2016 年 承 保 藥 物 清 單 ( 處 方 藥 目 錄 ) wellcare advocate complete fida (Medicare-Medicaid 計 劃 ) 09/01/2015 1-855-595-2063 (TTY: 1-877-247-6272) WellCare Advocate Complete FIDA 8 8 https//www.fida.wellcareny.com/ H2751_NY030536_MMP_FOR_CHI CMS Approved 09162015 WellCare 2015 NY_06_15 NY6MMPFOR67979C_0615
WellCare Advocate Complete FIDA v WellCare Medicare New York (Medicaid) (FIDA) v v 1 v www.fida.wellcareny.com WellCare Advocate Complete FIDA 1-855-595-2063 (TTY: 1-877-247-6272) WellCare Advocate Complete FIDA 8 8 v WellCare WellCare Advocate Complete FIDA v v 1-855-595-2063 (TTY: 1-877-247-6272) 8 8 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 8 8 1-877-374-4056 TTY/TDD 711 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 이 정보는 다른 언어로 무료로 제공됩니다. 월요일 - 일요일, 동부 표준시, 오전 8 시 ~ 오후 8시에 1-877-374-4056및 TTY/TDD 711으로 연락 주십시오. 이 전화 통화도 무료입니다. v Вы можете получить эту информацию на других языках бесплатно. Звоните по номеру 1-877-374-4056 и TTY/TDD 711 с 8 утра до 8 вечера по восточному поясному времени с понедельника по воскресенье. Звонок бесплатный. v New York (ICAN) WellCare Advocate Complete FIDA 1-844-614-8800 ICAN icannys.org 1-855-595-2063 (TTY: 1-877-247-6272) WellCare Advocate Complete FIDA 8 8 https://www.fida.wellcareny.com/ 1
常 見 問 題 (FAQ) FAQ 1. 承 保 藥 物 清 單 上 有 哪 些 處 方 藥 物 ( 我 們 將 承 保 藥 物 清 單 簡 稱 為 藥 物 清 單 ) 9 WellCare Advocate Complete FIDA WellCare Advocate Complete FIDA WellCare Advocate Complete FIDA WellCare Advocate Complete FIDA #5 https://www.fida.wellcareny.com 1-855-595-2063 (TTY: 1-877-247-6272) 8 8 2. 藥 物 清 單 是 否 會 發 生 變 化 WellCare Advocate Complete FIDA WellCare Advocate Complete FIDA (IDT) 3 1-855-595-2063 (TTY: 1-877-247-6272) WellCare Advocate Complete FIDA 8 8 https://www.fida.wellcareny.com/ 2
3 4 7 https://www.fida.wellcareny.com WellCare Advocate Complete FIDA 1-855-595-2063 (TTY: 1-877-247-6272) 8 8 3. 有 與 藥 物 清 單 上 現 有 藥 物 作 用 相 同 價 格 更 便 宜 的 藥 物 時 會 怎 麼 樣 WellCare Advocate Complete FIDA 60 60 WellCare Advocate Complete FIDA 4. 當 我 們 發 現 某 種 藥 物 不 安 全 時 會 怎 麼 樣 (FDA) 5. 藥 物 承 保 是 否 有 任 何 限 制 或 限 額 或 者 是 否 需 要 採 取 任 何 必 要 措 施 才 能 獲 得 某 些 藥 物 WellCare Advocate Complete FIDA (IDT) WellCare Advocate Complete FIDA WellCare Advocate Complete FIDA WellCare Advocate Complete FIDA 1-855-595-2063 (TTY: 1-877-247-6272) WellCare Advocate Complete FIDA 8 8 https://www.fida.wellcareny.com/ 3
9 https://www.fida.wellcareny.com 11 WellCare Advocate Complete FIDA 31 11 6. 您 如 何 知 道 您 想 要 的 藥 物 是 否 有 限 制 或 是 否 需 要 采 取 措 施 才 能 獲 得 該 藥 物 9 7. 當 我 們 變 更 對 一 些 藥 物 的 承 保 規 定 時 會 怎 麼 樣 例 如 如 果 我 們 新 增 某 種 藥 物 的 事 先 授 權 ( 核 準 ) 數 量 限 制 和 / 或 階 段 性 療 法 限 制 60 60 8. 您 如 何 在 藥 物 清 單 上 找 到 一 種 藥 物 177 9 9. 如 果 您 想 服 用 的 藥 物 不 在 藥 物 清 單 上 該 怎 麼 辦 1-855-595-2063 (TTY: 1-877-247-6272) 8 8 1-855-595-2063 (TTY: 1-877-247-6272) WellCare Advocate Complete FIDA 8 8 https://www.fida.wellcareny.com/ 4
WellCare Advocate Complete FIDA (IDT) 11 10. 如 果 您 是 一 位 WellCare Advocate Complete FIDA 新 參 保 者 而 且 不 能 在 藥 物 清 單 上 找 到 您 的 藥 物 或 難 以 獲 得 所 需 藥 物 該 怎 麼 辦 WellCare Advocate Complete FIDA 90 90 90 WellCare Advocate Complete FIDA (IDT) 98 98 31 11. 您 是 否 能 夠 申 請 例 外 處 理 以 承 保 您 所 需 藥 物 WellCare Advocate Complete FIDA (IDT) WellCare Advocate Complete FIDA IDT WellCare Advocate Complete FIDA IDT IDT 1-855-595-2063 (TTY: 1-877-247-6272) WellCare Advocate Complete FIDA 8 8 https://www.fida.wellcareny.com/ 5
