2016 LIST OF COVERED DRUGS - WellCare Advocate Complete
Transcription
2016 LIST OF COVERED DRUGS (FORMULARY) WELLCARE ADVOCATE COMPLETE FIDA (MEDICARE-MEDICAID PLAN) This formulary was updated on 9/01/2015. If you have any questions, please contact WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday–Sunday or visit https://fida.wellcareny.com/ H2751_NY030536_MMP_FOR_ENG CMS Approved 09162015 ©WellCare 2015 NY_06_15 NY6MMPFOR67979E_0615 This is a list of drugs that Participants can get in WellCare Advocate Complete FIDA. v WellCare is a managed care plan that contracts with both the Medicare and New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. v The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. v Benefits may change on January 1 of each year. v You can always check WellCare Advocate Complete FIDA’s up-to-date List of Covered Drugs online at https://fida.wellcareny.com/ or by calling WellCare Advocate Complete FIDA Participant Services at 1-855-595-2063 (TTY: 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday–Sunday. v Limitations and restrictions may apply. For more information, call WellCare Participant Services or read the WellCare Advocate Complete FIDA Participant Handbook. v There are no co-pays for any covered drugs. v You can get this information for free in other formats, such as large print, Braille or audio. Call 1-855-595-2063 or TTY 1-877-247-6272. Our hours of operation are 8 a.m. to 8 p.m. Eastern, Monday–Sunday. The call is free. v You can get this information for free in other languages. Call 1-877-374-4056 and TTY/TDD 711 during 8 a.m. to 8 p.m. Eastern, Monday–Sunday. The call is free. v Puede obtener esta información gratis en otros idiomas. Llame al 1-877-374-4056 y TTY/TDD al 711 de 8 a.m. a 8 p.m., hora del este, de lunes a domingo. La llamada es gratis. v v Ou kapab jwenn enfòmasyon sa yo gratis nan lòt lang yo. Rele nimewo 1-877-374-4056 ak TTY/TDD 711 depi 8 a.m. jiska 8 p.m. Lè Zòn Lès, Lendi–Dimanch. Koutfil la gratis. v Queste informazioni possono essere ottenute gratuitamente in altre lingue. Chiamare 1-877-374-4056 e TTY/TDD 711 dalle ore 8 alle 20, ora della costa orientale degli USA, dal lunedì alla domenica. La chiamata è gratuita. v v v The State of New York has created a Participant Ombudsman Program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by WellCare Advocate Complete FIDA. ICAN may be reached toll-free at 1-844-614-8800 or online at icannys.org. ? If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/ 1 FREQUENTLY ASKED QUESTIONS (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.) The drugs on the List of Covered Drugs that starts on page 9 are the drugs covered by WellCare Advocate Complete FIDA. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.” u WellCare Advocate Complete FIDA will cover all drugs on the Drug List if: • your doctor or other network prescriber says you need them to get better or stay healthy, • the drug is medically necessary for your condition, and • you fill the prescription at a WellCare Advocate Complete FIDA network pharmacy. u ellCare Advocate Complete FIDA may have additional steps to access certain drugs (see W question #5 below). In some cases, you may have to do something before you can get a drug, like try other drugs first. You can also see an up-to-date list of drugs that we cover on our website at https://fida. wellcareny.com/ or call Participant Services at 1-855-595-2063 (TTY: 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday–Sunday. 2. Does the Drug List ever change? Yes. WellCare Advocate Complete FIDA may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: • a new drug comes along that works as well as a drug on the Drug List now, or • we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: • Decide to require or not require prior approval for a drug. (Prior approval is permission from WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT) before you can get a drug.) • Add or change the amount of a drug you can get (called “quantity limits”). • Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page 3.) ? If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/ 2 We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4 and 7 below have more information on what happens when the Drug List changes. u Y ou can always check WellCare Advocate Complete FIDA’s up-to-date Drug List online at https://fida.wellcareny.com/. You can also call Participant Services to check the current Drug List at 1-855-595-2063 (TTY: 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday–Sunday. 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If a cheaper drug becomes available that works as well as a drug on the Drug List now: • Your pharmacist may give you the cheaper drug the next time you fill your prescription. If you and your provider decide that the cheaper drug is not right for you, your provider can tell the pharmacist to continue to give you the drug you take now. • WellCare Advocate Complete FIDA may decide to take the more expensive drug off of the Drug List. If you are taking a drug that we remove from the Drug List because a cheaper drug that works just as well comes along, we will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. If there is a change to coverage for a drug you are taking, WellCare Advocate Complete FIDA will mail you a letter to tell you. 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter and call you to tell you that the unsafe drug was taken off the Drug List. Your provider will also know about this change. After you receive this notice in the mail, you can work with your provider to find another drug for your condition. 5. A re there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example: • Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT) before you fill your prescription. If you don’t get approval, WellCare Advocate Complete FIDA may not cover the drug. • Quantity limits: Sometimes WellCare Advocate Complete FIDA limits the amount of a drug you can get. • Step therapy: Sometimes WellCare Advocate Complete FIDA requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second. ? If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/ 3 You can find out if your drug has any additional requirements or limits by looking in the tables beginning on page 9. You can also get more information by visiting our Web site at https://fida.wellcareny.com/. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can also ask for an “exception” from these limits. Please see question 11 for more information on exceptions. u If you are in a nursing facility or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new WellCare Advocate Complete FIDA Participant. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 9 has a column labeled “Necessary actions, restrictions, or limits on use.” 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: • You can search alphabetically (if you know how to spell the drug), or • You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section on page 177. Then look for the name of your drug in the list. To search by medical condition, find the section labeled “List of drugs by medical condition” on page 9. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. ? If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/ 4 9. What if the drug you want to take is not on the Drug List? If you don’t see your drug on the Drug List, call Participant Services at 1-855-595-2063 (TTY: 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday–Sunday and ask about it. If you learn that WellCare Advocate Complete FIDA will not cover the drug, you can do one of these things: • Ask Participant Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or • You can ask the plan or your Interdisciplinary Team (IDT) to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10. W hat if you are a new WellCare Advocate Complete FIDA Participant and can’t find your drug on the Drug List or have a problem getting your drug? We can help. We must cover up to 90 days of temporary supplies of your drug, as needed, during the first 90 days you are a Participant of WellCare Advocate Complete FIDA. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover up to 90 days of temporary supplies of your drug if: • you are taking a drug that is not on our Drug List, or • health plan rules do not let you get the amount ordered by your prescriber, or • the drug requires prior approval by WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT), or • you are taking a drug that is part of a step therapy restriction. If you live in a nursing facility or other long-term care facility, you may refill your prescription for as long as 93 days. You may refill the drug multiple times during your first 93 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. If you experience a level of care change (such as being discharged or admitted to a long-term care facility), your physician or pharmacy can call our Provider Service Center and request a one-time override. This one-time override will be up to a 31-day supply (unless you have a prescription written for fewer days). 11. Can you ask for an exception to cover your drug? Yes. You can ask WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT) to make an exception to cover a drug that is not on the Drug List. You can also ask WellCare Advocate Complete FIDA or your IDT to change the rules on your drug. ? If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/ 5 • For example, WellCare Advocate Complete FIDA may limit the amount of a drug we will cover. If your drug has a limit, you can ask us or your IDT to change the limit and cover more. • Other examples: You can ask us or your IDT to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT) must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, you will get a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, you will get a decision within 24 hours of receiving your prescriber’s supporting statement. 13. How can you ask for an exception? To ask for an exception, call your Care Manager. Your Care Manager will work with you and your provider to help you ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same ingredients as brand-name drugs. They usually cost less than the brand-name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). WellCare Advocate Complete FIDA covers both brand-name drugs and generic drugs. 15. What are OTC drugs? OTC stands for “over-the-counter.” WellCare Advocate Complete FIDA covers some OTC drugs when they are written as prescriptions by your provider. You can read the WellCare Advocate Complete FIDA Drug List to see what OTC drugs are covered. 16. D oes WellCare Advocate Complete FIDA cover OTC non-drug products? WellCare Advocate Complete FIDA covers some OTC non-drug products when they are written as prescriptions by your provider, e.g., alcohol prep pads, gauze pads, and insulin syringes. You can read the WellCare Advocate Complete FIDA Drug List to see what OTC non-drug products are covered. 17. What is your co-pay? You will not be charged a co-pay for drugs on the Drug List. ? If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/ 6 18. What are drug tiers? • Tier 1 (Generic) includes generic drugs covered under Medicare Part D. • Tier 2 (Brand) includes brand drugs and generic drugs covered under Medicare Part D. • Tier 3 (Non-Medicare Rx/OTC Drugs) includes generic & brand drugs covered under the Medicaid benefit. All tiers have no co-pay. List of Covered Drugs The list of covered drugs below gives you information about the drugs covered by WellCare Advocate Complete FIDA. If you have trouble finding your drug in the list, turn to the Index that begins on page 177. The first column of the chart lists the name of the drug. Brand-name drugs are capitalized (e.g., COUMADIN) and generic drugs are listed in lowercase italics (e.g., simvastatin). The information in the necessary actions, restrictions, or limits on use column tells you if WellCare Advocate Complete FIDA has any rules for covering your drug. • NM means the drug is not available by mail-order. Other pharmacies are available in our network. • PA stands for Prior Authorization: Please see page 3 for details. • B/D stands for Prior Authorization Restriction for Part B vs. Part D Determination: This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from WellCare Advocate Complete FIDA to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, WellCare Advocate Complete FIDA may not cover this drug. • QL stands for Quantity Limits: Please see page 3 for details. • LA stands for Limited Access medication. This medication is available from the Specialty Pharmacy, and may be available from certain other pharmacies. For more information, please refer to the Pharmacy section of your Provider and Pharmacy Directory or contact Participant Services at 1-855-595-2063 (TTY: 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday–Sunday. • ST stands for Step Therapy: Please see page 3 for details. ? If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/ 7 Note: The ^ symbol next to a drug means the drug is not a “Part D drug.” These drugs have different rules for appeals. An appeal is a formal way of asking for a review of and change to a coverage decision if you think there was a mistake. For example, WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT) might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor or other prescriber disagrees with the decision, you can appeal. To ask for instructions on how to appeal, call Participant Services at 1-855-595-2063 (TTY: 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday–Sunday or the Independent Consumer Advocacy Network (ICAN) at 1-844-614-8800. You can also read the Participant Handbook to learn how to appeal a decision. You can also read the Participant Handbook to learn how to appeal a decision. ? If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/ 8 List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE ANALGESICS GOUT allopurinol oral tablet 100 mg, 300 mg colchicine-probenecid oral tablet 0.5-500 mg COLCRYS ORAL TABLET 0.6 MG probenecid oral tablet 500 mg ULORIC ORAL TABLET 40 MG, 80 MG NSAIDS celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release 24 hr* 100 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg diflunisal oral tablet 500 mg etodolac er oral tablet extended release 24 hr* 400 mg, 500 mg, 600 mg 1 $0 1 $0 2 1 $0 $0 QL (120 EA per 30 days) 2 $0 ST 1 $0 QL (60 EA per 30 days) 1 $0 1 $0 1 $0 1 $0 1 $0 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 9 NAME OF DRUG etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg flurbiprofen oral tablet 100 mg, 50 mg ibuprofen oral suspension 100 mg/5ml ibuprofen oral tablet 400 mg, 600 mg, 800 mg ketoprofen oral capsule 50 mg, 75 mg meloxicam oral suspension 7.5 mg/5ml meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen dr oral tablet delayed release 375 mg, 500 mg naproxen oral suspension 125 mg/5ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg piroxicam oral capsule 10 mg, 20 mg sulindac oral tablet 150 mg, 200 mg OPIOID ANALGESICS, CII duramorph injection solution 0.5 mg/ml, 1 mg/ml TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE B/D You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 10 NAME OF DRUG endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg fentanyl citrate buccal lollipop 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hr 100 mcg/hr, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 72 hr 12 mcg/hr, 25 mcg/hr FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 7.5-200 mg hydromorphone hcl oral liquid† 1 mg/ml hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg hydromorphone hcl pf injection solution 500 mg/50ml lorcet hd oral tablet 10-325 mg lorcet oral tablet 5-325 mg lorcet plus oral tablet 7.5-325 mg lortab oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg methadone hcl intensol oral concentrate 10 mg/ml TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 QL (360 EA per 30 days) 2 $0 PA; QL (120 EA per 30 days) 1 $0 PA; QL (10 EA per 30 days) 1 $0 QL (10 EA per 30 days) 2 $0 PA; QL (120 EA per 30 days) 1 $0 QL (5400 ML per 30 days) 1 $0 QL (360 EA per 30 days) 1 $0 QL (150 EA per 30 days) 1 $0 1 $0 QL (270 EA per 30 days) 1 $0 B/D 1 1 1 $0 $0 $0 QL (360 EA per 30 days) QL (360 EA per 30 days) QL (360 EA per 30 days) 1 $0 QL (360 EA per 30 days) 1 $0 QL (120 ML per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 11 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE methadone hcl oral solution 10 1 $0 QL (600 ML per 30 days) mg/5ml, 5 mg/5ml methadone hcl oral tablet 10 mg, 5 1 $0 QL (240 EA per 30 days) mg morphine sulfate (concentrate) oral 1 $0 solution 20 mg/ml morphine sulfate (pf) injection 1 $0 B/D solution 0.5 mg/ml, 1 mg/ml morphine sulfate (pf) intravenous* solution 10 mg/ml, 15 mg/ml, 2 1 $0 B/D mg/ml, 4 mg/ml, 8 mg/ml morphine sulfate er beads oral capsule extended release 24 hour 1 $0 QL (60 EA per 30 days) 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine sulfate er oral capsule extended release 24 hour 10 mg, 20 1 $0 QL (60 EA per 30 days) mg, 30 mg, 50 mg, 60 mg morphine sulfate er oral capsule extended release 24 hour 100 mg, 2 $0 QL (60 EA per 30 days) 80 mg morphine sulfate er oral tablet extendedrelease* 100 mg, 15 mg, 1 $0 QL (90 EA per 30 days) 30 mg, 60 mg morphine sulfate er oral tablet 1 $0 QL (60 EA per 30 days) extendedrelease* 200 mg morphine sulfate intravenous* 1 $0 B/D solution 1 mg/ml morphine sulfate oral solution 10 1 $0 mg/5ml, 20 mg/5ml morphine sulfate oral tablet 15 mg, 1 $0 QL (180 EA per 30 days) 30 mg oxycodone hcl oral capsule 5 mg 1 $0 QL (180 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 12 NAME OF DRUG oxycodone hcl oral concentrate 100 mg/5ml oxycodone hcl oral solution 5 mg/5ml oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg roxicet oral solution 5-325 mg/5ml OPIOID ANALGESICS acetaminophen-codeine #2 oral tablet 300-15 mg acetaminophen-codeine #3 oral tablet 300-30 mg acetaminophen-codeine #4 oral tablet 300-60 mg acetaminophen-codeine oral solution 120-12 mg/5ml butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml nalbuphine hcl injection solution 10 mg/ml, 20 mg/ml tramadol hcl oral tablet 50 mg tramadol-acetaminophen oral tablet 37.5-325 mg ANESTHETICS TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 1 $0 1 $0 QL (180 EA per 30 days) 1 $0 QL (360 EA per 30 days) 2 $0 QL (1800 ML per 30 days) 1 $0 QL (400 EA per 30 days) 1 $0 QL (400 EA per 30 days) 1 $0 QL (400 EA per 30 days) 1 $0 QL (5000 ML per 30 days) 1 $0 1 $0 1 $0 QL (240 EA per 30 days) 1 $0 QL (240 EA per 30 days) LOCAL ANESTHETICS lidocaine hcl (pf) injection solution 1 $0 B/D 0.5 %, 1 % lidocaine hcl injection solution 0.5 1 $0 B/D %, 1 %, 1.5 %, 2 % You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 13 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE ANTI-INFECTIVES ANTI-BACTERIALS MISCELLANEOUS amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml gentamicin in saline intravenous* solution 0.8-0.9 mg/ml-%, 0.9-0.9 mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.4-0.9 mg/ml-%, 1.6-0.9 mg/ml-%, 2-0.9 mg/ml-% gentamicin sulfate injection solution 10 mg/ml, 40 mg/ml gentamicin sulfate intravenous* solution 10 mg/ml neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 250 mg streptomycin sulfate intramuscular* solution reconstituted 1 gm sulfadiazine oral tablet 500 mg tobramycin inhalation nebulization solution 300 mg/5ml tobramycin sulfate in saline intravenous* solution 0.8-0.9 mg/ml-% tobramycin sulfate injection solution 1.2 gm/30ml, 10 mg/ml, 2 gm/50ml, 80 mg/2ml tobramycin sulfate injection solution reconstituted 1.2 gm 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 2 $0 2 $0 2 $0 1 $0 1 $0 B/D You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 14 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE ANTIFUNGALS ABELCET INTRAVENOUS* SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS* SUSPENSION RECONSTITUTED 50 MG amphotericin b injection solution reconstituted 50 mg CANCIDAS INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG, 70 MG fluconazole in dextrose intravenous* solution 200 mg/100ml, 400 mg/200ml fluconazole in sodium chloride intravenous* solution 200-0.9 mg/100ml-%, 400-0.9 mg/200ml-% fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg flucytosine oral capsule 250 mg, 500 mg griseofulvin microsize oral suspension 125 mg/5ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 125 mg, 250 mg itraconazole oral capsule 100 mg ketoconazole oral tablet 200 mg 2 $0 B/D 2 $0 B/D 1 $0 B/D 2 $0 1 $0 1 $0 1 $0 1 $0 2 $0 1 $0 1 $0 1 $0 1 1 $0 $0 PA PA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 15 NAME OF DRUG MYCAMINE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 50 MG NOXAFIL ORAL SUSPENSION 40 MG/ML NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG nystatin oral tablet 500000 unit terbinafine hcl oral tablet 250 mg voriconazole intravenous* solution reconstituted 200 mg voriconazole oral suspension reconstituted 40 mg/ml voriconazole oral tablet 200 mg, 50 mg ANTI-INFECTIVES MISCELLANEOUS ALBENZA ORAL TABLET 200 MG ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5ml AZACTAM IN DEXTROSE INTRAVENOUS* SOLUTION 1 GM, 2 GM aztreonam injection solution reconstituted 1 gm, 2 gm BILTRICIDE ORAL TABLET 600 MG CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG TIER WHAT THE DRUG LEVEL WILL COST YOU 2 $0 2 $0 2 $0 1 1 $0 $0 1 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 1 $0 2 $0 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE QL (90 EA per 365 days) PA; LA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 16 NAME OF DRUG clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml clindamycin phosphate in d5w intravenous* solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 9 gm/60ml, 900 mg/6ml, 9000 mg/60ml clindamycin phosphate intravenous* solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml colistimethate sodium injection solution reconstituted 150 mg CUBICIN INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG dapsone oral tablet 100 mg, 25 mg DARAPRIM ORAL TABLET 25 MG imipenem-cilastatin intravenous* solution reconstituted 250 mg, 500 mg INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM INVANZ INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM ivermectin oral tablet 3 mg linezolid intravenous* solution 2 mg/ml LINEZOLID ORAL TABLET 600 MG TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 2 $0 1 2 $0 $0 1 $0 2 $0 2 $0 1 $0 2 $0 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 17 NAME OF DRUG meropenem intravenous* solution reconstituted 1 gm, 500 mg methenamine hippurate oral tablet 1 gm metronidazole in nacl intravenous* solution 500-0.79 mg/100ml-% metronidazole oral tablet 250 mg, 500 mg NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg nitrofurantoin monohyd macro oral capsule 100 mg PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG SIVEXTRO INTRAVENOUS* SOLUTION RECONSTITUTED 200 MG SIVEXTRO ORAL TABLET 200 MG sulfamethoxazole-tmp ds oral tablet 800-160 mg sulfamethoxazole-trimethoprim intravenous* solution 400-80 mg/5ml sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml sulfamethoxazole-trimethoprim oral tablet 400-80 mg SYNERCID INTRAVENOUS* SOLUTION RECONSTITUTED 150-350 MG trimethoprim oral tablet 100 mg TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 1 $0 1 $0 1 $0 2 $0 B/D 2 $0 PA 2 $0 PA 2 $0 2 $0 2 $0 1 $0 1 $0 1 $0 1 $0 2 $0 1 $0 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 18 NAME OF DRUG TYGACIL INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG vancomycin hcl intravenous* solution reconstituted 10 gm, 1000 mg, 500 mg, 5000 mg, 750 mg vancomycin hcl oral capsule 125 mg, 250 mg ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML ZYVOX ORAL TABLET 600 MG ANTIMALARIALS atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg chloroquine phosphate oral tablet 250 mg, 500 mg COARTEM ORAL TABLET 20-120 MG mefloquine hcl oral tablet 250 mg PRIMAQUINE PHOSPHATE ORAL TABLET 26.3 MG quinine sulfate oral capsule 324 mg ANTIRETROVIRAL AGENTS abacavir sulfate oral tablet 300 mg APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML CRIXIVAN ORAL CAPSULE 200 MG, 400 MG didanosine oral capsule delayed release 125 mg, 200 mg, 250 mg, 400 mg EDURANT ORAL TABLET 25 MG TIER WHAT THE DRUG LEVEL WILL COST YOU 2 $0 1 $0 2 $0 2 $0 2 $0 1 $0 1 $0 2 1 $0 $0 2 $0 1 $0 1 2 $0 $0 2 $0 2 $0 1 $0 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE PA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 19 NAME OF DRUG EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED 90 MG INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG lamivudine oral solution 10 mg/ml lamivudine oral tablet 150 mg, 300 mg LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG nevirapine er oral tablet extended release 24 hr* 400 mg nevirapine oral suspension 50 mg/5ml nevirapine oral tablet 200 mg NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG TIER WHAT THE DRUG LEVEL WILL COST YOU 2 $0 2 $0 2 $0 2 $0 2 2 2 2 $0 $0 $0 $0 2 $0 1 $0 1 $0 2 $0 2 $0 1 $0 1 $0 1 2 2 2 $0 $0 $0 $0 2 $0 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 20 NAME OF DRUG RESCRIPTOR ORAL TABLET 100 MG, 200 MG RETROVIR INTRAVENOUS* SOLUTION 10 MG/ML REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL PACKET 50 MG SELZENTRY ORAL TABLET 150 MG, 300 MG stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg stavudine oral solution reconstituted 1 mg/ml SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 50 MG TYBOST ORAL TABLET 150 MG VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM VIRACEPT ORAL TABLET 250 MG, 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG VIREAD ORAL POWDER 40 MG/GM VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG VITEKTA ORAL TABLET 150 MG, 85 MG ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 100 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 2 $0 2 $0 2 $0 2 $0 2 $0 1 $0 1 $0 2 $0 2 2 2 $0 $0 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 1 $0 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 21 NAME OF DRUG zidovudine oral syrup 50 mg/5ml zidovudine oral tablet 300 mg ANTIRETROVIRAL COMBINATION AGENTS abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg ATRIPLA ORAL TABLET 600-200-300 MG COMPLERA ORAL TABLET 200-25-300 MG EPZICOM ORAL TABLET 600-300 MG EVOTAZ ORAL TABLET 300-150 MG KALETRA ORAL SOLUTION 400-100 MG/5ML KALETRA ORAL TABLET 100-25 MG, 200-50 MG lamivudine-zidovudine oral tablet 150-300 mg PREZCOBIX ORAL TABLET 800-150 MG STRIBILD ORAL TABLET 150-150-200-300 MG TRIUMEQ ORAL TABLET 600-50-300 MG TRUVADA ORAL TABLET 200-300 MG ANTITUBERCULAR AGENTS CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM cycloserine oral capsule 250 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 1 1 $0 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE QL (30 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 22 NAME OF DRUG ethambutol hcl oral tablet 100 mg, 400 mg isoniazid injection solution 100 mg/ml isoniazid oral syrup 50 mg/5ml isoniazid oral tablet 100 mg, 300 mg paser oral packet 4 gm PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg rifampin intravenous* solution reconstituted 600 mg rifampin oral capsule 150 mg, 300 mg RIFATER ORAL TABLET 50-120-300 MG SIRTURO ORAL TABLET 100 MG TRECATOR ORAL TABLET 250 MG ANTIVIRALS acyclovir oral capsule 200 mg acyclovir oral suspension 200 mg/5ml acyclovir oral tablet 400 mg, 800 mg acyclovir sodium intravenous* solution 50 mg/ml acyclovir sodium intravenous* solution reconstituted 500 mg adefovir dipivoxil oral tablet 10 mg TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 1 $0 1 $0 1 $0 2 2 1 1 $0 $0 $0 $0 1 $0 1 $0 2 $0 2 2 $0 $0 1 $0 1 $0 1 $0 1 $0 B/D 1 $0 B/D 2 $0 PA; LA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 23 NAME OF DRUG BARACLUDE ORAL SOLUTION 0.05 MG/ML entecavir oral tablet 0.5 mg, 1 mg EPIVIR HBV ORAL SOLUTION 5 MG/ML famciclovir oral tablet 125 mg, 250 mg, 500 mg foscarnet sodium intravenous* solution 24 mg/ml ganciclovir sodium intravenous* solution reconstituted 500 mg HARVONI ORAL TABLET 90-400 MG lamivudine oral tablet 100 mg MODERIBA 1200 DOSE PACK ORAL TABLET 600 MG moderiba 800 dose pack oral tablet 400 mg moderiba oral 200 & 400 mg, 400 & 600 mg moderiba oral tablet 200 mg PEG-INTRON REDIPEN SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML PEGINTRON SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 80 MCG/0.5ML PEG-INTRON SUBCUTANEOUS* KIT 50 MCG/0.5ML REBETOL ORAL SOLUTION 40 MG/ML TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 2 $0 2 $0 1 $0 1 $0 1 $0 B/D 2 1 $0 $0 PA 2 $0 2 $0 2 $0 1 $0 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 24 NAME OF DRUG RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER ribasphere oral capsule 200 mg ribasphere oral tablet 200 mg, 400 mg ribasphere oral tablet 600 mg ribasphere ribapak oral tablet 200 & 400 mg, 400 & 600 mg, 400 mg, 600 mg ribavirin oral capsule 200 mg ribavirin oral tablet 200 mg rimantadine hcl oral tablet 100 mg SOVALDI ORAL TABLET 400 MG TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML TYZEKA ORAL TABLET 600 MG valacyclovir hcl oral tablet 1 gm, 500 mg VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML valganciclovir hcl oral tablet 450 mg CEPHALOSPORINS TIER WHAT THE DRUG LEVEL WILL COST YOU 2 $0 1 $0 1 $0 2 $0 2 $0 1 1 1 2 $0 $0 $0 $0 2 $0 2 $0 2 $0 1 $0 2 $0 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE PA cefaclor er oral tablet extended 2 $0 release 12 hr* 500 mg cefaclor oral capsule 250 mg, 500 1 $0 mg cefaclor oral suspension reconstituted 125 mg/5ml, 250 1 $0 mg/5ml, 375 mg/5ml You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 25 NAME OF DRUG cefadroxil oral capsule 500 mg cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml cefadroxil oral tablet 1 gm cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 20 gm, 500 mg cefazolin sodium intravenous* solution 1-5 gm-% cefazolin sodium intravenous* solution reconstituted 1 gm cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cefepime hcl injection solution reconstituted 1 gm, 2 gm cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml cefotaxime sodium injection solution reconstituted 1 gm, 2 gm, 500 mg cefoxitin sodium injection solution reconstituted 10 gm cefoxitin sodium intravenous* solution reconstituted 1 gm, 2 gm cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 200 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 1 $0 2 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 26 NAME OF DRUG cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cefprozil oral tablet 250 mg, 500 mg CEFTAZIDIME AND DEXTROSE INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM/50ML, 2 GM/50ML ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg ceftriaxone sodium intravenous* solution reconstituted 1 gm, 10 gm, 2 gm cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 mg cefuroxime sodium intravenous* solution reconstituted 1.5 gm, 7.5 gm cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 2 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 2 $0 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 27 NAME OF DRUG suprax oral tablet chewable 100 mg, 200 mg tazicef injection solution reconstituted 1 gm, 2 gm, 6 gm tazicef intravenous* solution reconstituted 1 gm, 2 gm TEFLARO INTRAVENOUS* SOLUTION RECONSTITUTED 400 MG, 600 MG ERYTHROMYCINS/MACROLIDES azithromycin intravenous* solution reconstituted 500 mg azithromycin oral packet 1 gm azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml azithromycin oral tablet 250 mg, 500 mg, 600 mg clarithromycin er oral tablet extended release 24 hr* 500 mg clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml clarithromycin oral tablet 250 mg, 500 mg DIFICID ORAL TABLET 200 MG e.e.s. 400 oral tablet 400 mg ery-tab oral tablet delayed release 250 mg, 333 mg, 500 mg erythrocin lactobionate intravenous* solution reconstituted 500 mg erythrocin stearate oral tablet 250 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 2 $0 1 $0 1 $0 2 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 2 1 $0 $0 2 $0 2 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 28 NAME OF DRUG erythromycin base oral capsule delayed release particles 250 mg erythromycin base oral tablet 250 mg, 500 mg erythromycin ethylsuccinate oral tablet 400 mg FLUOROQUINOLONES ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg ciprofloxacin in d5w intravenous* solution 200 mg/100ml, 400 mg/200ml ciprofloxacin intravenous* solution 200 mg/20ml, 400 mg/40ml ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (10%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hr* 1000 mg, 500 mg levofloxacin in d5w intravenous* solution 250 mg/50ml, 500 mg/100ml, 750 mg/150ml levofloxacin intravenous* solution 25 mg/ml levofloxacin oral solution 25 mg/ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg PENICILLINS amoxicillin oral capsule 250 mg, 500 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 29 NAME OF DRUG amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet chewable 125 mg, 250 mg amoxicillin-pot clavulanate er oral tablet extended release 12 hr* 1000-62.5 mg amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml ampicillin sodium injection solution reconstituted 1 gm, 125 mg, 2 gm, 250 mg, 500 mg ampicillin sodium intravenous* solution reconstituted 1 gm, 10 gm, 2 gm TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 30 NAME OF DRUG ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (2-1) gm ampicillin-sulbactam sodium intravenous* solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (2-1) gm BICILLIN L-A INTRAMUSCULAR* SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML dicloxacillin sodium oral capsule 250 mg, 500 mg nafcillin sodium injection solution reconstituted 1 gm nafcillin sodium injection solution reconstituted 10 gm, 2 gm nafcillin sodium intravenous* solution reconstituted 1 gm nafcillin sodium intravenous* solution reconstituted 2 gm oxacillin sodium injection solution reconstituted 1 gm, 2 gm oxacillin sodium injection solution reconstituted 10 gm PENICILLIN G POT IN DEXTROSE INTRAVENOUS* SOLUTION 40000 UNIT/ML, 60000 UNIT/ML penicillin g potassium injection solution reconstituted 20000000 unit, 5000000 unit TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 2 $0 1 $0 1 $0 2 $0 1 $0 2 $0 1 $0 2 $0 2 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 31 NAME OF DRUG penicillin g procaine intramuscular* suspension 600000 unit/ml penicillin g sodium injection solution reconstituted 5000000 unit penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg piperacillin sod-tazobactam so intravenous* solution reconstituted 2-0.25 gm, 3-0.375 gm, 36-4.5 gm, 4-0.5 gm TETRACYCLINES doxy 100 intravenous* solution reconstituted 100 mg doxycycline hyclate intravenous* solution reconstituted 100 mg doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg minocycline hcl oral capsule 100 mg, 50 mg, 75 mg ANTINEOPLASTIC AGENTS TIER WHAT THE DRUG LEVEL WILL COST YOU 2 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE ALKYLATING AGENTS BICNU INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG B/D You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 32 NAME OF DRUG BUSULFEX INTRAVENOUS* SOLUTION 6 MG/ML cyclophosphamide injection solution reconstituted 1 gm, 500 mg cyclophosphamide injection solution reconstituted 2 gm CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG dacarbazine intravenous* solution reconstituted 200 mg EMCYT ORAL CAPSULE 140 MG HEXALEN ORAL CAPSULE 50 MG IFEX INTRAVENOUS* SOLUTION RECONSTITUTED 3 GM ifosfamide intravenous* solution 1 gm/20ml, 3 gm/60ml ifosfamide intravenous* solution reconstituted 1 gm IFOSFAMIDE INTRAVENOUS* SOLUTION RECONSTITUTED 3 GM LEUKERAN ORAL TABLET 2 MG lomustine oral capsule 10 mg, 100 mg, 40 mg melphalan hcl intravenous* solution reconstituted 50 mg MUSTARGEN INJECTION SOLUTION RECONSTITUTED 10 MG TREANDA INTRAVENOUS* SOLUTION 180 MG/2ML, 45 MG/0.5ML TREANDA INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 25 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 B/D 2 $0 B/D 1 $0 B/D 2 $0 B/D 1 $0 B/D 2 2 $0 $0 2 $0 B/D 1 $0 B/D 1 $0 B/D 2 $0 B/D 2 $0 1 $0 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 33 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE ANTHRACYCLINES adriamycin intravenous* solution reconstituted 50 mg daunorubicin hcl intravenous* injectable 5 mg/ml doxorubicin hcl intravenous* solution 2 mg/ml doxorubicin hcl intravenous* solution reconstituted 50 mg doxorubicin hcl liposomal intravenous* injectable 2 mg/ml epirubicin hcl intravenous* solution 200 mg/100ml, 50 mg/25ml idarubicin hcl intravenous* solution 10 mg/10ml, 20 mg/20ml, 5 mg/5ml ANTIBIOTICS bleomycin sulfate injection solution reconstituted 15 unit, 30 unit mitomycin intravenous* solution reconstituted 20 mg, 40 mg, 5 mg ANTIMETABOLITES adrucil intravenous* solution 2.5 gm/50ml, 5 gm/100ml, 500 mg/10ml ALIMTA INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 500 MG azacitidine injection suspension reconstituted 100 mg cladribine intravenous* solution 1 mg/ml 1 $0 B/D 1 $0 B/D 1 $0 B/D 1 $0 B/D 2 $0 B/D 1 $0 B/D 2 $0 B/D 1 $0 B/D 1 $0 B/D 1 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 34 NAME OF DRUG cytarabine injection solution 20 mg/ml fludarabine phosphate intravenous* solution 50 mg/2ml fludarabine phosphate intravenous* solution reconstituted 50 mg fluorouracil intravenous* solution 1 gm/20ml, 2.5 gm/50ml, 500 mg/10ml GEMCITABINE HCL INTRAVENOUS* SOLUTION 1 GM/26.3ML, 2 GM/52.6ML, 200 MG/5.26ML gemcitabine hcl intravenous* solution reconstituted 1 gm, 2 gm, 200 mg mercaptopurine oral tablet 50 mg methotrexate sodium (pf) injection solution 1 gm/40ml methotrexate sodium injection solution 25 mg/ml methotrexate sodium injection solution reconstituted 1 gm NIPENT INTRAVENOUS* SOLUTION RECONSTITUTED 10 MG PURIXAN ORAL SUSPENSION 2000 MG/100ML TABLOID ORAL TABLET 40 MG ANTIMITOTIC, TAXOIDS ABRAXANE INTRAVENOUS* SUSPENSION RECONSTITUTED 100 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 B/D 1 $0 B/D 1 $0 B/D 1 $0 B/D 2 $0 B/D 2 $0 B/D 1 $0 1 $0 B/D 1 $0 B/D 1 $0 B/D 2 $0 B/D 2 $0 2 $0 2 $0 B/D You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 35 NAME OF DRUG docetaxel intravenous* concentrate 140 mg/7ml DOCETAXEL INTRAVENOUS* CONCENTRATE 20 MG/ML, 80 MG/4ML DOCETAXEL INTRAVENOUS* SOLUTION 200 MG/20ML, 80 MG/8ML paclitaxel intravenous* concentrate 100 mg/16.7ml, 150 mg/25ml, 30 mg/5ml, 300 mg/50ml ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate intravenous* solution 1 mg/ml vincasar pfs intravenous* solution 1 mg/ml vincristine sulfate intravenous* solution 1 mg/ml vinorelbine tartrate intravenous* solution 10 mg/ml, 50 mg/5ml BIOLOGIC RESPONSE MODIFIERS AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML, 400 MG/16ML BELEODAQ INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG ERIVEDGE ORAL CAPSULE 150 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG HERCEPTIN INTRAVENOUS* SOLUTION RECONSTITUTED 440 MG IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 B/D 2 $0 B/D 2 $0 B/D 1 $0 B/D 2 $0 B/D 1 $0 B/D 1 $0 B/D 1 $0 B/D 2 $0 B/D; LA 2 $0 PA 2 $0 PA; LA 2 $0 PA; LA 2 $0 B/D 2 $0 PA; LA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 36 NAME OF DRUG ISTODAX INTRAVENOUS* SOLUTION RECONSTITUTED 10 MG KADCYLA INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 160 MG KEYTRUDA INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG LYNPARZA ORAL CAPSULE 50 MG PROLEUKIN INTRAVENOUS* SOLUTION RECONSTITUTED 22000000 UNIT RITUXAN INTRAVENOUS* CONCENTRATE 10 MG/ML VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG YERVOY INTRAVENOUS* SOLUTION 50 MG/10ML ZOLINZA ORAL CAPSULE 100 MG HORMONAL ANTINEOPLASTIC AGENTS anastrozole oral tablet 1 mg bicalutamide oral tablet 50 mg DEPO-PROVERA INTRAMUSCULAR* SUSPENSION 400 MG/ML exemestane oral tablet 25 mg FARESTON ORAL TABLET 60 MG FASLODEX INTRAMUSCULAR* SOLUTION 250 MG/5ML flutamide oral capsule 125 mg letrozole oral tablet 2.5 mg leuprolide acetate injection kit 1 mg/0.2ml TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 B/D 2 $0 B/D 2 $0 PA 2 $0 PA; LA 2 $0 B/D 2 $0 PA; LA 2 $0 B/D 2 $0 PA 2 $0 PA 1 1 $0 $0 2 $0 1 2 $0 $0 2 $0 1 1 $0 $0 1 $0 B/D B/D PA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 37 NAME OF DRUG LUPRON DEPOT INTRAMUSCULAR* KIT 11.25 MG, 3.75 MG LUPRON DEPOT-PED INTRAMUSCULAR* KIT 11.25 MG, 11.25 MG (PED), 15 MG, 30 MG (PED), 7.5 MG LYSODREN ORAL TABLET 500 MG MEGACE ES ORAL SUSPENSION 625 MG/5ML megestrol acetate oral suspension 40 mg/ml megestrol acetate oral tablet 20 mg, 40 mg NILANDRON ORAL TABLET 150 MG SOLTAMOX ORAL SOLUTION 10 MG/5ML tamoxifen citrate oral tablet 10 mg, 20 mg TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 11.25 MG, 3.75 MG XTANDI ORAL CAPSULE 40 MG ZYTIGA ORAL TABLET 250 MG KINASE INHIBITORS AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG BOSULIF ORAL TABLET 100 MG, 500 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 PA 2 $0 PA 2 $0 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 2 $0 1 $0 2 $0 PA 2 2 $0 $0 PA; LA PA; LA 2 $0 PA 2 $0 PA 2 $0 PA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 38 