP TABLET 1 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) pimozide tablet 1 MG on Tier 2
ORAP TABLET 2 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) pimozide tablet 2 MG on Tier 2
TARGRETIN CAPSULE 75 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) bexarotene capsule 75 MG on Tier 5^ with PA
XENAZINE TABLET 125 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) tetrabenazine tablet 125 MG on Tier 5^ with PA QL (240 tablets per 30 days)
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Medication Name Change Description
XENAZINE TABLET 25 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) tetrabenazine tablet 25 MG on Tier 5^ with PA QL (120 tablets per 30 days)
ZYVOX SUSPENSION RECONSTITUTED 100 MG5ML
Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) linezolid suspension reconstituted 100 MG5ML on Tier 5^
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC= Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
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Fomulary File 16186
Effective Date512016 Formulary Version 10Medication Name Change Description
ADRIAMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) doxorubicin hcl intravenous solution reconstituted 50 MG on Tier 2 with BD
AMPHOTEC INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) amphotericin b injection solution reconstituted 50 MG on Tier 2 with BD
AMPHOTEC INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) amphotericin b injection solution reconstituted 50 MG on Tier 2 with BD
APEXICON EXTERNAL OINTMENT 005 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) diflorasone diacetate external ointment 005 on Tier 2
ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 800 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG 500 MG on Tier 5^ with PA LA
AUVI-Q INJECTION 015 MG015ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 05012016 ALTERNATIVE DRUG(S) EPIPEN on Tier 3
AUVI-Q INJECTION 03 MG03ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 05012016 ALTERNATIVE DRUG(S) EPIPEN on Tier 3
diltzac capsule extended release 120 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 120 MG diltiazem hcl beads capsule extended release 120 MG on Tier 2
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Medication Name Change Description
diltzac capsule extended release 180 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 180 MG diltiazem hcl beads capsule extended release 180 MG on Tier 2
diltzac capsule extended release 240 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 240 MG diltiazem hcl beads capsule extended release 240 MG on Tier 2
diltzac capsule extended release 300 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 300 MG diltiazem hcl beads capsule extended release 300 MG on Tier 2
ENDODAN TABLET 48355-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) oxycodone-aspirin tablet 48355-325 MG on Tier 2 with QL (360 tablets per 30 days)
FACTIVE TABLET 320 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) levofloxacin tablet on Tier 1 with GC
FLAGYL TABLET EXTENDED RELEASE 750 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) metronidazole tablet on Tier 1 with GC
GLYCATE TABLET 15 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S)glycopyrrolate tablet on Tier 2
LACLOTION EXTERNAL LOTION 12 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) ammonium lactate external lotion 12 on Tier 2
levobunolol hcl ophthalmic solution 025
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) levobunolol hcl ophthalmic solution 05 on Tier 2
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Medication Name Change Description
lomustine capsule 10 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 10 MG on Tier 4
lomustine capsule 100 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 100 MG on Tier 4
lomustine capsule 40 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 40 MG on Tier 4
MY WAY TABLET 15 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) levonorgestrel tablet 15 MG on Tier 2
NEXT CHOICE ONE DOSE TABLET 15 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) levonorgestrel tablet 15 MG on Tier 2
SOLIA TABLET 015-30 MG-MCG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) cyred tablet apri tablet emoquette tablet reclipsen tablet on Tier 2
tobramycin sulfate in saline intravenous solution 08-09 mgml-
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) tobramycin sulfate injection solution 80 mg2ml on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC= Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
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Fomulary File 16186
Effective Date612016 Formulary Version 11Medication Name Change Description
TEVETEN HCT TABLET 600-125 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04082016 ALTERNATIVE DRUG(S) valsartan-hydrochlorothiazide tablet on Tier 1 with GC
TEVETEN HCT TABLET 600-25 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04082016 ALTERNATIVE DRUG(S) valsartan-hydrochlorothiazide tablet on Tier 1 with GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
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Fomulary File 16186
Effective Date712016
Medication Name Change Description
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ALSUMA SUBCUTANEOUS 6 MG05ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) sumatriptan succinate subcutaneous solution 6 MG05ML on Tier 2 with QL (6 ML per 30 days)
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
9
Formulary Version 12
Medication Name Change Description
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
10
Fomulary File 16186
Effective Date812016 Formulary Version 13Medication Name Change Description
FLO-PRED SUSPENSION 167 (15 BASE) MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) prednisolone solution 15 mg5ml on Tier 1 with GC
ZAZOLE VAGINAL CREAM 04 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) terconazole vaginal cream 04 on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
11
Fomulary File 16186
Effective Date912016 Formulary Version 14Medication Name Change Description
cefuroxime sodium intravenous solution reconstituted 75 gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S) cefuroxime sodium injection solution reconstituted 75 GM on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
12
Fomulary File 16186
Effective Date1112016 Formulary Version 16Medication Name Change Description
ALTABAX EXTERNAL OINTMENT 1 Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) mupirocin external ointment 2 on Tier 1 with GC
ampicillin-sulbactam sodium intravenous solution reconstituted 15 (1-05) gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) ampicillin-sulbactam sodium injection solution reconstituted 15 (1-05) GM on Tier 2
heparin sodium (porcine) intravenous solution 2000 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
heparin sodium (porcine) intravenous solution 2500 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
ROXICET ORAL SOLUTION 5-325 MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral solution 5-325 MG5ML on Tier 2 with QL (1800 ML per 30 days)
ROXICET ORAL TABLET 5-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral tablet 5-325 MG on Tier 2 with QL (360 tablets per 30 days)
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
13
This information is available for free in other languages Please call our Customer Service number at 1-866-999-3945 MondayndashFriday 8 am to 8 pm Between October 1 and February 14 representatives are available MondayndashSunday 8 am to 8 pm TTY users should call 1-800-735-2929
Esta informacioacuten estaacute disponible gratis en otros idiomas Por favor llame a nuestro nuacutemero de Servicio al Cliente al 1-866-999-3945 de lunes a viernes de 8 am a 8 pm Entre el 1 de octubre y el 14 de febrero los representantes estaacuten disponibles de lunes a domingo de 8 am a 8 pm Los usuarios de TTY deben llamar al 1-800-735-2929
Easy Choice Health Plan (HMO) a WellCare company is a Medicare Advantage organization with a Medicare contract Enrollment in Easy Choice (HMO) depends on contract renewal This information is not a complete description of benefits Contact the plan for more information Limitations co-payments and restrictions may apply Benefits premiums andor co-paymentscoinsurance
may change on January 1 of each year The formulary pharmacy network andor provider network may change at any time You will receive notice when necessary Easy Choice uses a formulary Please contact Easy Choice for details
PO Box 31389 | Tampa FL 33631-3389 wwweasychoicehealthplancom 79
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Fomulary File 16186
Effective Date412016 Formulary Version 9Medication Name Change Description
AVODART CAPSULE 05 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) dutasteride capsule 05 MG capsule on Tier 2
CEDAX SUSPENSION RECONSTITUTED 90 MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) ceftibuten suspension reconstituted 180 MG5ML on Tier 2
foscarnet sodium intravenous solution 24 mgml
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) valganciclovir hcl tablet 450 MG on Tier 5^
GLEEVEC TABLET 100 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) imatinib mesylate tablet 100 MG on Tier 5^ with PA
GLEEVEC TABLET 400 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) imatinib mesylate tablet 400 MG on Tier 5^ with PA