12. 獲 得 例 外 處 理 需 要 多 長 時 間 WellCare Advocate Complete FIDA (IDT) 72 72 24 13. 您 如 何 要 求 例 外 處 理 14. 甚 麼 是 副 廠 藥 (FDA) WellCare Advocate Complete FIDA 15. 甚 麼 是 OTC 藥 物 OTC WellCare Advocate Complete FIDA OTC WellCare Advocate Complete FIDA OTC 16. WellCare Advocate Complete FIDA 是 否 承 保 OTC 非 藥 物 產 品 WellCare Advocate Complete FIDA OTC WellCare Advocate Complete FIDA OTC 17. 什 麼 是 共 付 款 18. 甚 麼 是 藥 物 層 級 1 Medicare Part D 2 Medicare Part D 3 Medicare /OTC Medicaid 1-855-595-2063 (TTY: 1-877-247-6272) WellCare Advocate Complete FIDA 8 8 https://www.fida.wellcareny.com/ 6
承 保 藥 物 清 單 WellCare Advocate Complete FIDA 177 COUMADIN simvastatin WellCare Advocate Complete FIDA NM PA 3 B/D Part B Part D Medicare Part B Part D WellCare Advocate Complete FIDA Medicare Part D WellCare Advocate Complete FIDA QL 3 LA Exactus 1-855-595-2063 (TTY: 1-877-247-6272) 8 8 ST 3 1-855-595-2063 (TTY: 1-877-247-6272) WellCare Advocate Complete FIDA 8 8 https://www.fida.wellcareny.com/ 7
^ Part D WellCare Advocate Complete FIDA (IDT) Medicare Medicaid 1-855-595-2063 (TTY: 1-877-247-6272) 8 8 1-844-614-8800 (ICAN) 1-855-595-2063 (TTY: 1-877-247-6272) WellCare Advocate Complete FIDA 8 8 https://www.fida.wellcareny.com/ 8
allopurinol 100 mg, 300 mg colchicine-probenecid 0.5-500 mg COLCRYS 0.6 MG QL 30 120 probenecid 500 mg ULORIC 40 MG, 80 MG ST celecoxib 100 mg, 200 mg, 400 mg, 50 mg QL 30 60 diclofenac potassium 50 mg diclofenac sodium er 24 * 100 mg diclofenac sodium 25 mg, 50 mg, 75 mg diflunisal 500 mg etodolac er 24 * 400 mg, 500 mg, 600 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 9
etodolac 200 mg, 300 mg etodolac 400 mg, 500 mg flurbiprofen 100 mg, 50 mg ibuprofen 100 mg/5ml ibuprofen 400 mg, 600 mg, 800 mg ketoprofen 50 mg, 75 mg meloxicam 7.5 mg/5ml meloxicam 15 mg, 7.5 mg nabumetone 500 mg, 750 mg naproxen dr 375 mg, 500 mg naproxen 125 mg/5ml naproxen 250 mg, 375 mg, 500 mg naproxen sodium 275 mg, 550 mg piroxicam 10 mg, 20 mg sulindac 150 mg, 200 mg CII duramorph 0.5 mg/ml, 1 mg/ml B/D 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 10
endocet 10-325 mg, 5-325 mg, 7.5-325 mg QL 30 360 fentanyl citrate 1200 mcg, 1600 mcg, 200 mcg, PA; QL 30 120 400 mcg, 600 mcg, 800 mcg fentanyl 72 100 mcg50 mcg PA; QL 30 10 75 mcg fentanyl 72 12 mcg25 mcg QL 30 10 FENTORA 100 MCG, 200 MCG, 400 MCG, 600 MCG, PA; QL 30 120 800 MCG hydrocodone-acetaminophen 7.5-325 mg/15ml QL 30 5400 ML hydrocodone-acetaminophen 10-325 mg, 5-325 mg, QL 30 360 7.5-325 mg hydrocodone-ibuprofen 7.5-200 mg QL 30 150 hydromorphone hcl 1 mg/ml hydromorphone hcl 2 mg, 4 mg, 8 mg QL 30 270 hydromorphone hcl pf 500 mg/50ml B/D lorcet hd 10-325 mg QL 30 360 lorcet 5-325 mg QL 30 360 lorcet plus 7.5-325 mg QL 30 360 lortab 10-325 mg, 5-325 mg, 7.5-325 mg QL 30 360 methadone hcl intensol 10 mg/ml QL 30 120 ML 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 11
methadone hcl 10 mg/5ml, 5 mg/5ml QL 30 600 ML methadone hcl 10 mg, 5 mg QL 30 240 morphine sulfate 20 mg/ml morphine sulfate (pf) 0.5 mg/ml, 1 mg/ml B/D morphine sulfate (pf) * 10 mg/ml, 15 mg/ml, 2 mg/ml, B/D 4 mg/ml, 8 mg/ml morphine sulfate er 24 120 mg, 30 mg, 45 mg, 60 mg, QL 30 60 75 mg, 90 mg morphine sulfate er 24 10 mg, 20 mg, QL 30 60 30 mg, 50 mg, 60 mg morphine sulfate er 24 100 mg, 80 mg QL 30 60 morphine sulfate er * 100 mg, 15 mg, 30 mg, QL 30 90 60 mg morphine sulfate er * 200 mg QL 30 60 morphine sulfate * 1 mg/ml B/D morphine sulfate 10 mg/5ml, 20 mg/5ml morphine sulfate 15 mg, 30 mg QL 30 180 oxycodone hcl 5 mg QL 30 180 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 12