NAME OF DRUG CAPRELSA ORAL TABLET 100 MG, 300 MG COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEEVEC ORAL TABLET 100 MG, 400 MG ICLUSIG ORAL TABLET 15 MG, 45 MG IMBRUVICA ORAL CAPSULE 140 MG INLYTA ORAL TABLET 1 MG, 5 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG LENVIMA 10 MG DAILY DOSE ORAL 10 MG LENVIMA 14 MG DAILY DOSE ORAL 10 & 4 MG LENVIMA 20 MG DAILY DOSE ORAL 10 (2) MG LENVIMA 24 MG DAILY DOSE ORAL 10 (2) & 4 MG MEKINIST ORAL TABLET 0.5 MG, 2 MG NEXAVAR ORAL TABLET 200 MG SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 PA; LA 2 $0 PA; LA 2 $0 PA; LA 2 $0 PA; LA 2 $0 PA; LA 2 $0 PA 2 $0 PA; LA 2 2 $0 $0 PA; LA PA; LA 2 $0 PA; LA 2 $0 PA; LA 2 $0 PA; LA 2 $0 PA; LA 2 $0 PA; LA 2 $0 PA; LA 2 $0 PA; LA 2 $0 PA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 39 NAME OF DRUG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TASIGNA ORAL CAPSULE 150 MG, 200 MG TYKERB ORAL TABLET 250 MG VOTRIENT ORAL TABLET 200 MG XALKORI ORAL CAPSULE 200 MG, 250 MG ZELBORAF ORAL TABLET 240 MG ZYDELIG ORAL TABLET 100 MG, 150 MG ZYKADIA ORAL CAPSULE 150 MG MISCELLANEOUS TIER WHAT THE DRUG LEVEL WILL COST YOU 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE PA; LA 2 $0 PA 2 $0 PA; LA 2 $0 PA; LA 2 $0 PA 2 2 $0 $0 PA; LA PA; LA 2 $0 PA; LA 2 $0 PA; LA 2 $0 PA; LA 2 $0 PA; LA DROXIA ORAL CAPSULE 200 MG, 2 $0 300 MG, 400 MG hydroxyurea oral capsule 500 mg 1 $0 MATULANE ORAL CAPSULE 50 MG 2 $0 LA mitoxantrone hcl intravenous* concentrate 20 mg/10ml, 25 1 $0 B/D mg/12.5ml, 30 mg/15ml POMALYST ORAL CAPSULE 1 MG, 2 2 $0 PA; LA MG, 3 MG, 4 MG SYLATRON SUBCUTANEOUS* KIT 200 MCG, 300 MCG, 4 X 200 MCG, 2 $0 PA 4 X 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS* 2 $0 PA SOLUTION RECONSTITUTED 3.5 MG You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 40 NAME OF DRUG TARGRETIN ORAL CAPSULE 75 MG tretinoin oral capsule 10 mg TRISENOX INTRAVENOUS* SOLUTION 10 MG/10ML PLATINUM-BASED AGENTS carboplatin intravenous* solution 150 mg/15ml, 450 mg/45ml, 50 mg/5ml, 600 mg/60ml cisplatin intravenous* solution 100 mg/100ml, 200 mg/200ml, 50 mg/50ml oxaliplatin intravenous* solution 100 mg/20ml, 50 mg/10ml oxaliplatin intravenous* solution reconstituted 100 mg, 50 mg PROTECTIVE AGENTS amifostine intravenous* solution reconstituted 500 mg dexrazoxane intravenous* solution reconstituted 250 mg ELITEK INTRAVENOUS* SOLUTION RECONSTITUTED 1.5 MG, 7.5 MG FUSILEV INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG leucovorin calcium injection solution reconstituted 100 mg, 200 mg, 350 mg, 50 mg, 500 mg leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg levoleucovorin calcium intravenous* solution 175 mg/17.5ml TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE PA 2 2 $0 $0 2 $0 B/D 1 $0 B/D 1 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 1 $0 B/D 1 $0 2 $0 B/D You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 41 NAME OF DRUG mesna intravenous* solution 100 mg/ml MESNEX ORAL TABLET 400 MG TOPOISOMERASE INHIBITORS etoposide intravenous* solution 500 mg/25ml irinotecan hcl intravenous* solution 100 mg/5ml, 40 mg/2ml, 500 mg/25ml toposar intravenous* solution 1 gm/50ml topotecan hcl intravenous* solution reconstituted 4 mg CARDIOVASCULAR TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 B/D 2 $0 1 $0 B/D 2 $0 B/D 1 $0 B/D 2 $0 B/D 1 $0 QL (30 EA per 30 days) 1 $0 1 $0 1 $0 1 $0 1 $0 ACE INHIBITOR COMBINATIONS amlodipine besy-benazepril hcl oral capsule 10-20 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine besy-benazepril hcl oral capsule 10-40 mg benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 42 NAME OF DRUG lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg, 7.5-12.5 mg quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg ACE INHIBITORS benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg moexipril hcl oral tablet 15 mg, 7.5 mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg trandolapril oral tablet 1 mg, 2 mg, 4 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 43 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone oral tablet 25 mg, 50 mg spironolactone oral tablet 100 mg, 25 mg, 50 mg ALPHA BLOCKERS doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg doxazosin mesylate oral tablet 8 mg prazosin hcl oral capsule 1 mg, 2 mg, 5 mg terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan oral tablet 10-160 mg, 5-160 mg, 5-320 mg amlodipine besylate-valsartan oral tablet 10-320 mg amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25 mg, 5-160-12.5 mg amlodipine-valsartan-hctz oral tablet 10-320-25 mg amlodipine-valsartan-hctz oral tablet 5-160-25 mg AZOR ORAL TABLET 10-20 MG, 5-20 MG, 5-40 MG AZOR ORAL TABLET 10-40 MG 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 QL (60 EA per 30 days) 2 $0 QL (30 EA per 30 days) 2 $0 QL (30 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 44 NAME OF DRUG BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, 40-25 MG irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg TRIBENZOR ORAL TABLET 20-5-12.5 MG, 40-10-12.5 MG, 40-5-12.5 MG, 40-5-25 MG TRIBENZOR ORAL TABLET 40-10-25 MG valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG irbesartan oral tablet 150 mg, 300 mg, 75 mg losartan potassium oral tablet 100 mg, 25 mg, 50 mg valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg ANTIARRHYTHMICS amiodarone hcl intravenous* solution 150 mg/3ml, 450 mg/9ml, 900 mg/18ml TIER WHAT THE DRUG LEVEL WILL COST YOU 2 $0 1 $0 1 $0 2 $0 2 $0 1 $0 2 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE QL (30 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 45 NAME OF DRUG amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg disopyramide phosphate oral capsule 100 mg, 150 mg flecainide acetate oral tablet 100 mg, 150 mg, 50 mg mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 150 MG pacerone oral tablet 100 mg, 200 mg, 400 mg propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg quinidine gluconate er oral tablet extendedrelease* 324 mg quinidine sulfate oral tablet 200 mg, 300 mg sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 2 $0 1 $0 1 $0 2 $0 2 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE PA PA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 46 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG lovastatin oral tablet 10 mg lovastatin oral tablet 20 mg lovastatin oral tablet 40 mg pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg ANTILIPEMICS, MISCELLANEOUS cholestyramine light oral packet 4 gm cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose colestipol hcl oral granules 5 gm colestipol hcl oral packet 5 gm colestipol hcl oral tablet 1 gm fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg fenofibric acid oral capsule delayed release 135 mg, 45 mg gemfibrozil oral tablet 600 mg 1 $0 QL (30 EA per 30 days) 2 $0 QL (30 EA per 30 days) 1 1 1 $0 $0 $0 QL (30 EA per 30 days) QL (120 EA per 30 days) QL (60 EA per 30 days) 1 $0 QL (30 EA per 30 days) 1 $0 QL (30 EA per 30 days) 1 $0 1 $0 1 $0 1 1 1 $0 $0 $0 1 $0 1 $0 1 $0 1 $0 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 47 NAME OF DRUG JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS* 200 MG/ML niacin er (antihyperlipidemic) oral tablet extendedrelease* 1000 mg, 750 mg niacin er (antihyperlipidemic) oral tablet extendedrelease* 500 mg niacor oral tablet 500 mg omega-3-acid ethyl esters oral capsule 1 gm prevalite oral powder 4 gm/dose VASCEPA ORAL CAPSULE 1 GM WELCHOL ORAL PACKET 3.75 GM WELCHOL ORAL TABLET 625 MG ZETIA ORAL TABLET 10 MG BETA-BLOCKER/DIURETIC COMBINATIONS atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg, 50-25 mg propranolol-hctz oral tablet 40-25 mg, 80-25 mg TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 PA; LA 2 $0 PA 1 $0 1 $0 1 $0 1 $0 1 2 2 2 2 $0 $0 $0 $0 $0 1 $0 1 $0 1 $0 1 $0 QL (90 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 48 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE BETA-BLOCKERS acebutolol hcl oral capsule 200 mg, 400 mg atenolol oral tablet 100 mg, 25 mg, 50 mg bisoprolol fumarate oral tablet 10 mg, 5 mg BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg labetalol hcl oral tablet 100 mg, 200 mg, 300 mg metoprolol succinate er oral tablet extended release 24 hr* 100 mg metoprolol succinate er oral tablet extended release 24 hr* 200 mg metoprolol succinate er oral tablet extended release 24 hr* 25 mg, 50 mg metoprolol tartrate intravenous* solution 1 mg/ml metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg nadolol oral tablet 20 mg, 40 mg, 80 mg pindolol oral tablet 10 mg, 5 mg propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg propranolol hcl intravenous* solution 1 mg/ml 1 $0 1 $0 1 $0 2 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 QL (45 EA per 30 days) QL (60 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 49 NAME OF DRUG propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg timolol maleate oral tablet 10 mg, 20 mg, 5 mg CALCIUM CHANNEL BLOCKERS afeditab cr oral tablet extended release 24 hr* 30 mg afeditab cr oral tablet extended release 24 hr* 60 mg amlodipine besylate oral tablet 10 mg amlodipine besylate oral tablet 2.5 mg, 5 mg cartia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 120 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE QL (60 EA per 30 days) QL (45 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 50 NAME OF DRUG diltiazem hcl intravenous* solution 125 mg/25ml, 25 mg/5ml, 50 mg/10ml diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg diltzac oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg felodipine er oral tablet extended release 24 hr* 10 mg felodipine er oral tablet extended release 24 hr* 2.5 mg felodipine er oral tablet extended release 24 hr* 5 mg isradipine oral capsule 2.5 mg, 5 mg nicardipine hcl oral capsule 20 mg, 30 mg nifedical xl oral tablet extended release 24 hr* 30 mg nifedical xl oral tablet extended release 24 hr* 60 mg nifedipine er oral tablet extended release 24 hr* 30 mg nifedipine er oral tablet extended release 24 hr* 60 mg, 90 mg nifedipine er osmotic oral tablet extended release 24 hr* 30 mg nifedipine er osmotic oral tablet extended release 24 hr* 60 mg, 90 mg TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 QL (30 EA per 30 days) 1 $0 QL (60 EA per 30 days) 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 QL (30 EA per 30 days) QL (60 EA per 30 days) QL (30 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 51 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE nimodipine oral capsule 30 mg NYMALIZE ORAL SOLUTION 60 MG/20ML taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg verapamil hcl er oral capsule extended release 24 hour 360 mg verapamil hcl er oral tablet extendedrelease* 120 mg, 180 mg, 240 mg verapamil hcl intravenous* solution 2.5 mg/ml verapamil hcl oral tablet 120 mg, 40 mg, 80 mg DIGITALIS GLYCOSIDES 2 $0 2 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 digitek oral tablet 125 mcg digitek oral tablet 250 mcg digoxin injection solution 0.25 mg/ml digoxin oral solution 0.05 mg/ml digoxin oral tablet 0.125 mg digoxin oral tablet 250 mcg DIRECT RENIN INHIBITORS/COMBINATIONS 1 1 $0 $0 1 $0 1 1 1 $0 $0 $0 PA QL (30 EA per 30 days) PA 2 $0 QL (30 EA per 30 days) TEKTURNA HCT ORAL TABLET 150-12.5 MG, 300-12.5 MG QL (30 EA per 30 days) PA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 52 NAME OF DRUG TEKTURNA HCT ORAL TABLET 150-25 MG TEKTURNA HCT ORAL TABLET 300-25 MG TEKTURNA ORAL TABLET 150 MG TEKTURNA ORAL TABLET 300 MG DIURETICS acetazolamide er oral capsule extended release 12 hour 500 mg acetazolamide oral tablet 125 mg, 250 mg amiloride hcl oral tablet 5 mg amiloride-hydrochlorothiazide oral tablet 5-50 mg bumetanide injection solution 0.25 mg/ml bumetanide oral tablet 0.5 mg, 1 mg, 2 mg chlorothiazide oral tablet 250 mg, 500 mg chlorthalidone oral tablet 25 mg, 50 mg furosemide injection solution 10 mg/ml furosemide oral solution 10 mg/ml, 8 mg/ml furosemide oral tablet 20 mg, 40 mg, 80 mg hydrochlorothiazide oral capsule 12.5 mg hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 2 $0 2 $0 2 2 $0 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE QL (60 EA per 30 days) QL (30 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 53 NAME OF DRUG indapamide oral tablet 1.25 mg, 2.5 mg methazolamide oral tablet 25 mg, 50 mg methyclothiazide oral tablet 5 mg metolazone oral tablet 10 mg, 2.5 mg, 5 mg spironolactone-hctz oral tablet 25-25 mg torsemide intravenous* solution 50 mg/5ml torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg triamterene-hctz oral capsule 37.5-25 mg triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg MISCELLANEOUS clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg clonidine hcl transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr DEMSER ORAL CAPSULE 250 MG hydralazine hcl injection solution 20 mg/ml hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg minoxidil oral tablet 10 mg, 2.5 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 2 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 54 NAME OF DRUG RANEXA ORAL TABLET EXTENDED RELEASE 12 HR* 1000 MG, 500 MG NITRATES isosorbide dinitrate er oral tablet extendedrelease* 40 mg isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg isosorbide mononitrate er oral tablet extended release 24 hr* 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg minitran transdermal patch 24 hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr nitro-bid transdermal ointment 2 % NITRO-DUR TRANSDERMAL PATCH 24 HR 0.3 MG/HR, 0.8 MG/HR nitroglycerin transdermal patch 24 hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG PULMONARY ARTERIAL HYPERTENSION ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG LETAIRIS ORAL TABLET 10 MG, 5 MG OPSUMIT ORAL TABLET 10 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 1 $0 1 $0 1 $0 1 $0 1 $0 2 $0 2 $0 1 $0 2 $0 2 $0 PA; LA ; QL (90 EA per 30 days) 2 $0 PA; LA ; QL (30 EA per 30 days) 2 $0 PA; LA ; QL (30 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 55 NAME OF DRUG REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML REVATIO ORAL SUSPENSION RECONSTITUTED 10 MG/ML sildenafil citrate oral tablet 20 mg TRACLEER ORAL TABLET 125 MG TRACLEER ORAL TABLET 62.5 MG CENTRAL NERVOUS SYSTEM TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 B/D; LA 2 $0 PA; QL (224 ML per 30 days) 1 2 2 $0 $0 $0 PA; QL (90 EA per 30 days) PA; LA ; QL (60 EA per 30 days) PA; LA ; QL (120 EA per 30 days) alprazolam oral tablet 0.25 mg alprazolam oral tablet 0.5 mg alprazolam oral tablet 1 mg alprazolam oral tablet 2 mg buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg fluvoxamine maleate oral tablet 100 mg fluvoxamine maleate oral tablet 25 mg, 50 mg lorazepam injection solution 2 mg/ml, 4 mg/ml lorazepam intensol oral concentrate 2 mg/ml lorazepam oral tablet 0.5 mg, 1 mg, 2 mg ANTICONVULSANTS 1 1 1 1 $0 $0 $0 $0 QL (480 EA per 30 days) QL (240 EA per 30 days) QL (120 EA per 30 days) QL (150 EA per 30 days) 1 $0 1 $0 1 $0 1 $0 1 $0 QL (150 ML per 30 days) 1 $0 QL (150 EA per 30 days) APTIOM ORAL TABLET 200 MG APTIOM ORAL TABLET 400 MG APTIOM ORAL TABLET 600 MG APTIOM ORAL TABLET 800 MG 2 2 2 2 $0 $0 $0 $0 QL (180 EA per 30 days) QL (90 EA per 30 days) QL (60 EA per 30 days) QL (30 EA per 30 days) ANTIANXIETY QL (45 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 56 NAME OF DRUG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg carbamazepine er oral tablet extended release 12 hr* 200 mg, 400 mg carbamazepine oral suspension 100 mg/5ml carbamazepine oral tablet 200 mg carbamazepine oral tablet chewable 100 mg CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 0.5 mg clonazepam oral tablet 1 mg clonazepam oral tablet 2 mg clonazepam oral tablet dispersible 0.125 mg clonazepam oral tablet dispersible 0.25 mg clonazepam oral tablet dispersible 0.5 mg clonazepam oral tablet dispersible 1 mg clonazepam oral tablet dispersible 2 mg clorazepate dipotassium oral tablet 15 mg TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 PA 2 $0 PA 1 $0 1 $0 1 $0 1 $0 1 $0 2 1 1 1 $0 $0 $0 $0 QL (240 EA per 30 days) QL (120 EA per 30 days) QL (300 EA per 30 days) 1 $0 QL (960 EA per 30 days) 1 $0 QL (480 EA per 30 days) 1 $0 QL (240 EA per 30 days) 1 $0 QL (120 EA per 30 days) 1 $0 QL (300 EA per 30 days) 1 $0 PA; QL (180 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 57 NAME OF DRUG clorazepate dipotassium oral tablet 3.75 mg, 7.5 mg diazepam 10 mg, 2.5 mg, 20 mg diazepam injection solution 5 mg/ml diazepam intensol oral concentrate 5 mg/ml diazepam oral solution 1 mg/ml diazepam oral tablet 10 mg, 2 mg, 5 mg dilantin infatabs oral tablet chewable 50 mg dilantin oral capsule 100 mg, 30 mg DILANTIN ORAL SUSPENSION 125 MG/5ML divalproex sodium er oral tablet extended release 24 hr* 250 mg, 500 mg divalproex sodium oral capsule sprinkle 125 mg divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg epitol oral tablet 200 mg ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5ml felbamate oral suspension 600 mg/5ml felbamate oral tablet 400 mg felbamate oral tablet 600 mg FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 PA; QL (120 EA per 30 days) 1 1 $0 $0 1 $0 PA; QL (240 ML per 30 days) 1 $0 PA; QL (1200 ML per 30 days) 1 $0 PA; QL (120 EA per 30 days) 2 $0 2 $0 2 $0 1 $0 1 $0 1 $0 1 1 $0 $0 1 $0 2 $0 1 2 $0 $0 2 $0 PA; QL (30 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 58 NAME OF DRUG FYCOMPA ORAL TABLET 2 MG FYCOMPA ORAL TABLET 4 MG FYCOMPA ORAL TABLET 6 MG gabapentin oral capsule 100 mg gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 250 mg/5ml gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG lamotrigine er oral tablet extended release 24 hr* 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg lamotrigine oral tablet chewable 25 mg, 5 mg levetiracetam er oral tablet extended release 24 hr* 500 mg, 750 mg LEVETIRACETAM IN NACL INTRAVENOUS* SOLUTION 1000 MG/100ML, 1500 MG/100ML, 500 MG/100ML levetiracetam intravenous* solution 500 mg/5ml levetiracetam oral solution 100 mg/ml levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 2 2 2 1 1 1 $0 $0 $0 $0 $0 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE PA; QL (180 EA per 30 days) PA; QL (90 EA per 30 days) PA; QL (60 EA per 30 days) QL (1080 EA per 30 days) QL (360 EA per 30 days) QL (270 EA per 30 days) 1 $0 QL (2160 ML per 30 days) 1 1 $0 $0 QL (180 EA per 30 days) QL (120 EA per 30 days) 2 $0 1 $0 1 $0 1 $0 1 $0 2 $0 1 $0 1 $0 1 $0 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 59 NAME OF DRUG LYRICA ORAL CAPSULE 100 MG, 150 MG, 25 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 200 MG LYRICA ORAL CAPSULE 225 MG, 300 MG LYRICA ORAL SOLUTION 20 MG/ML ONFI ORAL SUSPENSION 2.5 MG/ML ONFI ORAL TABLET 10 MG, 20 MG oxcarbazepine oral suspension 300 mg/5ml oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 mg/5ml phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenobarbital sodium injection solution 130 mg/ml PHENOBARBITAL SODIUM INJECTION SOLUTION 65 MG/ML phenytek oral capsule 200 mg, 300 mg phenytoin oral suspension 125 mg/5ml phenytoin oral tablet chewable 50 mg phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg phenytoin sodium injection solution 50 mg/ml POTIGA ORAL TABLET 200 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 QL (120 EA per 30 days) 2 $0 QL (90 EA per 30 days) 2 $0 QL (60 EA per 30 days) 2 2 2 $0 $0 $0 QL (946 ML per 30 days) PA PA 1 $0 1 $0 2 2 $0 $0 PA 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 1 $0 1 $0 1 $0 1 $0 2 $0 QL (180 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 60 NAME OF DRUG POTIGA ORAL TABLET 300 MG, 400 MG POTIGA ORAL TABLET 50 MG primidone oral tablet 250 mg, 50 mg SABRIL ORAL PACKET 500 MG SABRIL ORAL TABLET 500 MG TEGRETOL ORAL SUSPENSION 100 MG/5ML TEGRETOL ORAL TABLET 200 MG TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG, 200 MG, 400 MG tiagabine hcl oral tablet 2 mg, 4 mg topiramate oral capsule sprinkle 15 mg, 25 mg topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg valproate sodium intravenous* solution 500 mg/5ml valproic acid oral capsule 250 mg valproic acid oral syrup 250 mg/5ml VIMPAT INTRAVENOUS* SOLUTION 200 MG/20ML VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG VIMPAT ORAL TABLET 50 MG zonisamide oral capsule 100 mg, 25 mg, 50 mg TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 QL (90 EA per 30 days) 2 $0 1 $0 2 2 $0 $0 2 $0 2 $0 2 $0 1 $0 1 $0 1 $0 1 $0 1 1 $0 $0 2 $0 2 $0 QL (1200 ML per 30 days) 2 $0 QL (60 EA per 30 days) 2 $0 QL (180 EA per 30 days) 1 $0 PA; LA ; QL (180 EA per 30 days) PA; LA ; QL (180 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 61 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE ANTIDEMENTIA donepezil hcl oral tablet 10 mg, 23 mg donepezil hcl oral tablet 5 mg donepezil hcl oral tablet dispersible 10 mg donepezil hcl oral tablet dispersible 5 mg EXELON TRANSDERMAL PATCH 24 HR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 8 mg galantamine hydrobromide er oral capsule extended release 24 hour 24 mg galantamine hydrobromide oral solution 4 mg/ml galantamine hydrobromide oral tablet 12 mg galantamine hydrobromide oral tablet 4 mg galantamine hydrobromide oral tablet 8 mg NAMENDA ORAL SOLUTION 10 MG/5ML NAMENDA ORAL TABLET 10 MG, 5 MG NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG 1 $0 1 $0 1 $0 1 $0 QL (30 EA per 30 days) 2 $0 QL (30 EA per 30 days) 1 $0 QL (30 EA per 30 days) 1 $0 1 $0 1 $0 1 $0 QL (180 EA per 30 days) 1 $0 QL (90 EA per 30 days) 2 $0 PA 2 $0 PA 2 $0 PA QL (30 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 62 NAME OF DRUG NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg ANTIDEPRESSANTS amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg BRINTELLIX ORAL TABLET 10 MG BRINTELLIX ORAL TABLET 20 MG BRINTELLIX ORAL TABLET 5 MG bupropion hcl er (sr) oral tablet extended release 12 hr* 100 mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hr* 150 mg bupropion hcl er (xl) oral tablet extended release 24 hr* 300 mg bupropion hcl oral tablet 100 mg, 75 mg citalopram hydrobromide oral solution 10 mg/5ml citalopram hydrobromide oral tablet 10 mg, 20 mg citalopram hydrobromide oral tablet 40 mg clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 PA 1 $0 2 $0 1 $0 2 2 2 $0 $0 $0 1 $0 1 $0 QL (90 EA per 30 days) 1 $0 QL (30 EA per 30 days) 1 $0 1 $0 1 $0 QL (45 EA per 30 days) 1 $0 QL (30 EA per 30 days) 2 $0 PA PA QL (60 EA per 30 days) QL (30 EA per 30 days) QL (120 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 63 NAME OF DRUG desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral concentrate 10 mg/ml duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg EMSAM TRANSDERMAL PATCH 24 HR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR escitalopram oxalate oral solution 5 mg/5ml escitalopram oxalate oral tablet 10 mg, 5 mg escitalopram oxalate oral tablet 20 mg FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 MG FETZIMA TITRATION ORAL 20 & 40 MG fluoxetine hcl oral capsule 10 mg fluoxetine hcl oral capsule 20 mg fluoxetine hcl oral capsule 40 mg fluoxetine hcl oral solution 20 mg/5ml TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 2 $0 PA 2 $0 PA 1 $0 QL (60 EA per 30 days) 2 $0 PA; QL (30 EA per 30 days) 1 $0 QL (600 ML per 30 days) 1 $0 QL (45 EA per 30 days) 1 $0 QL (60 EA per 30 days) 2 $0 QL (30 EA per 30 days) 2 $0 QL (180 EA per 30 days) 2 $0 QL (90 EA per 30 days) 2 $0 1 1 1 $0 $0 $0 1 $0 QL (30 EA per 30 days) QL (120 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 64 NAME OF DRUG fluoxetine hcl oral tablet 10 mg fluoxetine hcl oral tablet 20 mg imipramine hcl oral tablet 10 mg, 25 mg, 50 mg maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg MARPLAN ORAL TABLET 10 MG mirtazapine oral tablet 15 mg, 7.5 mg mirtazapine oral tablet 30 mg, 45 mg mirtazapine oral tablet dispersible 15 mg mirtazapine oral tablet dispersible 30 mg, 45 mg nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg nortriptyline hcl oral solution 10 mg/5ml paroxetine hcl oral tablet 10 mg, 20 mg, 40 mg paroxetine hcl oral tablet 30 mg PAXIL ORAL SUSPENSION 10 MG/5ML phenelzine sulfate oral tablet 15 mg PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 25 MG, 50 MG protriptyline hcl oral tablet 10 mg, 5 mg TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE QL (45 EA per 30 days) 1 1 $0 $0 2 $0 1 $0 2 $0 QL (180 EA per 30 days) 1 $0 QL (45 EA per 30 days) 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 QL (45 EA per 30 days) 1 $0 QL (60 EA per 30 days) 2 $0 QL (900 ML per 30 days) 1 $0 2 $0 1 $0 PA QL (30 EA per 30 days) QL (30 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 65 NAME OF DRUG sertraline hcl oral concentrate 20 mg/ml sertraline hcl oral tablet 100 mg sertraline hcl oral tablet 25 mg, 50 mg SURMONTIL ORAL CAPSULE 100 MG SURMONTIL ORAL CAPSULE 25 MG SURMONTIL ORAL CAPSULE 50 MG tranylcypromine sulfate oral tablet 10 mg trazodone hcl oral tablet 100 mg, 150 mg, 50 mg venlafaxine hcl er oral capsule extended release 24 hour 150 mg venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg VIIBRYD ORAL KIT 10 & 20 & 40 MG VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG ANTIPARKINSONIAN AGENTS amantadine hcl oral capsule 100 mg amantadine hcl oral syrup 50 mg/5ml amantadine hcl oral tablet 100 mg APOKYN SUBCUTANEOUS* SOLUTION 10 MG/ML AZILECT ORAL TABLET 0.5 MG, 1 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 1 $0 1 $0 QL (45 EA per 30 days) 2 2 2 $0 $0 $0 PA; QL (60 EA per 30 days) PA; QL (240 EA per 30 days) PA; QL (120 EA per 30 days) 1 $0 1 $0 1 $0 QL (60 EA per 30 days) 1 $0 QL (30 EA per 30 days) 1 $0 2 $0 2 $0 1 $0 1 $0 1 $0 2 $0 2 $0 QL (30 EA per 30 days) PA; LA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 66 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE benztropine mesylate injection 1 $0 solution 1 mg/ml benztropine mesylate oral tablet 0.5 2 $0 PA mg, 1 mg, 2 mg bromocriptine mesylate oral capsule 1 $0 5 mg bromocriptine mesylate oral tablet 1 $0 2.5 mg carbidopa-levodopa er oral tablet extendedrelease* 25-100 mg, 1 $0 50-200 mg carbidopa-levodopa oral tablet 1 $0 10-100 mg, 25-100 mg, 25-250 mg carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 mg, 1 $0 25-250 mg carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 1 $0 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg entacapone oral tablet 200 mg 1 $0 NEUPRO TRANSDERMAL PATCH 24 HR 1 MG/24HR, 2 MG/24HR, 3 2 $0 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 1 $0 0.75 mg, 1 mg, 1.5 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 1 $0 mg selegiline hcl oral capsule 5 mg 1 $0 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 67 NAME OF DRUG selegiline hcl oral tablet 5 mg trihexyphenidyl hcl oral elixir 0.4 mg/ml trihexyphenidyl hcl oral tablet 2 mg, 5 mg ANTIPSYCHOTICS ABILIFY DISCMELT ORAL TABLET DISPERSIBLE 10 MG ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 300 MG, 400 MG aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg chlorpromazine hcl injection solution 25 mg/ml chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg clozapine oral tablet 100 mg clozapine oral tablet 200 mg clozapine oral tablet 25 mg, 50 mg clozapine oral tablet dispersible 100 mg clozapine oral tablet dispersible 12.5 mg, 25 mg CLOZAPINE ORAL TABLET DISPERSIBLE 150 MG CLOZAPINE ORAL TABLET DISPERSIBLE 200 MG FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 2 $0 PA 2 $0 PA 2 $0 QL (60 EA per 30 days) 2 $0 QL (1 EA per 28 days) 2 $0 QL (30 EA per 30 days) 2 $0 1 $0 1 1 1 $0 $0 $0 QL (270 EA per 30 days) QL (135 EA per 30 days) 1 $0 PA; QL (270 EA per 30 days) 1 $0 PA 2 $0 PA; QL (180 EA per 30 days) 2 $0 PA; QL (135 EA per 30 days) 2 $0 ST; QL (60 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 68 NAME OF DRUG FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG FAZACLO ORAL TABLET DISPERSIBLE 150 MG FAZACLO ORAL TABLET DISPERSIBLE 200 MG fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5ml fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg GEODON INTRAMUSCULAR* SOLUTION RECONSTITUTED 20 MG haloperidol decanoate intramuscular* solution 100 mg/ml, 50 mg/ml haloperidol lactate injection solution 5 mg/ml haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg INVEGA ORAL TABLET EXTENDED RELEASE 24 HR* 1.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET EXTENDED RELEASE 24 HR* 6 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 ST 2 $0 PA; QL (180 EA per 30 days) 2 $0 PA; QL (135 EA per 30 days) 1 $0 1 $0 1 $0 1 $0 1 $0 2 $0 1 $0 1 $0 1 $0 1 $0 2 $0 QL (30 EA per 30 days) 2 $0 QL (60 EA per 30 days) QL (6 EA per 3 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 69 NAME OF DRUG INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 117 MG/0.75ML INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 234 MG/1.5ML INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 39 MG/0.25ML INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 78 MG/0.5ML LATUDA ORAL TABLET 120 MG, 40 MG LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 60 MG, 80 MG loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg olanzapine intramuscular* solution reconstituted 10 mg olanzapine oral tablet 10 mg, 15 mg, 20 mg olanzapine oral tablet 2.5 mg, 5 mg, 7.5 mg olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg olanzapine oral tablet dispersible 5 mg TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 QL (0.75 ML per 28 days) 2 $0 QL (1 ML per 28 days) 2 $0 QL (1.5 ML per 28 days) 2 $0 QL (0.25 ML per 28 days) 2 $0 QL (0.5 ML per 28 days) 2 $0 QL (30 EA per 30 days) 2 $0 QL (240 EA per 30 days) 2 $0 QL (60 EA per 30 days) 1 $0 1 $0 QL (3 EA per 1 day) 1 $0 QL (60 EA per 30 days) 1 $0 QL (30 EA per 30 days) 1 $0 QL (60 EA per 30 days) 1 $0 QL (30 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 70 NAME OF DRUG ORAP ORAL TABLET 1 MG, 2 MG perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG risperidone oral solution 1 mg/ml risperidone oral tablet 0.25 mg, 0.5 mg risperidone oral tablet 1 mg, 2 mg, 3 mg risperidone oral tablet 4 mg risperidone oral tablet dispersible 0.25 mg, 0.5 mg risperidone oral tablet dispersible 1 mg, 2 mg, 3 mg risperidone oral tablet dispersible 4 mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 200 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 1 $0 1 $0 QL (90 EA per 30 days) 2 $0 QL (2 EA per 28 days) 1 $0 QL (240 ML per 30 days) 1 $0 QL (90 EA per 30 days) 1 $0 QL (60 EA per 30 days) 1 $0 QL (120 EA per 30 days) 1 $0 QL (90 EA per 30 days) 1 $0 QL (60 EA per 30 days) 1 $0 QL (120 EA per 30 days) 2 $0 QL (60 EA per 30 days) 2 $0 QL (240 EA per 30 days) 2 $0 QL (120 EA per 30 days) 2 $0 QL (30 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 71 NAME OF DRUG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 300 MG, 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 50 MG thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML ziprasidone hcl oral capsule 20 mg, 40 mg ziprasidone hcl oral capsule 60 mg, 80 mg ZYPREXA RELPREVV INTRAMUSCULAR* SUSPENSION RECONSTITUTED 210 MG, 300 MG ZYPREXA RELPREVV INTRAMUSCULAR* SUSPENSION RECONSTITUTED 405 MG ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 5 mg amphetamine-dextroamphet er oral capsule extended release 24 hour 15 mg, 20 mg, 25 mg, 30 mg TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 QL (60 EA per 30 days) 2 $0 QL (120 EA per 30 days) 2 $0 PA 1 $0 1 $0 2 $0 PA; QL (600 ML per 30 days) 1 $0 QL (60 EA per 30 days) 1 $0 QL (90 EA per 30 days) 2 $0 PA; QL (2 EA per 28 days) 2 $0 PA; QL (1 EA per 28 days) 1 $0 QL (90 EA per 30 days) 1 $0 QL (30 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 72 NAME OF DRUG amphetamine-dextroamphetamine oral tablet 10 mg amphetamine-dextroamphetamine oral tablet 12.5 mg amphetamine-dextroamphetamine oral tablet 15 mg amphetamine-dextroamphetamine oral tablet 20 mg amphetamine-dextroamphetamine oral tablet 30 mg amphetamine-dextroamphetamine oral tablet 5 mg amphetamine-dextroamphetamine oral tablet 7.5 mg guanfacine hcl er oral tablet extended release 24 hr* 1 mg, 2 mg, 3 mg, 4 mg metadate er oral tablet extendedrelease* 20 mg methylphenidate hcl er oral tablet extendedrelease* 10 mg, 20 mg methylphenidate hcl oral solution 10 mg/5ml methylphenidate hcl oral solution 5 mg/5ml methylphenidate hcl oral tablet 10 mg, 5 mg methylphenidate hcl oral tablet 20 mg STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 QL (180 EA per 30 days) 1 $0 QL (144 EA per 30 days) 1 $0 QL (120 EA per 30 days) 1 $0 QL (90 EA per 30 days) 1 $0 QL (60 EA per 30 days) 1 $0 QL (360 EA per 30 days) 1 $0 QL (240 EA per 30 days) 2 $0 PA 1 $0 QL (90 EA per 30 days) 1 $0 QL (90 EA per 30 days) 1 $0 QL (900 ML per 30 days) 1 $0 QL (1800 ML per 30 days) 1 $0 QL (180 EA per 30 days) 1 $0 QL (90 EA per 30 days) 2 $0 QL (120 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 73 NAME OF DRUG STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG STRATTERA ORAL CAPSULE 40 MG HYPNOTICS HETLIOZ ORAL CAPSULE 20 MG ROZEREM ORAL TABLET 8 MG SILENOR ORAL TABLET 3 MG SILENOR ORAL TABLET 6 MG temazepam oral capsule 15 mg temazepam oral capsule 7.5 mg zolpidem tartrate oral tablet 10 mg, 5 mg MIGRAINE dihydroergotamine mesylate injection solution 1 mg/ml naratriptan hcl oral tablet 1 mg, 2.5 mg RELPAX ORAL TABLET 20 MG, 40 MG rizatriptan benzoate oral tablet 10 mg, 5 mg rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg sumatriptan nasal solution 20 mg/act sumatriptan nasal solution 5 mg/act sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg sumatriptan succinate refill subcutaneous* 4 mg/0.5ml, 6 mg/0.5ml TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 QL (30 EA per 30 days) 2 $0 QL (60 EA per 30 days) 2 2 2 2 1 1 $0 $0 $0 $0 $0 $0 PA; LA QL (30 EA per 30 days) QL (60 EA per 30 days) QL (30 EA per 30 days) PA; QL (60 EA per 30 days) PA; QL (30 EA per 30 days) 2 $0 PA; QL (30 EA per 30 days) 1 $0 1 $0 QL (9 EA per 30 days) 2 $0 QL (12 EA per 30 days) 1 $0 QL (18 EA per 30 days) 1 $0 QL (18 EA per 30 days) 1 $0 QL (12 EA per 30 days) 1 $0 QL (24 EA per 30 days) 1 $0 QL (9 EA per 30 days) 1 $0 QL (6 ML per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 74 NAME OF DRUG sumatriptan succinate subcutaneous* 4 mg/0.5ml sumatriptan succinate subcutaneous* 6 mg/0.5ml sumatriptan succinate subcutaneous* solution 6 mg/0.5ml zolmitriptan oral tablet 2.5 mg, 5 mg zolmitriptan oral tablet dispersible 2.5 mg, 5 mg MISCELLANEOUS lithium carbonate er oral tablet extendedrelease* 300 mg, 450 mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg LITHIUM ORAL SOLUTION 8 MEQ/5ML NUEDEXTA ORAL CAPSULE 20-10 MG pyridostigmine bromide oral tablet 60 mg riluzole oral tablet 50 mg XENAZINE ORAL TABLET 12.5 MG XENAZINE ORAL TABLET 25 MG MULTIPLE SCLEROSIS AGENTS AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR* 10 MG BETASERON SUBCUTANEOUS* KIT 0.3 MG COPAXONE SUBCUTANEOUS* 40 MG/ML TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 QL (6 ML per 30 days) 1 $0 QL (6 ML per 30 days) 1 $0 QL (6 ML per 30 days) 1 $0 QL (12 EA per 30 days) 1 $0 QL (12 EA per 30 days) 1 $0 1 $0 1 $0 2 $0 2 $0 1 $0 1 2 2 $0 $0 $0 PA; LA ; QL (240 EA per 30 days) PA; LA ; QL (120 EA per 30 days) 2 $0 PA; LA 2 $0 PA; QL (14 EA per 28 days) 2 $0 PA; QL (12 ML per 28 days) PA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 75 NAME OF DRUG GILENYA ORAL CAPSULE 0.5 MG glatopa subcutaneous* 20 mg/ml TYSABRI INTRAVENOUS* CONCENTRATE 300 MG/15ML MUSCULOSKELETAL THERAPY AGENTS 2 2 $0 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE PA; QL (28 EA per 28 days) PA; QL (30 ML per 30 days) 2 $0 PA; LA baclofen oral tablet 10 mg, 20 mg dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg tizanidine hcl oral tablet 2 mg, 4 mg NARCOLEPSY/CATAPLEXY 1 $0 1 $0 1 $0 NUVIGIL ORAL TABLET 150 MG NUVIGIL ORAL TABLET 200 MG, 250 MG NUVIGIL ORAL TABLET 50 MG XYREM ORAL SOLUTION 500 MG/ML PSYCHOTHERAPEUTIC-MISC 2 $0 PA; QL (60 EA per 30 days) 2 $0 PA; QL (30 EA per 30 days) 2 2 $0 $0 PA; QL (150 EA per 30 days) PA; LA ; QL (540 ML per 30 days) 1 $0 1 $0 PA 1 $0 PA; QL (120 EA per 30 days) 1 $0 2 $0 PA 2 $0 PA acamprosate calcium oral tablet delayed release 333 mg buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg, 8-2 mg buproban oral tablet extended release 12 hr* 150 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG TIER WHAT THE DRUG LEVEL WILL COST YOU You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 76 NAME OF DRUG CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42 disulfiram oral tablet 250 mg, 500 mg naloxone hcl injection solution 0.4 mg/ml, 1 mg/ml naltrexone hcl oral tablet 50 mg NICOTROL INHALATION INHALER 10 MG NICOTROL NS NASAL SOLUTION 10 MG/ML SUBOXONE SUBLINGUAL FILM 12-3 MG SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG, 8-2 MG ENDOCRINE AND METABOLIC TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 PA 1 $0 1 $0 1 $0 2 $0 2 $0 2 $0 PA; QL (60 EA per 30 days) 2 $0 PA; QL (120 EA per 30 days) 2 $0 PA; QL (30 EA per 30 days) 2 $0 PA; QL (440 ML per 30 days) 2 1 $0 $0 PA PA 1 $0 PA 1 $0 PA ANDROGENS ANDRODERM TRANSDERMAL PATCH 24 HR 2 MG/24HR, 4 MG/24HR AXIRON TRANSDERMAL SOLUTION 30 MG/ACT oxandrolone oral tablet 10 mg oxandrolone oral tablet 2.5 mg testosterone cypionate intramuscular* solution 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular* solution 200 mg/ml You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 77 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE ANTIDIABETICS, INJECTABLE ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML BYDUREON SUBCUTANEOUS* 2 MG BYDUREON SUBCUTANEOUS* SUSPENSION RECONSTITUTED 2 MG BYETTA 10 MCG PEN SUBCUTANEOUS* 10 MCG/0.04ML BYETTA 5 MCG PEN SUBCUTANEOUS* 5 MCG/0.02ML EXCEL COMFORT POINT PEN NEEDLE 29G X 12MM GLOBAL ALCOHOL PREP EASE PAD 70 % HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML LANTUS SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS* 100 UNIT/ML LEVEMIR SUBCUTANEOUS* SOLUTION 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N SUBCUTANEOUS* SUSPENSION 100 UNIT/ML 2 $0 2 $0 QL (4 EA per 28 days) 2 $0 QL (4 EA per 28 days) 2 $0 QL (2.4 ML per 30 days) 2 $0 QL (1.2 ML per 30 days) 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 B/D You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 78 NAME OF DRUG NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS* 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS* (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS* 100 UNIT/ML NOVOLOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML PREFERRED PLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML RA STERILE PAD 2"X2" SYMLINPEN 120 SUBCUTANEOUS* 2700 MCG/2.7ML SYMLINPEN 60 SUBCUTANEOUS* 1500 MCG/1.5ML VICTOZA SUBCUTANEOUS* 18 MG/3ML ANTIDIABETICS, ORAL acarbose oral tablet 100 mg, 25 mg, 50 mg FARXIGA ORAL TABLET 10 MG FARXIGA ORAL TABLET 5 MG glimepiride oral tablet 1 mg glimepiride oral tablet 2 mg glimepiride oral tablet 4 mg TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 PA; QL (10.8 ML per 30 days) 2 $0 PA; QL (12 ML per 30 days) 2 $0 QL (9 ML per 30 days) 1 $0 2 2 1 1 1 $0 $0 $0 $0 $0 QL (30 EA per 30 days) QL (60 EA per 30 days) QL (240 EA per 30 days) QL (120 EA per 30 days) QL (60 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 79 NAME OF DRUG glipizide er oral tablet extended release 24 hr* 10 mg glipizide er oral tablet extended release 24 hr* 2.5 mg glipizide er oral tablet extended release 24 hr* 5 mg glipizide oral tablet 10 mg glipizide oral tablet 5 mg glipizide-metformin hcl oral tablet 2.5-250 mg glipizide-metformin hcl oral tablet 2.5-500 mg, 5-500 mg INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG INVOKAMET ORAL TABLET 50-500 MG INVOKANA ORAL TABLET 100 MG INVOKANA ORAL TABLET 300 MG JANUMET ORAL TABLET 50-1000 MG, 50-500 MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 100-1000 MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 50-1000 MG, 50-500 MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 QL (60 EA per 30 days) 1 $0 QL (240 EA per 30 days) 1 $0 QL (120 EA per 30 days) 1 1 $0 $0 QL (120 EA per 30 days) QL (240 EA per 30 days) 1 $0 QL (240 EA per 30 days) 1 $0 QL (120 EA per 30 days) 2 $0 QL (60 EA per 30 days) 2 $0 QL (120 EA per 30 days) 2 2 $0 $0 QL (90 EA per 30 days) QL (30 EA per 30 days) 2 $0 QL (60 EA per 30 days) 2 $0 QL (30 EA per 30 days) 2 $0 QL (60 EA per 30 days) 2 $0 QL (30 EA per 30 days) 2 $0 QL (60 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 80 NAME OF DRUG metformin hcl er oral tablet extended release 24 hr* 500 mg metformin hcl er oral tablet extended release 24 hr* 750 mg metformin hcl oral tablet 1000 mg metformin hcl oral tablet 500 mg metformin hcl oral tablet 850 mg nateglinide oral tablet 120 mg, 60 mg pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg repaglinide oral tablet 0.5 mg, 1 mg repaglinide oral tablet 2 mg TRADJENTA ORAL TABLET 5 MG ANTIDIABETICS, TESTING SUPPLIES TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 QL (120 EA per 30 days) 1 $0 QL (60 EA per 30 days) 1 1 1 $0 $0 $0 QL (75 EA per 30 days) QL (150 EA per 30 days) QL (90 EA per 30 days) 1 $0 QL (90 EA per 30 days) 1 $0 QL (30 EA per 30 days) 1 1 2 $0 $0 $0 QL (120 EA per 30 days) QL (240 EA per 30 days) QL (30 EA per 30 days) ONETOUCH ULTRA 2 KIT W/DEVICE Part B $0 ONETOUCH ULTRA BLUE IN VITRO STRIP Part B $0 ONETOUCH