JALYN CAPSULE 05-04 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) dutasteride-tamsulosin hcl capsule 05-04 MG on Tier 2
LIPTRUZET TABLET 10-10 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) VYTORIN TABLET on Tier 4 with ST
LIPTRUZET TABLET 10-20 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) VYTORIN TABLET on Tier 4 with ST
2
Medication Name Change Description
LIPTRUZET TABLET 10-40 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) VYTORIN TABLET on Tier 4 with ST
LIPTRUZET TABLET 10-80 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) VYTORIN TABLET on Tier 4 with ST
MEGACE ES SUSPESION 625 MG5ML Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) megestrol acetate suspension 625 MG5ML on Tier 5^ with PA
NAMENDA SOLUTION 10MG5ML Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) memantine hcl solution 2 MGML on Tier 2 with PA
NAMENDA TABLET 10 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) memantine tablet 10 MG on Tier 2 with PA
NAMENDA TABLET 5 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) memantine tablet 5 MG on Tier 2 with PA
ORAP TABLET 1 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) pimozide tablet 1 MG on Tier 2
ORAP TABLET 2 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) pimozide tablet 2 MG on Tier 2
TARGRETIN CAPSULE 75 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) bexarotene capsule 75 MG on Tier 5^ with PA
XENAZINE TABLET 125 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) tetrabenazine tablet 125 MG on Tier 5^ with PA QL (240 tablets per 30 days)
3
Medication Name Change Description
XENAZINE TABLET 25 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) tetrabenazine tablet 25 MG on Tier 5^ with PA QL (120 tablets per 30 days)
ZYVOX SUSPENSION RECONSTITUTED 100 MG5ML
Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) linezolid suspension reconstituted 100 MG5ML on Tier 5^
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC= Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
4
Fomulary File 16186
Effective Date512016 Formulary Version 10Medication Name Change Description
ADRIAMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) doxorubicin hcl intravenous solution reconstituted 50 MG on Tier 2 with BD
AMPHOTEC INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) amphotericin b injection solution reconstituted 50 MG on Tier 2 with BD
AMPHOTEC INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) amphotericin b injection solution reconstituted 50 MG on Tier 2 with BD
APEXICON EXTERNAL OINTMENT 005 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) diflorasone diacetate external ointment 005 on Tier 2
ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 800 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG 500 MG on Tier 5^ with PA LA
AUVI-Q INJECTION 015 MG015ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 05012016 ALTERNATIVE DRUG(S) EPIPEN on Tier 3
AUVI-Q INJECTION 03 MG03ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 05012016 ALTERNATIVE DRUG(S) EPIPEN on Tier 3
diltzac capsule extended release 120 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 120 MG diltiazem hcl beads capsule extended release 120 MG on Tier 2
5
Medication Name Change Description
diltzac capsule extended release 180 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 180 MG diltiazem hcl beads capsule extended release 180 MG on Tier 2
diltzac capsule extended release 240 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 240 MG diltiazem hcl beads capsule extended release 240 MG on Tier 2
diltzac capsule extended release 300 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 300 MG diltiazem hcl beads capsule extended release 300 MG on Tier 2
ENDODAN TABLET 48355-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) oxycodone-aspirin tablet 48355-325 MG on Tier 2 with QL (360 tablets per 30 days)
FACTIVE TABLET 320 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) levofloxacin tablet on Tier 1 with GC
FLAGYL TABLET EXTENDED RELEASE 750 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) metronidazole tablet on Tier 1 with GC
GLYCATE TABLET 15 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S)glycopyrrolate tablet on Tier 2
LACLOTION EXTERNAL LOTION 12 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) ammonium lactate external lotion 12 on Tier 2
levobunolol hcl ophthalmic solution 025
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) levobunolol hcl ophthalmic solution 05 on Tier 2
6
Medication Name Change Description
lomustine capsule 10 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 10 MG on Tier 4
lomustine capsule 100 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 100 MG on Tier 4
lomustine capsule 40 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 40 MG on Tier 4
MY WAY TABLET 15 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) levonorgestrel tablet 15 MG on Tier 2
NEXT CHOICE ONE DOSE TABLET 15 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) levonorgestrel tablet 15 MG on Tier 2
SOLIA TABLET 015-30 MG-MCG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) cyred tablet apri tablet emoquette tablet reclipsen tablet on Tier 2
tobramycin sulfate in saline intravenous solution 08-09 mgml-
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) tobramycin sulfate injection solution 80 mg2ml on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC= Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
7
Fomulary File 16186
Effective Date612016 Formulary Version 11Medication Name Change Description
TEVETEN HCT TABLET 600-125 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04082016 ALTERNATIVE DRUG(S) valsartan-hydrochlorothiazide tablet on Tier 1 with GC
TEVETEN HCT TABLET 600-25 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04082016 ALTERNATIVE DRUG(S) valsartan-hydrochlorothiazide tablet on Tier 1 with GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
8
Fomulary File 16186
Effective Date712016
Medication Name Change Description
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ALSUMA SUBCUTANEOUS 6 MG05ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) sumatriptan succinate subcutaneous solution 6 MG05ML on Tier 2 with QL (6 ML per 30 days)
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
9
Formulary Version 12
Medication Name Change Description
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
10
Fomulary File 16186
Effective Date812016 Formulary Version 13Medication Name Change Description
FLO-PRED SUSPENSION 167 (15 BASE) MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) prednisolone solution 15 mg5ml on Tier 1 with GC
ZAZOLE VAGINAL CREAM 04 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) terconazole vaginal cream 04 on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
11
Fomulary File 16186
Effective Date912016 Formulary Version 14Medication Name Change Description
cefuroxime sodium intravenous solution reconstituted 75 gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S) cefuroxime sodium injection solution reconstituted 75 GM on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
12
Fomulary File 16186
Effective Date1112016 Formulary Version 16Medication Name Change Description
ALTABAX EXTERNAL OINTMENT 1 Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) mupirocin external ointment 2 on Tier 1 with GC
ampicillin-sulbactam sodium intravenous solution reconstituted 15 (1-05) gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) ampicillin-sulbactam sodium injection solution reconstituted 15 (1-05) GM on Tier 2
heparin sodium (porcine) intravenous solution 2000 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
heparin sodium (porcine) intravenous solution 2500 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
ROXICET ORAL SOLUTION 5-325 MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral solution 5-325 MG5ML on Tier 2 with QL (1800 ML per 30 days)
ROXICET ORAL TABLET 5-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral tablet 5-325 MG on Tier 2 with QL (360 tablets per 30 days)
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
13
This information is available for free in other languages Please call our Customer Service number at 1-866-999-3945 MondayndashFriday 8 am to 8 pm Between October 1 and February 14 representatives are available MondayndashSunday 8 am to 8 pm TTY users should call 1-800-735-2929
Esta informacioacuten estaacute disponible gratis en otros idiomas Por favor llame a nuestro nuacutemero de Servicio al Cliente al 1-866-999-3945 de lunes a viernes de 8 am a 8 pm Entre el 1 de octubre y el 14 de febrero los representantes estaacuten disponibles de lunes a domingo de 8 am a 8 pm Los usuarios de TTY deben llamar al 1-800-735-2929
Easy Choice Health Plan (HMO) a WellCare company is a Medicare Advantage organization with a Medicare contract Enrollment in Easy Choice (HMO) depends on contract renewal This information is not a complete description of benefits Contact the plan for more information Limitations co-payments and restrictions may apply Benefits premiums andor co-paymentscoinsurance
may change on January 1 of each year The formulary pharmacy network andor provider network may change at any time You will receive notice when necessary Easy Choice uses a formulary Please contact Easy Choice for details
PO Box 31389 | Tampa FL 33631-3389 wwweasychoicehealthplancom 79