oxycodone hcl 100 mg/5ml oxycodone hcl 5 mg/5ml oxycodone hcl 10 mg, 15 mg, 20 mg, 30 mg, 5 mg QL 30 180 oxycodone-acetaminophen 10-325 mg, 2.5-325 mg, QL 30 360 5-325 mg, 7.5-325 mg roxicet 5-325 mg/5ml QL 30 1800 ML acetaminophen-codeine #2 300-15 mg QL 30 400 acetaminophen-codeine #3 300-30 mg QL 30 400 acetaminophen-codeine #4 300-60 mg QL 30 400 acetaminophen-codeine 120-12 mg/5ml QL 30 5000 ML butorphanol tartrate 1 mg/ml, 2 mg/ml nalbuphine hcl 10 mg/ml, 20 mg/ml tramadol hcl 50 mg QL 30 240 tramadol-acetaminophen 37.5-325 mg QL 30 240 lidocaine hcl (pf) 0.5 %, 1 % B/D lidocaine hcl 0.5 %, 1 %, 1.5 %, 2 % B/D 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 13
- amikacin sulfate 1 gm/4ml, 500 mg/2ml gentamicin saline * 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 10 mg/ml, 40 mg/ml gentamicin sulfate * 10 mg/ml neomycin sulfate 500 mg paromomycin sulfate 250 mg streptomycin sulfate * 1 gm sulfadiazine 500 mg tobramycin 300 mg/5ml B/D tobramycin sulfate saline * 0.8-0.9 mg/ml-% tobramycin sulfate 1.2 gm/30ml, 10 mg/ml, 2 gm/50ml, 80 mg/2ml tobramycin sulfate 1.2 gm 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 14
ABELCET * 5 MG/ML B/D AMBISOME * 50 MG B/D amphotericin b 50 mg B/D CANCIDAS * 50 MG, 70 MG fluconazole dextrose * 200 mg/100ml, 400 mg/200ml fluconazole sodium chloride * 200-0.9 mg/100ml-%, 400-0.9 mg/200ml-% fluconazole 10 mg/ml, 40 mg/ml fluconazole 100 mg, 150 mg, 200 mg, 50 mg flucytosine 250 mg, 500 mg griseofulvin microsize 125 mg/5ml griseofulvin microsize 500 mg griseofulvin ultramicrosize 125 mg, 250 mg itraconazole 100 mg PA ketoconazole 200 mg PA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 15
MYCAMINE * 100 MG, 50 MG NOXAFIL 40 MG/ML NOXAFIL 100 MG nystatin 500000 terbinafine hcl 250 mg voriconazole * 200 mg voriconazole 40 mg/ml voriconazole 200 mg, 50 mg - QL 365 90 ALBENZA 200 MG ALINIA 100 MG/5ML ALINIA 500 MG atovaquone 750 mg/5ml AZACTAM DEXTROSE * 1 GM, 2 GM aztreonam 1 gm, 2 gm BILTRICIDE 600 MG CAYSTON 75 MG PA; LA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 16
clindamycin hcl 150 mg, 300 mg, 75 mg clindamycin palmitate hcl 75 mg/5ml clindamycin phosphate d5w * 300 mg/50ml, 600 mg/50ml, 900 mg/50ml clindamycin phosphate 300 mg/2ml, 600 mg/4ml, 9 gm/60ml, 900 mg/6ml, 9000 mg/60ml clindamycin phosphate * 300 mg/2ml, 600 mg/4ml, 900 mg/6ml colistimethate sodium 150 mg CUBICIN * 500 MG dapsone 100 mg, 25 mg DARAPRIM 25 MG imipenem-cilastatin * 250 mg, 500 mg INVANZ 1 GM INVANZ * 1 GM ivermectin 3 mg linezolid * 2 mg/ml LINEZOLID 600 MG 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 17
meropenem * 1 gm, 500 mg methenamine hippurate 1 gm metronidazole nacl * 500-0.79 mg/100ml-% metronidazole 250 mg, 500 mg NEBUPENT 300 MG B/D nitrofurantoin macrocrystal 100 mg, 50 mg PA nitrofurantoin monohyd macro 100 mg PA PENTAM 300 MG SIVEXTRO * 200 MG SIVEXTRO 200 MG sulfamethoxazole-tmp ds 800-160 mg sulfamethoxazole-trimethoprim * 400-80 mg/5ml sulfamethoxazole-trimethoprim 200-40 mg/5ml sulfamethoxazole-trimethoprim 400-80 mg SYNERCID * 150-350 MG trimethoprim 100 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 18
TYGACIL * 50 MG vancomycin hcl * 10 gm, 1000 mg, 500 mg, 5000 mg, 750 mg vancomycin hcl 125 mg, 250 mg ZYVOX 100 MG/5ML ZYVOX 600 MG atovaquone-proguanil hcl 250-100 mg, 62.5-25 mg chloroquine phosphate 250 mg, 500 mg COARTEM 20-120 MG mefloquine hcl 250 mg PRIMAQUINE PHOSPHATE 26.3 MG quinine sulfate 324 mg PA abacavir sulfate 300 mg APTIVUS 250 MG APTIVUS 100 MG/ML CRIXIVAN 200 MG, 400 MG didanosine 125 mg, 200 mg, 250 mg, 400 mg EDURANT 25 MG 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 19
EMTRIVA 200 MG EMTRIVA 10 MG/ML FUZEON * 90 MG INTELENCE 100 MG, 200 MG, 25 MG INVIRASE 200 MG INVIRASE 500 MG ISENTRESS 100 MG ISENTRESS 400 MG ISENTRESS 100 MG, 25 MG lamivudine 10 mg/ml lamivudine 150 mg, 300 mg LEXIVA 50 MG/ML LEXIVA 700 MG nevirapine er 24 * 400 mg nevirapine 50 mg/5ml nevirapine 200 mg NORVIR 100 MG NORVIR 80 MG/ML NORVIR 100 MG PREZISTA 100 MG/ML PREZISTA 150 MG, 600 MG, 75 MG, 800 MG 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 20