ULTRA MINI KIT W/DEVICE Part B $0 ONETOUCH ULTRA SYSTEM KIT W/DEVICE ONETOUCH ULTRASMART KIT W/DEVICE NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE Part B $0 Part B $0 NDC (53885044801); QL (1 EA per 365 days) NDC (53885024450, 53885024510, 53885099425); QL (100 EA per 25 days) NDC (53885042101, 53885042001, 53885020801, 53885091101, 53885091201, 53885041901); QL (1 EA per 365 days) NDC (53885024701); QL (1 EA per 365 days) NDC (53885052401); QL (1 EA per 365 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 81 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU ONETOUCH VERIO IN VITRO STRIP Part B $0 ONETOUCH VERIO IQ SYSTEM KIT W/DEVICE Part B $0 ONETOUCH VERIO KIT W/DEVICE Part B $0 ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE BISPHOSPHONATES alendronate sodium oral tablet 10 mg, 40 mg, 5 mg alendronate sodium oral tablet 35 mg, 70 mg ibandronate sodium oral tablet 150 mg pamidronate disodium intravenous* solution 30 mg/10ml, 6 mg/ml, 90 mg/10ml zoledronic acid intravenous* concentrate 4 mg/5ml zoledronic acid intravenous* solution 5 mg/100ml CALCIUM RECEPTOR AGONISTS SENSIPAR ORAL TABLET 30 MG, 90 MG SENSIPAR ORAL TABLET 60 MG CHELATING AGENTS CHEMET ORAL CAPSULE 100 MG DEPEN TITRATABS ORAL TABLET 250 MG Part B $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE NDC (53885027210, 53885027150, 53885027025); QL (100 EA per 25 days) NDC (53885026701); QL (1 EA per 365 days) NDC (53885065701); QL (1 EA per 365 days) NDC (53885039601); QL (1 EA per 365 days) 1 $0 1 $0 QL (4 EA per 28 days) 1 $0 B/D; QL (1 EA per 30 days) 1 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 QL (120 EA per 30 days) 2 $0 QL (60 EA per 30 days) 2 $0 2 $0 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 82 NAME OF DRUG EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG FERRIPROX ORAL TABLET 500 MG kionex oral powder kionex oral suspension 15 gm/60ml sodium polystyrene sulfonate oral suspension 15 gm/60ml sps oral suspension 15 gm/60ml SYPRINE ORAL CAPSULE 250 MG CONTRACEPTIVES altavera oral tablet 0.15-30 mg-mcg apri oral tablet 0.15-30 mg-mcg aranelle oral tablet 0.5/1/0.5-35 mg-mcg aubra oral tablet 0.1-20 mg-mcg aviane oral tablet 0.1-20 mg-mcg balziva oral tablet 0.4-35 mg-mcg briellyn oral tablet 0.4-35 mg-mcg camila oral tablet 0.35 mg cryselle-28 oral tablet 0.3-30 mg-mcg cyclafem 1/35 oral tablet 1-35 mg-mcg cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg deblitane oral tablet 0.35 mg delyla oral tablet 0.1-20 mg-mcg desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5) drospirenone-ethinyl estradiol oral tablet 3-0.03 mg TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 PA; LA 2 1 1 $0 $0 $0 PA; LA 1 $0 1 2 $0 $0 1 1 $0 $0 1 $0 1 1 1 1 1 $0 $0 $0 $0 $0 1 $0 1 $0 1 $0 1 1 $0 $0 1 $0 1 $0 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 83 NAME OF DRUG emoquette oral tablet 0.15-30 mg-mcg enpresse-28 oral tablet errin oral tablet 0.35 mg falmina oral tablet 0.1-20 mg-mcg gianvi oral tablet 3-0.02 mg gildagia oral tablet 0.4-35 mg-mcg gildess 1.5/30 oral tablet 1.5-30 mg-mcg heather oral tablet 0.35 mg introvale oral tablet 0.15-0.03 mg jolessa oral tablet 0.15-0.03 mg jolivette oral tablet 0.35 mg junel 1.5/30 oral tablet 1.5-30 mg-mcg junel 1/20 oral tablet 1-20 mg-mcg junel fe 1.5/30 oral tablet 1.5-30 mg-mcg junel fe 1/20 oral tablet 1-20 mg-mcg kariva oral tablet 0.15-0.02/0.01 mg (21/5) kelnor 1/35 oral tablet 1-35 mg-mcg larin 1.5/30 oral tablet 1.5-30 mg-mcg larin 1/20 oral tablet 1-20 mg-mcg larin fe 1.5/30 oral tablet 1.5-30 mg-mcg larin fe 1/20 oral tablet 1-20 mg-mcg TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 1 1 1 1 $0 $0 $0 $0 $0 1 $0 1 1 1 1 $0 $0 $0 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 84 NAME OF DRUG leena oral tablet 0.5/1/0.5-35 mg-mcg lessina oral tablet 0.1-20 mg-mcg levonest oral tablet levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg levonorgestrel oral tablet 0.75 mg, 1.5 mg levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg levora 0.15/30 (28) oral tablet 0.15-30 mg-mcg loryna oral tablet 3-0.02 mg low-ogestrel oral tablet 0.3-30 mg-mcg lutera oral tablet 0.1-20 mg-mcg lyza oral tablet 0.35 mg marlissa oral tablet 0.15-30 mg-mcg medroxyprogesterone acetate intramuscular* suspension 150 mg/ml microgestin 1.5/30 oral tablet 1.5-30 mg-mcg microgestin 1/20 oral tablet 1-20 mg-mcg microgestin fe 1.5/30 oral tablet 1.5-30 mg-mcg microgestin fe 1/20 oral tablet 1-20 mg-mcg mononessa oral tablet 0.25-35 mg-mcg TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 1 $0 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 1 $0 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 85 NAME OF DRUG myzilra oral tablet necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg necon 1/35 (28) oral tablet 1-35 mg-mcg necon 1/50 (28) oral tablet 1-50 mg-mcg necon 10/11 (28) oral tablet 35 mcg necon 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg next choice one dose oral tablet 1.5 mg nikki oral tablet 3-0.02 mg nora-be oral tablet 0.35 mg norethindrone oral tablet 0.35 mg norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg norlyroc oral tablet 0.35 mg nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg nortrel 1/35 (21) oral tablet 1-35 mg-mcg nortrel 1/35 (28) oral tablet 1-35 mg-mcg nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg NUVARING VAGINAL RING 0.12-0.015 MG/24HR ocella oral tablet 3-0.03 mg orsythia oral tablet 0.1-20 mg-mcg philith oral tablet 0.4-35 mg-mcg TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 1 $0 2 $0 1 $0 1 $0 1 1 1 $0 $0 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 2 $0 1 1 1 $0 $0 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 86 NAME OF DRUG pimtrea oral tablet 0.15-0.02/0.01 mg (21/5) pirmella 1/35 oral tablet 1-35 mg-mcg portia-28 oral tablet 0.15-30 mg-mcg previfem oral tablet 0.25-35 mg-mcg quasense oral tablet 0.15-0.03 mg reclipsen oral tablet 0.15-30 mg-mcg sharobel oral tablet 0.35 mg solia oral tablet 0.15-30 mg-mcg sprintec 28 oral tablet 0.25-35 mg-mcg sronyx oral tablet 0.1-20 mg-mcg syeda oral tablet 3-0.03 mg tarina fe 1/20 oral tablet 1-20 mg-mcg tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg trivora (28) oral tablet velivet oral tablet 0.1/0.125/0.15 -0.025 mg vestura oral tablet 3-0.02 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 1 $0 $0 1 $0 1 1 $0 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 87 NAME OF DRUG viorele oral tablet 0.15-0.02/0.01 mg (21/5) vyfemla oral tablet 0.4-35 mg-mcg xulane transdermal patch weekly 150-35 mcg/24hr zarah oral tablet 3-0.03 mg zenchent oral tablet 0.4-35 mg-mcg zovia 1/35e (28) oral tablet 1-35 mg-mcg zovia 1/50e (28) oral tablet 1-50 mg-mcg ENDOMETRIOSIS danazol oral capsule 100 mg, 200 mg, 50 mg SYNAREL NASAL SOLUTION 2 MG/ML ENZYME REPLACEMENTS TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 1 1 $0 $0 1 $0 1 $0 1 $0 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE ADAGEN INTRAMUSCULAR* 2 $0 PA; LA SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS* 2 $0 PA; LA SOLUTION 2.9 MG/5ML CARBAGLU ORAL TABLET 200 MG 2 $0 PA; LA CERDELGA ORAL CAPSULE 84 MG 2 $0 PA CEREZYME INTRAVENOUS* SOLUTION RECONSTITUTED 200 2 $0 PA; LA UNIT, 400 UNIT CYSTADANE ORAL POWDER 2 $0 LA CYSTAGON ORAL CAPSULE 150 MG, 2 $0 PA; LA 50 MG FABRAZYME INTRAVENOUS* SOLUTION RECONSTITUTED 35 MG, 2 $0 PA; LA 5 MG You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 88 NAME OF DRUG KUVAN ORAL PACKET 100 MG, 500 MG KUVAN ORAL TABLET SOLUBLE 100 MG levocarnitine intravenous* solution 200 mg/ml levocarnitine oral solution 1 gm/10ml levocarnitine oral tablet 330 mg LUMIZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG MYOZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG NAGLAZYME INTRAVENOUS* SOLUTION 1 MG/ML ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG RAVICTI ORAL LIQUID† 1.1 GM/ML sodium phenylbutyrate oral powder 3 gm/tsp ZAVESCA ORAL CAPSULE 100 MG ESTROGENS DELESTROGEN INTRAMUSCULAR* OIL 10 MG/ML estrace vaginal cream 0.1 mg/gm estradiol oral tablet 0.5 mg, 1 mg, 2 mg estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 PA; LA 2 $0 PA; LA 1 $0 B/D 1 $0 B/D 1 $0 B/D 2 $0 PA; LA 2 $0 PA; LA 2 $0 PA; LA 2 $0 PA; LA 2 $0 PA 2 $0 2 $0 2 $0 2 $0 2 $0 PA 2 $0 PA PA; LA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 89 NAME OF DRUG estradiol valerate intramuscular* oil 20 mg/ml, 40 mg/ml jinteli oral tablet 1-5 mg-mcg norethindrone-eth estradiol oral tablet 1-5 mg-mcg VAGIFEM VAGINAL TABLET 10 MCG GLUCOCORTICOIDS a-hydrocort injection solution reconstituted 100 mg cortisone acetate oral tablet 25 mg dexamethasone intensol oral concentrate 1 mg/ml dexamethasone oral elixir 0.5 mg/5ml dexamethasone oral solution 0.5 mg/5ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg dexamethasone sod phosphate pf injection solution 10 mg/ml dexamethasone sodium phosphate injection solution 10 mg/ml, 100 mg/10ml, 120 mg/30ml, 20 mg/5ml fludrocortisone acetate oral tablet 0.1 mg hydrocortisone oral tablet 10 mg, 20 mg, 5 mg methylprednisolone (pak) oral tablet 4 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 2 $0 PA 2 $0 PA 2 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 B/D 1 $0 B/D You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 90 NAME OF DRUG methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg methylprednisolone sodium succ injection solution reconstituted 1 gm, 125 mg, 40 mg prednisolone oral solution 15 mg/5ml prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml prednisone (pak) oral tablet 10 mg, 5 mg prednisone intensol oral concentrate 5 mg/ml prednisone oral solution 5 mg/5ml prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 250 MG GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG KORLYM ORAL TABLET 300 MG PROGLYCEM ORAL SUSPENSION 50 MG/ML HUMAN GROWTH HORMONES NORDITROPIN FLEXPRO SUBCUTANEOUS* SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 5 MG/1.5ML TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 B/D 1 $0 B/D 1 $0 B/D 1 $0 B/D 1 $0 B/D 2 $0 B/D 1 $0 B/D 1 $0 B/D 2 $0 2 $0 2 $0 2 $0 2 $0 2 $0 PA; LA PA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 91 NAME OF DRUG NORDITROPIN NORDIFLEX PEN SUBCUTANEOUS* SOLUTION 30 MG/3ML MISCELLANEOUS cabergoline oral tablet 0.5 mg calcitonin (salmon) nasal solution 200 unit/act FORTICAL NASAL SOLUTION 200 UNIT/ACT INCRELEX SUBCUTANEOUS* SOLUTION 40 MG/4ML methylergonovine maleate oral tablet 0.2 mg MIACALCIN INJECTION SOLUTION 200 UNIT/ML octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml octreotide acetate injection solution 1000 mcg/ml, 200 mcg/ml, 500 mcg/ml PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML raloxifene hcl oral tablet 60 mg SANDOSTATIN LAR DEPOT INTRAMUSCULAR* KIT 10 MG, 20 MG, 30 MG SIGNIFOR SUBCUTANEOUS* SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 PA 1 $0 1 $0 2 $0 2 $0 1 $0 2 $0 B/D 1 $0 PA 2 $0 PA 2 $0 QL (1 ML per 180 days) 1 $0 2 $0 PA 2 $0 PA; LA PA; LA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 92 NAME OF DRUG SOMATULINE DEPOT SUBCUTANEOUS* SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML SOMAVERT SUBCUTANEOUS* SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG XGEVA SUBCUTANEOUS* SOLUTION 120 MG/1.7ML PARATHYROID HORMONES FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML NATPARA SUBCUTANEOUS* 100 MCG, 25 MCG, 50 MCG, 75 MCG PHOSPHATE BINDER AGENTS calcium acetate oral capsule 667 mg RENVELA ORAL PACKET 0.8 GM, 2.4 GM RENVELA ORAL TABLET 800 MG PROGESTINS medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg norethindrone acetate oral tablet 5 mg THYROID AGENTS levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 PA 2 $0 PA; LA 2 $0 PA 2 $0 PA; QL (2.4 ML per 28 days) 2 $0 PA 1 $0 2 $0 2 $0 1 $0 1 $0 1 $0 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 93 NAME OF DRUG levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg methimazole oral tablet 10 mg, 5 mg propylthiouracil oral tablet 50 mg SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg VASOPRESSINS desmopressin ace rhinal tube nasal solution 0.01 % desmopressin ace spray refrig nasal solution 0.01 % desmopressin acetate injection solution 4 mcg/ml desmopressin acetate oral tablet 0.1 mg, 0.2 mg desmopressin acetate spray nasal solution 0.01 % GASTROINTESTINAL TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 1 $0 2 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE ANTIEMETICS compro suppository 25 mg You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 94 NAME OF DRUG dronabinol oral capsule 10 mg dronabinol oral capsule 2.5 mg, 5 mg EMEND ORAL CAPSULE 125 MG, 40 MG, 80 & 125 MG, 80 MG granisetron hcl intravenous* solution 0.1 mg/ml, 1 mg/ml, 4 mg/4ml granisetron hcl oral tablet 1 mg meclizine hcl oral tablet 12.5 mg, 25 mg metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 5 mg/5ml metoclopramide hcl oral tablet 10 mg, 5 mg ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml ondansetron hcl oral solution 4 mg/5ml ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg ondansetron oral tablet dispersible 4 mg, 8 mg phenadoz suppository 12.5 mg phenergan suppository 12.5 mg, 25 mg, 50 mg prochlorperazine edisylate injection solution 5 mg/ml prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine suppository 25 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE B/D; QL (60 EA per 30 days) 1 $0 B/D; QL (60 EA per 30 days) 2 $0 B/D 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 B/D 1 $0 B/D 1 $0 B/D 2 $0 PA 2 $0 PA 1 $0 1 $0 1 $0 B/D You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 95 NAME OF DRUG promethazine hcl injection solution 25 mg/ml, 50 mg/ml promethazine hcl oral syrup 6.25 mg/5ml promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg promethazine hcl suppository 12.5 mg, 25 mg, 50 mg promethegan suppository 25 mg, 50 mg TRANSDERM-SCOP TRANSDERMAL PATCH 72 HR 1 MG/3DAYS ANTISPASMODICS CUVPOSA ORAL SOLUTION 1 MG/5ML dicyclomine hcl oral capsule 10 mg dicyclomine hcl oral solution 10 mg/5ml dicyclomine hcl oral tablet 20 mg glycopyrrolate injection solution 4 mg/20ml glycopyrrolate oral tablet 1 mg, 2 mg H2-RECEPTOR ANTAGONISTS famotidine intravenous* solution 20 mg/2ml, 200 mg/20ml, 40 mg/4ml famotidine oral suspension reconstituted 40 mg/5ml famotidine oral tablet 20 mg, 40 mg famotidine premixed intravenous* solution 20-0.9 mg/50ml-% TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 PA; QL (10 EA per 30 days) 2 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 96 NAME OF DRUG ranitidine hcl injection solution 150 mg/6ml, 50 mg/2ml ranitidine hcl oral syrup 15 mg/ml ranitidine hcl oral tablet 150 mg, 300 mg INFLAMMATORY BOWEL DISEASE APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM ASACOL HD ORAL TABLET DELAYED RELEASE 800 MG balsalazide disodium oral capsule 750 mg budesonide er oral capsule extended release 24 hour 3 mg CANASA SUPPOSITORY 1000 MG colocort enema 100 mg/60ml DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG DIPENTUM ORAL CAPSULE 250 MG hydrocortisone enema 100 mg/60ml mesalamine enema 4 gm mesalamine-cleanser kit 4 gm sulfasalazine oral tablet 500 mg sulfazine ec oral tablet delayed release 500 mg UCERIS ORAL TABLET EXTENDED RELEASE 24 HR* 9 MG LAXATIVES constulose oral solution 10 gm/15ml enulose oral solution 10 gm/15ml TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 2 $0 2 $0 1 $0 2 $0 2 1 $0 $0 2 $0 2 1 1 1 1 $0 $0 $0 $0 $0 1 $0 2 $0 1 1 $0 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 97 NAME OF DRUG gavilyte-c oral solution reconstituted 240 gm gavilyte-g oral solution reconstituted 236 gm gavilyte-h oral kit 5-210 mg-gm gavilyte-n with flavor pack oral solution reconstituted 420 gm generlac oral solution 10 gm/15ml GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM, 236 GM lactulose encephalopathy oral solution 10 gm/15ml lactulose oral solution 10 gm/15ml MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM NULYTELY WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 420 GM peg 3350/electrolytes oral solution reconstituted 240 gm peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm peg-3350/electrolytes oral solution reconstituted 236 gm polyethylene glycol 3350 oral packet polyethylene glycol 3350 oral powder RELISTOR SUBCUTANEOUS* SOLUTION 12 MG/0.6ML, 8 MG/0.4ML TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 1 $0 1 $0 2 $0 1 $0 1 $0 2 $0 2 $0 1 $0 1 $0 1 $0 1 $0 1 $0 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE PA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 98 NAME OF DRUG SUPREP BOWEL PREP ORAL SOLUTION trilyte oral solution reconstituted 420 gm MISCELLANEOUS alosetron hcl oral tablet 0.5 mg, 1 mg AMITIZA ORAL CAPSULE 24 MCG, 8 MCG cromolyn sodium oral concentrate 100 mg/5ml diphenoxylate-atropine oral liquid† 2.5-0.025 mg/5ml diphenoxylate-atropine oral tablet 2.5-0.025 mg GATTEX SUBCUTANEOUS* KIT 5 MG LINZESS ORAL CAPSULE 145 MCG LINZESS ORAL CAPSULE 290 MCG loperamide hcl oral capsule 2 mg misoprostol oral tablet 100 mcg, 200 mcg MOVANTIK ORAL TABLET 12.5 MG MOVANTIK ORAL TABLET 25 MG SUCRAID ORAL SOLUTION 8500 UNIT/ML sucralfate oral tablet 1 gm ursodiol oral capsule 300 mg ursodiol oral tablet 250 mg, 500 mg XIFAXAN ORAL TABLET 550 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 1 $0 2 $0 PA 2 $0 QL (60 EA per 30 days) 2 $0 1 $0 1 $0 2 2 2 1 $0 $0 $0 $0 1 $0 2 2 $0 $0 QL (60 EA per 30 days) QL (30 EA per 30 days) 2 $0 LA 1 1 1 2 $0 $0 $0 $0 PA PA; LA QL (60 EA per 30 days) QL (30 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 99 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE PANCREATIC ENZYMES CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000 UNIT, 20000 UNIT, 25000 UNIT, 3000-10000 UNIT, 40000 UNIT, 5000 UNIT PROTON PUMP INHIBITORS DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 MG esomeprazole sodium intravenous* solution reconstituted 20 mg, 40 mg NEXIUM ORAL CAPSULE DELAYED RELEASE 20 MG, 40 MG NEXIUM ORAL PACKET 10 MG, 20 MG, 40 MG NEXIUM ORAL PACKET 2.5 MG, 5 MG omeprazole oral capsule delayed release 10 mg, 40 mg omeprazole oral capsule delayed release 20 mg pantoprazole sodium oral tablet delayed release 20 mg, 40 mg GENITOURINARY 2 $0 2 $0 2 $0 1 $0 2 $0 QL (30 EA per 30 days) 2 $0 QL (30 EA per 30 days) 2 $0 1 $0 QL (30 EA per 30 days) 1 $0 QL (60 EA per 30 days) 1 $0 QL (30 EA per 30 days) 1 $0 QL (30 EA per 30 days) 2 $0 QL (30 EA per 30 days) QL (30 EA per 30 days) BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl er oral tablet extended release 24 hr* 10 mg AVODART ORAL CAPSULE 0.5 MG You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 100 NAME OF DRUG finasteride oral tablet 5 mg JALYN ORAL CAPSULE 0.5-0.4 MG tamsulosin hcl oral capsule 0.4 mg MISCELLANEOUS bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg ELMIRON ORAL CAPSULE 100 MG potassium citrate er oral tablet extendedrelease* 10 meq (1080 mg), 5 meq (540 mg) URINARY ANTISPASMODICS MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR* 25 MG MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR* 50 MG oxybutynin chloride er oral tablet extended release 24 hr* 10 mg, 15 mg oxybutynin chloride er oral tablet extended release 24 hr* 5 mg oxybutynin chloride oral syrup 5 mg/5ml oxybutynin chloride oral tablet 5 mg tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg tolterodine tartrate oral tablet 1 mg, 2 mg TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR* 4 MG, 8 MG trospium chloride oral tablet 20 mg TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 2 1 $0 $0 $0 1 $0 2 $0 1 $0 2 $0 QL (60 EA per 30 days) 2 $0 QL (30 EA per 30 days) 1 $0 QL (60 EA per 30 days) 1 $0 QL (30 EA per 30 days) 1 $0 1 $0 1 $0 1 $0 2 $0 QL (30 EA per 30 days) 1 $0 QL (60 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 101 NAME OF DRUG VESICARE ORAL TABLET 10 MG, 5 MG VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal cream 2 % metronidazole vaginal 0.75 % terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg vandazole vaginal 0.75 % zazole vaginal cream 0.4 % zazole vaginal cream 0.8 % HEMATOLOGIC TIER WHAT THE DRUG LEVEL WILL COST YOU 2 $0 1 $0 1 $0 1 $0 1 $0 1 1 1 $0 $0 $0 2 $0 2 $0 1 $0 2 $0 1 $0 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE QL (30 EA per 30 days) ANTICOAGULANTS COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG ELIQUIS ORAL TABLET 2.5 MG, 5 MG enoxaparin sodium injection solution 300 mg/3ml enoxaparin sodium subcutaneous* solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml enoxaparin sodium subcutaneous* solution 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml fondaparinux sodium subcutaneous* solution 10 mg/0.8ml, 5 mg/0.4ml, 7.5 mg/0.6ml You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 102 NAME OF DRUG fondaparinux sodium subcutaneous* solution 2.5 mg/0.5ml HEPARIN (PORCINE) IN D5W INTRAVENOUS* SOLUTION 40-5 UNIT/ML-%, 50-5 UNIT/ML-% HEPARIN (PORCINE) IN NACL INJECTION SOLUTION 100-0.45 UNIT/ML-%, 50-0.45 UNIT/ML-% HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS* SOLUTION 100 UNIT/ML heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml HEPARIN SODIUM (PORCINE) INJECTION SOLUTION 2500 UNIT/ML HEPARIN SODIUM (PORCINE) INTRAVENOUS* SOLUTION 2000 UNIT/ML jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 150 MG, 75 MG warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO STARTER PACK ORAL 15 & 20 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 2 $0 2 $0 2 $0 1 $0 B/D 2 $0 B/D 2 $0 B/D 1 $0 2 $0 1 $0 2 $0 2 $0 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 103 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE HEMATOPOIETIC GROWTH FACTORS GRANIX SUBCUTANEOUS* 300 MCG/0.5ML, 480 MCG/0.8ML LEUKINE INTRAVENOUS* SOLUTION RECONSTITUTED 250 MCG MOZOBIL SUBCUTANEOUS* SOLUTION 24 MG/1.2ML NEUMEGA SUBCUTANEOUS* SOLUTION RECONSTITUTED 5 MG NEUPOGEN INJECTION SOLUTION 300 MCG/0.5ML, 300 MCG/ML, 480 MCG/0.8ML, 480 MCG/1.6ML PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML MISCELLANEOUS anagrelide hcl oral capsule 0.5 mg, 1 mg cilostazol oral tablet 100 mg, 50 mg CINRYZE INTRAVENOUS* SOLUTION RECONSTITUTED 500 UNIT FIRAZYR SUBCUTANEOUS* SOLUTION 30 MG/3ML pentoxifylline er oral tablet extendedrelease* 400 mg PROMACTA ORAL TABLET 12.5 MG PROMACTA ORAL TABLET 25 MG PROMACTA ORAL TABLET 50 MG PROMACTA ORAL TABLET 75 MG 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 2 $0 PA 2 $0 PA 1 $0 1 $0 2 $0 PA; LA 2 $0 PA 1 $0 2 2 2 2 $0 $0 $0 $0 PA; LA ; QL (360 EA per 30 days) PA; LA ; QL (180 EA per 30 days) PA; LA ; QL (90 EA per 30 days) PA; LA ; QL (60 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 104 NAME OF DRUG tranexamic acid intravenous* solution 100 mg/ml tranexamic acid oral tablet 650 mg PLATELET AGGREGATION INHIBITORS AGGRENOX ORAL CAPSULE EXTENDED RELEASE 12 HOUR 25-200 MG BRILINTA ORAL TABLET 90 MG clopidogrel bisulfate oral tablet 75 mg EFFIENT ORAL TABLET 10 MG, 5 MG ZONTIVITY ORAL TABLET 2.08 MG IMMUNOLOGIC AGENTS TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 1 $0 2 $0 2 $0 1 $0 2 2 $0 $0 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 PA DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) CIMZIA PREFILLED SUBCUTANEOUS* KIT 2 X 200 MG/ML CIMZIA STARTER KIT SUBCUTANEOUS* KIT 6 X 200 MG/ML CIMZIA SUBCUTANEOUS* KIT 2 X 200 MG HUMIRA PEN SUBCUTANEOUS* 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS* 40 MG/0.8ML You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 105 NAME OF DRUG HUMIRA SUBCUTANEOUS* 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML hydroxychloroquine sulfate oral tablet 200 mg leflunomide oral tablet 10 mg, 20 mg methotrexate oral tablet 2.5 mg REMICADE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG IMMUNOGLOBULINS BIVIGAM INTRAVENOUS* SOLUTION 10 GM/100ML, 5 GM/50ML CARIMUNE NF INTRAVENOUS* SOLUTION RECONSTITUTED 12 GM FLEBOGAMMA DIF INTRAVENOUS* SOLUTION 0.5 GM/10ML, 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML, 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML FLEBOGAMMA INTRAVENOUS* SOLUTION 0.5 GM/10ML GAMASTAN S/D INTRAMUSCULAR* INJECTABLE GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML GAMMAGARD S/D INTRAVENOUS* SOLUTION RECONSTITUTED 2.5 GM TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 PA 1 $0 1 $0 1 $0 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 B/D 2 $0 PA 2 $0 PA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 106 NAME OF DRUG GAMMAGARD S/D LESS IGA INTRAVENOUS* SOLUTION RECONSTITUTED 10 GM, 5 GM GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML GAMMAPLEX INTRAVENOUS* SOLUTION 10 GM/200ML, 5 GM/100ML GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML OCTAGAM INTRAVENOUS* SOLUTION 1 GM/20ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 25 GM/500ML, 5 GM/100ML PRIVIGEN INTRAVENOUS* SOLUTION 10 GM/100ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML IMMUNOMODULATORS ACTIMMUNE SUBCUTANEOUS* SOLUTION 2000000 UNIT/0.5ML ARCALYST SUBCUTANEOUS* SOLUTION RECONSTITUTED 220 MG INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 6000000 UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 PA; LA 2 $0 PA 2 $0 B/D 2 $0 B/D You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 107 NAME OF DRUG REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG IMMUNOSUPPRESSANTS azathioprine oral tablet 50 mg BENLYSTA INTRAVENOUS* SOLUTION RECONSTITUTED 120 MG cyclosporine intravenous* solution 50 mg/ml cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg cyclosporine modified oral solution 100 mg/ml cyclosporine oral capsule 100 mg, 25 mg gengraf oral capsule 100 mg, 25 mg gengraf oral solution 100 mg/ml mycophenolate mofetil oral capsule 250 mg mycophenolate mofetil oral suspension reconstituted 200 mg/ml mycophenolate mofetil oral tablet 500 mg mycophenolic acid oral tablet delayed release 180 mg mycophenolic acid oral tablet delayed release 360 mg NEORAL ORAL CAPSULE 100 MG, 25 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 PA; LA 2 $0 PA 1 $0 B/D 2 $0 PA 1 $0 B/D 1 $0 B/D 1 $0 B/D 1 $0 B/D 1 1 $0 $0 B/D B/D 1 $0 B/D 2 $0 B/D 1 $0 B/D 1 $0 B/D 2 $0 B/D 2 $0 B/D You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 108 NAME OF DRUG NEORAL ORAL SOLUTION 100 MG/ML NULOJIX INTRAVENOUS* SOLUTION RECONSTITUTED 250 MG PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5 MG RAPAMUNE ORAL SOLUTION 1 MG/ML SANDIMMUNE ORAL SOLUTION 100 MG/ML sirolimus oral tablet 0.5 mg, 1 mg SIROLIMUS ORAL TABLET 2 MG tacrolimus oral capsule 0.5 mg, 1 mg tacrolimus oral capsule 5 mg ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG VACCINES ACTHIB INTRAMUSCULAR* SOLUTION RECONSTITUTED ADACEL INTRAMUSCULAR* SUSPENSION 5-2-15.5 LF-MCG/0.5 BCG VACCINE INJECTION INJECTABLE BEXSERO INTRAMUSCULAR* BOOSTRIX INTRAMUSCULAR* SUSPENSION 5-2.5-18.5 CERVARIX INTRAMUSCULAR* SUSPENSION COMVAX INTRAMUSCULAR* SUSPENSION 7.5-5 MCG/0.5ML TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 1 2 $0 $0 B/D B/D 1 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 NM You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 109 NAME OF DRUG DAPTACEL INTRAMUSCULAR* SUSPENSION 10-15-5 DIPHTHERIA-TETANUS TOXOIDS DT INTRAMUSCULAR* SUSPENSION 25-5 LFU/0.5ML ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 MCG/ML GARDASIL 9 INTRAMUSCULAR* GARDASIL 9 INTRAMUSCULAR* SUSPENSION GARDASIL INTRAMUSCULAR* SUSPENSION HAVRIX INTRAMUSCULAR* SUSPENSION 1440 EL U/ML, 720 EL U/0.5ML HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG IMOVAX RABIES INTRAMUSCULAR* INJECTABLE 2.5 UNIT/ML INFANRIX INTRAMUSCULAR* SUSPENSION 25-58-10 IPOL INJECTION INJECTABLE IXIARO INTRAMUSCULAR* SUSPENSION MENACTRA INTRAMUSCULAR* INJECTABLE MENOMUNE SUBCUTANEOUS* INJECTABLE MENVEO INTRAMUSCULAR* SOLUTION RECONSTITUTED M-M-R II SUBCUTANEOUS* INJECTABLE TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 NM 2 $0 B/D; NM 2 $0 B/D; NM 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 NM You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 110 NAME OF DRUG PEDVAX HIB INTRAMUSCULAR* SUSPENSION 7.5 MCG/0.5ML PROQUAD SUBCUTANEOUS* INJECTABLE RABAVERT INTRAMUSCULAR* SUSPENSION RECONSTITUTED RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML ROTARIX ORAL SUSPENSION RECONSTITUTED ROTATEQ ORAL SOLUTION SYNAGIS INTRAMUSCULAR* SOLUTION 100 MG/ML, 50 MG/0.5ML TENIVAC INTRAMUSCULAR* INJECTABLE 5-2 LFU TETANUS-DIPHTHERIA TOXOIDS TD INTRAMUSCULAR* SUSPENSION 2-2 LF/0.5ML TRUMENBA INTRAMUSCULAR* TWINRIX INTRAMUSCULAR* SUSPENSION 720-20 TYPHIM VI INTRAMUSCULAR* SOLUTION 25 MCG/0.5ML VAQTA INTRAMUSCULAR* SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML VARIVAX SUBCUTANEOUS* INJECTABLE 1350 PFU/0.5ML YF-VAX SUBCUTANEOUS* INJECTABLE TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 B/D; NM 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 B/D; NM 2 $0 B/D; NM 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 NM 2 $0 NM You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 111 NAME OF DRUG ZOSTAVAX SUBCUTANEOUS* SOLUTION RECONSTITUTED 19400 UNT/0.65ML NON-MEDICARE RX/OTC TIER WHAT THE DRUG LEVEL WILL COST YOU 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE NM; QL (1 EA per 999 days) NON-MEDICARE RX/OTC 12 hour decongestant oral tablet 3^ $0 extended release 12 hr* 120 mg ABREVA EXTERNAL CREAM 10 % 3^ $0 ACEPHEN SUPPOSITORY 120 MG, 3^ $0 325 MG, 650 MG ACEROLA C 500 ORAL WAFER 500 3^ $0 MG acetaminophen 8 hour oral tablet 3^ $0 650 mg acetaminophen junior strength oral 3^ $0 tablet dispersible 160 mg acetaminophen oral solution 160 3^ $0 mg/5ml ACID GONE ORAL SUSPENSION 3^ $0 95-358 MG/15ML ACID GONE ORAL TABLET 3^ $0 CHEWABLE 160-105 MG acid reducer oral tablet 10 mg 3^ $0 acidophilus/l-sporogenes oral tablet 3^ $0 acne medication 5 external lotion 5 3^ $0 % acne medication external lotion 10 3^ $0 % advanced calcium formula oral 3^ $0 tablet 200 mg ADVIL ALLERGY & CONGESTION 3^ $0 ORAL TABLET 4-10-200 MG You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 112 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE ADVIL ALLERGY SINUS ORAL 3^ $0 TABLET 2-30-200 MG ADVIL COLD & SINUS LIQUI-GELS 3^ $0 ORAL CAPSULE 30-200 MG ADVIL JUNIOR STRENGTH ORAL 3^ $0 TABLET 100 MG AFRIN CHILDRENS NASAL SOLUTION 3^ $0 0.25 % ALA-HIST IR ORAL TABLET 2 MG 3^ $0 ALA-HIST PE ORAL TABLET 2-10 MG 3^ $0 all day allergy-d oral tablet extended 3^ $0 release 12 hr* 5-120 mg all day pain relief oral tablet 220 mg 3^ $0 ALLEGRA ALLERGY CHILDRENS 3^ $0 ORAL TABLET 30 MG aller-ease oral tablet 60 mg 3^ $0 allergy relief oral capsule 25 mg 3^ $0 allergy relief oral tablet 10 mg, 25 3^ $0 mg aluminum hydroxide gel oral 3^ $0 suspension 320 mg/5ml ambi 12.5cpd/1dcpm/30pse oral 3^ $0 liquid† 30-1-12.5 mg/5ml ambi 40pse/400gfn/20dm oral 3^ $0 tablet 40-400-20 mg antacid maximum strength oral 3^ $0 suspension 400-400-40 mg/5ml anti-diarrheal oral liquid† 1 mg/5ml 3^ $0 anti-diarrheal oral tablet 2 mg 3^ $0 antifungal external cream 2 % 3^ $0 antioxidant formula sg oral capsule 3^ $0 extended release* You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 113 NAME OF DRUG apap 500 oral liquid† 500 mg/5ml ap-hist dm oral liquid† 7.5-4-15 mg/5ml AQUADEKS ORAL LIQUID† AQUA-E ORAL LIQUID† 30-2 MG/ML AQUANIL HC EXTERNAL LOTION 1 % artificial tears ophthalmic solution 1.4 % ascorbic acid oral powder aspirin ec oral tablet delayed release 325 mg aspirin oral tablet 325 mg, 81 mg aspirin suppository 300 mg, 600 mg athletes foot spray external aerosol† 1% AXID AR ORAL TABLET 75 MG AYR SALINE NASAL DROPS NASAL SOLUTION 0.65 % AYR SALINE NASAL NASAL b complex oral capsule b complex oral tablet B-12 DOTS ORAL TABLET DISPERSIBLE 500 MCG b-12 oral tablet 2000 mcg b-12 oral tablet dispersible 5000 mcg b-12 sublingual tablet sublingual 2500 mcg bacitracin external ointment 500 unit/gm TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ 3^ 3^ $0 $0 $0 3^ $0 3^ $0 3^ $0 3^ 3^ $0 $0 3^ $0 3^ $0 3^ $0 3^ 3^ 3^ $0 $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 114 NAME OF DRUG bacitracin zinc external ointment 500 unit/gm b-complex/vitamin c oral tablet bee zee oral tablet benzonatate oral capsule 100 mg, 200 mg benzoyl peroxide cleanser external lotion 6 % benzoyl peroxide external 2.5 % benzoyl peroxide wash external liquid† 5 % beta carotene oral capsule 25000 unit biospec dmx oral liquid† 15-25 mg/5ml biotin oral tablet 300 mcg B-NATAL MOUTH/THROAT LOLLIPOP 25 MG B-NATAL MOUTH/THROAT LOZENGE 25 MG BONE DENSITY ORAL TABLET 300-200 MG-UNIT bone meal oral tablet BOUDREAUXS BUTT PASTE EXTERNAL OINTMENT 16 % brohist d oral tablet 4-10 mg c-500 oral tablet chewable 500 mg cal/mag oral tablet 200-100 mg CALCET CREAMY BITES ORAL TABLET CHEWABLE 500-400 MG-UNIT TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ 3^ $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ 3^ 3^ $0 $0 $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 115 NAME OF DRUG CALCET PETITES ORAL TABLET 200-250 MG-UNIT CALCI-MIX ORAL CAPSULE 1250 MG calcionate oral syrup 1.8 gm/5ml cal-citrate plus vitamin d oral tablet 250-100 mg-unit calcium + d oral tablet chewable 500-1000-40 mg-unt-mcg calcium + d3 oral tablet 600-200 mg-unit calcium 1000 + d oral tablet 1000-800 mg-unit calcium 500 oral tablet 500-250-200 mg-mg-unit calcium 500/d oral tablet chewable 500-400 mg-unit calcium 500+d high potency oral tablet 500-400 mg-unit calcium 600 oral tablet 600 mg calcium 600/vitamin d oral tablet chewable 600-400 mg-unit calcium 600+d plus minerals oral tablet 600-400 mg-unit calcium 600+d plus minerals oral tablet chewable 600-400 mg-unit calcium antacid extra strength oral tablet chewable 750 mg calcium antacid oral tablet chewable 500 mg calcium antacid ultra max st oral tablet chewable 1000 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ 3^ $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 116 NAME OF DRUG calcium ascorbate oral tablet 500 mg calcium carbonate oral powder 800 mg/2gm calcium carbonate oral suspension 1250 mg/5ml calcium carbonate oral tablet 1250 mg calcium carbonate oral tablet chewable 260 mg calcium carbonate-vitamin d oral tablet 600-400 mg-unit calcium citrate + d oral tablet 250-200 mg-unit, 315-200 mg-unit calcium citrate malate-vit d oral tablet 250-100 mg-unit calcium citrate oral granules 760 mg/3.5gm calcium citrate oral tablet 250 mg calcium citrate-vitamin d oral tablet 200-125 mg-unit calcium for women oral tablet chewable 500-100-40 calcium gluconate oral tablet 50 mg, 500 mg calcium gummies oral tablet chewable 250-100-500 mg-unit calcium lactate oral tablet 100 mg, 648 mg, 650 mg calcium oral tablet 500 mg calcium pantothenate oral tablet 500 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 117 NAME OF DRUG calcium soft chews oral tablet chewable 500-500-40 mg-unt-mcg calcium/c/d oral tablet chewable 500-10-250 mg-mg-unit calcium+d3 gradual release oral tablet extended release 24 hr* 600-40-500 mg-mg-unit calcium-magnesium oral tablet 500-250 mg, 750-465 mg calcium-magnesium-vitamin d oral tablet 400-166.7-133.3 mg-mg-unit calcium-magnesium-zinc oral tablet 167-83-8 mg calcium-vitamin d3 oral tablet 500-400 mg-unit, 600-400 mg-unit calmag thins oral tablet 200-50 mg CAL-QUICK ORAL LIQUID† 500-400 MG-UNT/5ML CALTRATE 600+D SOFT ORAL TABLET CHEWABLE 600-800 MG-UNIT castellani paint modified external liquid† 1.5 % CENTRUM KIDS COMPLETE ORAL TABLET CHEWABLE 60 MG CENTRUM SILVER ORAL TABLET CHEWABLE CEROVITE ADVANCED FORMULA ORAL LIQUID† cetirizine hcl oral tablet 5 mg cetirizine hcl oral tablet chewable 10 mg, 5 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 118 NAME OF DRUG chelated calcium oral tablet 200 mg chewable calcium oral tablet chewable 500-200-40 mg-unt-mcg chewable vite childrens oral tablet chewable chewable vite/iron childrens oral tablet chewable 15 mg childrens acetaminophen oral tablet dispersible 80 mg childrens cold & allergy oral elixir 1-2.5 mg/5ml childrens complete allergy oral tablet chewable 12.5 mg childrens non-aspirin oral tablet chewable 80 mg childrens plus cold & allergy oral suspension 12.5-2.5-160 mg/5ml childrens plus cold oral suspension 1-2.5-160 mg/5ml chlo tuss ex oral liquid† 12.5-100 mg/5ml chlorpheniramine maleate er oral tablet extendedrelease* 12 mg CITRACAL CALCIUM GUMMIES ORAL TABLET CHEWABLE 250-115-250 MG-MG-UNIT CITRACAL PLUS HEART HEALTH ORAL TABLET 315-250-200 MG-UNIT-MG citrus calcium +d oral tablet 315-250 mg-unit TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 119 NAME OF DRUG citrus calcium/vitamin d oral tablet 200-250 mg-unit CLARITIN ORAL TABLET CHEWABLE 5 MG CLARITIN REDITABS ORAL TABLET DISPERSIBLE 5 MG classic prenatal oral tablet 28-0.8 mg clotrimazole 3 vaginal cream 2 % clotrimazole vaginal cream 1 % cod liver oil oral capsule codituss dm oral syrup 5-8.33-10 mg/5ml cold head congestion severe oral tablet 5-10-200-325 mg cold/cough childrens oral elixir 2.5-1-5 mg/5ml cold/cough/sore throat child oral liquid† 5-10-200-325 mg/10ml complete sinus relief oral tablet 2-10-500 mg COMTREX SEVERE COLD & SINUS ORAL 2-5-325 & 5-325 MG CONEX COLD/ALLERGY ORAL SOLUTION 1-30 MG/5ML CONEX COLD/ALLERGY ORAL TABLET 2-60 MG CONTAC COLD+FLU MAX ST ORAL TABLET 2-5-500 MG TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ 3^ 3^ $0 $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 120 NAME OF DRUG coral calcium oral capsule 133-66.7-133 mg-mg-unit, 185-50-100 mg-mg-unit, 250-125-100 mg-unit coral calcium plus oral capsule 250-125-200 mg-mg-unit CORICIDIN HBP CONGESTION/COUGH ORAL CAPSULE 10-200 MG CORTIZONE-10 EXTERNAL 1 % cough & cold oral tablet 4-30 mg cough & sore throat day oral liquid† 500-15 mg/15ml cough dm oral liquid extendedrelease* 30 mg/5ml cromolyn sodium nasal aerosol, solution 5.2 mg/act cvs calcium citrate oral tablet 200 mg cvs easy fiber/calcium oral tablet chewable cvs hydrocortisone acetate external cream 0.5 % cvs laxative dietary supplemnt oral tablet 500 mg cvs lubricant drops ophthalmic 1 % cvs lubricating/dry eye ophthalmic solution 0.5-0.9 % cvs nasal mist nasal aerosol, solution 0.9 % cvs pain relief adult oral liquid† 500 mg/15ml TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ 3^ $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 121 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE cvs probiotic (lactobacillus) oral 3^ $0 capsule cvs senna-extra oral tablet 17.2 mg 3^ $0 cvs stool softener oral capsule 50 3^ $0 mg cvs vitamin b-6 oral tablet 200 mg 3^ $0 cvs vitamin c oral tablet chewable 3^ $0 1000 mg cyanocobalamin injection solution 3^ $0 1000 mcg/ml CYTO B2 ORAL POWDER 343 3^ $0 MG/GM d 1000 oral tablet chewable 1000 3^ $0 unit d 10000 oral capsule 10000 unit 3^ $0 d 400 oral tablet chewable 400 unit 3^ $0 D3-50 ORAL CAPSULE 50000 UNIT 3^ $0 d-5000 oral tablet 5000 unit 3^ $0 daily-vite/iron/beta-carotene oral 3^ $0 tablet day-time sinus oral capsule 5-325 3^ $0 mg DELTUSS DP ORAL LIQUID† 1-30 3^ $0 MG/5ML DESENEX EXTERNAL POWDER 2 % 3^ $0 DESENEX SPRAY EXTERNAL 3^ $0 AEROSOL† 2 % DESITIN EXTERNAL CREAM 13 % 3^ $0 DIALYVITE 800 ORAL TABLET 0.8 3^ $0 MG DIALYVITE 800-ZINC 15 ORAL 3^ $0 TABLET You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 122 NAME OF DRUG DIALYVITE VITAMIN D3 MAX ORAL TABLET 50000 UNIT DIMETAPP LONG ACT COUGH/COLD ORAL SYRUP 1-7.5 MG/5ML DIMETAPP NIGHT COLD/CONGESTION ORAL LIQUID† 6.25-2.5 MG/5ML diphenhydramine hcl oral capsule 50 mg docusate sodium oral liquid† 50 mg/5ml DOK ORAL TABLET 100 MG double antibiotic external ointment 500-10000 unit/gm DRAMAMINE LESS DROWSY ORAL TABLET 25 MG dual action complete oral tablet chewable 10-800-165 mg DURAFLU ORAL TABLET 60-20-200-500 MG ecee plus oral tablet ECOTRIN MAXIMUM STRENGTH ORAL TABLET DELAYED RELEASE 500 MG ed bron gp oral liquid† 5-100 mg/5ml ED CHLORPED D ORAL LIQUID† 2-5 MG/ML ed chlorped jr oral syrup 2 mg/5ml ED CHLORPED ORAL LIQUID† 2 MG/ML TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 123 NAME OF DRUG ed-a-hist dm oral liquid† 10-4-15 mg/5ml ed-apap oral liquid† 160 mg/5ml ELDERTONIC ORAL ELIXIR enema enema 7-19 gm/118ml enema mineral oil enema ENEMEEZ MINI ENEMA 283 MG ENEMEEZ PLUS ENEMA 20-283 MG entre-cough oral liquid† 30-15-175 mg/5ml entre-hist pse oral liquid† 0.938-10 mg/ml ENUCLENE OPHTHALMIC SOLUTION 0.25 % e-oil oral oil 100 unt/0.25ml epsom salt oral granules eq allergy relief childrens oral tablet dispersible 12.5 mg eql antifungal (tolnaftate) external cream 1 % eql calcium/vitamin d oral capsule 600-100 mg-unit eql childrens calcium gummies oral tablet chewable 100-50-100 mg-mg-unit eql childrens multivitamins oral tablet chewable eql iron supplement therapy oral tablet 200 (65 fe) mg eql lice solution combination kit 0.5-0.33-4 % TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ 3^ 3^ 3^ 3^ 3^ $0 $0 $0 $0 $0 $0 3^ $0 3^ $0 3^ $0 3^ 3^ $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 124 NAME OF DRUG eql oyster shell calcium/d oral tablet 500-200 mg-unit EQUALACTIN ORAL TABLET CHEWABLE 625 MG exefen-ir oral tablet 60-400 mg EX-LAX ULTRA ORAL TABLET DELAYED RELEASE 5 MG eye drops allergy relief ophthalmic solution 0.05-0.25 % eye drops ophthalmic solution 0.05 % eye wash ophthalmic solution EZFE 200 ORAL CAPSULE 434.8 (200 FE) MG ezfe forte oral capsule 155-1 mg FEBROL ORAL SOLUTION 325 MG/5ML fer-iron oral solution 75 (15 fe) mg/ml ferretts ips oral solution 40 mg/15ml ferretts oral tablet 325 (106 fe) mg FERRIMIN 150 ORAL TABLET 150 MG ferrous fumarate oral tablet 29 mg, 90 mg ferrous gluconate oral tablet 225 (27 fe) mg, 240 (27 fe) mg, 324 (38 