429
Medication Name Change Description
LIPTRUZET TABLET 10-40 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) VYTORIN TABLET on Tier 4 with ST
LIPTRUZET TABLET 10-80 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) VYTORIN TABLET on Tier 4 with ST
MEGACE ES SUSPESION 625 MG5ML Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) megestrol acetate suspension 625 MG5ML on Tier 5^ with PA
NAMENDA SOLUTION 10MG5ML Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) memantine hcl solution 2 MGML on Tier 2 with PA
NAMENDA TABLET 10 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) memantine tablet 10 MG on Tier 2 with PA
NAMENDA TABLET 5 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) memantine tablet 5 MG on Tier 2 with PA
ORAP TABLET 1 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) pimozide tablet 1 MG on Tier 2
ORAP TABLET 2 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) pimozide tablet 2 MG on Tier 2
TARGRETIN CAPSULE 75 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) bexarotene capsule 75 MG on Tier 5^ with PA
XENAZINE TABLET 125 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) tetrabenazine tablet 125 MG on Tier 5^ with PA QL (240 tablets per 30 days)
3
Medication Name Change Description
XENAZINE TABLET 25 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) tetrabenazine tablet 25 MG on Tier 5^ with PA QL (120 tablets per 30 days)
ZYVOX SUSPENSION RECONSTITUTED 100 MG5ML
Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) linezolid suspension reconstituted 100 MG5ML on Tier 5^
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC= Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
4
Fomulary File 16186
Effective Date512016 Formulary Version 10Medication Name Change Description
ADRIAMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) doxorubicin hcl intravenous solution reconstituted 50 MG on Tier 2 with BD
AMPHOTEC INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) amphotericin b injection solution reconstituted 50 MG on Tier 2 with BD
AMPHOTEC INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) amphotericin b injection solution reconstituted 50 MG on Tier 2 with BD
APEXICON EXTERNAL OINTMENT 005 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) diflorasone diacetate external ointment 005 on Tier 2
ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 800 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG 500 MG on Tier 5^ with PA LA
AUVI-Q INJECTION 015 MG015ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 05012016 ALTERNATIVE DRUG(S) EPIPEN on Tier 3
AUVI-Q INJECTION 03 MG03ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 05012016 ALTERNATIVE DRUG(S) EPIPEN on Tier 3
diltzac capsule extended release 120 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 120 MG diltiazem hcl beads capsule extended release 120 MG on Tier 2
5
Medication Name Change Description
diltzac capsule extended release 180 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 180 MG diltiazem hcl beads capsule extended release 180 MG on Tier 2
diltzac capsule extended release 240 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 240 MG diltiazem hcl beads capsule extended release 240 MG on Tier 2
diltzac capsule extended release 300 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 300 MG diltiazem hcl beads capsule extended release 300 MG on Tier 2
ENDODAN TABLET 48355-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) oxycodone-aspirin tablet 48355-325 MG on Tier 2 with QL (360 tablets per 30 days)
FACTIVE TABLET 320 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) levofloxacin tablet on Tier 1 with GC
FLAGYL TABLET EXTENDED RELEASE 750 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) metronidazole tablet on Tier 1 with GC
GLYCATE TABLET 15 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S)glycopyrrolate tablet on Tier 2
LACLOTION EXTERNAL LOTION 12 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) ammonium lactate external lotion 12 on Tier 2
levobunolol hcl ophthalmic solution 025
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) levobunolol hcl ophthalmic solution 05 on Tier 2
6
Medication Name Change Description
lomustine capsule 10 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 10 MG on Tier 4
lomustine capsule 100 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 100 MG on Tier 4
lomustine capsule 40 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 40 MG on Tier 4
MY WAY TABLET 15 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) levonorgestrel tablet 15 MG on Tier 2
NEXT CHOICE ONE DOSE TABLET 15 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) levonorgestrel tablet 15 MG on Tier 2
SOLIA TABLET 015-30 MG-MCG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) cyred tablet apri tablet emoquette tablet reclipsen tablet on Tier 2
tobramycin sulfate in saline intravenous solution 08-09 mgml-
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) tobramycin sulfate injection solution 80 mg2ml on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC= Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
7
Fomulary File 16186
Effective Date612016 Formulary Version 11Medication Name Change Description
TEVETEN HCT TABLET 600-125 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04082016 ALTERNATIVE DRUG(S) valsartan-hydrochlorothiazide tablet on Tier 1 with GC
TEVETEN HCT TABLET 600-25 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04082016 ALTERNATIVE DRUG(S) valsartan-hydrochlorothiazide tablet on Tier 1 with GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
8
Fomulary File 16186
Effective Date712016
Medication Name Change Description
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ALSUMA SUBCUTANEOUS 6 MG05ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) sumatriptan succinate subcutaneous solution 6 MG05ML on Tier 2 with QL (6 ML per 30 days)
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
9
Formulary Version 12
Medication Name Change Description
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
10
Fomulary File 16186
Effective Date812016 Formulary Version 13Medication Name Change Description
FLO-PRED SUSPENSION 167 (15 BASE) MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) prednisolone solution 15 mg5ml on Tier 1 with GC
ZAZOLE VAGINAL CREAM 04 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) terconazole vaginal cream 04 on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
11
Fomulary File 16186
Effective Date912016 Formulary Version 14Medication Name Change Description
cefuroxime sodium intravenous solution reconstituted 75 gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S) cefuroxime sodium injection solution reconstituted 75 GM on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
12
Fomulary File 16186
Effective Date1112016 Formulary Version 16Medication Name Change Description
ALTABAX EXTERNAL OINTMENT 1 Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) mupirocin external ointment 2 on Tier 1 with GC
ampicillin-sulbactam sodium intravenous solution reconstituted 15 (1-05) gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) ampicillin-sulbactam sodium injection solution reconstituted 15 (1-05) GM on Tier 2
heparin sodium (porcine) intravenous solution 2000 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
heparin sodium (porcine) intravenous solution 2500 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
ROXICET ORAL SOLUTION 5-325 MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral solution 5-325 MG5ML on Tier 2 with QL (1800 ML per 30 days)
ROXICET ORAL TABLET 5-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral tablet 5-325 MG on Tier 2 with QL (360 tablets per 30 days)
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
13
This information is available for free in other languages Please call our Customer Service number at 1-866-999-3945 MondayndashFriday 8 am to 8 pm Between October 1 and February 14 representatives are available MondayndashSunday 8 am to 8 pm TTY users should call 1-800-735-2929
Esta informacioacuten estaacute disponible gratis en otros idiomas Por favor llame a nuestro nuacutemero de Servicio al Cliente al 1-866-999-3945 de lunes a viernes de 8 am a 8 pm Entre el 1 de octubre y el 14 de febrero los representantes estaacuten disponibles de lunes a domingo de 8 am a 8 pm Los usuarios de TTY deben llamar al 1-800-735-2929
Easy Choice Health Plan (HMO) a WellCare company is a Medicare Advantage organization with a Medicare contract Enrollment in Easy Choice (HMO) depends on contract renewal This information is not a complete description of benefits Contact the plan for more information Limitations co-payments and restrictions may apply Benefits premiums andor co-paymentscoinsurance
may change on January 1 of each year The formulary pharmacy network andor provider network may change at any time You will receive notice when necessary Easy Choice uses a formulary Please contact Easy Choice for details
PO Box 31389 | Tampa FL 33631-3389 wwweasychoicehealthplancom 79
429
Medication Name Change Description
XENAZINE TABLET 25 MG Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) tetrabenazine tablet 25 MG on Tier 5^ with PA QL (120 tablets per 30 days)
ZYVOX SUSPENSION RECONSTITUTED 100 MG5ML
Drug Removed Generic Available Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) linezolid suspension reconstituted 100 MG5ML on Tier 5^