RESCRIPTOR 100 MG, 200 MG RETROVIR * 10 MG/ML REYATAZ 150 MG, 200 MG, 300 MG REYATAZ 50 MG SELZENTRY 150 MG, 300 MG stavudine 15 mg, 20 mg, 30 mg, 40 mg stavudine 1 mg/ml SUSTIVA 200 MG, 50 MG SUSTIVA 600 MG TIVICAY 50 MG TYBOST 150 MG VIDEX 2 GM, 4 GM VIRACEPT 250 MG, 625 MG VIRAMUNE XR 24 * 100 MG VIREAD 40 MG/GM VIREAD 150 MG, 200 MG, 250 MG, 300 MG VITEKTA 150 MG, 85 MG ZIAGEN 20 MG/ML zidovudine 100 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 21
zidovudine 50 mg/5ml zidovudine 300 mg abacavir-lamivudine-zidovudine 300-150-300 mg ATRIPLA 600-200-300 MG COMPLERA 200-25-300 MG EPZICOM 600-300 MG EVOTAZ 300-150 MG KALETRA 400-100 MG/5ML KALETRA 100-25 MG, 200-50 MG lamivudine-zidovudine 150-300 mg PREZCOBIX 800-150 MG STRIBILD 150-150-200-300 MG TRIUMEQ 600-50-300 MG TRUVADA 200-300 MG QL 30 30 CAPASTAT SULFATE 1 GM cycloserine 250 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 22
ethambutol hcl 100 mg, 400 mg isoniazid 100 mg/ml isoniazid 50 mg/5ml isoniazid 100 mg, 300 mg paser 4 gm PRIFTIN 150 MG pyrazinamide 500 mg rifabutin 150 mg rifampin * 600 mg rifampin 150 mg, 300 mg RIFATER 50-120-300 MG SIRTURO 100 MG PA; LA TRECATOR 250 MG acyclovir 200 mg acyclovir 200 mg/5ml acyclovir 400 mg, 800 mg acyclovir sodium * 50 mg/ml B/D acyclovir sodium * 500 mg B/D adefovir dipivoxil 10 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 23
BARACLUDE 0.05 MG/ML entecavir 0.5 mg, 1 mg EPIVIR HBV 5 MG/ML famciclovir 125 mg, 250 mg, 500 mg foscarnet sodium * 24 mg/ml ganciclovir sodium * 500 mg B/D HARVONI 90-400 MG PA lamivudine 100 mg MODERIBA 1200 600 MG moderiba 800 400 mg moderiba 200 & 400 mg, 400 & 600 mg moderiba 200 mg PEG-INTRON REDIPEN * 120 MCG/0.5ML, 150 MCG/0.5ML, PA 50 MCG/0.5ML, 80 MCG/0.5ML PEGINTRON * 120 MCG/0.5ML, 150 MCG/0.5ML, PA 80 MCG/0.5ML PEG-INTRON * 50 MCG/0.5ML PA REBETOL 40 MG/ML 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 24
RELENZA DISKHALER 5 MG ribasphere 200 mg ribasphere 200 mg, 400 mg ribasphere 600 mg ribasphere ribapak 200 & 400 mg, 400 & 600 mg, 400 mg, 600 mg ribavirin 200 mg ribavirin 200 mg rimantadine hcl 100 mg SOVALDI 400 MG PA TAMIFLU 30 MG, 45 MG, 75 MG TAMIFLU 6 MG/ML TYZEKA 600 MG valacyclovir hcl 1 gm, 500 mg VALCYTE 50 MG/ML valganciclovir hcl 450 mg cefaclor er 12 * 500 mg cefaclor 250 mg, 500 mg cefaclor 125 mg/5ml, 250 mg/5ml, 375 mg/5ml 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 25
cefadroxil 500 mg cefadroxil 250 mg/5ml, 500 mg/5ml cefadroxil 1 gm cefazolin sodium 1 gm, 10 gm, 20 gm, 500 mg cefazolin sodium * 1-5 gm-% cefazolin sodium * 1 gm cefdinir 300 mg cefdinir 125 mg/5ml, 250 mg/5ml cefepime hcl 1 gm, 2 gm cefixime 100 mg/5ml, 200 mg/5ml cefotaxime sodium 1 gm, 2 gm, 500 mg cefoxitin sodium 10 gm cefoxitin sodium * 1 gm, 2 gm cefpodoxime proxetil 100 mg/5ml, 50 mg/5ml cefpodoxime proxetil 100 mg, 200 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 26
cefprozil 125 mg/5ml, 250 mg/5ml cefprozil 250 mg, 500 mg CEFTAZIDIME AND DEXTROSE * 1 GM/50ML, 2 GM/50ML ceftazidime 1 gm, 2 gm, 6 gm ceftriaxone sodium 1 gm, 2 gm, 250 mg, 500 mg ceftriaxone sodium * 1 gm, 10 gm, 2 gm cefuroxime axetil 250 mg, 500 mg cefuroxime sodium 1.5 gm, 7.5 gm, 750 mg cefuroxime sodium * 1.5 gm, 7.5 gm cephalexin 250 mg, 500 mg cephalexin 125 mg/5ml, 250 mg/5ml SUPRAX 400 MG SUPRAX 500 MG/5ML 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 27