fe) mg ferrous sulfate er oral tablet extendedrelease* 140 (45 fe) mg ferrous sulfate oral elixir 220 (44 fe) mg/5ml TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ 3^ $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 125 NAME OF DRUG ferrous sulfate oral liquid† 220 (44 fe) mg/5ml ferrous sulfate oral syrup 300 (60 fe) mg/5ml ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 325 (65 fe) mg FEVERALL INFANTS SUPPOSITORY 80 MG fexofenadine hcl childrens oral suspension 30 mg/5ml fexofenadine hcl oral tablet 180 mg fiber (corn dextrin) oral powder fiber (guar gum) oral tablet chewable fiber laxative oral tablet 625 mg fiber oral powder FLEET BISACODYL ENEMA 10 MG/30ML FLORANEX ORAL PACKET FLORASTOR KIDS ORAL PACKET 250 MG FOLGARD ORAL TABLET folic acid injection solution 5 mg/ml folic acid oral capsule 20 mg folic acid oral tablet 1 mg, 400 mcg, 800 mcg FOLITAB 500 ORAL TABLET EXTENDEDRELEASE* 525-500-0.8 MG FOLTABS 800 ORAL TABLET 800-10-115 MCG-MG-MCG TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ 3^ $0 $0 3^ $0 3^ 3^ $0 $0 3^ $0 3^ $0 3^ $0 3^ 3^ 3^ $0 $0 $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 126 NAME OF DRUG FRESHKOTE OPHTHALMIC SOLUTION 2.7-2 % FUNGICURE INTENSIVE/NAILGUARD EXTERNAL SOLUTION 1 % FUNGOID TINCTURE EXTERNAL KIT 2% FUNGOID TINCTURE EXTERNAL SOLUTION 2 % GAVISCON EXTRA RELIEF FORMULA ORAL SUSPENSION 508-475 MG/10ML GAVISCON ORAL TABLET CHEWABLE 80-14.2 MG gentian violet external solution 1 %, 2% gentle laxative suppository 10 mg geravim oral liquid† gnp antacid & anti-gas oral tablet chewable 1000-60 mg gnp artificial tears ophthalmic solution 5-6 mg/ml gnp calcium 1200 oral tablet chewable 1200-1000 mg-unit gnp childrens chewables/ex c oral tablet chewable gnp childrens pain relief/cold oral suspension 2.5-1-5-160 mg/5ml gnp cold multi-sympt day/night oral 5-2-10-325 mg gnp cold multi-symptom night oral tablet 5-2-10-325 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ 3^ $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 127 NAME OF DRUG gnp foaming antacid oral tablet chewable 80-20 mg gnp iron oral tablet extendedrelease* 142 (45 fe) mg gnp multi-symptom cold night oral liquid† 5-6.25-10-325 mg/15ml gnp stool softener oral syrup 60 mg/15ml GONIOTAIRE OPHTHALMIC SOLUTION 2.5 % goodsense all day allergy oral tablet 10 mg goodsense pain relief pm ex st oral tablet 500-25 mg guaifenesin dm oral tablet 400-20 mg guaifenesin-codeine oral solution 100-10 mg/5ml GUMMI BEAR MULTIVITAMIN/MIN ORAL TABLET CHEWABLE headache pm oral tablet 25-500 mg hm allergy childrens oral liquid† 12.5 mg/5ml hm famotidine oral tablet 20 mg hm rapid melts junior oral tablet dispersible 160 mg HONEY BEARS ORAL TABLET CHEWABLE HONEY BEARS W/IRON-ZINC ORAL TABLET CHEWABLE 30-200-3 HYDROCIL ORAL PACKET 95 % TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 128 NAME OF DRUG hydrocortisone external cream 0.5 % hydrocortisone external ointment 0.5 % hydrocortisone-aloe external cream 0.5 %, 1 % hydroxocobalamin intramuscular* solution 1000 mcg/ml HYPOTEARS OPHTHALMIC SOLUTION 1-1 % ibuprofen junior strength oral tablet chewable 100 mg ibuprofen oral capsule 200 mg ibuprofen pm oral tablet 200-38 mg ICAPS LUTEIN-ZEAXANTHIN ORAL TABLET EXTENDEDRELEASE* ICAPS MV ORAL TABLET ICAPS ORAL CAPSULE infants ibuprofen oral suspension 50 mg/1.25ml infants pain relief oral suspension 80 mg/0.8ml INTEGRA ORAL CAPSULE 62.5-62.5-40-3 MG intense cold/flu medicine oral tablet 25-10-650 mg intense cough reliever ex st oral liquid† 20-300 mg/5ml IROMIN-G ORAL TABLET iron (ferrous gluconate) oral tablet 256 (28 fe) mg TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ 3^ $0 $0 3^ $0 3^ 3^ $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 129 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE iron 100 plus oral tablet 3^ $0 100-250-0.025-1 mg iron 100/c oral tablet 100-250 mg 3^ $0 iron chews pediatric oral tablet 3^ $0 chewable 15 mg iron oral tablet 90 (18 fe) mg 3^ $0 IRON UP ORAL LIQUID† 15 3^ $0 MG/0.5ML ISOPTO TEARS OPHTHALMIC 3^ $0 SOLUTION 0.5 % J-MAX ORAL SYRUP 5-200 MG/5ML 3^ $0 J-TAN D PD ORAL LIQUID† 1-7.5 3^ $0 MG/ML J-TAN PD ORAL LIQUID† 1 MG/ML 3^ $0 k 100 oral tablet 100 mcg 3^ $0 KAOPECTATE ORAL SUSPENSION 3^ $0 262 MG/15ML kidkare cough/cold oral liquid† 3^ $0 15-1-5 mg/5ml kls acid reducer max st oral tablet 3^ $0 150 mg KONSYL ORAL CAPSULE 520 MG 3^ $0 KONSYL ORAL PACKET 100 %, 28.3 3^ $0 % KONSYL ORAL POWDER 28.3 %, 3^ $0 30.9 %, 60.3 %, 71.67 % KONSYL-D ORAL POWDER 52.3 % 3^ $0 kp b complex-c oral tablet 3^ $0 kp benzoyl peroxide external 10 %, 3^ $0 5% kp calcium 600+d oral capsule 3^ $0 600-500 mg-unit You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 130 NAME OF DRUG kp calcium 600+d oral tablet 600-400 mg-unit kp calcium-magnesium-zinc oral tablet 333-133-5 mg kp ferrous gluconate oral tablet 324 (37.5 fe) mg kp ferrous sulfate oral tablet 325 (65 fe) mg kp hydrocortisone external cream 1 % kp ketotifen fumarate ophthalmic solution 0.025 % kp pseudoephedrine hcl oral tablet 60 mg kp terbinafine hydrochloride external cream 1 % kp vitamin d oral capsule 1000 unit kp vitamin e oral capsule 100 unit kpn prenatal oral tablet 0.1 mg LAMISIL ADVANCED EXTERNAL 1 % LAMISIL AF DEFENSE EXTERNAL AEROSOL, POWDER 1 % laxative pills oral tablet 25 mg lice killing maximum strength external liquid† 0.33-4 % lice killing maximum strength external shampoo 0.33-4 % lice treatment external liquid† 1 % liquid calcium with d3 oral capsule 600-1000 mg-unit liquid calcium/vitamin d oral capsule 600-200 mg-unit TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ 3^ 3^ 3^ $0 $0 $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 131 NAME OF DRUG liquituss gg oral liquid† 200 mg/5ml localnesium oral tablet 166.67-83.33 mg localnesium-c oral tablet 400-116.7-166.7 mg LODRANE D ORAL CAPSULE 4-60 MG LOHIST-D ORAL LIQUID† 2-30 MG/5ML lohist-dm oral syrup 5-2-10 mg/5ml lohist-peb oral liquid† 4-10 mg/5ml loperamide hcl oral suspension 1 mg/7.5ml loratadine oral tablet 10 mg loratadine-pseudoephedrine er oral tablet extended release 24 hr* 10-240 mg LOTRIMIN ULTRA EXTERNAL CREAM 1% lubricating plus eye drops ophthalmic solution 0.5 % LUMITENE ORAL CAPSULE 30 MG MAALOX CHILDRENS ORAL TABLET CHEWABLE 400 MG MAALOX REGULAR STRENGTH ORAL SUSPENSION 200-200-20 MG/5ML mag-al oral liquid† 200-200 mg/5ml mag-delay oral tablet extendedrelease* 535 (64 mg) mg MAGINEX ORAL TABLET DELAYED RELEASE 615 MG TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ 3^ $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 132 NAME OF DRUG MAGNEBIND 300 ORAL TABLET 250-300 MG magnesium citrate oral solution 1.745 gm/30ml magnesium citrate oral tablet 100 mg magnesium oral capsule 300 mg, 400 mg magnesium oral tablet 200 mg, 30 mg magnesium oxide oral capsule 400 mg magnesium oxide oral tablet 250 mg, 400 (240 mg) mg, 400 mg, 420 mg, 500 mg MAG-TAB SR ORAL TABLET EXTENDEDRELEASE* 84 MG (7MEQ) MAPAP COLD FORMULA MULTI-SYMPT ORAL TABLET 10-5-325 MG m-end dmx oral liquid† 20-0.667-10 mg/5ml MEPHYTON ORAL TABLET 5 MG MERIBIN ORAL CAPSULE 5 MG METAMUCIL MULTIHEALTH FIBER ORAL POWDER 63 % METAMUCIL ORAL WAFER METAMUCIL SMOOTH TEXTURE ORAL PACKET 28 % MEXSANA EXTERNAL POWDER 10.8 % TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ 3^ $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 133 NAME OF DRUG MI-ACID ORAL TABLET CHEWABLE 700-300 MG miconazole 1 vaginal kit 1200-2 mg-% miconazole 3 combo pack vaginal kit 200-2 mg-% (9gm) miconazole 3 vaginal cream 4 % miconazole 3 vaginal kit miconazole 7 vaginal cream 2 % miconazole 7 vaginal suppository 100 mg milk of magnesia concentrate oral suspension 2400 mg/10ml milk of magnesia oral suspension 1200 mg/15ml mineral oil oral oil MINTOX PLUS ORAL TABLET CHEWABLE 200-200-25 MG MISSION PRENATAL HP ORAL TABLET MISSION PRENATAL ORAL TABLET motion sickness relief oral tablet chewable 25 mg MOTRIN IB ORAL TABLET 200 MG mucaphed oral tablet 10-400 mg MUCINEX COUGH FOR KIDS ORAL PACKET 5-100 MG MUCINEX D ORAL TABLET EXTENDED RELEASE 12 HR* 120-1200 MG, 60-600 MG MUCINEX FAST-MAX COLD & SINUS ORAL TABLET 5-325-200 MG TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ 3^ 3^ $0 $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ 3^ $0 $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 134 NAME OF DRUG MUCINEX FOR KIDS ORAL PACKET 100 MG MUCINEX MAXIMUM STRENGTH ORAL TABLET EXTENDED RELEASE 12 HR* 1200 MG mucus relief cold/sinus max st oral liquid† 10-650-400 mg/20ml mucus relief cough childrens oral liquid† 5-100 mg/5ml mucus relief er oral tablet extended release 12 hr* 600 mg mucus relief oral tablet 400 mg mucus-dm max oral tablet extended release 12 hr* 60-1200 mg mucus-dm oral tablet extended release 12 hr* 30-600 mg multi-delyn oral liquid† multi-delyn/iron oral liquid† multi-symptom cold childrens oral liquid† 5-10-200 mg/10ml MURO 128 OPHTHALMIC SOLUTION 2% my way oral tablet 1.5 mg MYKIDZ IRON 10 ORAL SUSPENSION 15 MG/1.5ML MYKIDZ IRON ORAL SUSPENSION 10 MG/2ML naproxen sodium oral capsule 220 mg nasal decongestant oral liquid† 30 mg/5ml TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ 3^ $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 135 NAME OF DRUG nasal decongestant oral syrup 30 mg/5ml nasal decongestant pe max st oral tablet 10 mg nasal spray extra moisturizing nasal solution 0.05 % NASCOBAL NASAL SOLUTION 500 MCG/0.1ML NASOPEN PE ORAL LIQUID† 50-10 MG/15ML natural fiber laxative oral powder 68 % natural fiber therapy oral powder 48.57 % natures tears ophthalmic solution 0.4 % neotuss oral liquid† 30-200 mg/5ml NEPHRONEX ORAL LIQUID† NEXAFED ORAL 30 MG NEXAFED SINUS PRESSURE + PAIN ORAL TABLET 30-325 MG niacin er oral capsule extended release* 250 mg, 500 mg niacin er oral tablet extendedrelease* 1000 mg, 500 mg, 750 mg niacin oral tablet 100 mg, 50 mg, 500 mg niacinamide oral tablet 100 mg, 500 mg nicotine polacrilex mouth/throat gum 2 mg, 4 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ 3^ 3^ $0 $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 136 NAME OF DRUG nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg nicotine transdermal kit 21-14-7 mg/24hr nicotine transdermal patch 24 hr 14 mg/24hr, 21 mg/24hr, 7 mg/24hr night-time sinus oral capsule 6.25-5-325 mg nohist-lq oral liquid† 4-10 mg/5ml NOREL AD ORAL TABLET 4-10-325 MG NOVAFERRUM 125 ORAL LIQUID† 125-100 MG-UNT/5ML NOVAFERRUM PEDIATRIC DROPS ORAL LIQUID† 15 MG/ML NU-IRON ORAL CAPSULE 150 MG NUTRISOURCE FIBER ORAL PACKET NUTRISOURCE FIBER ORAL POWDER omeprazole oral tablet delayed release 20 mg organ-i nr oral tablet 200 mg OS-CAL EXTRA D3 ORAL TABLET 500-600 MG-UNIT OSTEO-PORETICAL ORAL TABLET 600-1000 MG-UNIT OYSCO 500 ORAL TABLET 500 MG oyster shell calcium 250+d oral tablet 250-125 mg-unit oyster shell calcium/d oral tablet 500-400 mg-unit pain relief 8 hour oral tablet extendedrelease* 650 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ 3^ 3^ $0 $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 137 NAME OF DRUG pain relief childrens oral suspension 160 mg/5ml pain relief extra strength oral tablet 500 mg pain reliever oral tablet 325 mg PANOXYL EXTERNAL BAR 10 % PANOXYL WASH EXTERNAL LIQUID† 10 % PANOXYL-4 CREAMY WASH EXTERNAL LIQUID† 4 % parva-cal oral tablet 500-200 mg-unit PEDIACARE CHILDRENS LONG-ACT ORAL LIQUID† 7.5 MG/5ML PEDIA-LAX ORAL LIQUID† 50 MG/15ML PEPCID AC ORAL TABLET CHEWABLE 10 MG peptic relief oral tablet chewable 262 mg PERDIEM OVERNIGHT RELIEF ORAL TABLET 15 MG permethrin external lotion 1 % PERRY PRENATAL ORAL CAPSULE 13.5-0.4 MG PHENAGIL ORAL TABLET 3.5-10 MG phos-nak oral packet 280-160-250 mg polyvitamin oral solution 35 mg/ml polyvitamin/iron oral solution 10 mg/ml prenatal oral tablet 27-0.8 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ 3^ $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 138 NAME OF DRUG PRETZ NASAL SOLUTION PRILOSEC OTC ORAL TABLET DELAYED RELEASE 20 MG pro-chlo oral liquid† 5-12.5-12.5 mg/5ml PROFE ORAL CAPSULE 391.3 (180 FE) MG PRONUTRIENTS CALCIUM+D3 ORAL TABLET 600-800 MG-UNIT pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml psyldex oral powder 30 % PURE & GENTLE LUBRICANT OPHTHALMIC SOLUTION 0.3 % pyrethins-piperonyl butoxide external liquid† 0.2-2 % pyridoxine hcl injection solution 100 mg/ml pyrilamine-phenylephrine oral suspension 5-16 mg/5ml pyrilamine-phenylephrine oral tablet 25-10 mg qc 3 day vaginal cream 4 % qc natural vegetable oral powder 95 % q-pap infants oral solution 80 mg/0.8ml Q-TAPP DM ORAL ELIXIR 15-1-5 MG/5ML ra anti-itch maximum strength external ointment 1 % TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 139 NAME OF DRUG ra b-complex/vitamin c cr oral tablet extendedrelease* ra beta carotene oral capsule 15 mg ra calamine external lotion 6.971-6.971 % ra calcium 600/vit d/minerals oral tablet 600-200 mg-unit ra calcium-boron oral tablet 500-1.5 mg ra central-vite performance oral tablet ra col-rite oral capsule 50 mg ra coral calcium oral capsule 200-100-100 mg-unit ra high potency iron oral tablet 27 mg ra hydrocortisone plus external cream 0.5 % ra ibuprofen childrens oral suspension 100 mg/5ml ra lubricant eye ophthalmic solution 0.4-0.3 % ra magnesium oral capsule 500 mg ra multi-symptom day/night oral 5-2-10-325 mg ra omeprazole-sodium bicarb oral capsule 20-1100 mg ra ophthalmic ophthalmic solution 5 % ra oyster shell calcium/d oral tablet 250-125 mg-unit, 500-200 mg-unit ra probiotic complex oral capsule TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 140 NAME OF DRUG ra severe cold/sinus relief pe oral tablet 12.5-5-325 mg ra slow release iron oral tablet extendedrelease* 45 mg, 47.5 mg ra soluble fiber oral tablet 500 mg ra vitamin c drops mouth/throat lozenge 60 mg ra vitamin c/rose hips cr oral tablet extendedrelease* 1000 mg ranitidine hcl oral tablet 75 mg REFRESH CELLUVISC OPHTHALMIC SOLUTION 1 % REFRESH OPTIVE ADVANCED OPHTHALMIC SOLUTION 0.5-1-0.5 % REFRESH P.M. OPHTHALMIC OINTMENT REGULOID ORAL POWDER 48.57 %, 58.6 % REHYDRALYTE ORAL SOLUTION RESCON DM ORAL SYRUP 30-2-10 MG/5ML RESCON ORAL TABLET 2-60 MG RESPAIRE-30 ORAL CAPSULE 30-150 MG RETAINE MGD OPHTHALMIC EMULSION 0.5-0.5 % RHINARIS NASAL 0.2 % RHINARIS NASAL SOLUTION 0.2 % RID ESSENTIAL LICE ELIMINATION EXTERNAL KIT 0.33-4 % RISA-BID PROBIOTIC ORAL TABLET TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ 3^ $0 $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 141 NAME OF DRUG RISAMINE EXTERNAL OINTMENT 0.44-20.625 % robafen cf cough/cold oral syrup 5-10-100 mg/5ml robafen cough oral capsule 15 mg ROBITUSSIN CHILD COUGH/COLD CF ORAL LIQUID† 2.5-5-50 MG/5ML ROBITUSSIN CHILD COUGH/COLD LA ORAL LIQUID† 1-7.5 MG/5ML ROBITUSSIN CHILDRENS COUGH LA ORAL SYRUP 7.5 MG/5ML ROBITUSSIN COLD+FLU DAYTIME ORAL CAPSULE 10-5-325 MG ROBITUSSIN LINGERING LA COUGH ORAL LIQUID† 15 MG/5ML ROBITUSSIN MUCUS+CHEST CONGEST ORAL LIQUID† 100 MG/5ML ROBITUSSIN MULTI-SYMPTOM MAX ORAL LIQUID† 5-10-200 MG/5ML ROBITUSSIN PEAK COLD MULTI-SYM ORAL LIQUID† 6.25-2.5-160 MG/5ML rymed oral tablet 2-10 mg rynex dm oral liquid† 2.5-1-5 mg/5ml rynex pse oral liquid† 1-15 mg/5ml saline laxative oral solution 0.9-2.4 gm/5ml sb fib lax orange oral powder 33 % sb lice treatment external liquid† 0.3-3 % TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 142 NAME OF DRUG sb natural fiber laxative oral powder 49 % SCOOBY-DOO ONE A DAY ORAL TABLET CHEWABLE SCOT-TUSSIN DM ORAL LIQUID† 2-15 MG/5ML SCOT-TUSSIN SENIOR ORAL LIQUID† 15-200 MG/5ML SECURA EXTRA PROTECTIVE EXTERNAL CREAM 30.6 % SECURA PROTECTIVE EXTERNAL CREAM 10 % selenium er oral tablet extendedrelease* 200 mcg selenium oral tablet 100 mcg senna laxative oral tablet 8.6 mg senna oral capsule 8.6 mg senna oral syrup 176 mg/5ml, 8.8 mg/5ml SENNA PROMPT ORAL CAPSULE 9-500 MG senna s oral tablet 8.6-50 mg SENSI-CARE PROTECTIVE BARRIER EXTERNAL OINTMENT 49-15 % sleep aid oral tablet 25 mg SLO-NIACIN ORAL TABLET EXTENDEDRELEASE* 250 MG slow magnesium/calcium oral tablet delayed release 64-106 mg slow release iron oral tablet extendedrelease* 140 (45 fe) mg, 50 mg TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ 3^ 3^ $0 $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 143 NAME OF DRUG SLOW-MAG ORAL TABLET DELAYED RELEASE 71.5-119 MG sm adult nasal decongestant oral liquid† 15 mg/5ml sm calcium/vitamin d3 oral tablet 600-800 mg-unit sm calcium-magnesium-zinc oral tablet 333-133-8.3 mg SM CORAL CALCIUM ORAL TABLET 1000 (390 CA) MG sm iron slow release oral tablet extendedrelease* 160 (50 fe) mg sm lansoprazole oral capsule delayed release 15 mg sm magnesium oxide oral tablet 250 mg sm motion sickness relief oral tablet 50 mg sm redness relief ophthalmic solution 0.012-0.2 % sm slow release iron oral tablet extendedrelease* 143 (45 fe) mg sm vitamin b12 tr oral tablet extendedrelease* 2000 mcg sm vitamin c cr oral tablet extendedrelease* 500 mg sm vitamin d3 oral capsule 4000 unit sodium bicarbonate oral powder sodium chloride (hypertonic) ophthalmic ointment 5 % TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 144 NAME OF DRUG SOLUBLE FIBER THERAPY ORAL POWDER SOOTHE OPHTHALMIC SOLUTION 0.6-0.6 % SOOTHE ORAL TABLET 262 MG sorbulax oral powder 100 % stahist ad oral liquid† 25-60 mg/5ml stahist ad oral tablet 25-60 mg STERILE LUBRICANT OPHTHALMIC LIQUID† 0.7 % stomach relief max st oral suspension 525 mg/15ml stool softener laxative dc oral capsule 240 mg stool softener oral capsule 100 mg SUMMERS EVE DISP MEDICATED VAGINAL SOLUTION 0.3 % SYSTANE BALANCE OPHTHALMIC SOLUTION 0.6 % SYSTANE NIGHTTIME OPHTHALMIC OINTMENT SYSTANE OVERNIGHT THERAPY OPHTHALMIC 0.3 % TEARS AGAIN NIGHT & DAY OPHTHALMIC 2-0.1 % tg 10peh/380gfn oral tablet 10-380 mg tg 10peh/380gfn/15dm oral tablet 10-380-15 mg tgt cough formula dm max adult oral liquid† 10-200 mg/5ml TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ 3^ 3^ 3^ $0 $0 $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 145 NAME OF DRUG tgt eye allergy relief ophthalmic solution 0.027-0.315 % tgt flu/severe cold/cough rlf oral packet 25-10-650 mg tgt lubricant eye drops ophthalmic solution 1-0.3 % tgt pain reliever pm ex st oral tablet 25-500 mg th calcium-magnesium-zinc oral tablet 334-134-5 mg th eye drop tears ophthalmic solution 0.2-0.2-1 % THERA/BETA-CAROTENE ORAL TABLET THERA-D 4000 ORAL TABLET 4000 UNIT THERANATAL CORE NUTRITION ORAL TABLET 27-1 MG THERATEARS OPHTHALMIC SOLUTION 0.25 % thiamine hcl injection solution 100 mg/ml tioconazole-1 vaginal ointment 6.5 % TITRALAC ORAL TABLET CHEWABLE 420 MG tolnaftate external cream 1 % tolnaftate external powder 1 % tolnaftate external solution 1 % total b/c oral tablet triacting day time cold/cough oral solution 2.5-5 mg/5ml TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ 3^ 3^ 3^ $0 $0 $0 $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 146 NAME OF DRUG TRIAMINIC COUGH/RUNNY NOSE ORAL STRIP 12.5 MG TRIAMINIC FEVER REDUCER ORAL SYRUP 160 MG/5ML TRIAMINIC NIGHT TIME COLD/CGH ORAL SYRUP 6.25-2.5 MG/5ML tri-buffered aspirin oral tablet 325 mg triple antibiotic external ointment 3.5-400-5000 triple paste af external ointment 2 % TRIPLE PASTE EXTERNAL OINTMENT 12.8 % TRI-VI-SOL ORAL SOLUTION 750-400-35 UNIT-MG/ML TRI-VITA ORAL SOLUTION 1500-400-35 UNIT-MG/ML tri-vitamin oral solution 1500-400-35 TUSNEL ORAL LIQUID† 30-15-200 MG/5ML TUSNEL PEDIATRIC ORAL LIQUID† 15-5-50 MG/5ML, 7.5-50 MG/ML TUSNEL-DM PEDIATRIC ORAL LIQUID† 7.5-2.5-25 MG/ML tussin cf cough & cold oral liquid† 5-10-100 mg/5ml tussin dm oral syrup 100-10 mg/5ml tussi-pres b oral liquid† 10-4-20 mg/5ml TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 147 NAME OF DRUG UPCAL D ORAL PACKET 500-500 MG-UNIT UPCAL D ORAL POWDER 500-500 MG-UNT/5GM VAGISTAT-3 VAGINAL KIT 200-2 MG-% (9GM) VICKS DAYQUIL MUCUS CONTROL DM ORAL LIQUID† 10-200 MG/15ML VICKS NYQUIL D COLD & FLU ORAL LIQUID† 60-12.5-30-1000 MG/30ML VICKS VAPORUB EXTERNAL OINTMENT 4.73-1.2-2.6 % VISINE-LR OPHTHALMIC SOLUTION 0.025 % VITALETS ORAL TABLET CHEWABLE 40 MG VITAMELTS ENERGY VITAMIN B-12 ORAL TABLET DISPERSIBLE 1500 MCG vitamin a & d oral capsule 5000-400 unit vitamin a palmitate oral tablet 15000 unit vitamin b-1 oral tablet 100 mg, 50 mg vitamin b-12 oral liquid† 1000 mcg/15ml vitamin b-12 oral tablet 250 mcg, 500 mcg TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 148 NAME OF DRUG vitamin b-12 sublingual tablet sublingual 1000 mcg vitamin b12-folic acid oral tablet 500-400 mcg vitamin b-2 oral tablet 25 mg, 50 mg vitamin b-6 er oral tablet extendedrelease* 200 mg vitamin b-6 oral tablet 100 mg, 25 mg, 50 mg vitamin c (calcium ascorbate) oral solution reconstituted vitamin c oral syrup 500 mg/5ml vitamin c oral tablet 100 mg, 250 mg, 500 mg vitamin c oral tablet chewable 100 mg, 250 mg vitamin d (ergocalciferol) oral capsule 50000 unit vitamin d oral tablet 1000 unit, 2000 unit vitamin d2 oral tablet 2000 unit, 400 unit vitamin d3 oral capsule 2000 unit, 400 unit, 5000 unit vitamin d3 oral liquid† 1200 unit/15ml, 400 unit/ml, 5000 unit/ml vitamin d3 oral tablet 3000 unit, 400 unit vitamin e oral capsule 1000 unit, 200 unit vitamin e oral solution 15 unit/0.3ml TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 149 NAME OF DRUG vitamin e oral tablet 100 unit vitamin e-selenium oral capsule 400-50 unit-mcg vitamin k (phytonadione) oral tablet 100 mcg vitamin k1 injection solution 1 mg/0.5ml, 10 mg/ml vitatrum oral tablet chewable WAL-ACT ORAL TABLET 2.5-60 MG WAL-DRYL ALLRGY/SINUS HEADACHE ORAL TABLET 25-5-325 MG WAL-DRYL-D ALLERGY/SINUS ORAL TABLET 25-10 MG WAL-FEX D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HR* 60-120 MG WAL-FLU SEVERE COLD DAYTIME ORAL PACKET 10-650 MG WAL-ITIN D ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG WAL-ITIN ORAL SYRUP 5 MG/5ML WAL-PHED PE SINUS/ALLERGY ORAL TABLET 4-10 MG WAL-PHED SINUS/ALLERGY ORAL TABLET 4-60 MG wal-som maximum strength oral capsule 50 mg wee care oral suspension 15 mg/1.25ml TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ $0 3^ $0 3^ $0 3^ 3^ $0 $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 3^ $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 150 NAME OF DRUG zinc oxide external ointment 20 %, 40 % zinc oxide external paste 25 % ZONATUSS ORAL CAPSULE 150 MG zoo friends complete oral tablet chewable 30 mg NUTRITIONAL/SUPPLEMENTS TIER WHAT THE DRUG LEVEL WILL COST YOU 3^ $0 3^ 3^ $0 $0 3^ $0 1 $0 1 $0 1 $0 1 $0 1 $0 2 $0 2 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE ELECTROLYTES klor-con 10 oral tablet extendedrelease* 10 meq klor-con m15 oral tablet extendedrelease* 15 meq klor-con m20 oral tablet extendedrelease* 20 meq klor-con oral packet 20 meq klor-con oral tablet extendedrelease* 8 meq MAGNESIUM SULFATE IN D5W INTRAVENOUS* SOLUTION 10-5 MG/ML-%, 20-5 MG/ML-% MAGNESIUM SULFATE INJECTION SOLUTION 40 MG/ML, 80 MG/ML magnesium sulfate injection solution 50 % potassium chloride crys er oral tablet extendedrelease* 10 meq, 20 meq potassium chloride er oral capsule extended release* 10 meq, 8 meq potassium chloride er oral tablet extendedrelease* 10 meq, 20 meq You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 151 NAME OF DRUG potassium chloride er oral tablet extendedrelease* 8 meq potassium chloride oral liquid† 20 meq/15ml (10%), 40 meq/15ml (20%) sodium chloride injection solution 2.5 meq/ml sodium fluoride oral tablet 2.2 (1 f) mg TPN ELECTROLYTES INTRAVENOUS* SOLUTION IV NUTRITION AMINOSYN II INTRAVENOUS* SOLUTION 10 %, 7 %, 8.5 % AMINOSYN II/ELECTROLYTES INTRAVENOUS* SOLUTION 8.5 % AMINOSYN INTRAVENOUS* SOLUTION 10 %, 8.5 % AMINOSYN M INTRAVENOUS* SOLUTION 3.5 % AMINOSYN/ELECTROLYTES INTRAVENOUS* SOLUTION 7 %, 8.5 % AMINOSYN-HBC INTRAVENOUS* SOLUTION 7 % AMINOSYN-PF INTRAVENOUS* SOLUTION 10 %, 7 % AMINOSYN-RF INTRAVENOUS* SOLUTION 5.2 % CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS* SOLUTION 2.75 % TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 1 $0 1 $0 1 $0 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 152 NAME OF DRUG CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS* SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/20) INTRAVENOUS* SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/25) INTRAVENOUS* SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS* SOLUTION 4.25 % CLINIMIX/DEXTROSE (5/15) INTRAVENOUS* SOLUTION 5 % CLINIMIX/DEXTROSE (5/20) INTRAVENOUS* SOLUTION 5 % CLINIMIX/DEXTROSE (5/25) INTRAVENOUS* SOLUTION 5 % FREAMINE HBC INTRAVENOUS* SOLUTION 6.9 % FREAMINE III INTRAVENOUS* SOLUTION 10 % HEPATAMINE INTRAVENOUS* SOLUTION 8 % INTRALIPID INTRAVENOUS* EMULSION 20 %, 30 % NEPHRAMINE INTRAVENOUS* SOLUTION 5.4 % NUTRILIPID INTRAVENOUS* EMULSION 20 % premasol intravenous* solution 10 % premasol intravenous* solution 6 % PROCALAMINE INTRAVENOUS* SOLUTION 3 % TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 B/D 1 $0 B/D 2 $0 B/D You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 153 NAME OF DRUG PROSOL INTRAVENOUS* SOLUTION 20 % TRAVASOL INTRAVENOUS* SOLUTION 10 % TROPHAMINE INTRAVENOUS* SOLUTION 10 % IV REPLACEMENT SOLUTIONS DEXTROSE 5%/ELECTROLYTE #48 INTRAVENOUS* SOLUTION dextrose in lactated ringers intravenous* solution 5 % dextrose intravenous* solution 10 %, 5 %, 50 %, 70 % DEXTROSE-NACL INTRAVENOUS* SOLUTION 10-0.2 % dextrose-nacl intravenous* solution 10-0.45 %, 2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5-0.3 %, 5-0.33 %, 5-0.45 %, 5-0.9 % IONOSOL-B IN D5W INTRAVENOUS* SOLUTION IONOSOL-MB IN D5W INTRAVENOUS* SOLUTION ISOLYTE-P IN D5W INTRAVENOUS* SOLUTION ISOLYTE-S INTRAVENOUS* SOLUTION TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 B/D 2 $0 B/D 2 $0 B/D 2 $0 1 $0 1 $0 2 $0 1 $0 2 $0 2 $0 2 $0 2 $0 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 154 NAME OF DRUG kcl in dextrose-nacl intravenous* solution 10-5-0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.33 meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5-0.45 meq/l-%-%, 40-5-0.9 meq/l-%-% KCL IN DEXTROSE-NACL INTRAVENOUS* SOLUTION 20-5-0.225 MEQ/L-%-% lactated ringers intravenous* solution normosol-m in d5w intravenous* solution NORMOSOL-R IN D5W INTRAVENOUS* SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS* SOLUTION PLASMA-LYTE 148 INTRAVENOUS* SOLUTION PLASMA-LYTE A INTRAVENOUS* SOLUTION PLASMA-LYTE-56 IN D5W INTRAVENOUS* SOLUTION potassium chloride in dextrose intravenous* solution 20-5 meq/l-%, 40-5 meq/l-% potassium chloride in nacl intravenous* solution 20-0.45 meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l-% TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 2 $0 1 $0 1 $0 2 $0 2 $0 2 $0 2 $0 2 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 155 NAME OF DRUG potassium chloride intravenous* solution 0.4 meq/ml, 10 meq/100ml, 10 meq/50ml, 20 meq/100ml, 40 meq/100ml potassium chloride intravenous* solution 2 meq/ml ringers intravenous* solution sodium chloride intravenous* solution 0.45 %, 0.9 %, 3 %, 5 % VITAMINS calcitriol intravenous* solution 1 mcg/ml calcitriol oral capsule 0.25 mcg, 0.5 mcg calcitriol oral solution 1 mcg/ml paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg prenatal oral tablet 27-1 mg OPHTHALMIC TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 1 $0 1 $0 1 $0 1 $0 1 $0 B/D 1 $0 B/D 1 $0 B/D 1 $0 B/D 1 $0 ANTIALLERGICS azelastine hcl ophthalmic solution 1 $0 0.05 % BEPREVE OPHTHALMIC SOLUTION 2 $0 1.5 % cromolyn sodium ophthalmic 1 $0 solution 4 % LASTACAFT OPHTHALMIC SOLUTION 2 $0 0.25 % PATADAY OPHTHALMIC SOLUTION 2 $0 0.2 % PAZEO OPHTHALMIC SOLUTION 0.7 2 $0 % You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 156 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE ANTIGLAUCOMA ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % AZOPT OPHTHALMIC SUSPENSION 1 % betaxolol hcl ophthalmic solution 0.5 % BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % brimonidine tartrate ophthalmic solution 0.15 % brimonidine tartrate ophthalmic solution 0.2 % carteolol hcl ophthalmic solution 1 % COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % dorzolamide hcl ophthalmic solution 2% dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml ISTALOL OPHTHALMIC SOLUTION 0.5 % latanoprost ophthalmic solution 0.005 % levobunolol hcl ophthalmic solution 0.25 % levobunolol hcl ophthalmic solution 0.5 % LUMIGAN OPHTHALMIC SOLUTION 0.01 % 2 $0 2 $0 1 $0 2 $0 1 $0 1 $0 1 $0 2 $0 1 $0 1 $0 2 $0 1 $0 1 $0 1 $0 2 $0 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 157 NAME OF DRUG metipranolol ophthalmic solution 0.3 % PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 % pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % timolol maleate ophthalmic solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC SOLUTION 0.004 % ANTI-INFECTIVE/ANTI-INFLAMMA TORY bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % blephamide s.o.p. ophthalmic ointment 10-0.2 % neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 sulfacetamide-prednisolone ophthalmic solution 10-0.23 % TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 2 $0 1 $0 2 $0 1 $0 1 $0 2 $0 1 $0 2 $0 1 $0 1 $0 1 $0 1 $0 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 158 NAME OF DRUG TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 % tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % ANTI-INFECTIVES bacitracin ophthalmic ointment 500 unit/gm bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm BESIVANCE OPHTHALMIC SUSPENSION 0.6 % CILOXAN OPHTHALMIC OINTMENT 0.3 % ciprofloxacin hcl ophthalmic solution 0.3 % erythromycin ophthalmic ointment 5 mg/gm gatifloxacin ophthalmic solution 0.5 % gentak ophthalmic ointment 0.3 % gentamicin sulfate ophthalmic ointment 0.3 % gentamicin sulfate ophthalmic solution 0.3 % ilotycin ophthalmic ointment 5 mg/gm MOXEZA OPHTHALMIC SOLUTION 0.5 % NATACYN OPHTHALMIC SUSPENSION 5 % TIER WHAT THE DRUG LEVEL WILL COST YOU 2 $0 1 $0 2 $0 1 $0 1 $0 2 $0 2 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 2 $0 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 159 NAME OF DRUG neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000 neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-0.25 ofloxacin ophthalmic solution 0.3 % polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-% sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide sodium ophthalmic solution 10 % tobramycin ophthalmic solution 0.3 % TOBREX OPHTHALMIC OINTMENT 0.3 % trifluridine ophthalmic solution 1 % VIGAMOX OPHTHALMIC SOLUTION 0.5 % ZIRGAN OPHTHALMIC 0.15 % ANTI-INFLAMMATORIES ALREX OPHTHALMIC SUSPENSION 0.2 % bromfenac sodium (once-daily) ophthalmic solution 0.09 % bromfenac sodium ophthalmic solution 0.09 % dexamethasone sodium phosphate ophthalmic solution 0.1 % diclofenac sodium ophthalmic solution 0.1 % TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 2 $0 1 $0 2 $0 2 $0 2 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 160 NAME OF DRUG DUREZOL OPHTHALMIC EMULSION 0.05 % fluorometholone ophthalmic suspension 0.1 % flurbiprofen sodium ophthalmic solution 0.03 % ILEVRO OPHTHALMIC SUSPENSION 0.3 % ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % LOTEMAX OPHTHALMIC 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % LOTEMAX OPHTHALMIC SUSPENSION 0.5 % MAXIDEX OPHTHALMIC SUSPENSION 0.1 % prednisolone acetate ophthalmic suspension 1 % prednisolone sodium phosphate ophthalmic solution 1 % MISCELLANEOUS naphazoline hcl ophthalmic solution 0.1 % PROLENSA OPHTHALMIC SOLUTION 0.07 % proparacaine hcl ophthalmic solution 0.5 % RESTASIS OPHTHALMIC EMULSION 0.05 % TIER WHAT THE DRUG LEVEL WILL COST YOU 2 $0 1 $0 1 $0 2 $0 1 $0 2 $0 2 $0 2 $0 2 $0 1 $0 2 $0 1 $0 2 $0 1 $0 2 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE QL (64 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 161 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 62.5-25 MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION 20-100 MCG/ACT ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml ANTICHOLINERGICS ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 62.5 MCG/INH ipratropium bromide inhalation solution 0.02 % ipratropium bromide nasal solution 0.03 %, 0.06 % ANTIHISTAMINES 2 $0 QL (60 EA per 30 days) 2 $0 QL (8 GM per 30 days) 1 $0 B/D 2 $0 QL (25.8 GM per 30 days) 2 $0 QL (30 EA per 30 days) 1 $0 B/D 1 $0 ASTEPRO NASAL SOLUTION 0.15 % 2 $0 azelastine hcl nasal solution 0.1 %, 1 $0 0.15 % cetirizine hcl oral syrup 1 mg/ml 1 $0 diphenhydramine hcl injection 1 $0 solution 50 mg/ml hydroxyzine hcl intramuscular* 2 $0 PA solution 25 mg/ml, 50 mg/ml hydroxyzine hcl oral solution 10 2 $0 PA mg/5ml You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 162 NAME OF DRUG hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg levocetirizine dihydrochloride oral solution 2.5 mg/5ml levocetirizine dihydrochloride oral tablet 5 mg olopatadine hcl nasal solution 0.6 % BETA AGONISTS albuterol sulfate er oral tablet extended release 12 hr* 4 mg, 8 mg albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml albuterol sulfate oral syrup 2 mg/5ml albuterol sulfate oral tablet 2 mg, 4 mg levalbuterol hcl inhalation nebulization solution 1.25 mg/0.5ml PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 MCG/2ML SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 50 MCG/DOSE terbutaline sulfate injection solution 1 mg/ml terbutaline sulfate oral tablet 2.5 mg, 5 mg TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 PA 2 $0 PA 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 B/D 2 $0 B/D 2 $0 QL (60 EA per 30 days) 2 $0 1 $0 B/D You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 163 NAME OF DRUG VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT XOPENEX HFA INHALATION AEROSOL† 45 MCG/ACT LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium oral packet 4 mg montelukast sodium oral tablet 10 mg montelukast sodium oral tablet chewable 4 mg, 5 mg zafirlukast oral tablet 10 mg, 20 mg MAST CELL STABILIZERS cromolyn sodium inhalation nebulization solution 20 mg/2ml MISCELLANEOUS acetylcysteine inhalation solution 10 %, 20 % ARALAST NP INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG, 400 MG, 500 MG, 800 MG AUVI-Q INJECTION 0.15 MG/0.15ML, 0.3 MG/0.3ML DALIRESP ORAL TABLET 500 MCG EPIPEN 2-PAK INJECTION 0.3 MG/0.3ML EPIPEN JR 2-PAK INJECTION 0.15 MG/0.3ML ESBRIET ORAL CAPSULE 267 MG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 QL (36 GM per 30 days) 2 $0 QL (30 GM per 30 days) 1 $0 1 $0 1 $0 1 $0 1 $0 B/D 1 $0 B/D 2 $0 PA; LA 2 $0 2 $0 2 $0 2 $0 2 $0 PA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 164 NAME OF DRUG KALYDECO ORAL PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG OFEV ORAL CAPSULE 100 MG, 150 MG PROLASTIN-C INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG PULMOZYME INHALATION SOLUTION 1 MG/ML XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG ZEMAIRA INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG NASAL STEROIDS flunisolide nasal solution 25 mcg/act (0.025%) fluticasone propionate nasal suspension 50 mcg/act STEROID INHALANTS ARNUITY ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 PA 2 $0 PA 2 $0 PA 2 $0 PA; LA 2 $0 B/D 2 $0 PA; LA 2 $0 PA; LA 1 $0 QL (50 ML per 30 days) 1 $0 QL (16 GM per 30 days) 2 $0 QL (30 EA per 30 days) 1 $0 B/D 2 $0 QL (120 EA per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 165 NAME OF DRUG FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 250 MCG/BLIST FLOVENT HFA INHALATION AEROSOL† 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL† 44 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION AEROSOL† 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 100-25 MCG/INH, 200-25 MCG/INH SYMBICORT INHALATION AEROSOL† 160-4.5 MCG/ACT, 80-4.5 MCG/ACT XANTHINES aminophylline intravenous* solution 25 mg/ml elixophyllin oral elixir 80 mg/15ml TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE 2 $0 QL (240 EA per 30 days) 2 $0 QL (24 GM per 30 days) 2 $0 QL (21.2 GM per 30 days) 2 $0 QL (2 EA per 30 days) 2 $0 QL (60 EA per 30 days) 2 $0 QL (12 GM per 30 days) 2 $0 QL (60 EA per 30 days) 2 $0 QL (10.2 GM per 30 days) 1 $0 2 $0 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 166 NAME OF DRUG theo-24 oral capsule extended release 24 hour 100 mg, 200 mg, 300 mg, 400 mg theophylline er oral tablet extended release 12 hr* 100 mg, 200 mg, 300 mg, 450 mg theophylline er oral tablet extended release 24 hr* 400 mg, 600 mg theophylline oral solution 80 mg/15ml TOPICAL TIER WHAT THE DRUG LEVEL WILL COST YOU 2 $0 1 $0 1 $0 1 $0 1 1 $0 $0 1 $0 1 1 $0 $0 1 $0 1 $0 1 1 $0 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE DERMATOLOGY, ACNE adapalene external 0.1 % adapalene external cream 0.1 % amnesteem oral capsule 10 mg, 20 mg, 40 mg avita external 0.025 % avita external cream 0.025 % benzoyl peroxide-erythromycin external 5-3 % claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg clindamax external 1 % clindamycin phosphate external 1 % clindamycin phosphate external lotion 1 % clindamycin phosphate external solution 1 % clindamycin phosphate external swab 1 % ery external pad 2 % You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 167 NAME OF DRUG erythromycin external 2 % erythromycin external solution 2 % myorisan oral capsule 10 mg, 20 mg, 40 mg sulfacetamide sodium external suspension 10 % tretinoin external 0.01 %, 0.025 % tretinoin external cream 0.025 %, 0.05 %, 0.1 % zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg DERMATOLOGY, ANTIBIOTICS gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % mupirocin external ointment 2 % silver sulfadiazine external cream 1 % ssd external cream 1 % SULFAMYLON EXTERNAL CREAM 85 MG/GM SULFAMYLON EXTERNAL PACKET 5 % DERMATOLOGY, ANTIFUNGALS ciclopirox external 0.77 % ciclopirox external shampoo 1 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % TIER WHAT THE DRUG LEVEL WILL COST YOU 1 1 $0 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 2 $0 2 $0 1 1 $0 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 168 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU clotrimazole external cream 1 % clotrimazole external solution 1 % econazole nitrate external cream 1 % ketoconazole external cream 2 % nyamyc external powder 100000 unit/gm nystatin external cream 100000 unit/gm nystatin external ointment 100000 unit/gm nystatin external powder 100000 unit/gm nystop external powder 100000 unit/gm DERMATOLOGY, ANTIPRURITIC 1 1 $0 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 procto-pak cream 1 % proctosol hc cream 2.5 % proctozone-hc cream 2.5 % prudoxin external cream 5 % DERMATOLOGY, ANTIPSORIATICS 1 1 1 1 $0 $0 $0 $0 8-MOP ORAL CAPSULE 10 MG acitretin oral capsule 10 mg, 17.5 mg, 25 mg calcipotriene external cream 0.005 % calcipotriene external ointment 0.005 % calcipotriene external solution 0.005 % 2 $0 2 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE PA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 169 NAME OF DRUG calcitrene external ointment 0.005 % TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % DERMATOLOGY, ANTISEBORRHEICS TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 2 $0 ketoconazole external shampoo 2 % selenium sulfide external lotion 2.5 % DERMATOLOGY, CORTICOSTEROIDS 1 $0 1 $0 ala cort external cream 1 % alclometasone dipropionate external cream 0.05 % alclometasone dipropionate external ointment 0.05 % apexicon external ointment 0.05 % betamethasone dipropionate aug external 0.05 % betamethasone dipropionate aug external cream 0.05 % betamethasone dipropionate aug external lotion 0.05 % betamethasone dipropionate aug external ointment 0.05 % betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external lotion 0.05 % betamethasone dipropionate external ointment 0.05 % 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE PA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 170 NAME OF DRUG betamethasone valerate external cream 0.1 % betamethasone valerate external lotion 0.1 % betamethasone valerate external ointment 0.1 % clobetasol propionate e external cream 0.05 % clobetasol propionate external 0.05 % clobetasol propionate external cream 0.05 % clobetasol propionate external ointment 0.05 % clobetasol propionate external solution 0.05 % cormax scalp application external solution 0.05 % desonide external cream 0.05 % desonide external lotion 0.05 % desonide external ointment 0.05 % desoximetasone external 0.05 % desoximetasone external cream 0.05 %, 0.25 % desoximetasone external ointment 0.05 % desoximetasone external ointment 0.25 % diflorasone diacetate external cream 0.05 % diflorasone diacetate external ointment 0.05 % TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 1 1 1 $0 $0 $0 $0 1 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 171 NAME OF DRUG fluocinolone acetonide body external oil 0.01 % fluocinolone acetonide external cream 0.01 %, 0.025 % fluocinolone acetonide external ointment 0.025 % fluocinolone acetonide external solution 0.01 % fluocinolone acetonide scalp external oil 0.01 % fluocinonide external 0.05 % fluocinonide external cream 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % fluocinonide-e external cream 0.05 % fluticasone propionate external cream 0.05 % fluticasone propionate external ointment 0.005 % halobetasol propionate external cream 0.05 % halobetasol propionate external ointment 0.05 % hydrocortisone butyrate external cream 0.1 % hydrocortisone butyrate external ointment 0.1 % hydrocortisone butyrate external solution 0.1 % TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 1 $0 1 $0 1 1 $0 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 172 NAME OF DRUG hydrocortisone external cream 1 %, 2.5 % hydrocortisone external lotion 2.5 % hydrocortisone external ointment 1 %, 2.5 % hydrocortisone valerate external cream 0.2 % hydrocortisone valerate external ointment 0.2 % lokara external lotion 0.05 % mometasone furoate external cream 0.1 % mometasone furoate external ointment 0.1 % mometasone furoate external solution 0.1 % texacort external solution 2.5 % triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 % triamcinolone acetonide external lotion 0.025 %, 0.1 % triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % triderm external cream 0.1 % DERMATOLOGY, LOCAL ANESTHETICS TIER WHAT THE DRUG LEVEL WILL COST YOU 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 2 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE lidocaine external ointment 5 % 1 $0 lidocaine external patch 5 % 1 $0 PA; QL (3 EA per 1 day) lidocaine hcl external 2 % 1 $0 lidocaine hcl external solution 4 % 1 $0 lidocaine-prilocaine external cream 1 $0 B/D 2.5-2.5 % You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 173 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir external ointment 5 % ammonium lactate external cream 12 % ammonium lactate external lotion 12 % ELIDEL EXTERNAL CREAM 1 % fluorouracil external cream 5 % fluorouracil external solution 2 %, 5 % imiquimod external cream 5 % laclotion external lotion 12 % metronidazole external 0.75 % metronidazole external cream 0.75 % metronidazole external lotion 0.75 % PANRETIN EXTERNAL 0.1 % podofilox external solution 0.5 % rosadan external cream 0.75 % tacrolimus external ointment 0.03 %, 0.1 % TARGRETIN EXTERNAL 1 % VALCHLOR EXTERNAL 0.016 % VOLTAREN TRANSDERMAL 1 % DERMATOLOGY, SCABICIDES AND PEDICULIDES 1 $0 1 $0 1 $0 2 1 $0 $0 1 $0 1 1 1 $0 $0 $0 1 $0 1 $0 2 1 1 $0 $0 $0 1 $0 PA 2 2 2 $0 $0 $0 PA PA; LA EURAX EXTERNAL CREAM 10 % EURAX EXTERNAL LOTION 10 % malathion external lotion 0.5 % 2 2 1 $0 $0 $0 PA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 174 NAME OF DRUG TIER WHAT THE DRUG LEVEL WILL COST YOU permethrin external cream 5 % DERMATOLOGY, WOUND CARE AGENTS 1 $0 acetic acid irrigation solution 0.25 % REGRANEX EXTERNAL 0.01 % SANTYL EXTERNAL OINTMENT 250 UNIT/GM sodium chloride irrigation solution 0.9 % sterile water for irrigation irrigation solution MOUTH/THROAT/DENTAL AGENTS 1 2 $0 $0 2 $0 1 $0 1 $0 cevimeline hcl oral capsule 30 mg chlorhexidine gluconate mouth/throat solution 0.12 % clotrimazole mouth/throat troche 10 mg lidocaine viscous mouth/throat solution 2 % nystatin mouth/throat suspension 100000 unit/ml periogard mouth/throat solution 0.12 % pilocarpine hcl oral tablet 5 mg pilocarpine hcl oral tablet 7.5 mg triamcinolone acetonide mouth/throat paste 0.1 % OTIC 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 1 $0 $0 1 $0 acetic acid otic solution 2 % acetic acid-aluminum acetate otic solution 2 % 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE PA You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 175 NAME OF DRUG CIPRODEX OTIC SUSPENSION 0.3-0.1 % fluocinolone acetonide otic oil 0.01 % neomycin-polymyxin-hc otic solution 1 % neomycin-polymyxin-hc otic suspension 3.5-10000-1 ofloxacin otic solution 0.3 % TIER WHAT THE DRUG LEVEL WILL COST YOU 2 $0 1 $0 1 $0 1 $0 1 $0 NECESSARY ACTIONS, RESTRICTIONS, OR LIMITS OF USE You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 176 Index Index Index Index of Drugs 12 hour decongestant ...................... 