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC= Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
4
Fomulary File 16186
Effective Date512016 Formulary Version 10Medication Name Change Description
ADRIAMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) doxorubicin hcl intravenous solution reconstituted 50 MG on Tier 2 with BD
AMPHOTEC INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) amphotericin b injection solution reconstituted 50 MG on Tier 2 with BD
AMPHOTEC INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) amphotericin b injection solution reconstituted 50 MG on Tier 2 with BD
APEXICON EXTERNAL OINTMENT 005 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) diflorasone diacetate external ointment 005 on Tier 2
ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 800 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG 500 MG on Tier 5^ with PA LA
AUVI-Q INJECTION 015 MG015ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 05012016 ALTERNATIVE DRUG(S) EPIPEN on Tier 3
AUVI-Q INJECTION 03 MG03ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 05012016 ALTERNATIVE DRUG(S) EPIPEN on Tier 3
diltzac capsule extended release 120 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 120 MG diltiazem hcl beads capsule extended release 120 MG on Tier 2
5
Medication Name Change Description
diltzac capsule extended release 180 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 180 MG diltiazem hcl beads capsule extended release 180 MG on Tier 2
diltzac capsule extended release 240 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 240 MG diltiazem hcl beads capsule extended release 240 MG on Tier 2
diltzac capsule extended release 300 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 300 MG diltiazem hcl beads capsule extended release 300 MG on Tier 2
ENDODAN TABLET 48355-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) oxycodone-aspirin tablet 48355-325 MG on Tier 2 with QL (360 tablets per 30 days)
FACTIVE TABLET 320 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) levofloxacin tablet on Tier 1 with GC
FLAGYL TABLET EXTENDED RELEASE 750 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) metronidazole tablet on Tier 1 with GC
GLYCATE TABLET 15 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S)glycopyrrolate tablet on Tier 2
LACLOTION EXTERNAL LOTION 12 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) ammonium lactate external lotion 12 on Tier 2
levobunolol hcl ophthalmic solution 025
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) levobunolol hcl ophthalmic solution 05 on Tier 2
6
Medication Name Change Description
lomustine capsule 10 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 10 MG on Tier 4
lomustine capsule 100 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 100 MG on Tier 4
lomustine capsule 40 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 40 MG on Tier 4
MY WAY TABLET 15 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) levonorgestrel tablet 15 MG on Tier 2
NEXT CHOICE ONE DOSE TABLET 15 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) levonorgestrel tablet 15 MG on Tier 2
SOLIA TABLET 015-30 MG-MCG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) cyred tablet apri tablet emoquette tablet reclipsen tablet on Tier 2
tobramycin sulfate in saline intravenous solution 08-09 mgml-
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) tobramycin sulfate injection solution 80 mg2ml on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC= Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
7
Fomulary File 16186
Effective Date612016 Formulary Version 11Medication Name Change Description
TEVETEN HCT TABLET 600-125 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04082016 ALTERNATIVE DRUG(S) valsartan-hydrochlorothiazide tablet on Tier 1 with GC
TEVETEN HCT TABLET 600-25 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04082016 ALTERNATIVE DRUG(S) valsartan-hydrochlorothiazide tablet on Tier 1 with GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
8
Fomulary File 16186
Effective Date712016
Medication Name Change Description
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ALSUMA SUBCUTANEOUS 6 MG05ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) sumatriptan succinate subcutaneous solution 6 MG05ML on Tier 2 with QL (6 ML per 30 days)
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
9
Formulary Version 12
Medication Name Change Description
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
10
Fomulary File 16186
Effective Date812016 Formulary Version 13Medication Name Change Description
FLO-PRED SUSPENSION 167 (15 BASE) MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) prednisolone solution 15 mg5ml on Tier 1 with GC
ZAZOLE VAGINAL CREAM 04 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) terconazole vaginal cream 04 on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
11
Fomulary File 16186
Effective Date912016 Formulary Version 14Medication Name Change Description
cefuroxime sodium intravenous solution reconstituted 75 gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S) cefuroxime sodium injection solution reconstituted 75 GM on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
12
Fomulary File 16186
Effective Date1112016 Formulary Version 16Medication Name Change Description
ALTABAX EXTERNAL OINTMENT 1 Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) mupirocin external ointment 2 on Tier 1 with GC
ampicillin-sulbactam sodium intravenous solution reconstituted 15 (1-05) gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) ampicillin-sulbactam sodium injection solution reconstituted 15 (1-05) GM on Tier 2
heparin sodium (porcine) intravenous solution 2000 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
heparin sodium (porcine) intravenous solution 2500 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
ROXICET ORAL SOLUTION 5-325 MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral solution 5-325 MG5ML on Tier 2 with QL (1800 ML per 30 days)
ROXICET ORAL TABLET 5-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral tablet 5-325 MG on Tier 2 with QL (360 tablets per 30 days)
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
13
This information is available for free in other languages Please call our Customer Service number at 1-866-999-3945 MondayndashFriday 8 am to 8 pm Between October 1 and February 14 representatives are available MondayndashSunday 8 am to 8 pm TTY users should call 1-800-735-2929
Esta informacioacuten estaacute disponible gratis en otros idiomas Por favor llame a nuestro nuacutemero de Servicio al Cliente al 1-866-999-3945 de lunes a viernes de 8 am a 8 pm Entre el 1 de octubre y el 14 de febrero los representantes estaacuten disponibles de lunes a domingo de 8 am a 8 pm Los usuarios de TTY deben llamar al 1-800-735-2929
Easy Choice Health Plan (HMO) a WellCare company is a Medicare Advantage organization with a Medicare contract Enrollment in Easy Choice (HMO) depends on contract renewal This information is not a complete description of benefits Contact the plan for more information Limitations co-payments and restrictions may apply Benefits premiums andor co-paymentscoinsurance
may change on January 1 of each year The formulary pharmacy network andor provider network may change at any time You will receive notice when necessary Easy Choice uses a formulary Please contact Easy Choice for details
PO Box 31389 | Tampa FL 33631-3389 wwweasychoicehealthplancom 79
429
Fomulary File 16186
Effective Date512016 Formulary Version 10Medication Name Change Description
ADRIAMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) doxorubicin hcl intravenous solution reconstituted 50 MG on Tier 2 with BD
AMPHOTEC INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) amphotericin b injection solution reconstituted 50 MG on Tier 2 with BD
AMPHOTEC INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) amphotericin b injection solution reconstituted 50 MG on Tier 2 with BD
APEXICON EXTERNAL OINTMENT 005 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) diflorasone diacetate external ointment 005 on Tier 2
ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 800 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG 500 MG on Tier 5^ with PA LA
AUVI-Q INJECTION 015 MG015ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 05012016 ALTERNATIVE DRUG(S) EPIPEN on Tier 3
AUVI-Q INJECTION 03 MG03ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 05012016 ALTERNATIVE DRUG(S) EPIPEN on Tier 3
diltzac capsule extended release 120 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 120 MG diltiazem hcl beads capsule extended release 120 MG on Tier 2
5
Medication Name Change Description
diltzac capsule extended release 180 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 180 MG diltiazem hcl beads capsule extended release 180 MG on Tier 2
diltzac capsule extended release 240 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 240 MG diltiazem hcl beads capsule extended release 240 MG on Tier 2
diltzac capsule extended release 300 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 300 MG diltiazem hcl beads capsule extended release 300 MG on Tier 2
ENDODAN TABLET 48355-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) oxycodone-aspirin tablet 48355-325 MG on Tier 2 with QL (360 tablets per 30 days)