suprax 100 mg, 200 mg tazicef 1 gm, 2 gm, 6 gm tazicef * 1 gm, 2 gm TEFLARO * 400 MG, 600 MG azithromycin * 500 mg azithromycin 1 gm azithromycin 100 mg/5ml, 200 mg/5ml azithromycin 250 mg, 500 mg, 600 mg clarithromycin er 24 * 500 mg clarithromycin 125 mg/5ml, 250 mg/5ml clarithromycin 250 mg, 500 mg DIFICID 200 MG e.e.s. 400 400 mg ery-tab 250 mg, 333 mg, 500 mg erythrocin lactobionate * 500 mg erythrocin stearate 250 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 28
erythromycin base 250 mg erythromycin base 250 mg, 500 mg erythromycin ethylsuccinate 400 mg 喹 ciprofloxacin hcl 100 mg, 250 mg, 500 mg, 750 mg ciprofloxacin d5w * 200 mg/100ml, 400 mg/200ml ciprofloxacin * 200 mg/20ml, 400 mg/40ml ciprofloxacin 250 mg/5ml (5%), 500 mg/5ml (10%) ciprofloxacin-ciproflox hcl er 24 * 1000 mg, 500 mg levofloxacin d5w * 250 mg/50ml, 500 mg/100ml, 750 mg/150ml levofloxacin * 25 mg/ml levofloxacin 25 mg/ml levofloxacin 250 mg, 500 mg, 750 mg amoxicillin 250 mg, 500 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 29
amoxicillin 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin 500 mg, 875 mg amoxicillin 125 mg, 250 mg amoxicillin-pot clavulanate er 12 * 1000-62.5 mg amoxicillin-pot clavulanate 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml amoxicillin-pot clavulanate 250-125 mg, 500-125 mg, 875-125 mg amoxicillin-pot clavulanate 200-28.5 mg, 400-57 mg ampicillin 250 mg, 500 mg ampicillin 125 mg/5ml, 250 mg/5ml ampicillin sodium 1 gm, 125 mg, 2 gm, 250 mg, 500 mg ampicillin sodium * 1 gm, 10 gm, 2 gm 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 30
ampicillin-sulbactam sodium 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (2-1) gm ampicillin-sulbactam sodium * 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (2-1) gm BICILLIN L-A * 1200000 2ML, 2400000 4ML, 600000 ML dicloxacillin sodium 250 mg, 500 mg nafcillin sodium 1 gm nafcillin sodium 10 gm, 2 gm nafcillin sodium * 1 gm nafcillin sodium * 2 gm oxacillin sodium 1 gm, 2 gm oxacillin sodium 10 gm PENICILLIN G POT DEXTROSE * 40000 ML, 60000 ML penicillin g potassium 20000000, 5000000 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 31
penicillin g procaine * 600000 ml penicillin g sodium 5000000 penicillin v potassium 125 mg/5ml, 250 mg/5ml penicillin v potassium 250 mg, 500 mg piperacillin sod-tazobactam so * 2-0.25 gm, 3-0.375 gm, 36-4.5 gm, 4-0.5 gm doxy 100 * 100 mg doxycycline hyclate * 100 mg doxycycline hyclate 100 mg, 50 mg doxycycline hyclate 100 mg, 20 mg doxycycline monohydrate 100 mg, 50 mg doxycycline monohydrate 100 mg, 150 mg, 50 mg, 75 mg minocycline hcl 100 mg, 50 mg, 75 mg BICNU * 100 MG B/D 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 32
BUSULFEX * 6 MG/ML B/D cyclophosphamide 1 gm, 500 mg B/D cyclophosphamide 2 gm B/D CYCLOPHOSPHAMIDE 25 MG, 50 MG B/D dacarbazine * 200 mg B/D EMCYT 140 MG HEXALEN 50 MG IFEX * 3 GM B/D ifosfamide * 1 gm/20ml, 3 gm/60ml B/D ifosfamide * 1 gm B/D IFOSFAMIDE * 3 GM B/D LEUKERAN 2 MG lomustine 10 mg, 100 mg, 40 mg melphalan hcl * 50 mg B/D MUSTARGEN 10 MG B/D TREANDA * 180 MG/2ML, 45 MG/0.5ML B/D TREANDA * 100 MG, 25 MG B/D 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 33
adriamycin * 50 mg B/D daunorubicin hcl * 5 mg/ml B/D doxorubicin hcl * 2 mg/ml B/D doxorubicin hcl * 50 mg B/D doxorubicin hcl liposomal * 2 mg/ml B/D epirubicin hcl * 200 mg/100ml, 50 mg/25ml B/D idarubicin hcl * 10 mg/10ml, 20 mg/20ml, B/D 5 mg/5ml bleomycin sulfate 15 30 B/D mitomycin * 20 mg, 40 mg, 5 mg B/D adrucil * 2.5 gm/50ml, 5 gm/100ml, 500 mg/10ml B/D ALIMTA * 100 MG, 500 MG B/D azacitidine 100 mg B/D cladribine * 1 mg/ml B/D 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 34