112 adapalene ................................................................ 167 ALPHAGAN P ...................................................... 157 8-MOP ............................................................................ 169 adefovir dipivoxil ............................................. 23 alprazolam .................................................................. 56 abacavir sulfate ................................................. 19 ADEMPAS ..................................................................... 55 ALREX ............................................................................. 160 abacavir-lamivudine-zidovudine adriamycin .................................................................. 34 altavera ............................................................................. 83 .......................................................................................................... 22 adrucil ................................................................................. 34 aluminum hydroxide gel .............. 113 ABELCET ......................................................................... 15 ADVAIR DISKUS ............................................. 166 amantadine hcl .................................................. 66 ABILIFY DISCMELT ....................................... 68 ADVAIR HFA ......................................................... 166 ambi 12.5cpd/1dcpm/30pse ABILIFY MAINTENA ...................................... 68 advanced calcium formula ...... 112 ...................................................................................................... 113 ABRAXANE .................................................................. 35 ADVIL ALLERGY & CONGESTION ambi 40pse/400gfn/20dm ....... 113 ABREVA ........................................................................ 112 ...................................................................................................... 112 AMBISOME ................................................................. 15 acamprosate calcium ............................ 76 ADVIL ALLERGY SINUS .................... 113 amifostine .................................................................... 41 acarbose ......................................................................... 79 ADVIL COLD & SINUS amikacin sulfate .............................................. 14 acebutolol hcl ....................................................... 49 LIQUI-GELS ............................................................ 113 amiloride hcl ........................................................... 53 ACEPHEN .................................................................. 112 ADVIL JUNIOR STRENGTH ......... 113 amiloride-hydrochlorothiazide ACEROLA C 500 ........................................... 112 afeditab cr ................................................................... 50 .......................................................................................................... 53 acetaminophen ............................................. 112 AFINITOR ........................................................................ 38 aminophylline ................................................... 166 acetaminophen 8 hour .................... 112 AFINITOR DISPERZ ....................................... 38 AMINOSYN ............................................................. 152 AFRIN CHILDRENS ................................... 113 AMINOSYN II ....................................................... 152 acetaminophen junior strength ...................................................................................................... 112 AGGRENOX ............................................................ 105 AMINOSYN II/ELECTROLYTES acetaminophen-codeine ................... 13 a-hydrocort ................................................................ 90 ...................................................................................................... 152 acetaminophen-codeine #2 ....... 13 ala cort .......................................................................... 170 AMINOSYN M .................................................... 152 acetaminophen-codeine #3 ....... 13 ALA-HIST IR ......................................................... 113 AMINOSYN/ELECTROLYTES ... 152 acetaminophen-codeine #4 ....... 13 ALA-HIST PE ....................................................... 113 AMINOSYN-HBC ........................................... 152 acetazolamide ...................................................... 53 ALBENZA ........................................................................ 16 AMINOSYN-PF ................................................. 152 acetazolamide er ............................................ 53 albuterol sulfate ........................................... 163 AMINOSYN-RF ................................................. 152 acetic acid .............................................................. 175 albuterol sulfate er ................................. 163 amiodarone hcl .................................... 45, 46 acetic acid-aluminum acetate alclometasone dipropionate AMITIZA ............................................................................ 99 ...................................................................................................... 175 ...................................................................................................... 170 amitriptyline hcl ................................................ 63 acetylcysteine .................................................. 164 ALDURAZYME ....................................................... 88 amlodipine besy-benazepril hcl ACID GONE ............................................................. 112 alendronate sodium .................................. 82 .......................................................................................................... 42 acid reducer ........................................................ 112 alfuzosin hcl er .............................................. 100 amlodipine besylate .................................. 50 acidophilus/l-sporogenes .......... 112 ALIMTA .............................................................................. 34 amlodipine besylate-valsartan acitretin ........................................................................ 169 ALINIA .................................................................................. 16 .......................................................................................................... 44 acne medication ......................................... 112 all day allergy-d ........................................... 113 amlodipine-valsartan-hctz ........... 44 acne medication 5 .................................. 112 all day pain relief ....................................... 113 ammonium lactate .................................. 174 ACTHIB .......................................................................... 109 ALLEGRA ALLERGY CHILDRENS amnesteem .......................................................... 167 ACTIMMUNE ........................................................ 107 ...................................................................................................... 113 amoxapine .................................................................. 63 acyclovir ....................................................... 23, 174 aller-ease ................................................................. 113 amoxicillin ..................................................... 29, 30 acyclovir sodium ............................................. 23 allergy relief ........................................................ 113 amoxicillin-pot clavulanate ......... 30 ADACEL ........................................................................ 109 allopurinol ......................................................................... 9 amoxicillin-pot clavulanate er ADAGEN ........................................................................... 88 alosetron hcl ........................................................... 99 .......................................................................................................... 30 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 177 Index Index Index amphetamine-dextroamphet er atenolol ............................................................................. 49 bee zee ......................................................................... 115 .......................................................................................................... 72 atenolol-chlorthalidone ....................... 48 BELEODAQ .................................................................. 36 amphetamine-dextroamphetami athletes foot spray .................................. 114 benazepril hcl ....................................................... 43 ne ................................................................................................. 73 atorvastatin calcium ................................. 47 benazepril-hydrochlorothiazide amphotericin b .................................................... 15 atovaquone ................................................................ 16 .......................................................................................................... 42 ampicillin ....................................................................... 30 atovaquone-proguanil hcl .............. 19 BENICAR ......................................................................... 45 ampicillin sodium .......................................... 30 ATRIPLA ........................................................................... 22 BENICAR HCT ........................................................ 45 ampicillin-sulbactam sodium ATROVENT HFA ............................................. 162 BENLYSTA ............................................................... 108 .......................................................................................................... 31 aubra ..................................................................................... 83 benzonatate ......................................................... 115 AMPYRA ........................................................................... 75 AUVI-Q ........................................................................... 164 benzoyl peroxide ........................................ 115 anagrelide hcl .................................................. 104 AVASTIN .......................................................................... 36 benzoyl peroxide cleanser ....... 115 anastrozole ................................................................ 37 aviane .................................................................................. 83 benzoyl peroxide wash ................... 115 ANDRODERM ......................................................... 77 avita .................................................................................... 167 benzoyl peroxide-erythromycin ANORO ELLIPTA ........................................... 162 AVODART .................................................................. 100 ...................................................................................................... 167 antacid maximum strength .... 113 AXID AR ........................................................................ 114 benztropine mesylate ............................. 67 anti-diarrheal .................................................... 113 AXIRON .............................................................................. 77 BEPREVE .................................................................... 156 antifungal ................................................................. 113 AYR SALINE NASAL ............................... 114 BESIVANCE ............................................................ 159 antioxidant formula sg ..................... 113 AYR SALINE NASAL DROPS .... 114 beta carotene ................................................... 115 apap 500 ................................................................... 114 azacitidine ................................................................... 34 betamethasone dipropionate apexicon ..................................................................... 170 AZACTAM IN DEXTROSE ................... 16 ...................................................................................................... 170 ap-hist dm .............................................................. 114 azathioprine ......................................................... 108 betamethasone dipropionate aug APOKYN ............................................................................ 66 azelastine hcl ................................. 156, 162 ...................................................................................................... 170 apri ............................................................................................ 83 AZILECT ............................................................................ 66 betamethasone valerate .............. 171 APRISO ............................................................................... 97 azithromycin ........................................................... 28 BETASERON ............................................................. 75 APTIOM ............................................................................. 56 AZOPT ............................................................................. 157 betaxolol hcl ........................................................ 157 APTIVUS ........................................................................... 19 AZOR ...................................................................................... 44 bethanechol chloride .......................... 101 AQUADEKS ............................................................. 114 aztreonam ................................................................... 16 BETOPTIC-S ......................................................... 157 AQUA-E ......................................................................... 114 b complex ................................................................ 114 BEXSERO ................................................................... 109 AQUANIL HC ........................................................ 114 b-12 ................................................................................... 114 bicalutamide ........................................................... 37 ARALAST NP ....................................................... 164 B-12 DOTS ............................................................ 114 BICILLIN L-A ............................................................ 31 aranelle ............................................................................. 83 bacitracin ............................................... 114, 159 BICNU ................................................................................... 32 ARCALYST ............................................................... 107 bacitracin zinc ................................................. 115 BILTRICIDE .................................................................. 16 aripiprazole ................................................................ 68 bacitracin-polymyxin b ................... 159 biospec dmx ....................................................... 115 ARNUITY ELLIPTA ...................................... 165 bacitra-neomycin-polymyxin-hc biotin ................................................................................. 115 artificial tears .................................................... 114 ...................................................................................................... 158 bisoprolol fumarate .................................... 49 ASACOL HD ............................................................... 97 baclofen ........................................................................... 76 bisoprolol-hydrochlorothiazide ascorbic acid ..................................................... 114 balsalazide disodium .............................. 97 .......................................................................................................... 48 aspirin ............................................................................. 114 balziva ................................................................................. 83 BIVIGAM ...................................................................... 106 aspirin ec .................................................................. 114 BANZEL ............................................................................. 57 bleomycin sulfate .......................................... 34 ASSURE ID INSULIN SAFETY SYR BARACLUDE ............................................................. 24 blephamide s.o.p. ..................................... 158 .......................................................................................................... 78 BCG VACCINE .................................................... 109 B-NATAL .................................................................... 115 ASTEPRO ................................................................... 162 b-complex/vitamin c ........................... 115 BONE DENSITY ............................................... 115 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 178 Index Index Index bone meal ............................................................... 115 calcitriol ...................................................................... 156 calmag thins ....................................................... 118 BOOSTRIX ................................................................ 109 calcium ......................................................................... 117 CAL-QUICK ............................................................. 118 BOSULIF .......................................................................... 38 calcium + d .......................................................... 116 CALTRATE 600+D SOFT .............. 118 BOUDREAUXS BUTT PASTE .... 115 calcium + d3 ..................................................... 116 camila .................................................................................. 83 BREO ELLIPTA ................................................. 166 calcium 1000 + d ..................................... 116 CANASA ........................................................................... 97 briellyn ............................................................................... 83 calcium 500 ........................................................ 116 CANCIDAS .................................................................... 15 BRILINTA .................................................................... 105 calcium 500/d ................................................. 116 CAPASTAT SULFATE ................................ 22 brimonidine tartrate .............................. 157 calcium 500+d high potency CAPRELSA ................................................................... 39 BRINTELLIX ................................................................ 63 ...................................................................................................... 116 captopril .......................................................................... 43 brohist d ..................................................................... 115 calcium 600 ........................................................ 116 captopril-hydrochlorothiazide bromfenac sodium .................................. 160 calcium 600/vitamin d .................... 116 .......................................................................................................... 42 bromfenac sodium (once-daily) calcium 600+d plus minerals CARBAGLU .................................................................. 88 ...................................................................................................... 160 ...................................................................................................... 116 carbamazepine .................................................. 57 bromocriptine mesylate ..................... 67 calcium acetate ................................................ 93 carbamazepine er ......................................... 57 budesonide ........................................................... 165 calcium antacid ............................................ 116 carbidopa-levodopa .................................. 67 budesonide er ...................................................... 97 calcium antacid extra strength carbidopa-levodopa er ......................... 67 bumetanide ............................................................... 53 ...................................................................................................... 116 carbidopa-levodopa-entacapone .......................................................................................................... 67 buprenorphine hcl ........................................ 76 calcium antacid ultra max st buprenorphine hcl-naloxone hcl ...................................................................................................... 116 carboplatin ................................................................. 41 calcium ascorbate ................................... 117 CARIMUNE NF .................................................. 106 .......................................................................................................... 76 buproban ....................................................................... 76 calcium carbonate .................................. 117 carteolol hcl ......................................................... 157 bupropion hcl ........................................................ 63 calcium carbonate-vitamin d cartia xt ............................................................................ 50 bupropion hcl er (sr) ................................. 63 ...................................................................................................... 117 carvedilol ....................................................................... 49 bupropion hcl er (xl) .................................. 63 calcium citrate ................................................ 117 castellani paint modified ............. 118 buspirone hcl ......................................................... 56 calcium citrate + d ................................. 117 CAYSTON ....................................................................... 16 BUSULFEX .................................................................... 33 calcium citrate malate-vit d cefaclor ............................................................................. 25 butorphanol tartrate .................................. 13 ...................................................................................................... 117 cefaclor er ................................................................... 25 BYDUREON ................................................................. 78 calcium citrate-vitamin d ........... 117 cefadroxil ...................................................................... 26 BYETTA 10 MCG PEN ............................. 78 calcium for women ................................ 117 cefazolin sodium ............................................. 26 BYETTA 5 MCG PEN .................................. 78 calcium gluconate ................................... 117 cefdinir ............................................................................... 26 BYSTOLIC ...................................................................... 49 calcium gummies ..................................... 117 cefepime hcl ........................................................... 26 c-500 ............................................................................... 115 calcium lactate .............................................. 117 cefixime ........................................................................... 26 cabergoline ................................................................ 92 calcium pantothenate ....................... 117 cefotaxime sodium ..................................... 26 cal/mag ........................................................................ 115 calcium soft chews ............................... 118 cefoxitin sodium ............................................... 26 CALCET CREAMY BITES ................ 115 calcium/c/d ........................................................... 118 cefpodoxime proxetil ............................... 26 CALCET PETITES ......................................... 116 calcium+d3 gradual release cefprozil ........................................................................... 27 CALCI-MIX ............................................................... 116 ...................................................................................................... 118 ceftazidime ................................................................ 27 calcionate ................................................................ 116 calcium-magnesium ........................... 118 CEFTAZIDIME AND DEXTROSE .......................................................................................................... 27 calcipotriene ....................................................... 169 calcium-magnesium-vitamin d calcitonin (salmon) ...................................... 92 ...................................................................................................... 118 ceftriaxone sodium ..................................... 27 cal-citrate plus vitamin d ........... 116 calcium-magnesium-zinc ......... 118 cefuroxime axetil ............................................ 27 calcitrene .................................................................. 170 calcium-vitamin d3 ............................... 118 cefuroxime sodium ..................................... 27 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 179 Index Index Index celecoxib ............................................................................ 9 cilostazol ................................................................... 104 CLINIMIX/DEXTROSE (4.25/5) CELONTIN ..................................................................... 57 CILOXAN ..................................................................... 159 ...................................................................................................... 153 CENTRUM KIDS COMPLETE ... 118 CIMZIA ........................................................................... 105 CLINIMIX/DEXTROSE (5/15) ... 153 CENTRUM SILVER ..................................... 118 CIMZIA PREFILLED .................................. 105 CLINIMIX/DEXTROSE (5/20) ... 153 cephalexin ................................................................... 27 CIMZIA STARTER KIT .......................... 105 CLINIMIX/DEXTROSE (5/25) ... 153 CERDELGA .................................................................. 88 CINRYZE ...................................................................... 104 clobetasol propionate ........................ 171 CEREZYME .................................................................. 88 CIPRODEX ................................................................ 176 clobetasol propionate e ................. 171 CEROVITE ADVANCED FORMULA ciprofloxacin ............................................................ 29 clomipramine hcl ........................................... 63 ...................................................................................................... 118 ciprofloxacin hcl ............................ 29, 159 clonazepam .............................................................. 57 CERVARIX ................................................................. 109 ciprofloxacin in d5w ................................. 29 clonidine hcl ............................................................ 54 cetirizine hcl ..................................... 118, 162 ciprofloxacin-ciproflox hcl er ... 29 clopidogrel bisulfate ............................ 105 cevimeline hcl ................................................. 175 cisplatin ........................................................................... 41 clorazepate dipotassium .... 57, 58 CHANTIX .......................................................................... 76 citalopram hydrobromide ............... 63 clotrimazole .................... 120, 169, 175 CHANTIX CONTINUING MONTH CITRACAL CALCIUM GUMMIES clotrimazole 3 .................................................. 120 PAK ........................................................................................... 76 ...................................................................................................... 119 clozapine ........................................................................ 68 CHANTIX STARTING MONTH PAK CITRACAL PLUS HEART HEALTH CLOZAPINE ................................................................. 68 .......................................................................................................... 77 ...................................................................................................... 119 COARTEM ..................................................................... 19 chelated calcium ........................................ 119 citrus calcium +d ...................................... 119 cod liver oil ............................................................ 120 CHEMET ........................................................................... 82 citrus calcium/vitamin d .............. 120 codituss dm ......................................................... 120 chewable calcium .................................... 119 cladribine ...................................................................... 34 colchicine-probenecid ............................... 9 chewable vite childrens ................ 119 claravis ......................................................................... 167 COLCRYS ............................................................................ 9 chewable vite/iron childrens clarithromycin ...................................................... 28 cold head congestion severe ...................................................................................................... 119 clarithromycin er ............................................. 28 ...................................................................................................... 120 childrens acetaminophen .......... 119 CLARITIN .................................................................... 120 cold/cough childrens .......................... 120 childrens cold & allergy ................. 119 CLARITIN REDITABS ............................. 120 cold/cough/sore throat child childrens complete allergy ...... 119 classic prenatal ............................................. 120 ...................................................................................................... 120 childrens non-aspirin ......................... 119 clindamax ................................................................ 167 colestipol hcl .......................................................... 47 childrens plus cold ................................. 119 clindamycin hcl ................................................. 17 colistimethate sodium .......................... 17 childrens plus cold & allergy clindamycin palmitate hcl .............. 17 colocort ............................................................................. 97 ...................................................................................................... 119 clindamycin phosphate COMBIGAN ............................................................. 157 chlo tuss ex .......................................................... 119 ..................................................................... 17, 102, 167 COMBIVENT RESPIMAT .................. 162 chlorhexidine gluconate ............... 175 clindamycin phosphate in d5w COMETRIQ (100 MG DAILY chloroquine phosphate ........................ 19 .......................................................................................................... 17 DOSE) ................................................................................... 39 chlorothiazide ....................................................... 53 CLINIMIX/DEXTROSE (2.75/5) COMETRIQ (140 MG DAILY chlorpheniramine maleate er ...................................................................................................... 152 DOSE) ................................................................................... 39 ...................................................................................................... 119 CLINIMIX/DEXTROSE (4.25/10) COMETRIQ (60 MG DAILY DOSE) chlorpromazine hcl ..................................... 68 ...................................................................................................... 153 .......................................................................................................... 39 chlorthalidone ....................................................... 53 CLINIMIX/DEXTROSE (4.25/20) COMPLERA ................................................................. 22 cholestyramine ................................................... 47 ...................................................................................................... 153 complete sinus relief .......................... 120 cholestyramine light ................................. 47 CLINIMIX/DEXTROSE (4.25/25) compro .............................................................................. 94 ciclopirox .................................................................. 168 ...................................................................................................... 153 COMTREX SEVERE COLD & ciclopirox olamine .................................... 168 SINUS ............................................................................... 120 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 180 Index Index Index COMVAX ..................................................................... 109 cyclophosphamide ...................................... 33 desmopressin acetate spray .... 94 CONEX COLD/ALLERGY .................. 120 CYCLOPHOSPHAMIDE ........................... 33 desogestrel-ethinyl estradiol .... 83 constulose ................................................................... 97 cycloserine ................................................................. 22 desonide .................................................................... 171 CONTAC COLD+FLU MAX ST cyclosporine ........................................................ 108 desoximetasone .......................................... 171 ...................................................................................................... 120 cyclosporine modified ...................... 108 dexamethasone ................................................. 90 COPAXONE ................................................................. 75 CYSTADANE ............................................................. 88 dexamethasone intensol .................. 90 coral calcium ..................................................... 121 CYSTAGON .................................................................. 88 dexamethasone sod phosphate coral calcium plus ................................... 121 cytarabine .................................................................... 35 pf .................................................................................................. 90 CORICIDIN HBP CYTO B2 ..................................................................... 122 dexamethasone sodium CONGESTION/COUGH ........................ 121 d 1000 ........................................................................... 122 phosphate ................................................. 90, 160 cormax scalp application ........... 171 d 10000 ....................................................................... 122 DEXILANT ................................................................. 100 cortisone acetate ............................................ 90 d 400 ................................................................................ 122 dexrazoxane ............................................................ 41 CORTIZONE-10 .............................................. 121 D3-50 .............................................................................. 122 dextrose ...................................................................... 154 cough & cold ...................................................... 121 d-5000 .......................................................................... 122 DEXTROSE 5%/ELECTROLYTE cough & sore throat day ............... 121 dacarbazine .............................................................. 33 #48 ....................................................................................... 154 cough dm ................................................................. 121 daily-vite/iron/beta-carotene dextrose in lactated ringers ... 154 COUMADIN ............................................................. 102 ...................................................................................................... 122 DEXTROSE-NACL ....................................... 