FACTIVE TABLET 320 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) levofloxacin tablet on Tier 1 with GC
FLAGYL TABLET EXTENDED RELEASE 750 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) metronidazole tablet on Tier 1 with GC
GLYCATE TABLET 15 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S)glycopyrrolate tablet on Tier 2
LACLOTION EXTERNAL LOTION 12 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) ammonium lactate external lotion 12 on Tier 2
levobunolol hcl ophthalmic solution 025
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) levobunolol hcl ophthalmic solution 05 on Tier 2
6
Medication Name Change Description
lomustine capsule 10 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 10 MG on Tier 4
lomustine capsule 100 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 100 MG on Tier 4
lomustine capsule 40 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 40 MG on Tier 4
MY WAY TABLET 15 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) levonorgestrel tablet 15 MG on Tier 2
NEXT CHOICE ONE DOSE TABLET 15 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) levonorgestrel tablet 15 MG on Tier 2
SOLIA TABLET 015-30 MG-MCG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) cyred tablet apri tablet emoquette tablet reclipsen tablet on Tier 2
tobramycin sulfate in saline intravenous solution 08-09 mgml-
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) tobramycin sulfate injection solution 80 mg2ml on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC= Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
7
Fomulary File 16186
Effective Date612016 Formulary Version 11Medication Name Change Description
TEVETEN HCT TABLET 600-125 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04082016 ALTERNATIVE DRUG(S) valsartan-hydrochlorothiazide tablet on Tier 1 with GC
TEVETEN HCT TABLET 600-25 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04082016 ALTERNATIVE DRUG(S) valsartan-hydrochlorothiazide tablet on Tier 1 with GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
8
Fomulary File 16186
Effective Date712016
Medication Name Change Description
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ALSUMA SUBCUTANEOUS 6 MG05ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) sumatriptan succinate subcutaneous solution 6 MG05ML on Tier 2 with QL (6 ML per 30 days)
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
9
Formulary Version 12
Medication Name Change Description
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
10
Fomulary File 16186
Effective Date812016 Formulary Version 13Medication Name Change Description
FLO-PRED SUSPENSION 167 (15 BASE) MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) prednisolone solution 15 mg5ml on Tier 1 with GC
ZAZOLE VAGINAL CREAM 04 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) terconazole vaginal cream 04 on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
11
Fomulary File 16186
Effective Date912016 Formulary Version 14Medication Name Change Description
cefuroxime sodium intravenous solution reconstituted 75 gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S) cefuroxime sodium injection solution reconstituted 75 GM on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
12
Fomulary File 16186
Effective Date1112016 Formulary Version 16Medication Name Change Description
ALTABAX EXTERNAL OINTMENT 1 Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) mupirocin external ointment 2 on Tier 1 with GC
ampicillin-sulbactam sodium intravenous solution reconstituted 15 (1-05) gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) ampicillin-sulbactam sodium injection solution reconstituted 15 (1-05) GM on Tier 2
heparin sodium (porcine) intravenous solution 2000 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
heparin sodium (porcine) intravenous solution 2500 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
ROXICET ORAL SOLUTION 5-325 MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral solution 5-325 MG5ML on Tier 2 with QL (1800 ML per 30 days)
ROXICET ORAL TABLET 5-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral tablet 5-325 MG on Tier 2 with QL (360 tablets per 30 days)
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
13
This information is available for free in other languages Please call our Customer Service number at 1-866-999-3945 MondayndashFriday 8 am to 8 pm Between October 1 and February 14 representatives are available MondayndashSunday 8 am to 8 pm TTY users should call 1-800-735-2929
Esta informacioacuten estaacute disponible gratis en otros idiomas Por favor llame a nuestro nuacutemero de Servicio al Cliente al 1-866-999-3945 de lunes a viernes de 8 am a 8 pm Entre el 1 de octubre y el 14 de febrero los representantes estaacuten disponibles de lunes a domingo de 8 am a 8 pm Los usuarios de TTY deben llamar al 1-800-735-2929
Easy Choice Health Plan (HMO) a WellCare company is a Medicare Advantage organization with a Medicare contract Enrollment in Easy Choice (HMO) depends on contract renewal This information is not a complete description of benefits Contact the plan for more information Limitations co-payments and restrictions may apply Benefits premiums andor co-paymentscoinsurance
may change on January 1 of each year The formulary pharmacy network andor provider network may change at any time You will receive notice when necessary Easy Choice uses a formulary Please contact Easy Choice for details
PO Box 31389 | Tampa FL 33631-3389 wwweasychoicehealthplancom 79
429
Medication Name Change Description
diltzac capsule extended release 180 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 180 MG diltiazem hcl beads capsule extended release 180 MG on Tier 2
diltzac capsule extended release 240 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 240 MG diltiazem hcl beads capsule extended release 240 MG on Tier 2
diltzac capsule extended release 300 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) taztia xt capsule extended release 300 MG diltiazem hcl beads capsule extended release 300 MG on Tier 2
ENDODAN TABLET 48355-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) oxycodone-aspirin tablet 48355-325 MG on Tier 2 with QL (360 tablets per 30 days)
FACTIVE TABLET 320 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) levofloxacin tablet on Tier 1 with GC
FLAGYL TABLET EXTENDED RELEASE 750 MG
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) metronidazole tablet on Tier 1 with GC
GLYCATE TABLET 15 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S)glycopyrrolate tablet on Tier 2
LACLOTION EXTERNAL LOTION 12 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) ammonium lactate external lotion 12 on Tier 2
levobunolol hcl ophthalmic solution 025
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) levobunolol hcl ophthalmic solution 05 on Tier 2
6
Medication Name Change Description
lomustine capsule 10 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 10 MG on Tier 4
lomustine capsule 100 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 100 MG on Tier 4
lomustine capsule 40 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 40 MG on Tier 4
MY WAY TABLET 15 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) levonorgestrel tablet 15 MG on Tier 2
NEXT CHOICE ONE DOSE TABLET 15 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) levonorgestrel tablet 15 MG on Tier 2
SOLIA TABLET 015-30 MG-MCG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) cyred tablet apri tablet emoquette tablet reclipsen tablet on Tier 2
tobramycin sulfate in saline intravenous solution 08-09 mgml-
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) tobramycin sulfate injection solution 80 mg2ml on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC= Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
7
Fomulary File 16186
Effective Date612016 Formulary Version 11Medication Name Change Description
TEVETEN HCT TABLET 600-125 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04082016 ALTERNATIVE DRUG(S) valsartan-hydrochlorothiazide tablet on Tier 1 with GC
TEVETEN HCT TABLET 600-25 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04082016 ALTERNATIVE DRUG(S) valsartan-hydrochlorothiazide tablet on Tier 1 with GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
8
Fomulary File 16186
Effective Date712016
Medication Name Change Description
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ALSUMA SUBCUTANEOUS 6 MG05ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) sumatriptan succinate subcutaneous solution 6 MG05ML on Tier 2 with QL (6 ML per 30 days)
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
9
Formulary Version 12
Medication Name Change Description
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
10
Fomulary File 16186
Effective Date812016 Formulary Version 13Medication Name Change Description
FLO-PRED SUSPENSION 167 (15 BASE) MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) prednisolone solution 15 mg5ml on Tier 1 with GC
ZAZOLE VAGINAL CREAM 04 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) terconazole vaginal cream 04 on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
11
Fomulary File 16186
Effective Date912016 Formulary Version 14Medication Name Change Description
cefuroxime sodium intravenous solution reconstituted 75 gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S) cefuroxime sodium injection solution reconstituted 75 GM on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