cytarabine 20 mg/ml B/D fludarabine phosphate * 50 mg/2ml B/D fludarabine phosphate * 50 mg B/D fluorouracil * 1 gm/20ml, 2.5 gm/50ml, 500 mg/10ml B/D GEMCITABINE HCL * 1 GM/26.3ML, 2 GM/52.6ML, B/D 200 MG/5.26ML gemcitabine hcl * 1 gm, 2 gm, 200 mg B/D mercaptopurine 50 mg methotrexate sodium (pf) 1 gm/40ml B/D methotrexate sodium 25 mg/ml B/D methotrexate sodium 1 gm B/D NIPENT * 10 MG B/D PURIXAN 2000 MG/100ML TABLOID 40 MG ABRAXANE * 100 MG B/D 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 35
docetaxel * 140 mg/7ml B/D DOCETAXEL * 20 MG/ML, 80 MG/4ML B/D DOCETAXEL * 200 MG/20ML, 80 MG/8ML B/D paclitaxel * 100 mg/16.7ml, 150 mg/25ml, B/D 30 mg/5ml, 300 mg/50ml vinblastine sulfate * 1 mg/ml B/D vincasar pfs * 1 mg/ml B/D vincristine sulfate * 1 mg/ml B/D vinorelbine tartrate * 10 mg/ml, 50 mg/5ml B/D AVASTIN * 100 MG/4ML, 400 MG/16ML B/D; LA BELEODAQ * 500 MG PA ERIVEDGE 150 MG PA; LA FARYDAK 10 MG, 15 MG, 20 MG PA; LA HERCEPTIN * 440 MG B/D IBRANCE 100 MG, 125 MG, 75 MG PA; LA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 36
ISTODAX * 10 MG B/D KADCYLA * 100 MG, 160 MG B/D KEYTRUDA * 50 MG PA LYNPARZA 50 MG PA; LA PROLEUKIN * 22000000 B/D RITUXAN * 10 MG/ML PA; LA VELCADE 3.5 MG B/D YERVOY * 50 MG/10ML PA ZOLINZA 100 MG PA anastrozole 1 mg bicalutamide 50 mg DEPO-PROVERA * 400 MG/ML B/D exemestane 25 mg FARESTON 60 MG FASLODEX * 250 MG/5ML B/D flutamide 125 mg letrozole 2.5 mg leuprolide acetate 1 mg/0.2ml PA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 37
LUPRON DEPOT * 11.25 MG, 3.75 MG PA LUPRON DEPOT-PED * 11.25 MG, 11.25 MG (PED), PA 15 MG, 30 MG (PED), 7.5 MG LYSODREN 500 MG MEGACE ES 625 MG/5ML PA megestrol acetate 40 mg/ml PA megestrol acetate 20 mg, 40 mg PA NILANDRON 150 MG SOLTAMOX 10 MG/5ML tamoxifen citrate 10 mg, 20 mg TRELSTAR MIXJECT * 11.25 MG, 3.75 MG PA XTANDI 40 MG PA; LA ZYTIGA 250 MG PA; LA AFINITOR DISPERZ 2 MG, 3 MG, 5 MG PA AFINITOR 10 MG, 2.5 MG, 5 MG, 7.5 MG PA BOSULIF 100 MG, 500 MG PA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 38
CAPRELSA 100 MG, 300 MG PA; LA COMETRIQ 100 MG 1 X 80 & 1 X 20 MG PA; LA COMETRIQ 140 MG 1 X 80 & 3 X 20 MG PA; LA COMETRIQ 60 MG 20 MG PA; LA GILOTRIF 20 MG, 30 MG, 40 MG PA; LA GLEEVEC 100 MG, 400 MG PA ICLUSIG 15 MG, 45 MG PA; LA IMBRUVICA 140 MG PA; LA INLYTA 1 MG, 5 MG PA; LA JAKAFI 10 MG, 15 MG, 20 MG, 25 MG, 5 MG PA; LA LENVIMA 10 MG 10 MG PA; LA LENVIMA 14 MG 10 & 4 MG PA; LA LENVIMA 20 MG 10 (2) MG PA; LA LENVIMA 24 MG 10 (2) & 4 MG PA; LA MEKINIST 0.5 MG, 2 MG PA; LA NEXAVAR 200 MG PA; LA SPRYCEL 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG PA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 39
STIVARGA 40 MG PA; LA SUTENT 12.5 MG, 25 MG, 37.5 MG, 50 MG PA TAFINLAR 50 MG, 75 MG PA; LA TARCEVA 100 MG, 150 MG, 25 MG PA; LA TASIGNA 150 MG, 200 MG PA TYKERB 250 MG PA; LA VOTRIENT 200 MG PA; LA XALKORI 200 MG, 250 MG PA; LA ZELBORAF 240 MG PA; LA ZYDELIG 100 MG, 150 MG PA; LA ZYKADIA 150 MG PA; LA DROXIA 200 MG, 300 MG, 400 MG hydroxyurea 500 mg MATULANE 50 MG LA mitoxantrone hcl * 20 mg/10ml, 25 mg/12.5ml, B/D 30 mg/15ml POMALYST 1 MG, 2 MG, 3 MG, 4 MG PA; LA SYLATRON * 200 MCG, 300 MCG, 4 X 200 MCG, 4 X 300 MCG, PA 600 MCG SYNRIBO * 3.5 MG PA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 40