154 CREON ........................................................................... 100 DALIRESP ................................................................. 164 dextrose-nacl .................................................... 154 CRESTOR ....................................................................... 47 danazol .............................................................................. 88 DIALYVITE 800 ................................................ 122 CRIXIVAN ........................................................................ 19 dantrolene sodium ....................................... 76 DIALYVITE 800-ZINC 15 ................ 122 cromolyn sodium ....................................................... dapsone ........................................................................... 17 DIALYVITE VITAMIN D3 MAX 99, 121, 156, 164 DAPTACEL ............................................................... 110 ...................................................................................................... 123 cryselle-28 ................................................................. 83 DARAPRIM ................................................................... 17 diazepam ....................................................................... 58 CUBICIN ............................................................................ 17 daunorubicin hcl .............................................. 34 diazepam intensol ........................................ 58 CUVPOSA ....................................................................... 96 day-time sinus ............................................... 122 diclofenac potassium .................................. 9 cvs calcium citrate ................................. 121 deblitane ........................................................................ 83 diclofenac sodium .......................... 9, 160 cvs easy fiber/calcium .................... 121 DELESTROGEN .................................................... 89 diclofenac sodium er ................................... 9 cvs hydrocortisone acetate .... 121 DELTUSS DP ....................................................... 122 dicloxacillin sodium ................................... 31 cvs laxative dietary supplemnt delyla .................................................................................... 83 dicyclomine hcl .................................................. 96 ...................................................................................................... 121 DELZICOL ...................................................................... 97 didanosine .................................................................. 19 cvs lubricant drops ................................ 121 DEMSER .......................................................................... 54 DIFICID ............................................................................... 28 cvs lubricating/dry eye .................... 121 DEPEN TITRATABS ...................................... 82 diflorasone diacetate .......................... 171 cvs nasal mist ................................................. 121 DEPO-PROVERA ................................................ 37 diflunisal .............................................................................. 9 cvs pain relief adult ............................... 121 DESENEX ................................................................... 122 digitek ................................................................................. 52 cvs probiotic (lactobacillus) .... 122 DESENEX SPRAY ......................................... 122 digoxin ................................................................................ 52 cvs senna-extra ........................................... 122 desipramine hcl ................................................ 64 dihydroergotamine mesylate ... 74 cvs stool softener ...................................... 122 DESITIN ........................................................................ 122 dilantin ............................................................................... 58 cvs vitamin b-6 ............................................. 122 desmopressin ace rhinal tube DILANTIN ....................................................................... 58 cvs vitamin c ...................................................... 122 .......................................................................................................... 94 dilantin infatabs ................................................ 58 cyanocobalamin .......................................... 122 desmopressin ace spray refrig diltiazem hcl ............................................................ 51 cyclafem 1/35 ...................................................... 83 .......................................................................................................... 94 diltiazem hcl er .................................................. 50 cyclafem 7/7/7 ................................................... 83 desmopressin acetate .......................... 94 diltiazem hcl er beads ........................... 50 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 181 Index Index duramorph .................................................................. 10 enulose ............................................................................. 97 50 DUREZOL .................................................................. 161 e-oil ..................................................................................... 124 dilt-xr .................................................................................... 51 e.e.s. 400 ..................................................................... 28 EPIPEN 2-PAK .................................................. 164 diltzac .................................................................................. 51 ecee plus .................................................................. 123 EPIPEN JR 2-PAK ....................................... 164 DIMETAPP LONG ACT econazole nitrate ....................................... 169 epirubicin hcl ......................................................... 34 COUGH/COLD .................................................... 123 ECOTRIN MAXIMUM STRENGTH epitol ...................................................................................... 58 DIMETAPP NIGHT ...................................................................................................... 123 EPIVIR HBV .................................................................. 24 COLD/CONGESTION .............................. 123 ed bron gp .............................................................. 123 eplerenone ................................................................. 44 DIPENTUM ................................................................... 97 ED CHLORPED ................................................. 123 epsom salt ............................................................. 124 diphenhydramine hcl ....... 123, 162 ED CHLORPED D ......................................... 123 EPZICOM ........................................................................ 22 diphenoxylate-atropine ....................... 99 ed chlorped jr ................................................... 123 eq allergy relief childrens .......... 124 DIPHTHERIA-TETANUS TOXOIDS ed-a-hist dm ...................................................... 124 eql antifungal (tolnaftate) ........... 124 DT ........................................................................................... 110 ed-apap ....................................................................... 124 eql calcium/vitamin d ........................ 124 disopyramide phosphate ................. 46 EDURANT ....................................................................... 19 eql childrens calcium gummies disulfiram ...................................................................... 77 EFFIENT ....................................................................... 105 ...................................................................................................... 124 divalproex sodium ........................................ 58 ELDERTONIC ....................................................... 124 eql childrens multivitamins .... 124 divalproex sodium er ............................... 58 ELIDEL ............................................................................ 174 eql iron supplement therapy docetaxel ....................................................................... 36 ELIQUIS ......................................................................... 102 ...................................................................................................... 124 DOCETAXEL .............................................................. 36 ELITEK ................................................................................. 41 eql lice solution ............................................. 124 docusate sodium ........................................ 123 elixophyllin ............................................................. 166 eql oyster shell calcium/d ......... 125 DOK ..................................................................................... 123 ELMIRON ................................................................... 101 EQUALACTIN ....................................................... 125 donepezil hcl .......................................................... 62 EMCYT ................................................................................ 33 ERIVEDGE ...................................................................... 36 dorzolamide hcl ............................................ 157 EMEND ............................................................................... 95 errin ......................................................................................... 84 dorzolamide hcl-timolol mal emoquette ................................................................... 84 ery .......................................................................................... 167 ...................................................................................................... 157 EMSAM ............................................................................. 64 ery-tab ............................................................................... 28 double antibiotic ......................................... 123 EMTRIVA ......................................................................... 20 erythrocin lactobionate ....................... 28 doxazosin mesylate ................................... 44 enalapril maleate ........................................... 43 erythrocin stearate ...................................... 28 doxepin hcl ................................................................ 64 enalapril-hydrochlorothiazide erythromycin ................................... 159, 168 doxorubicin hcl ................................................... 34 .......................................................................................................... 42 erythromycin base ....................................... 29 doxorubicin hcl liposomal .............. 34 endocet ............................................................................. 11 erythromycin ethylsuccinate .... 29 doxy 100 ........................................................................ 32 enema ............................................................................ 124 ESBRIET ...................................................................... 164 doxycycline hyclate .................................... 32 enema mineral oil .................................... 124 escitalopram oxalate ............................... 64 doxycycline monohydrate .............. 32 ENEMEEZ MINI ............................................... 124 esomeprazole sodium ...................... 100 DRAMAMINE LESS DROWSY ENEMEEZ PLUS ............................................. 124 estrace ............................................................................... 89 ...................................................................................................... 123 ENGERIX-B ............................................................. 110 estradiol ........................................................................... 89 dronabinol .................................................................... 95 enoxaparin sodium ................................ 102 estradiol valerate ............................................ 90 drospirenone-ethinyl estradiol enpresse-28 ............................................................ 84 ethambutol hcl .................................................... 23 .......................................................................................................... 83 entacapone ................................................................ 67 ethosuximide ......................................................... 58 DROXIA .............................................................................. 40 entecavir ........................................................................ 24 etodolac ........................................................................... 10 dual action complete .......................... 123 entre-cough ......................................................... 124 etodolac er ...................................................................... 9 duloxetine hcl ........................................................ 64 entre-hist pse ................................................... 124 etoposide ....................................................................... 42 DURAFLU ................................................................... 123 ENUCLENE .............................................................. 124 EURAX ............................................................................. 174 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. Index diltiazem hcl er coated beads .......................................................................................................... If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 182 Index Index Index EVOTAZ ............................................................................. 22 ferrous sulfate er ....................................... 125 flurbiprofen sodium ............................... 161 EXCEL COMFORT POINT PEN FETZIMA .......................................................................... 64 flutamide ........................................................................ 37 NEEDLE ............................................................................. 78 FETZIMA TITRATION ................................. 64 fluticasone propionate exefen-ir .................................................................... 125 FEVERALL INFANTS ............................... 126 ................................................................................... 165, 172 EXELON ............................................................................. 62 fexofenadine hcl .......................................... 126 fluvoxamine maleate ............................... 56 exemestane .............................................................. 37 fexofenadine hcl childrens ....... 126 FOLGARD .................................................................. 126 EXJADE ............................................................................. 83 fiber .................................................................................... 126 folic acid .................................................................... 126 EX-LAX ULTRA ................................................ 125 fiber (corn dextrin) ................................... 126 FOLITAB 500 ...................................................... 126 eye drops .................................................................. 125 fiber (guar gum) ........................................... 126 FOLTABS 800 ................................................... 126 eye drops allergy relief ................... 125 fiber laxative ....................................................... 126 fondaparinux sodium ....... 102, 103 eye wash ................................................................... 125 finasteride ............................................................... 101 FORTEO ............................................................................ 93 EZFE 200 ................................................................... 125 FIRAZYR ...................................................................... 104 FORTICAL ...................................................................... 92 ezfe forte ................................................................... 125 FLEBOGAMMA ................................................ 106 foscarnet sodium ........................................... 24 FABRAZYME ............................................................. 88 FLEBOGAMMA DIF .................................. 106 fosinopril sodium ............................................ 43 falmina ............................................................................... 84 flecainide acetate .......................................... 46 fosinopril sodium-hctz ......................... 42 famciclovir .................................................................. 24 FLEET BISACODYL ................................... 126 FREAMINE HBC .............................................. 153 famotidine ................................................................... 96 FLORANEX .............................................................. 126 FREAMINE III ....................................................... 153 famotidine premixed ................................ 96 FLORASTOR KIDS ..................................... 126 FRESHKOTE ......................................................... 127 FANAPT ............................................................................. 68 FLOVENT DISKUS .................... 165, 166 FUNGICURE FANAPT TITRATION PACK .............. 69 FLOVENT HFA ................................................... 166 INTENSIVE/NAILGUARD .................. 127 FARESTON .................................................................. 37 fluconazole ................................................................. 15 FUNGOID TINCTURE .............................. 127 FARXIGA .......................................................................... 79 fluconazole in dextrose ....................... 15 furosemide ................................................................. 53 FARYDAK ........................................................................ 36 fluconazole in sodium chloride FUSILEV ............................................................................ 41 FASLODEX ................................................................... 37 .......................................................................................................... 15 FUZEON ............................................................................ 20 FAZACLO ........................................................................ 69 flucytosine ................................................................... 15 FYCOMPA ........................................................ 58, 59 FEBROL ........................................................................ 125 fludarabine phosphate ......................... 35 gabapentin ................................................................. 59 felbamate ...................................................................... 58 fludrocortisone acetate ....................... 90 GABITRIL ........................................................................ 59 felodipine er ............................................................. 51 flunisolide ................................................................ 165 galantamine hydrobromide ......... 62 fenofibrate ................................................................... 47 fluocinolone acetonide galantamine hydrobromide er fenofibrate micronized ......................... 47 ................................................................................... 172, 176 .......................................................................................................... 62 fenofibric acid ...................................................... 47 fluocinolone acetonide body GAMASTAN S/D ............................................ 106 fentanyl ............................................................................. 11 ...................................................................................................... 172 GAMMAGARD .................................................... 106 fentanyl citrate .................................................... 11 fluocinolone acetonide scalp GAMMAGARD S/D .................................... 106 FENTORA ....................................................................... 11 ...................................................................................................... 172 GAMMAGARD S/D LESS IGA fer-iron .......................................................................... 125 fluocinonide ......................................................... 172 ...................................................................................................... 107 ferretts ........................................................................... 125 fluocinonide-e ................................................. 172 GAMMAKED ......................................................... 107 ferretts ips .............................................................. 125 fluorometholone .......................................... 161 GAMMAPLEX ...................................................... 107 FERRIMIN 150 ................................................. 125 fluorouracil .............................................. 35, 174 GAMUNEX-C ........................................................ 107 FERRIPROX ................................................................. 83 fluoxetine hcl ........................................... 64, 65 ganciclovir sodium ...................................... 24 ferrous fumarate ......................................... 125 fluphenazine decanoate .................... 69 GARDASIL ................................................................ 110 ferrous gluconate ...................................... 125 fluphenazine hcl ............................................... 69 GARDASIL 9 ......................................................... 110 ferrous sulfate .............................. 125, 126 flurbiprofen ................................................................ 10 gatifloxacin ............................................................ 159 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 183 Index Index Index GATTEX ............................................................................. 99 gnp childrens pain relief/cold HEPATAMINE ..................................................... 153 gavilyte-c ...................................................................... 98 ...................................................................................................... 127 HERCEPTIN ................................................................ 36 gavilyte-g ...................................................................... 98 gnp cold multi-sympt day/night HETLIOZ ........................................................................... 74 gavilyte-h ...................................................................... 98 ...................................................................................................... 127 HEXALEN ........................................................................ 33 gavilyte-n with flavor pack .......... 98 gnp cold multi-symptom night HIBERIX ........................................................................ 110 GAVISCON ............................................................... 127 ...................................................................................................... 127 hm allergy childrens ............................ 128 gnp foaming antacid ........................... 128 hm famotidine ................................................. 128 GAVISCON EXTRA RELIEF FORMULA ................................................................. 127 gnp iron ....................................................................... 128 hm rapid melts junior ........................ 128 GEMCITABINE HCL ....................................... 35 gnp multi-symptom cold night HONEY BEARS ................................................. 128 gemcitabine hcl ................................................ 35 ...................................................................................................... 128 HONEY BEARS W/IRON-ZINC gemfibrozil .................................................................. 47 gnp stool softener .................................... 128 ...................................................................................................... 128 generlac .......................................................................... 98 GOLYTELY .................................................................... 98 HUMIRA ........................................................................ 106 gengraf ......................................................................... 108 GONIOTAIRE ........................................................ 128 HUMIRA PEN ....................................................... 105 gentak ............................................................................ 159 goodsense all day allergy .......... 128 HUMIRA PEN-CROHNS STARTER gentamicin in saline ................................. 14 goodsense pain relief pm ex st ...................................................................................................... 105 gentamicin sulfate ...................................................................................................... 128 HUMIRA PEN-PSORIASIS ..................................................................... 14, 159, 168 granisetron hcl .................................................... 95 STARTER ................................................................... 105 gentian violet ..................................................... 127 GRANIX ......................................................................... 104 HUMULIN R U-500 gentle laxative ................................................. 127 griseofulvin microsize ........................... 15 (CONCENTRATED) ......................................... 78 GEODON .......................................................................... 69 griseofulvin ultramicrosize ........... 15 hydralazine hcl ................................................... 54 geravim ........................................................................ 127 guaifenesin dm ............................................. 128 hydrochlorothiazide ................................... 53 gianvi .................................................................................... 84 guaifenesin-codeine ............................ 128 HYDROCIL ................................................................ 128 gildagia ............................................................................. 84 guanfacine hcl er ........................................... 73 hydrocodone-acetaminophen gildess 1.5/30 ...................................................... 84 GUMMI BEAR .......................................................................................................... 11 GILENYA ........................................................................... 76 MULTIVITAMIN/MIN ............................... 128 hydrocodone-ibuprofen ...................... 11 GILOTRIF ......................................................................... 39 halobetasol propionate ................... 172 hydrocortisone ................................................................ glatopa ............................................................................... 76 haloperidol .................................................................. 69 90, 97, 129, 173 GLEEVEC ......................................................................... 39 haloperidol decanoate .......................... 69 hydrocortisone butyrate ................ 172 glimepiride ................................................................. 79 haloperidol lactate ....................................... 69 hydrocortisone valerate ................. 173 glipizide ............................................................................ 80 HARVONI ......................................................................... 24 hydrocortisone-aloe ............................. 129 glipizide er .................................................................. 80 HAVRIX .......................................................................... 110 hydromorphone hcl .................................... 11 glipizide-metformin hcl ...................... 80 headache pm .................................................... 128 hydromorphone hcl pf ........................... 11 GLOBAL ALCOHOL PREP EASE heather .............................................................................. 84 hydroxocobalamin ................................... 129 .......................................................................................................... 78 HEPARIN (PORCINE) IN D5W hydroxychloroquine sulfate .... 106 GLUCAGEN HYPOKIT ................................ 91 ...................................................................................................... 103 hydroxyurea ............................................................. 40 GLUCAGON EMERGENCY ................. 91 HEPARIN (PORCINE) IN NACL hydroxyzine hcl .......................... 162, 163 glycopyrrolate ....................................................... 96 ...................................................................................................... 103 hydroxyzine pamoate ........................ 163 gnp antacid & anti-gas ................... 127 HEPARIN SOD (PORCINE) IN D5W HYPOTEARS ......................................................... 129 gnp artificial tears .................................... 127 ...................................................................................................... 103 ibandronate sodium .................................. 82 gnp calcium 1200 .................................... 127 heparin sodium (porcine) ........... 103 IBRANCE ......................................................................... 36 HEPARIN SODIUM (PORCINE) ibuprofen ..................................................... 10, 129 gnp childrens chewables/ex c ...................................................................................................... 103 ibuprofen junior strength ............ 129 ...................................................................................................... 127 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 184 Index Index Index ibuprofen pm ..................................................... 129 ipratropium bromide ........................... 162 junel 1/20 ..................................................................... 84 ICAPS ............................................................................... 129 ipratropium-albuterol ......................... 162 junel fe 1.5/30 ..................................................... 84 ICAPS LUTEIN-ZEAXANTHIN irbesartan ..................................................................... 45 junel fe 1/20 ............................................................ 84 ...................................................................................................... 129 irbesartan-hydrochlorothiazide JUXTAPID ...................................................................... 48 ICAPS MV .................................................................. 129 .......................................................................................................... 45 k 100 ................................................................................ 130 ICLUSIG ............................................................................. 39 irinotecan hcl ......................................................... 42 KADCYLA ........................................................................ 37 idarubicin hcl ......................................................... 34 IROMIN-G ................................................................. 129 KALETRA ........................................................................ 22 IFEX .......................................................................................... 33 iron ....................................................................................... 130 KALYDECO .............................................................. 165 ifosfamide .................................................................... 33 iron (ferrous gluconate) ................. 129 KAOPECTATE ..................................................... 130 IFOSFAMIDE ............................................................. 33 iron 100 plus ..................................................... 130 kariva .................................................................................... 84 ILEVRO ........................................................................... 161 iron 100/c ................................................................ 130 kcl in dextrose-nacl .............................. 155 ilotycin ........................................................................... 159 iron chews pediatric ............................ 130 KCL IN DEXTROSE-NACL ............ 155 IMBRUVICA ................................................................. 39 IRON UP ....................................................................... 130 kelnor 1/35 ................................................................ 84 imipenem-cilastatin .................................. 17 ISENTRESS ................................................................. 20 ketoconazole ..................... 15, 169, 170 imipramine hcl .................................................... 65 ISOLYTE-P IN D5W ................................. 154 ketoprofen ................................................................... 10 imiquimod ............................................................... 174 ISOLYTE-S .............................................................. 154 ketorolac tromethamine ............... 161 IMOVAX RABIES ............................................ 110 isoniazid .......................................................................... 23 KEYTRUDA ................................................................... 37 INCRELEX ...................................................................... 92 ISOPTO TEARS ................................................ 130 kidkare cough/cold ................................ 130 INCRUSE ELLIPTA ..................................... 162 isosorbide dinitrate ..................................... 55 kionex .................................................................................. 83 indapamide ............................................................... 54 isosorbide dinitrate er ........................... 55 klor-con ....................................................................... 151 INFANRIX ................................................................... 110 isosorbide mononitrate ....................... 55 klor-con 10 ........................................................... 151 infants ibuprofen ........................................ 129 isosorbide mononitrate er .............. 55 klor-con m15 .................................................... 151 infants pain relief ...................................... 129 isradipine ...................................................................... 51 klor-con m20 .................................................... 151 INLYTA ................................................................................ 39 ISTALOL ...................................................................... 157 kls acid reducer max st ................. 130 INSULIN SYRINGE ........................................... 78 ISTODAX .......................................................................... 37 KONSYL ....................................................................... 130 INTEGRA ..................................................................... 129 itraconazole .............................................................. 15 KONSYL-D ............................................................... 130 INTELENCE ................................................................. 20 ivermectin .................................................................... 17 KORLYM .......................................................................... 91 intense cold/flu medicine ........... 129 IXIARO ............................................................................. 110 kp b complex-c ............................................. 130 intense cough reliever ex st JAKAFI ................................................................................ 39 kp benzoyl peroxide ............................. 130 ...................................................................................................... 129 JALYN ............................................................................. 101 kp calcium 600+d ................ 130, 131 INTRALIPID ............................................................. 153 jantoven ...................................................................... 103 kp calcium-magnesium-zinc INTRON A .................................................................. 107 JANUMET ...................................................................... 80 ...................................................................................................... 131 introvale ........................................................................... 84 JANUMET XR .......................................................... 80 kp ferrous gluconate ........................... 131 INVANZ ............................................................................... 17 JANUVIA ........................................................................... 80 kp ferrous sulfate ...................................... 131 INVEGA ............................................................................... 69 JENTADUETO ......................................................... 80 kp hydrocortisone .................................... 131 INVEGA SUSTENNA ..................................... 70 jinteli ...................................................................................... 90 kp ketotifen fumarate ........................ 131 INVIRASE ........................................................................ 20 J-MAX ............................................................................. 130 kp pseudoephedrine hcl ............... 131 INVOKAMET .............................................................. 80 jolessa ................................................................................. 84 kp terbinafine hydrochloride INVOKANA .................................................................... 80 jolivette ............................................................................. 84 ...................................................................................................... 131 IONOSOL-B IN D5W .............................. 154 J-TAN D PD .......................................................... 130 kp vitamin d ........................................................ 131 IONOSOL-MB IN D5W ....................... 154 J-TAN PD .................................................................. 130 kp vitamin e ......................................................... 131 IPOL .................................................................................... 110 junel 1.5/30 .............................................................. 84 kpn prenatal ........................................................ 131 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 185 Index Index Index KUVAN ................................................................................. 89 LEVEMIR FLEXTOUCH ............................ 78 localnesium-c .................................................. 132 KYNAMRO .................................................................... 48 levetiracetam ......................................................... 59 LODRANE D .......................................................... 132 labetalol hcl .............................................................. 49 levetiracetam er ............................................... 