12
Fomulary File 16186
Effective Date1112016 Formulary Version 16Medication Name Change Description
ALTABAX EXTERNAL OINTMENT 1 Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) mupirocin external ointment 2 on Tier 1 with GC
ampicillin-sulbactam sodium intravenous solution reconstituted 15 (1-05) gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) ampicillin-sulbactam sodium injection solution reconstituted 15 (1-05) GM on Tier 2
heparin sodium (porcine) intravenous solution 2000 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
heparin sodium (porcine) intravenous solution 2500 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
ROXICET ORAL SOLUTION 5-325 MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral solution 5-325 MG5ML on Tier 2 with QL (1800 ML per 30 days)
ROXICET ORAL TABLET 5-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral tablet 5-325 MG on Tier 2 with QL (360 tablets per 30 days)
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
13
This information is available for free in other languages Please call our Customer Service number at 1-866-999-3945 MondayndashFriday 8 am to 8 pm Between October 1 and February 14 representatives are available MondayndashSunday 8 am to 8 pm TTY users should call 1-800-735-2929
Esta informacioacuten estaacute disponible gratis en otros idiomas Por favor llame a nuestro nuacutemero de Servicio al Cliente al 1-866-999-3945 de lunes a viernes de 8 am a 8 pm Entre el 1 de octubre y el 14 de febrero los representantes estaacuten disponibles de lunes a domingo de 8 am a 8 pm Los usuarios de TTY deben llamar al 1-800-735-2929
Easy Choice Health Plan (HMO) a WellCare company is a Medicare Advantage organization with a Medicare contract Enrollment in Easy Choice (HMO) depends on contract renewal This information is not a complete description of benefits Contact the plan for more information Limitations co-payments and restrictions may apply Benefits premiums andor co-paymentscoinsurance
may change on January 1 of each year The formulary pharmacy network andor provider network may change at any time You will receive notice when necessary Easy Choice uses a formulary Please contact Easy Choice for details
PO Box 31389 | Tampa FL 33631-3389 wwweasychoicehealthplancom 79
429
Medication Name Change Description
lomustine capsule 10 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 10 MG on Tier 4
lomustine capsule 100 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 100 MG on Tier 4
lomustine capsule 40 mg Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) GLEOSTINE CAPSULE 40 MG on Tier 4
MY WAY TABLET 15 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) levonorgestrel tablet 15 MG on Tier 2
NEXT CHOICE ONE DOSE TABLET 15 MG Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 03012016 ALTERNATIVE DRUG(S) levonorgestrel tablet 15 MG on Tier 2
SOLIA TABLET 015-30 MG-MCG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) cyred tablet apri tablet emoquette tablet reclipsen tablet on Tier 2
tobramycin sulfate in saline intravenous solution 08-09 mgml-
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 04012016 ALTERNATIVE DRUG(S) tobramycin sulfate injection solution 80 mg2ml on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC= Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
7
Fomulary File 16186
Effective Date612016 Formulary Version 11Medication Name Change Description
TEVETEN HCT TABLET 600-125 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04082016 ALTERNATIVE DRUG(S) valsartan-hydrochlorothiazide tablet on Tier 1 with GC
TEVETEN HCT TABLET 600-25 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04082016 ALTERNATIVE DRUG(S) valsartan-hydrochlorothiazide tablet on Tier 1 with GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
8
Fomulary File 16186
Effective Date712016
Medication Name Change Description
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ALSUMA SUBCUTANEOUS 6 MG05ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) sumatriptan succinate subcutaneous solution 6 MG05ML on Tier 2 with QL (6 ML per 30 days)
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
9
Formulary Version 12
Medication Name Change Description
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
10
Fomulary File 16186
Effective Date812016 Formulary Version 13Medication Name Change Description
FLO-PRED SUSPENSION 167 (15 BASE) MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) prednisolone solution 15 mg5ml on Tier 1 with GC
ZAZOLE VAGINAL CREAM 04 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) terconazole vaginal cream 04 on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
11
Fomulary File 16186
Effective Date912016 Formulary Version 14Medication Name Change Description
cefuroxime sodium intravenous solution reconstituted 75 gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S) cefuroxime sodium injection solution reconstituted 75 GM on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
12
Fomulary File 16186
Effective Date1112016 Formulary Version 16Medication Name Change Description
ALTABAX EXTERNAL OINTMENT 1 Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) mupirocin external ointment 2 on Tier 1 with GC
ampicillin-sulbactam sodium intravenous solution reconstituted 15 (1-05) gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) ampicillin-sulbactam sodium injection solution reconstituted 15 (1-05) GM on Tier 2
heparin sodium (porcine) intravenous solution 2000 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
heparin sodium (porcine) intravenous solution 2500 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
ROXICET ORAL SOLUTION 5-325 MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral solution 5-325 MG5ML on Tier 2 with QL (1800 ML per 30 days)
ROXICET ORAL TABLET 5-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral tablet 5-325 MG on Tier 2 with QL (360 tablets per 30 days)
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
13
This information is available for free in other languages Please call our Customer Service number at 1-866-999-3945 MondayndashFriday 8 am to 8 pm Between October 1 and February 14 representatives are available MondayndashSunday 8 am to 8 pm TTY users should call 1-800-735-2929
Esta informacioacuten estaacute disponible gratis en otros idiomas Por favor llame a nuestro nuacutemero de Servicio al Cliente al 1-866-999-3945 de lunes a viernes de 8 am a 8 pm Entre el 1 de octubre y el 14 de febrero los representantes estaacuten disponibles de lunes a domingo de 8 am a 8 pm Los usuarios de TTY deben llamar al 1-800-735-2929
Easy Choice Health Plan (HMO) a WellCare company is a Medicare Advantage organization with a Medicare contract Enrollment in Easy Choice (HMO) depends on contract renewal This information is not a complete description of benefits Contact the plan for more information Limitations co-payments and restrictions may apply Benefits premiums andor co-paymentscoinsurance
may change on January 1 of each year The formulary pharmacy network andor provider network may change at any time You will receive notice when necessary Easy Choice uses a formulary Please contact Easy Choice for details
PO Box 31389 | Tampa FL 33631-3389 wwweasychoicehealthplancom 79
429
Fomulary File 16186
Effective Date612016 Formulary Version 11Medication Name Change Description
TEVETEN HCT TABLET 600-125 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04082016 ALTERNATIVE DRUG(S) valsartan-hydrochlorothiazide tablet on Tier 1 with GC
TEVETEN HCT TABLET 600-25 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 04082016 ALTERNATIVE DRUG(S) valsartan-hydrochlorothiazide tablet on Tier 1 with GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
8
Fomulary File 16186
Effective Date712016
Medication Name Change Description
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ALSUMA SUBCUTANEOUS 6 MG05ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) sumatriptan succinate subcutaneous solution 6 MG05ML on Tier 2 with QL (6 ML per 30 days)
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
9
Formulary Version 12
Medication Name Change Description
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
10
Fomulary File 16186
Effective Date812016 Formulary Version 13Medication Name Change Description
FLO-PRED SUSPENSION 167 (15 BASE) MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) prednisolone solution 15 mg5ml on Tier 1 with GC
ZAZOLE VAGINAL CREAM 04 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) terconazole vaginal cream 04 on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
11
Fomulary File 16186
Effective Date912016 Formulary Version 14Medication Name Change Description
cefuroxime sodium intravenous solution reconstituted 75 gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S) cefuroxime sodium injection solution reconstituted 75 GM on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
12
Fomulary File 16186
Effective Date1112016 Formulary Version 16Medication Name Change Description
ALTABAX EXTERNAL OINTMENT 1 Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) mupirocin external ointment 2 on Tier 1 with GC
ampicillin-sulbactam sodium intravenous solution reconstituted 15 (1-05) gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) ampicillin-sulbactam sodium injection solution reconstituted 15 (1-05) GM on Tier 2