TARGRETIN 75 MG PA tretinoin 10 mg TRISENOX * 10 MG/10ML B/D carboplatin * 150 mg/15ml, 450 mg/45ml, B/D 50 mg/5ml, 600 mg/60ml cisplatin * 100 mg/100ml, 200 mg/200ml, B/D 50 mg/50ml oxaliplatin * 100 mg/20ml, 50 mg/10ml B/D oxaliplatin * 100 mg, 50 mg B/D amifostine * 500 mg B/D dexrazoxane * 250 mg B/D ELITEK * 1.5 MG, 7.5 MG B/D FUSILEV * 50 MG B/D leucovorin calcium 100 mg, 200 mg, 350 mg, 50 mg, B/D 500 mg leucovorin calcium 10 mg, 15 mg, 25 mg, 5 mg levoleucovorin calcium * 175 mg/17.5ml B/D 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 41
mesna * 100 mg/ml B/D MESNEX 400 MG etoposide * 500 mg/25ml B/D irinotecan hcl * 100 mg/5ml, 40 mg/2ml, B/D 500 mg/25ml toposar * 1 gm/50ml B/D topotecan hcl * 4 mg B/D amlodipine besy-benazepril hcl 10-20 mg, 2.5-10 mg, QL 30 30 5-10 mg, 5-20 mg, 5-40 mg amlodipine besy-benazepril hcl 10-40 mg benazepril-hydrochlorothiazide 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg captopril-hydrochlorothiazide 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg enalapril-hydrochlorothiazide 10-25 mg, 5-12.5 mg fosinopril sodium-hctz 10-12.5 mg, 20-12.5 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 42
lisinopril-hydrochlorothiazide 10-12.5 mg, 20-12.5 mg, 20-25 mg moexipril-hydrochlorothiazide 15-12.5 mg, 15-25 mg, 7.5-12.5 mg quinapril-hydrochlorothiazide 10-12.5 mg, 20-12.5 mg, 20-25 mg benazepril hcl 10 mg, 20 mg, 40 mg, 5 mg captopril 100 mg, 12.5 mg, 25 mg, 50 mg enalapril maleate 10 mg, 2.5 mg, 20 mg, 5 mg fosinopril sodium 10 mg, 20 mg, 40 mg lisinopril 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg moexipril hcl 15 mg, 7.5 mg perindopril erbumine 2 mg, 4 mg, 8 mg quinapril hcl 10 mg, 20 mg, 40 mg, 5 mg ramipril 1.25 mg, 10 mg, 2.5 mg, 5 mg trandolapril 1 mg, 2 mg, 4 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 43
eplerenone 25 mg, 50 mg spironolactone 100 mg, 25 mg, 50 mg - doxazosin mesylate 1 mg, 2 mg, 4 mg QL 30 30 doxazosin mesylate 8 mg prazosin hcl 1 mg, 2 mg, 5 mg terazosin hcl 1 mg, 10 mg, 2 mg, 5 mg II amlodipine besylate-valsartan 10-160 mg, 5-160 mg, QL 30 30 5-320 mg amlodipine besylate-valsartan 10-320 mg amlodipine-valsartan-hctz 10-160-12.5 mg, QL 30 30 10-160-25 mg, 5-160-12.5 mg amlodipine-valsartan-hctz 10-320-25 mg amlodipine-valsartan-hctz 5-160-25 mg QL 30 60 AZOR 10-20 MG, 5-20 MG, 5-40 MG QL 30 30 AZOR 10-40 MG 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 44
BENICAR HCT 20-12.5 MG, 40-12.5 MG, 40-25 MG irbesartan-hydrochlorothiazide 150-12.5 mg, 300-12.5 mg losartan potassium-hctz 100-12.5 mg, 100-25 mg, 50-12.5 mg TRIBENZOR 20-5-12.5 MG, 40-10-12.5 MG, 40-5-12.5 MG, 40-5-25 MG TRIBENZOR 40-10-25 MG valsartan-hydrochlorothiazide 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg II BENICAR 20 MG, 40 MG, 5 MG irbesartan 150 mg, 300 mg, 75 mg losartan potassium 100 mg, 25 mg, 50 mg valsartan 160 mg, 320 mg, 40 mg, 80 mg amiodarone hcl * 150 mg/3ml, 450 mg/9ml, 900 mg/18ml QL 30 30 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 45
amiodamne hcl 100 mg, 200 mg, 400 mg disopyramide phosphate 100 mg, 150 mg PA flecainide acetate 100 mg, 150 mg, 50 mg mexiletine hcl 150 mg, 200 mg, 250 mg MULTAQ 400 MG NORPACE CR 12 100 MG, 150 MG PA pacerone 100 mg, 200 mg, 400 mg propafenone hcl er 12 225 mg, 325 mg, 425 mg propafenone hcl 150 mg, 225 mg, 300 mg quinidine gluconate er * 324 mg quinidine sulfate 200 mg, 300 mg sorine 120 mg, 160 mg, 240 mg, 80 mg sotalol hcl (af) 120 mg, 160 mg, 80 mg sotalol hcl 120 mg, 160 mg, 240 mg, 80 mg TIKOSYN 125 MCG, 250 MCG, 500 MCG 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 46
