2016 LIST OF COVERED DRUGS - WellCare Advocate Complete

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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
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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
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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
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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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