heparin sodium (porcine) intravenous solution 2000 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
heparin sodium (porcine) intravenous solution 2500 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
ROXICET ORAL SOLUTION 5-325 MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral solution 5-325 MG5ML on Tier 2 with QL (1800 ML per 30 days)
ROXICET ORAL TABLET 5-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral tablet 5-325 MG on Tier 2 with QL (360 tablets per 30 days)
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
13
This information is available for free in other languages Please call our Customer Service number at 1-866-999-3945 MondayndashFriday 8 am to 8 pm Between October 1 and February 14 representatives are available MondayndashSunday 8 am to 8 pm TTY users should call 1-800-735-2929
Esta informacioacuten estaacute disponible gratis en otros idiomas Por favor llame a nuestro nuacutemero de Servicio al Cliente al 1-866-999-3945 de lunes a viernes de 8 am a 8 pm Entre el 1 de octubre y el 14 de febrero los representantes estaacuten disponibles de lunes a domingo de 8 am a 8 pm Los usuarios de TTY deben llamar al 1-800-735-2929
Easy Choice Health Plan (HMO) a WellCare company is a Medicare Advantage organization with a Medicare contract Enrollment in Easy Choice (HMO) depends on contract renewal This information is not a complete description of benefits Contact the plan for more information Limitations co-payments and restrictions may apply Benefits premiums andor co-paymentscoinsurance
may change on January 1 of each year The formulary pharmacy network andor provider network may change at any time You will receive notice when necessary Easy Choice uses a formulary Please contact Easy Choice for details
PO Box 31389 | Tampa FL 33631-3389 wwweasychoicehealthplancom 79
429
Fomulary File 16186
Effective Date712016
Medication Name Change Description
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ADVICOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) lovastatin tablets on Tier 1 with GC
ALSUMA SUBCUTANEOUS 6 MG05ML Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) sumatriptan succinate subcutaneous solution 6 MG05ML on Tier 2 with QL (6 ML per 30 days)
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 1000-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
9
Formulary Version 12
Medication Name Change Description
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
10
Fomulary File 16186
Effective Date812016 Formulary Version 13Medication Name Change Description
FLO-PRED SUSPENSION 167 (15 BASE) MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) prednisolone solution 15 mg5ml on Tier 1 with GC
ZAZOLE VAGINAL CREAM 04 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) terconazole vaginal cream 04 on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
11
Fomulary File 16186
Effective Date912016 Formulary Version 14Medication Name Change Description
cefuroxime sodium intravenous solution reconstituted 75 gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S) cefuroxime sodium injection solution reconstituted 75 GM on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
12
Fomulary File 16186
Effective Date1112016 Formulary Version 16Medication Name Change Description
ALTABAX EXTERNAL OINTMENT 1 Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) mupirocin external ointment 2 on Tier 1 with GC
ampicillin-sulbactam sodium intravenous solution reconstituted 15 (1-05) gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) ampicillin-sulbactam sodium injection solution reconstituted 15 (1-05) GM on Tier 2
heparin sodium (porcine) intravenous solution 2000 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
heparin sodium (porcine) intravenous solution 2500 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
ROXICET ORAL SOLUTION 5-325 MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral solution 5-325 MG5ML on Tier 2 with QL (1800 ML per 30 days)
ROXICET ORAL TABLET 5-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral tablet 5-325 MG on Tier 2 with QL (360 tablets per 30 days)
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
13
This information is available for free in other languages Please call our Customer Service number at 1-866-999-3945 MondayndashFriday 8 am to 8 pm Between October 1 and February 14 representatives are available MondayndashSunday 8 am to 8 pm TTY users should call 1-800-735-2929
Esta informacioacuten estaacute disponible gratis en otros idiomas Por favor llame a nuestro nuacutemero de Servicio al Cliente al 1-866-999-3945 de lunes a viernes de 8 am a 8 pm Entre el 1 de octubre y el 14 de febrero los representantes estaacuten disponibles de lunes a domingo de 8 am a 8 pm Los usuarios de TTY deben llamar al 1-800-735-2929
Easy Choice Health Plan (HMO) a WellCare company is a Medicare Advantage organization with a Medicare contract Enrollment in Easy Choice (HMO) depends on contract renewal This information is not a complete description of benefits Contact the plan for more information Limitations co-payments and restrictions may apply Benefits premiums andor co-paymentscoinsurance
may change on January 1 of each year The formulary pharmacy network andor provider network may change at any time You will receive notice when necessary Easy Choice uses a formulary Please contact Easy Choice for details
PO Box 31389 | Tampa FL 33631-3389 wwweasychoicehealthplancom 79
429
Medication Name Change Description
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 500-40 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
SIMCOR TABLET EXTENDED RELEASE 24 HR 750-20 MG
Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 04282016 ALTERNATIVE DRUG(S) simvastatin tablet 10MG 20MG 40MG 5MG on Tier 1 80MG on Tier 1 with QL (30 tablets per 30 days) GC
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
10
Fomulary File 16186
Effective Date812016 Formulary Version 13Medication Name Change Description
FLO-PRED SUSPENSION 167 (15 BASE) MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) prednisolone solution 15 mg5ml on Tier 1 with GC
ZAZOLE VAGINAL CREAM 04 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) terconazole vaginal cream 04 on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
11
Fomulary File 16186
Effective Date912016 Formulary Version 14Medication Name Change Description
cefuroxime sodium intravenous solution reconstituted 75 gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S) cefuroxime sodium injection solution reconstituted 75 GM on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
12
Fomulary File 16186
Effective Date1112016 Formulary Version 16Medication Name Change Description
ALTABAX EXTERNAL OINTMENT 1 Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) mupirocin external ointment 2 on Tier 1 with GC
ampicillin-sulbactam sodium intravenous solution reconstituted 15 (1-05) gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) ampicillin-sulbactam sodium injection solution reconstituted 15 (1-05) GM on Tier 2
heparin sodium (porcine) intravenous solution 2000 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
heparin sodium (porcine) intravenous solution 2500 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
ROXICET ORAL SOLUTION 5-325 MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral solution 5-325 MG5ML on Tier 2 with QL (1800 ML per 30 days)
ROXICET ORAL TABLET 5-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral tablet 5-325 MG on Tier 2 with QL (360 tablets per 30 days)
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
13
This information is available for free in other languages Please call our Customer Service number at 1-866-999-3945 MondayndashFriday 8 am to 8 pm Between October 1 and February 14 representatives are available MondayndashSunday 8 am to 8 pm TTY users should call 1-800-735-2929
Esta informacioacuten estaacute disponible gratis en otros idiomas Por favor llame a nuestro nuacutemero de Servicio al Cliente al 1-866-999-3945 de lunes a viernes de 8 am a 8 pm Entre el 1 de octubre y el 14 de febrero los representantes estaacuten disponibles de lunes a domingo de 8 am a 8 pm Los usuarios de TTY deben llamar al 1-800-735-2929
Easy Choice Health Plan (HMO) a WellCare company is a Medicare Advantage organization with a Medicare contract Enrollment in Easy Choice (HMO) depends on contract renewal This information is not a complete description of benefits Contact the plan for more information Limitations co-payments and restrictions may apply Benefits premiums andor co-paymentscoinsurance
may change on January 1 of each year The formulary pharmacy network andor provider network may change at any time You will receive notice when necessary Easy Choice uses a formulary Please contact Easy Choice for details
PO Box 31389 | Tampa FL 33631-3389 wwweasychoicehealthplancom 79
429
Fomulary File 16186
Effective Date812016 Formulary Version 13Medication Name Change Description
FLO-PRED SUSPENSION 167 (15 BASE) MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) prednisolone solution 15 mg5ml on Tier 1 with GC
ZAZOLE VAGINAL CREAM 04 Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 06012016 ALTERNATIVE DRUG(S) terconazole vaginal cream 04 on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy GC=Gap Coverage ED=Excluded Drug ^ = Drug may be available for up to a 30-day supply only