59 LOHIST-D .................................................................. 132 laclotion ....................................................................... 174 LEVETIRACETAM IN NACL .............. 59 lohist-dm .................................................................. 132 lactated ringers ............................................. 155 levobunolol hcl ............................................... 157 lohist-peb ................................................................. 132 lactulose ......................................................................... 98 levocarnitine ............................................................ 89 lokara ............................................................................... 173 lactulose encephalopathy .............. 98 levocetirizine dihydrochloride lomustine ...................................................................... 33 LAMISIL ADVANCED ............................. 131 ...................................................................................................... 163 loperamide hcl .................................. 99, 132 LAMISIL AF DEFENSE ........................ 131 levofloxacin ............................................................... 29 loratadine ................................................................. 132 lamivudine .................................................... 20, 24 levofloxacin in d5w .................................... 29 loratadine-pseudoephedrine er lamivudine-zidovudine ......................... 22 levoleucovorin calcium ....................... 41 ...................................................................................................... 132 lamotrigine ................................................................. 59 levonest ........................................................................... 85 lorazepam .................................................................... 56 lamotrigine er ........................................................ 59 levonorgest-eth estrad 91-day lorazepam intensol ...................................... 56 LANTUS ............................................................................ 78 .......................................................................................................... 85 lorcet ..................................................................................... 11 LANTUS SOLOSTAR ................................... 78 levonorgestrel ....................................................... 85 lorcet hd .......................................................................... 11 larin 1.5/30 ................................................................ 84 levonorgestrel-ethinyl estrad ... 85 lorcet plus .................................................................... 11 larin 1/20 ....................................................................... 84 levora 0.15/30 (28) ..................................... 85 lortab ..................................................................................... 11 larin fe 1.5/30 ...................................................... 84 levothyroxine sodium ............................. 93 loryna ................................................................................... 85 larin fe 1/20 ............................................................. 84 levoxyl ................................................................................. 94 losartan potassium ..................................... 45 LASTACAFT ........................................................... 156 LEXIVA ................................................................................. 20 losartan potassium-hctz ................... 45 latanoprost ............................................................. 157 lice killing maximum strength LOTEMAX .................................................................. 161 LATUDA ............................................................................ 70 ...................................................................................................... 131 LOTRIMIN ULTRA ....................................... 132 laxative pills ......................................................... 131 lice treatment ................................................... 131 lovastatin ....................................................................... 47 leena ...................................................................................... 85 lidocaine ..................................................................... 173 low-ogestrel ............................................................. 85 leflunomide ........................................................... 106 lidocaine hcl .......................................... 13, 173 loxapine succinate ....................................... 70 LENVIMA 10 MG DAILY DOSE lidocaine hcl (pf) .............................................. 13 lubricating plus eye drops ........ 132 .......................................................................................................... 39 lidocaine viscous ........................................ 175 LUMIGAN ................................................................... 157 lidocaine-prilocaine .............................. 173 LUMITENE ................................................................ 132 LENVIMA 14 MG DAILY DOSE linezolid ............................................................................ 17 LUMIZYME ................................................................... 89 .......................................................................................................... 39 LENVIMA 20 MG DAILY DOSE LINEZOLID .................................................................... 17 LUPRON DEPOT ................................................. 38 .......................................................................................................... 39 LINZESS ........................................................................... 99 LUPRON DEPOT-PED ............................... 38 LENVIMA 24 MG DAILY DOSE liothyronine sodium ................................... 94 lutera ..................................................................................... 85 .......................................................................................................... 39 liquid calcium with d3 ...................... 131 LYNPARZA ................................................................... 37 lessina ................................................................................ 85 liquid calcium/vitamin d ............... 131 LYRICA ................................................................................ 60 LETAIRIS ......................................................................... 55 liquituss gg ........................................................... 132 LYSODREN .................................................................. 38 letrozole ........................................................................... 37 lisinopril ........................................................................... 43 lyza ........................................................................................... 85 leucovorin calcium ...................................... 41 lisinopril-hydrochlorothiazide MAALOX CHILDRENS .......................... 132 LEUKERAN ................................................................... 33 .......................................................................................................... 43 MAALOX REGULAR STRENGTH LEUKINE ...................................................................... 104 LITHIUM ........................................................................... 75 ...................................................................................................... 132 leuprolide acetate ......................................... 37 lithium carbonate ........................................... 75 mag-al ........................................................................... 132 levalbuterol hcl .............................................. 163 lithium carbonate er ................................. 75 mag-delay .............................................................. 132 LEVEMIR .......................................................................... 78 localnesium .......................................................... 132 MAGINEX ................................................................... 132 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 186 Index Index Index MAGNEBIND 300 ........................................ 133 METAMUCIL SMOOTH TEXTURE midodrine hcl ........................................................ 54 magnesium ........................................................... 133 ...................................................................................................... 133 milk of magnesia ....................................... 134 magnesium citrate .................................. 133 metformin hcl ....................................................... 81 milk of magnesia concentrate magnesium oxide ..................................... 133 metformin hcl er .............................................. 81 ...................................................................................................... 134 MAGNESIUM SULFATE .................... 151 methadone hcl .................................................... 12 mineral oil ............................................................... 134 magnesium sulfate ................................ 151 methadone hcl intensol ...................... 11 minitran ............................................................................ 55 methazolamide .................................................. 54 minocycline hcl .................................................. 32 MAGNESIUM SULFATE IN D5W ...................................................................................................... 151 methenamine hippurate .................... 18 minoxidil ......................................................................... 54 MAG-TAB SR ...................................................... 133 methimazole ........................................................... 94 MINTOX PLUS ................................................... 134 malathion ................................................................. 174 methotrexate ..................................................... 106 mirtazapine ............................................................... 65 MAPAP COLD FORMULA methotrexate sodium ............................. 35 misoprostol ................................................................ 99 MULTI-SYMPT ................................................. 133 methotrexate sodium (pf) ............... 35 MISSION PRENATAL ............................. 134 maprotiline hcl .................................................... 65 methyclothiazide ............................................. 54 MISSION PRENATAL HP ................. 134 marlissa ........................................................................... 85 methylergonovine maleate .......... 92 mitomycin .................................................................... 34 MARPLAN ..................................................................... 65 methylphenidate hcl ................................. 73 mitoxantrone hcl ............................................. 40 MATULANE ................................................................. 40 methylphenidate hcl er ....................... 73 M-M-R II ..................................................................... 110 MAXIDEX .................................................................... 161 methylprednisolone ................................... 91 moderiba ........................................................................ 24 meclizine hcl .......................................................... 95 methylprednisolone (pak) ............... 90 MODERIBA 1200 DOSE PACK medroxyprogesterone acetate methylprednisolone acetate ...... 90 .......................................................................................................... 24 ............................................................................................ 85, 93 methylprednisolone sodium succ moderiba 800 dose pack ................ 24 mefloquine hcl .................................................... 19 .......................................................................................................... 91 moexipril hcl ........................................................... 43 MEGACE ES ............................................................... 38 metipranolol ........................................................ 158 moexipril-hydrochlorothiazide megestrol acetate ......................................... 38 metoclopramide hcl .................................. 95 .......................................................................................................... 43 MEKINIST ...................................................................... 39 metolazone ................................................................ 54 mometasone furoate .......................... 173 meloxicam .................................................................. 10 metoprolol succinate er ..................... 49 mononessa ................................................................ 85 melphalan hcl ....................................................... 33 metoprolol tartrate ....................................... 49 montelukast sodium ............................ 164 MENACTRA ............................................................ 110 metoprolol-hydrochlorothiazide morphine sulfate ............................................. 12 m-end dmx ........................................................... 133 .......................................................................................................... 48 morphine sulfate (concentrate) MENOMUNE ......................................................... 110 metronidazole ................. 18, 102, 174 .......................................................................................................... 12 MENVEO ...................................................................... 110 metronidazole in nacl ............................. 18 morphine sulfate (pf) ............................... 12 MEPHYTON ............................................................ 133 mexiletine hcl ........................................................ 46 morphine sulfate er ................................... 12 mercaptopurine ................................................. 35 MEXSANA ................................................................. 133 morphine sulfate er beads ........... 12 MERIBIN ...................................................................... 133 MIACALCIN ................................................................. 92 motion sickness relief ...................... 134 meropenem .............................................................. 18 MI-ACID ....................................................................... 134 MOTRIN IB .............................................................. 134 mesalamine .............................................................. 97 miconazole 1 ..................................................... 134 MOVANTIK ................................................................... 99 mesalamine-cleanser ............................ 97 miconazole 3 ..................................................... 134 MOVIPREP .................................................................... 98 mesna ................................................................................. 42 miconazole 3 combo pack ....... 134 MOXEZA ...................................................................... 159 MESNEX ........................................................................... 42 miconazole 7 ..................................................... 134 MOZOBIL ................................................................... 104 metadate er .............................................................. 73 microgestin 1.5/30 ..................................... 85 mucaphed ............................................................... 134 METAMUCIL ......................................................... 133 microgestin 1/20 ............................................ 85 MUCINEX COUGH FOR KIDS METAMUCIL MULTIHEALTH microgestin fe 1.5/30 ............................ 85 ...................................................................................................... 134 FIBER ................................................................................ 133 microgestin fe 1/20 ................................... 85 MUCINEX D ........................................................... 134 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 187 Index Index Index MUCINEX FAST-MAX COLD & naphazoline hcl ............................................. 161 nevirapine er ........................................................... 20 SINUS ............................................................................... 134 naproxen ........................................................................ 10 NEXAFED ................................................................... 136 MUCINEX FOR KIDS ............................... 135 naproxen dr .............................................................. 10 NEXAFED SINUS PRESSURE + MUCINEX MAXIMUM STRENGTH naproxen sodium ......................... 10, 135 PAIN .................................................................................... 136 ...................................................................................................... 135 naratriptan hcl ..................................................... 74 NEXAVAR ........................................................................ 39 mucus relief ........................................................ 135 nasal decongestant ............ 135, 136 NEXIUM ........................................................................ 100 mucus relief cold/sinus max st next choice one dose ............................. 86 nasal decongestant pe max st ...................................................................................................... 135 ...................................................................................................... 136 niacin ............................................................................... 136 mucus relief cough childrens nasal spray extra moisturizing niacin er ...................................................................... 136 ...................................................................................................... 135 ...................................................................................................... 136 niacin er (antihyperlipidemic) mucus relief er ............................................... 135 NASCOBAL ............................................................. 136 .......................................................................................................... 48 mucus-dm .............................................................. 135 NASOPEN PE ...................................................... 136 niacinamide ......................................................... 136 mucus-dm max ............................................ 135 NATACYN .................................................................. 159 niacor ................................................................................... 48 MULTAQ .......................................................................... 46 nateglinide .................................................................. 81 nicardipine hcl ..................................................... 51 multi-delyn ............................................................ 135 NATPARA ....................................................................... 93 nicotine ........................................................................ 137 multi-delyn/iron ............................................ 135 natural fiber laxative ........................... 136 nicotine polacrilex ................. 136, 137 multi-symptom cold childrens natural fiber therapy ............................ 136 NICOTROL .................................................................... 77 ...................................................................................................... 135 natures tears ..................................................... 136 NICOTROL NS ........................................................ 77 mupirocin ................................................................. 168 NEBUPENT .................................................................. 18 nifedical xl ................................................................... 51 MURO 128 .............................................................. 135 necon 0.5/35 (28) ......................................... 86 nifedipine er ............................................................. 51 MUSTARGEN ........................................................... 33 necon 1/35 (28) ................................................ 86 nifedipine er osmotic .............................. 51 my way ......................................................................... 135 necon 1/50 (28) ................................................ 86 night-time sinus .......................................... 137 MYCAMINE ................................................................. 16 necon 10/11 (28) ............................................ 86 nikki ........................................................................................ 86 mycophenolate mofetil ................... 108 necon 7/7/7 .............................................................. 86 NILANDRON .............................................................. 38 mycophenolic acid .................................. 108 nefazodone hcl ................................................... 65 nimodipine .................................................................. 52 MYKIDZ IRON .................................................... 135 neomycin sulfate ............................................ 14 NIPENT ............................................................................... 35 MYKIDZ IRON 10 ......................................... 135 neomycin-bacitracin zn-polymyx nitro-bid ........................................................................... 55 myorisan .................................................................... 168 ...................................................................................................... 160 NITRO-DUR ................................................................ 55 MYOZYME .................................................................... 89 neomycin-polymyxin-dexameth nitrofurantoin macrocrystal ........ 18 MYRBETRIQ .......................................................... 101 ...................................................................................................... 158 nitrofurantoin monohyd macro myzilra ............................................................................... 86 neomycin-polymyxin-gramicidin .......................................................................................................... 18 nabumetone ............................................................. 10 ...................................................................................................... 160 nitroglycerin ............................................................. 55 nadolol ............................................................................... 49 neomycin-polymyxin-hc NITROSTAT ................................................................ 55 nafcillin sodium ................................................. 31 ................................................................................... 158, 176 nohist-lq ..................................................................... 137 NAGLAZYME ............................................................ 89 NEORAL .................................................... 108, 109 nora-be ............................................................................. 86 nalbuphine hcl ..................................................... 13 neotuss ......................................................................... 136 NORDITROPIN FLEXPRO .................... 91 naloxone hcl ............................................................ 77 NEPHRAMINE .................................................... 153 NORDITROPIN NORDIFLEX PEN naltrexone hcl ....................................................... 77 NEPHRONEX ........................................................ 136 .......................................................................................................... 92 NAMENDA .................................................................... 62 NEUMEGA ................................................................ 104 NOREL AD ............................................................... 137 NAMENDA XR ........................................................ 62 NEUPOGEN ............................................................. 104 norethindrone ....................................................... 86 NAMENDA XR TITRATION PACK NEUPRO ........................................................................... 67 norethindrone acetate ........................... 93 .......................................................................................................... 63 nevirapine .................................................................... 20 norethindrone-eth estradiol ....... 90 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 188 Index Index Index norgestim-eth estrad triphasic OFEV .................................................................................. 165 pain reliever ........................................................ 138 .......................................................................................................... 86 ofloxacin .................................................. 160, 176 pamidronate disodium ......................... 82 norlyroc ............................................................................ 86 olanzapine ................................................................... 70 PANOXYL ................................................................... 138 normosol-m in d5w .............................. 155 olopatadine hcl .............................................. 163 PANOXYL WASH ........................................... 138 NORMOSOL-R IN D5W .................... 155 omega-3-acid ethyl esters ........... 48 PANOXYL-4 CREAMY WASH NORMOSOL-R PH 7.4 ....................... 155 omeprazole ........................................ 100, 137 ...................................................................................................... 138 NORPACE CR .......................................................... 46 ondansetron ............................................................. 95 PANRETIN ................................................................ 174 nortrel 0.5/35 (28) ........................................ 86 ondansetron hcl ................................................ 95 pantoprazole sodium .......................... 100 nortrel 1/35 (21) ............................................... 86 ONETOUCH ULTRA 2 ................................ 81 paricalcitol .............................................................. 156 nortrel 1/35 (28) ............................................... 86 ONETOUCH ULTRA BLUE ................. 81 paromomycin sulfate .............................. 14 nortrel 7/7/7 ............................................................ 86 ONETOUCH ULTRA MINI .................... 81 paroxetine hcl ....................................................... 65 nortriptyline hcl .................................................. 65 ONETOUCH ULTRA SYSTEM ...... 81 parva-cal ................................................................... 138 NORVIR .............................................................................. 20 ONETOUCH ULTRASMART ............. 81 paser ..................................................................................... 23 NOVAFERRUM 125 ................................. 137 ONETOUCH VERIO ......................................... 82 PATADAY ................................................................... 156 NOVAFERRUM PEDIATRIC ONETOUCH VERIO IQ SYSTEM PAXIL ..................................................................................... 65 DROPS ........................................................................... 137 .......................................................................................................... 82 PAZEO ............................................................................. 156 NOVOLIN 70/30 ................................................. 78 ONETOUCH VERIO SYNC PEDIACARE CHILDRENS NOVOLIN N ................................................................. 78 SYSTEM ........................................................................... 82 LONG-ACT ............................................................... 138 NOVOLIN R .................................................................. 79 ONFI ........................................................................................ 60 PEDIA-LAX .............................................................. 138 NOVOLOG ...................................................................... 79 OPSUMIT ........................................................................ 55 PEDVAX HIB ......................................................... 111 NOVOLOG FLEXPEN ................................... 79 ORAP ..................................................................................... 71 peg 3350/electrolytes ........................... 98 NOVOLOG MIX 70/30 .............................. 79 ORFADIN ......................................................................... 89 peg 3350-kcl-na bicarb-nacl NOVOLOG MIX 70/30 FLEXPEN organ-i nr ................................................................. 137 .......................................................................................................... 98 .......................................................................................................... 79 orsythia ............................................................................. 86 peg-3350/electrolytes .......................... 98 NOVOLOG PENFILL ...................................... 79 OS-CAL EXTRA D3 .................................. 137 PEGANONE ................................................................. 60 NOXAFIL .......................................................................... 16 OSTEO-PORETICAL ................................ 137 PEGINTRON ............................................................... 24 NUEDEXTA .................................................................. 75 oxacillin sodium ................................................ 31 PEG-INTRON ............................................................ 24 NU-IRON ..................................................................... 137 oxaliplatin ..................................................................... 41 PEG-INTRON REDIPEN .......................... 24 NULOJIX ...................................................................... 109 oxandrolone ............................................................. 77 PENICILLIN G POT IN DEXTROSE NULYTELY WITH FLAVOR PACKS oxcarbazepine ...................................................... 60 .......................................................................................................... 31 .......................................................................................................... 98 oxybutynin chloride ............................... 101 penicillin g potassium ........................... 31 NUTRILIPID ............................................................ 153 oxybutynin chloride er ...................... 101 penicillin g procaine ................................. 32 NUTRISOURCE FIBER .......................... 137 oxycodone hcl ........................................ 12, 13 penicillin g sodium ...................................... 32 NUVARING .................................................................... 86 oxycodone-acetaminophen ........ 13 penicillin v potassium ............................ 32 NUVIGIL ............................................................................. 76 OYSCO 500 ........................................................... 137 PENTAM ........................................................................... 18 nyamyc ......................................................................... 169 oyster shell calcium 250+d ... 137 pentoxifylline er ............................................ 104 NYMALIZE .................................................................... 52 oyster shell calcium/d ...................... 137 PEPCID AC .............................................................. 138 nystatin ........................................ 16, 169, 175 pacerone ........................................................................ 46 peptic relief .......................................................... 138 nystop ............................................................................. 169 paclitaxel ....................................................................... 36 PERDIEM OVERNIGHT RELIEF ocella .................................................................................... 86 pain relief 8 hour ........................................ 137 ...................................................................................................... 138 OCTAGAM ................................................................ 107 pain relief childrens .............................. 138 PERFOROMIST ................................................ 163 octreotide acetate ......................................... 92 pain relief extra strength ............. 138 perindopril erbumine ............................... 43 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 189 Index Index Index periogard .................................................................. 175 potassium citrate er ............................. 101 PROLENSA .............................................................. 161 permethrin ........................................... 138, 175 POTIGA ................................................................. 60, 61 PROLEUKIN ................................................................ 37 perphenazine ......................................................... 71 PRADAXA .................................................................. 103 PROLIA ............................................................................... 92 PERRY PRENATAL .................................... 138 pramipexole dihydrochloride .... 67 PROMACTA ........................................................... 104 phenadoz ....................................................................... 95 pravastatin sodium ..................................... 47 promethazine hcl ........................................... 96 PHENAGIL ................................................................ 138 prazosin hcl .............................................................. 44 promethegan .......................................................... 96 phenelzine sulfate ........................................ 65 prednisolone ........................................................... 91 PRONUTRIENTS CALCIUM+D3 phenergan ................................................................... 95 prednisolone acetate .......................... 161 ...................................................................................................... 139 phenobarbital ........................................................ 60 prednisolone sodium phosphate propafenone hcl ............................................... 46 phenobarbital sodium ............................ 60 ........................................................................................ 91, 161 propafenone hcl er ...................................... 46 PHENOBARBITAL SODIUM ............. 60 prednisone .................................................................. 91 proparacaine hcl ......................................... 161 phenytek ........................................................................ 60 prednisone (pak) ............................................. 91 propranolol hcl ...................................... 49, 50 phenytoin ...................................................................... 60 prednisone intensol ................................... 91 propranolol hcl er .......................................... 49 phenytoin sodium .......................................... 60 PREFERRED PLUS INSULIN propranolol-hctz .............................................. 48 phenytoin sodium extended ...... 60 SYRINGE .......................................................................... 79 propylthiouracil .................................................. 94 philith ................................................................................... 86 premasol ................................................................... 153 PROQUAD ................................................................. 111 phos-nak ................................................................... 138 prenatal ..................................................... 138, 156 PROSOL ....................................................................... 154 PHOSPHOLINE IODIDE ...................... 158 PRETZ ............................................................................. 139 protriptyline hcl .................................................. 65 pilocarpine hcl .............................. 158, 175 prevalite ........................................................................... 48 prudoxin ...................................................................... 169 pimtrea .............................................................................. 87 previfem .......................................................................... 87 pseudoeph-bromphen-dm ...... 139 pindolol ............................................................................. 49 PREZCOBIX ................................................................ 22 psyldex .......................................................................... 139 pioglitazone hcl ................................................. 81 PREZISTA ...................................................................... 20 PULMICORT FLEXHALER .............. 166 piperacillin sod-tazobactam so PRIFTIN ............................................................................. 23 PULMOZYME ...................................................... 165 .......................................................................................................... 32 PRILOSEC OTC ................................................ 139 PURE & GENTLE LUBRICANT pirmella 1/35 ......................................................... 87 PRIMAQUINE PHOSPHATE ............. 19 ...................................................................................................... 139 piroxicam ...................................................................... 10 primidone ..................................................................... 61 PURIXAN .......................................................................... 35 PLASMA-LYTE 148 ................................. 155 PRISTIQ ............................................................................. 65 pyrazinamide ......................................................... 23 PLASMA-LYTE A .......................................... 155 PRIVIGEN ................................................................... 107 pyrethins-piperonyl butoxide PLASMA-LYTE-56 IN D5W ....... 155 probenecid ...................................................................... 9 ...................................................................................................... 139 podofilox .................................................................... 174 PROCALAMINE ................................................ 153 pyridostigmine bromide ..................... 75 polyethylene glycol 3350 ................ 98 pro-chlo ....................................................................... 139 pyridoxine hcl ................................................... 139 polymyxin b-trimethoprim ........ 160 prochlorperazine ............................................. 