11
Fomulary File 16186
Effective Date912016 Formulary Version 14Medication Name Change Description
cefuroxime sodium intravenous solution reconstituted 75 gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S) cefuroxime sodium injection solution reconstituted 75 GM on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
12
Fomulary File 16186
Effective Date1112016 Formulary Version 16Medication Name Change Description
ALTABAX EXTERNAL OINTMENT 1 Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) mupirocin external ointment 2 on Tier 1 with GC
ampicillin-sulbactam sodium intravenous solution reconstituted 15 (1-05) gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) ampicillin-sulbactam sodium injection solution reconstituted 15 (1-05) GM on Tier 2
heparin sodium (porcine) intravenous solution 2000 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
heparin sodium (porcine) intravenous solution 2500 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
ROXICET ORAL SOLUTION 5-325 MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral solution 5-325 MG5ML on Tier 2 with QL (1800 ML per 30 days)
ROXICET ORAL TABLET 5-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral tablet 5-325 MG on Tier 2 with QL (360 tablets per 30 days)
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
13
This information is available for free in other languages Please call our Customer Service number at 1-866-999-3945 MondayndashFriday 8 am to 8 pm Between October 1 and February 14 representatives are available MondayndashSunday 8 am to 8 pm TTY users should call 1-800-735-2929
Esta informacioacuten estaacute disponible gratis en otros idiomas Por favor llame a nuestro nuacutemero de Servicio al Cliente al 1-866-999-3945 de lunes a viernes de 8 am a 8 pm Entre el 1 de octubre y el 14 de febrero los representantes estaacuten disponibles de lunes a domingo de 8 am a 8 pm Los usuarios de TTY deben llamar al 1-800-735-2929
Easy Choice Health Plan (HMO) a WellCare company is a Medicare Advantage organization with a Medicare contract Enrollment in Easy Choice (HMO) depends on contract renewal This information is not a complete description of benefits Contact the plan for more information Limitations co-payments and restrictions may apply Benefits premiums andor co-paymentscoinsurance
may change on January 1 of each year The formulary pharmacy network andor provider network may change at any time You will receive notice when necessary Easy Choice uses a formulary Please contact Easy Choice for details
PO Box 31389 | Tampa FL 33631-3389 wwweasychoicehealthplancom 79
429
Fomulary File 16186
Effective Date912016 Formulary Version 14Medication Name Change Description
cefuroxime sodium intravenous solution reconstituted 75 gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 08012016 ALTERNATIVE DRUG(S) cefuroxime sodium injection solution reconstituted 75 GM on Tier 2
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
12
Fomulary File 16186
Effective Date1112016 Formulary Version 16Medication Name Change Description
ALTABAX EXTERNAL OINTMENT 1 Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) mupirocin external ointment 2 on Tier 1 with GC
ampicillin-sulbactam sodium intravenous solution reconstituted 15 (1-05) gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) ampicillin-sulbactam sodium injection solution reconstituted 15 (1-05) GM on Tier 2
heparin sodium (porcine) intravenous solution 2000 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
heparin sodium (porcine) intravenous solution 2500 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
ROXICET ORAL SOLUTION 5-325 MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral solution 5-325 MG5ML on Tier 2 with QL (1800 ML per 30 days)
ROXICET ORAL TABLET 5-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral tablet 5-325 MG on Tier 2 with QL (360 tablets per 30 days)
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
13
This information is available for free in other languages Please call our Customer Service number at 1-866-999-3945 MondayndashFriday 8 am to 8 pm Between October 1 and February 14 representatives are available MondayndashSunday 8 am to 8 pm TTY users should call 1-800-735-2929
Esta informacioacuten estaacute disponible gratis en otros idiomas Por favor llame a nuestro nuacutemero de Servicio al Cliente al 1-866-999-3945 de lunes a viernes de 8 am a 8 pm Entre el 1 de octubre y el 14 de febrero los representantes estaacuten disponibles de lunes a domingo de 8 am a 8 pm Los usuarios de TTY deben llamar al 1-800-735-2929
Easy Choice Health Plan (HMO) a WellCare company is a Medicare Advantage organization with a Medicare contract Enrollment in Easy Choice (HMO) depends on contract renewal This information is not a complete description of benefits Contact the plan for more information Limitations co-payments and restrictions may apply Benefits premiums andor co-paymentscoinsurance
may change on January 1 of each year The formulary pharmacy network andor provider network may change at any time You will receive notice when necessary Easy Choice uses a formulary Please contact Easy Choice for details
PO Box 31389 | Tampa FL 33631-3389 wwweasychoicehealthplancom 79
429
Fomulary File 16186
Effective Date1112016 Formulary Version 16Medication Name Change Description
ALTABAX EXTERNAL OINTMENT 1 Drug Removed Medicare will no longer cover Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) mupirocin external ointment 2 on Tier 1 with GC
ampicillin-sulbactam sodium intravenous solution reconstituted 15 (1-05) gm
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) ampicillin-sulbactam sodium injection solution reconstituted 15 (1-05) GM on Tier 2
heparin sodium (porcine) intravenous solution 2000 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
heparin sodium (porcine) intravenous solution 2500 unitml)
Drug Removed Manufacturer Discontinuation Generic name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) heparin sodium (porcine) injection solution 1000 UNITML on Tier 2 with BD
ROXICET ORAL SOLUTION 5-325 MG5ML
Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 10012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral solution 5-325 MG5ML on Tier 2 with QL (1800 ML per 30 days)
ROXICET ORAL TABLET 5-325 MG Drug Removed Manufacturer Discontinuation Brand name medication will be removed from the formulary effective 11012016 ALTERNATIVE DRUG(S) oxycodone-acetaminophen oral tablet 5-325 MG on Tier 2 with QL (360 tablets per 30 days)
Brand drugs- UPPERCASE Generics- lowercase LA=Limited Access NM=Not Available by Mail Service PA=Prior Authorization BD=Covered under Medicare B or D QL=Quantity Limits ST=Step Therapy ED=Excluded Drug GC=Gap Coverage ^ = Drug may be available for up to a 30-day supply only
13
This information is available for free in other languages Please call our Customer Service number at 1-866-999-3945 MondayndashFriday 8 am to 8 pm Between October 1 and February 14 representatives are available MondayndashSunday 8 am to 8 pm TTY users should call 1-800-735-2929
Esta informacioacuten estaacute disponible gratis en otros idiomas Por favor llame a nuestro nuacutemero de Servicio al Cliente al 1-866-999-3945 de lunes a viernes de 8 am a 8 pm Entre el 1 de octubre y el 14 de febrero los representantes estaacuten disponibles de lunes a domingo de 8 am a 8 pm Los usuarios de TTY deben llamar al 1-800-735-2929
Easy Choice Health Plan (HMO) a WellCare company is a Medicare Advantage organization with a Medicare contract Enrollment in Easy Choice (HMO) depends on contract renewal This information is not a complete description of benefits Contact the plan for more information Limitations co-payments and restrictions may apply Benefits premiums andor co-paymentscoinsurance
may change on January 1 of each year The formulary pharmacy network andor provider network may change at any time You will receive notice when necessary Easy Choice uses a formulary Please contact Easy Choice for details
PO Box 31389 | Tampa FL 33631-3389 wwweasychoicehealthplancom 79
429
This information is available for free in other languages Please call our Customer Service number at 1-866-999-3945 MondayndashFriday 8 am to 8 pm Between October 1 and February 14 representatives are available MondayndashSunday 8 am to 8 pm TTY users should call 1-800-735-2929
Esta informacioacuten estaacute disponible gratis en otros idiomas Por favor llame a nuestro nuacutemero de Servicio al Cliente al 1-866-999-3945 de lunes a viernes de 8 am a 8 pm Entre el 1 de octubre y el 14 de febrero los representantes estaacuten disponibles de lunes a domingo de 8 am a 8 pm Los usuarios de TTY deben llamar al 1-800-735-2929
Easy Choice Health Plan (HMO) a WellCare company is a Medicare Advantage organization with a Medicare contract Enrollment in Easy Choice (HMO) depends on contract renewal This information is not a complete description of benefits Contact the plan for more information Limitations co-payments and restrictions may apply Benefits premiums andor co-paymentscoinsurance
may change on January 1 of each year The formulary pharmacy network andor provider network may change at any time You will receive notice when necessary Easy Choice uses a formulary Please contact Easy Choice for details
PO Box 31389 | Tampa FL 33631-3389 wwweasychoicehealthplancom 79
429