95 pyrilamine-phenylephrine ......... 139 polyvitamin ............................................................ 138 prochlorperazine edisylate ........... 95 qc 3 day ...................................................................... 139 polyvitamin/iron ........................................... 138 prochlorperazine maleate .............. 95 qc natural vegetable ............................ 139 POMALYST ................................................................. 40 PROCRIT ..................................................................... 104 q-pap infants ..................................................... 139 portia-28 ........................................................................ 87 procto-pak ............................................................. 169 Q-TAPP DM ........................................................... 139 potassium chloride .............. 152, 156 proctosol hc ......................................................... 169 quasense ....................................................................... 87 potassium chloride crys er ...... 151 proctozone-hc ................................................. 169 quetiapine fumarate ................................. 71 potassium chloride er .... 151, 152 PROFE ............................................................................. 139 quinapril hcl ............................................................. 43 potassium chloride in dextrose PROGLYCEM ............................................................ 91 quinapril-hydrochlorothiazide ...................................................................................................... 155 PROGRAF .................................................................. 109 .......................................................................................................... 43 potassium chloride in nacl ....... 155 PROLASTIN-C ................................................... 165 quinidine gluconate er .......................... 46 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 190 Index Index Index quinidine sulfate .............................................. 46 RECOMBIVAX HB ........................................ 111 rivastigmine tartrate ................................. 63 quinine sulfate ..................................................... 19 REFRESH CELLUVISC ......................... 141 rizatriptan benzoate .................................. 74 ra anti-itch maximum strength REFRESH OPTIVE ADVANCED robafen cf cough/cold ...................... 142 ...................................................................................................... 139 ...................................................................................................... 141 robafen cough ................................................. 142 ra b-complex/vitamin c cr ........ 140 REFRESH P.M. ................................................. 141 ROBITUSSIN CHILD ra beta carotene .......................................... 140 REGRANEX ............................................................. 175 COUGH/COLD CF ........................................ 142 ra calamine ........................................................... 140 REGULOID ................................................................ 141 ROBITUSSIN CHILD ra calcium 600/vit d/minerals REHYDRALYTE ................................................ 141 COUGH/COLD LA ........................................ 142 ...................................................................................................... 140 RELENZA DISKHALER ............................. 25 ROBITUSSIN CHILDRENS COUGH ra calcium-boron ....................................... 140 RELISTOR ...................................................................... 98 LA ............................................................................................ 142 ra central-vite performance RELPAX ............................................................................. 74 ROBITUSSIN COLD+FLU ...................................................................................................... 140 REMICADE .............................................................. 106 DAYTIME .................................................................... 142 ra col-rite .................................................................. 140 REMODULIN ............................................................. 56 ROBITUSSIN LINGERING LA ra coral calcium ........................................... 140 RENVELA ........................................................................ 93 COUGH ........................................................................... 142 ra high potency iron ............................. 140 repaglinide .................................................................. 81 ROBITUSSIN MUCUS+CHEST ra hydrocortisone plus ..................... 140 RESCON ...................................................................... 141 CONGEST .................................................................. 142 ra ibuprofen childrens ...................... 140 RESCON DM ........................................................ 141 ROBITUSSIN MULTI-SYMPTOM ra lubricant eye ............................................. 140 RESCRIPTOR ........................................................... 21 MAX .................................................................................... 142 ra magnesium ................................................. 140 RESPAIRE-30 .................................................... 141 ROBITUSSIN PEAK COLD ra multi-symptom day/night RESTASIS ................................................................. 161 MULTI-SYM .......................................................... 142 ...................................................................................................... 140 RETAINE MGD .................................................. 141 ropinirole hcl ........................................................... 67 ra omeprazole-sodium bicarb RETROVIR ..................................................................... 21 rosadan ........................................................................ 174 ...................................................................................................... 140 REVATIO ........................................................................... 56 ROTARIX ..................................................................... 111 ra ophthalmic ................................................... 140 REVLIMID .................................................................. 108 ROTATEQ .................................................................. 111 ra oyster shell calcium/d ............. 140 REYATAZ ......................................................................... 21 roxicet ................................................................................. 13 ra probiotic complex ........................... 140 RHINARIS .................................................................. 141 ROZEREM ...................................................................... 74 ra severe cold/sinus relief pe ribasphere ................................................................... 25 rymed .............................................................................. 142 ...................................................................................................... 141 ribasphere ribapak ...................................... 25 rynex dm ................................................................... 142 ra slow release iron .............................. 141 ribavirin ............................................................................ 25 rynex pse .................................................................. 142 ra soluble fiber ............................................... 141 RID ESSENTIAL LICE SABRIL ............................................................................... 61 RA STERILE ............................................................... 79 ELIMINATION ..................................................... 141 saline laxative .................................................. 142 ra vitamin c drops .................................... 141 rifabutin ............................................................................ 23 SANDIMMUNE .................................................. 109 ra vitamin c/rose hips cr .............. 141 rifampin ............................................................................ 23 SANDOSTATIN LAR DEPOT .......... 92 RABAVERT .............................................................. 111 RIFATER ........................................................................... 23 SANTYL ........................................................................ 175 raloxifene hcl ......................................................... 92 riluzole ................................................................................ 75 SAPHRIS .......................................................................... 71 ramipril .............................................................................. 43 rimantadine hcl .................................................. 25 sb fib lax orange ......................................... 142 RANEXA ............................................................................ 55 ringers ............................................................................ 156 sb lice treatment ........................................ 142 ranitidine hcl ........................................ 97, 141 RISA-BID PROBIOTIC ........................... 141 sb natural fiber laxative ................. 143 RAPAMUNE ........................................................... 109 RISAMINE ................................................................. 142 SCOOBY-DOO ONE A DAY ......... 143 RAVICTI ............................................................................. 89 RISPERDAL CONSTA ................................ 71 SCOT-TUSSIN DM .................................... 143 REBETOL ........................................................................ 24 risperidone ................................................................. 71 SCOT-TUSSIN SENIOR ..................... 143 reclipsen ......................................................................... 87 RITUXAN .......................................................................... 37 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 191 Index Index sm magnesium oxide ........................ 144 STRATTERA ................................................. 73, 74 143 sm motion sickness relief ......... 144 streptomycin sulfate ................................ 14 SECURA PROTECTIVE ........................ 143 sm redness relief ....................................... 144 STRIBILD ........................................................................ 22 selegiline hcl ............................................. 67, 68 sm slow release iron .......................... 144 SUBOXONE ................................................................. 77 selenium .................................................................... 143 sm vitamin b12 tr ..................................... 144 SUCRAID ......................................................................... 99 selenium er ........................................................... 143 sm vitamin c cr ............................................. 144 sucralfate ...................................................................... 99 selenium sulfide .......................................... 170 sm vitamin d3 .................................................. 144 sulfacetamide sodium ... 160, 168 SELZENTRY ............................................................... 21 sodium bicarbonate .............................. 144 sulfacetamide-prednisolone senna ............................................................................... 143 sodium chloride ...... 152, 156, 175 ...................................................................................................... 158 senna laxative ................................................. 143 sodium chloride (hypertonic) sulfadiazine ............................................................... 14 SENNA PROMPT .......................................... 143 ...................................................................................................... 144 sulfamethoxazole-tmp ds .............. 18 senna s ......................................................................... 143 sodium fluoride ............................................. 152 sulfamethoxazole-trimethoprim SENSI-CARE PROTECTIVE sodium phenylbutyrate ....................... 89 .......................................................................................................... 18 BARRIER ..................................................................... 143 sodium polystyrene sulfonate SULFAMYLON ................................................... 168 SENSIPAR ..................................................................... 82 .......................................................................................................... 83 sulfasalazine ........................................................... 97 SEREVENT DISKUS .................................. 163 solia ......................................................................................... 87 sulfazine ec ............................................................... 97 SEROQUEL XR ........................................ 71, 72 SOLTAMOX ................................................................ 38 sulindac ........................................................................... 10 sertraline hcl ........................................................... 66 SOLUBLE FIBER THERAPY ........ 145 sumatriptan .............................................................. 74 sharobel ........................................................................... 87 SOLU-CORTEF ..................................................... 91 sumatriptan succinate ............ 74, 75 SIGNIFOR ....................................................................... 92 SOMATULINE DEPOT ............................... 93 sumatriptan succinate refill ........ 74 sildenafil citrate ................................................ 56 SOMAVERT ................................................................. 93 SUMMERS EVE DISP MEDICATED SILENOR .......................................................................... 74 SOOTHE ....................................................................... 145 ...................................................................................................... 145 silver sulfadiazine ..................................... 168 sorbulax ...................................................................... 145 SUPRAX ............................................................................ 27 SIMBRINZA ............................................................ 158 sorine ................................................................................... 46 suprax ................................................................................. 28 simvastatin ................................................................ 47 sotalol hcl ..................................................................... 46 SUPREP BOWEL PREP ........................... 99 sirolimus .................................................................... 109 sotalol hcl (af) ....................................................... 46 SURMONTIL .............................................................. 66 SIROLIMUS ............................................................ 109 SOVALDI .......................................................................... 25 SUSTIVA ........................................................................... 21 SIRTURO ......................................................................... 23 spironolactone ..................................................... 44 SUTENT ............................................................................. 40 SIVEXTRO ...................................................................... 18 spironolactone-hctz .................................. 54 syeda .................................................................................... 87 sleep aid .................................................................... 143 sprintec 28 ................................................................. 87 SYLATRON .................................................................. 40 SLO-NIACIN .......................................................... 143 SPRYCEL ........................................................................ 39 SYMBICORT ......................................................... 166 slow magnesium/calcium ......... 143 sps ............................................................................................. 83 SYMLINPEN 120 ............................................... 79 slow release iron ........................................ 143 sronyx .................................................................................. 87 SYMLINPEN 60 ................................................... 79 SLOW-MAG ........................................................... 144 ssd ........................................................................................ 168 SYNAGIS ..................................................................... 111 sm adult nasal decongestant stahist ad .................................................................. 145 SYNAREL ........................................................................ 88 ...................................................................................................... 144 stavudine ....................................................................... 21 SYNERCID ..................................................................... 18 sm calcium/vitamin d3 ................... 144 STERILE LUBRICANT ........................... 145 SYNRIBO ......................................................................... 40 sm calcium-magnesium-zinc sterile water for irrigation .......... 175 SYNTHROID ............................................................... 94 ...................................................................................................... 144 STIVARGA ...................................................................... 40 SYPRINE .......................................................................... 83 SM CORAL CALCIUM .......................... 144 stomach relief max st ....................... 145 SYSTANE BALANCE ............................... 145 sm iron slow release .......................... 144 stool softener .................................................... 145 SYSTANE NIGHTTIME ......................... 145 sm lansoprazole .......................................... 144 stool softener laxative dc ........... 145 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. Index SECURA EXTRA PROTECTIVE ...................................................................................................... If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 192 tramadol hcl ............................................................. 13 146 tramadol-acetaminophen ............... 13 th eye drop tears ........................................ 146 trandolapril ................................................................. 43 THALOMID .............................................................. 108 tranexamic acid ........................................... 105 theo-24 ........................................................................ 167 TRANSDERM-SCOP ................................... 96 theophylline ......................................................... 167 tranylcypromine sulfate ..................... 66 theophylline er ................................................ 167 TRAVASOL .............................................................. 154 THERA/BETA-CAROTENE ............ 146 TRAVATAN Z ....................................................... 158 THERA-D 4000 ............................................... 146 trazodone hcl ......................................................... 66 THERANATAL CORE NUTRITION TREANDA ....................................................................... 33 ...................................................................................................... 146 TRECATOR .................................................................. 23 THERATEARS ..................................................... 146 TRELSTAR MIXJECT .................................. 38 thiamine hcl ......................................................... 146 tretinoin ......................................................... 41, 168 thioridazine hcl ................................................... 72 triacting day time cold/cough thiothixene .................................................................. 72 ...................................................................................................... 146 tiagabine hcl ........................................................... 61 triamcinolone acetonide TIKOSYN .......................................................................... 46 ................................................................................... 173, 175 timolol maleate ............................... 50, 158 TRIAMINIC COUGH/RUNNY NOSE tioconazole-1 .................................................... 146 ...................................................................................................... 147 TITRALAC .................................................................. 146 TRIAMINIC FEVER REDUCER TIVICAY .............................................................................. 21 ...................................................................................................... 147 tizanidine hcl .......................................................... 76 TRIAMINIC NIGHT TIME TOBRADEX ............................................................. 158 COLD/CGH .............................................................. 147 TOBRADEX ST .................................................. 159 triamterene-hctz ............................................. 54 tobramycin ............................................... 14, 160 TRIBENZOR ................................................................ 45 tobramycin sulfate ....................................... 14 tri-buffered aspirin ................................. 147 tobramycin sulfate in saline ....... 14 triderm ........................................................................... 173 tobramycin-dexamethasone trifluoperazine hcl ......................................... 72 ...................................................................................................... 159 trifluridine ................................................................ 160 TOBREX ........................................................................ 160 trihexyphenidyl hcl ...................................... 68 tolnaftate ................................................................... 146 tri-legest fe ................................................................ 87 tolterodine tartrate .................................. 101 trilyte ..................................................................................... 99 tolterodine tartrate er ........................ 101 trimethoprim ........................................................... 18 topiramate ................................................................... 61 trinessa (28) ............................................................. 87 toposar ............................................................................... 42 triple antibiotic ............................................... 147 topotecan hcl ......................................................... 42 TRIPLE PASTE .................................................. 147 torsemide ...................................................................... 54 triple paste af ................................................... 147 total b/c ....................................................................... 146 tri-previfem ............................................................... 87 TOVIAZ ........................................................................... 101 TRISENOX ..................................................................... 41 TPN ELECTROLYTES ............................ 152 tri-sprintec .................................................................. 87 TRACLEER .................................................................... 56 TRIUMEQ ........................................................................ 22 TRADJENTA .............................................................. 81 TRI-VI-SOL ............................................................. 147 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. Index th calcium-magnesium-zinc Index Index SYSTANE OVERNIGHT THERAPY ...................................................................................................... 145 TABLOID .......................................................................... 35 tacrolimus ............................................ 109, 174 TAFINLAR ...................................................................... 40 TAMIFLU ......................................................................... 25 tamoxifen citrate ............................................. 38 tamsulosin hcl ................................................. 101 TARCEVA ........................................................................ 40 TARGRETIN .............................................. 41, 174 tarina fe 1/20 ......................................................... 87 TASIGNA .......................................................................... 40 tazicef .................................................................................. 28 TAZORAC .................................................................. 170 taztia xt ............................................................................. 52 TEARS AGAIN NIGHT & DAY ... 145 TEFLARO ........................................................................ 28 TEGRETOL ................................................................... 61 TEGRETOL-XR ...................................................... 61 TEKTURNA ................................................................... 53 TEKTURNA HCT .................................... 52, 53 temazepam ............................................................... 74 TENIVAC ...................................................................... 111 terazosin hcl ............................................................ 44 terbinafine hcl ...................................................... 16 terbutaline sulfate .................................... 163 terconazole ........................................................... 102 testosterone cypionate ........................ 77 testosterone enanthate ....................... 77 TETANUS-DIPHTHERIA TOXOIDS TD ........................................................................................... 111 texacort ........................................................................ 173 tg 10peh/380gfn ........................................ 145 tg 10peh/380gfn/15dm ................. 145 tgt cough formula dm max adult ...................................................................................................... 145 tgt eye allergy relief .............................. 146 tgt flu/severe cold/cough rlf ...................................................................................................... 146 tgt lubricant eye drops .................... 146 tgt pain reliever pm ex st ........... 146 ...................................................................................................... If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 193 Index Index Index TRI-VITA ...................................................................... 147 velivet .................................................................................. 87 vitamin d .................................................................... 149 tri-vitamin ................................................................ 147 venlafaxine hcl .................................................... 66 vitamin d (ergocalciferol) ............ 149 trivora (28) .................................................................. 87 venlafaxine hcl er .......................................... 66 vitamin d2 ............................................................... 149 TROPHAMINE .................................................... 154 VENTOLIN HFA ................................................ 164 vitamin d3 ............................................................... 149 trospium chloride ...................................... 101 verapamil hcl ......................................................... 52 vitamin e ................................................. 149, 150 TRUMENBA ........................................................... 111 verapamil hcl er ................................................ 52 vitamin e-selenium ................................ 150 TRUVADA ....................................................................... 22 VERSACLOZ .............................................................. 72 vitamin k (phytonadione) ............. 150 TUSNEL ........................................................................ 147 VESICARE ................................................................. 102 vitamin k1 ............................................................... 150 TUSNEL PEDIATRIC ................................ 147 vestura ............................................................................... 87 vitatrum ....................................................................... 150 TUSNEL-DM PEDIATRIC ................ 147 VICKS DAYQUIL MUCUS VITEKTA ............................................................................ 21 tussin cf cough & cold ..................... 147 CONTROL DM ................................................... 148 VOLTAREN .............................................................. 174 tussin dm ................................................................. 147 VICKS NYQUIL D COLD & FLU voriconazole ............................................................. 16 tussi-pres b .......................................................... 147 ...................................................................................................... 148 VOTRIENT ...................................................................... 40 TWINRIX ...................................................................... 111 VICKS VAPORUB ........................................... 148 vyfemla ............................................................................. 88 TYBOST ............................................................................. 21 VICTOZA ........................................................................... 79 WAL-ACT ................................................................... 150 TYGACIL ........................................................................... 19 VIDEX .................................................................................... 21 WAL-DRYL ALLRGY/SINUS TYKERB ............................................................................. 40 VIGAMOX ................................................................... 160 HEADACHE ............................................................. 150 TYPHIM VI ................................................................ 111 VIIBRYD ............................................................................. 66 WAL-DRYL-D ALLERGY/SINUS TYSABRI ........................................................................... 76 VIMPAT .............................................................................. 61 ...................................................................................................... 150 TYZEKA .............................................................................. 25 vinblastine sulfate ........................................ 36 WAL-FEX D ALLERGY & UCERIS ............................................................................... 97 vincasar pfs .............................................................. 36 CONGESTION ..................................................... 150 ULORIC ................................................................................... 9 vincristine sulfate .......................................... 36 WAL-FLU SEVERE COLD unithroid .......................................................................... 94 vinorelbine tartrate ...................................... 36 DAYTIME .................................................................... 150 UPCAL D ..................................................................... 148 viorele .................................................................................. 88 WAL-ITIN ................................................................... 150 ursodiol ............................................................................. 99 VIRACEPT ...................................................................... 21 WAL-ITIN D ........................................................... 150 VAGIFEM ......................................................................... 90 VIRAMUNE XR ....................................................... 21 WAL-PHED PE SINUS/ALLERGY VAGISTAT-3 ......................................................... 148 VIREAD ............................................................................... 21 ...................................................................................................... 150 valacyclovir hcl .................................................. 25 VISINE-LR ................................................................. 148 WAL-PHED SINUS/ALLERGY VALCHLOR .............................................................. 174 VITALETS ................................................................... 148 ...................................................................................................... 150 wal-som maximum strength VALCYTE ......................................................................... 25 VITAMELTS ENERGY VITAMIN valganciclovir hcl ........................................... 25 B-12 ................................................................................... 148 ...................................................................................................... 150 valproate sodium ............................................ 61 vitamin a & d ..................................................... 148 warfarin sodium .......................................... 103 valproic acid ............................................................ 61 vitamin a palmitate ................................ 148 wee care .................................................................... 150 valsartan ......................................................................... 45 vitamin b-1 ........................................................... 148 WELCHOL ...................................................................... 48 valsartan-hydrochlorothiazide vitamin b-12 .................................... 148, 149 XALKORI .......................................................................... 40 .......................................................................................................... 45 vitamin b12-folic acid ....................... 149 XARELTO ................................................................... 103 vancomycin hcl .................................................. 19 vitamin b-2 ........................................................... 149 XARELTO STARTER PACK .......... 103 vandazole ................................................................. 102 vitamin b-6 ........................................................... 149 XENAZINE ...................................................................... 75 VAQTA ............................................................................. 111 vitamin b-6 er .................................................. 149 XGEVA .................................................................................. 93 VARIVAX ...................................................................... 111 vitamin c .................................................................... 149 XIFAXAN ........................................................................... 99 XOLAIR .......................................................................... 165 VASCEPA ........................................................................ 48 vitamin c (calcium ascorbate) VELCADE ........................................................................ 37 ...................................................................................................... 149 XOPENEX HFA .................................................. 164 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 194 Index XTANDI ............................................................................... 38 xulane .................................................................................. 88 XYREM ................................................................................ 76 YERVOY ............................................................................. 37 YF-VAX .......................................................................... 111 zafirlukast ................................................................ 164 zarah ...................................................................................... 88 ZAVESCA ........................................................................ 89 zazole .............................................................................. 102 ZELBORAF ................................................................... 40 ZEMAIRA .................................................................... 165 zenatane .................................................................... 168 zenchent ......................................................................... 88 ZENPEP ........................................................................ 100 ZETIA ..................................................................................... 48 ZIAGEN ............................................................................... 21 zidovudine ..................................................... 21, 22 zinc oxide ................................................................. 151 ziprasidone hcl ................................................... 72 ZIRGAN .......................................................................... 160 zoledronic acid ................................................... 82 ZOLINZA .......................................................................... 37 zolmitriptan ............................................................... 75 zolpidem tartrate ............................................ 74 ZONATUSS ............................................................. 151 zonisamide ................................................................. 61 ZONTIVITY ............................................................... 105 zoo friends complete .......................... 151 ZORTRESS .............................................................. 109 ZOSTAVAX ............................................................... 112 zovia 1/35e (28) ............................................... 88 zovia 1/50e (28) ............................................... 88 ZYDELIG ........................................................................... 40 ZYKADIA .......................................................................... 40 ZYLET .............................................................................. 159 ZYPREXA RELPREVV ................................. 72 ZYTIGA ................................................................................ 38 ZYVOX .................................................................................. 19 You can find information on what the symbols and abbreviations on this table mean by going to pages 7 and 8. If you have questions, please call WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8a.m. to 8p.m. Eastern, Monday-Sunday. The call is free. For more information, visit https://fida.wellcareny.com/. 195 68075 This formulary was updated on 9/01/2015. If you have any questions, please contact WellCare Advocate Complete FIDA at 1-855-595-2063 (TTY: 1-877-247-6272), 8 a.m. to 8 p.m. Eastern, Monday–Sunday or visit https://fida.wellcareny.com/
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