HMG-COA atorvastatin calcium 10 mg, 20 mg, 40 mg, 80 mg QL 30 30 CRESTOR 10 MG, 20 MG, 40 MG, 5 MG QL 30 30 lovastatin 10 mg QL 30 30 lovastatin 20 mg QL 30 120 lovastatin 40 mg QL 30 60 pravastatin sodium 10 mg, 20 mg, 40 mg, 80 mg QL 30 30 simvastatin 10 mg, 20 mg, 40 mg, 5 mg, 80 mg QL 30 30 cholestyramine light 4 gm cholestyramine 4 gm cholestyramine 4 gm/dose colestipol hcl 5 gm colestipol hcl 5 gm colestipol hcl 1 gm fenofibrate micronized 134 mg, 200 mg, 67 mg fenofibrate 145 mg, 160 mg, 48 mg, 54 mg fenofibric acid 135 mg, 45 mg gemfibrozil 600 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 47
JUXTAPID 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, PA; LA 60 MG KYNAMRO * 200 MG/ML PA niacin er* 1000 mg, 750 mg niacin er* 500 mg QL 30 90 niacor 500 mg omega-3-acid ethyl esters 1 gm prevalite 4 gm/dose VASCEPA 1 GM WELCHOL 3.75 GM WELCHOL 625 MG ZETIA 10 MG - atenolol-chlorthalidone 100-25 mg, 50-25 mg bisoprolol-hydrochlorothiazide 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg metoprolol-hydrochlorothiazide 100-25 mg, 100-50 mg, 50-25 mg propranolol-hctz 40-25 mg, 80-25 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 48
- acebutolol hcl 200 mg, 400 mg atenolol 100 mg, 25 mg, 50 mg bisoprolol fumarate 10 mg, 5 mg BYSTOLIC 10 MG, 2.5 MG, 20 MG, 5 MG carvedilol 12.5 mg, 25 mg, 3.125 mg, 6.25 mg labetalol hcl 100 mg, 200 mg, 300 mg metoprolol succinate er 24 * 100 mg QL 30 45 metoprolol succinate er 24 * 200 mg metoprolol succinate er 24 * 25 mg, 50 mg QL 30 60 metoprolol tartrate * 1 mg/ml metoprolol tartrate 100 mg, 25 mg, 50 mg nadolol 20 mg, 40 mg, 80 mg pindolol 10 mg, 5 mg propranolol hcl er 24 120 mg, 160 mg, 60 mg, 80 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 49
propranolol hcl * 1 mg/ml propranolol hcl 20 mg/5ml, 40 mg/5ml propranolol hcl 10 mg, 20 mg, 40 mg, 60 mg, 80 mg timolol maleate 10 mg, 20 mg, 5 mg afeditab cr 24 * 30 mg afeditab cr 24 * 60 mg amlodipine besylate 10 mg amlodipine besylate 2.5 mg, 5 mg cartia xt 24 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl er 24 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er 24 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er 12 120 mg, 60 mg, 90 mg diltiazem hcl er 24 120 mg QL 30 60 QL 30 45 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 50
diltiazem hcl * 125 mg/25ml, 25 mg/5ml, 50 mg/10ml diltiazem hcl 120 mg, 30 mg, 60 mg, 90 mg dilt-xr 24 120 mg, 180 mg, 240 mg diltzac 24 120 mg, 180 mg, 240 mg, 300 mg felodipine er 24 * 10 mg felodipine er 24 * 2.5 mg QL 30 30 felodipine er 24 * 5 mg QL 30 60 isradipine 2.5 mg, 5 mg nicardipine hcl 20 mg, 30 mg nifedical xl 24 * 30 mg QL 30 30 nifedical xl 24 * 60 mg nifedipine er 24 * 30 mg QL 30 60 nifedipine er 24 * 60 mg, 90 mg nifedipine er osmotic 24 * 30 mg QL 30 30 nifedipine er osmotic 24 * 60 mg, 90 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 51
nimodipine 30 mg NYMALIZE 60 MG/20ML taztia xt 24 120 mg, 180 mg, 240 mg, 300 mg, 360 mg verapamil hcl er 24 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg verapamil hcl er 24 360 mg verapamil hcl er * 120 mg, 180 mg, 240 mg verapamil hcl * 2.5 mg/ml verapamil hcl 120 mg, 40 mg, 80 mg digitek 125 mcg QL 30 30 digitek 250 mcg PA digoxin 0.25 mg/ml digoxin 0.05 mg/ml PA digoxin 0.125 mg QL 30 30 digoxin 250 mcg PA TEKTURNA HCT 150-12.5 MG, 300-12.5 MG QL 30 30 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 52
TEKTURNA HCT 150-25 MG QL 30 60 TEKTURNA HCT 300-25 MG TEKTURNA 150 MG QL 30 30 TEKTURNA 300 MG acetazolamide er 12 500 mg acetazolamide 125 mg, 250 mg amiloride hcl 5 mg amiloride-hydrochlorothiazide 5-50 mg bumetanide 0.25 mg/ml bumetanide 0.5 mg, 1 mg, 2 mg chlorothiazide 250 mg, 500 mg chlorthalidone 25 mg, 50 mg furosemide 10 mg/ml furosemide 10 mg/ml, 8 mg/ml furosemide 20 mg, 40 mg, 80 mg hydrochlorothiazide 12.5 mg hydrochlorothiazide 12.5 mg, 25 mg, 50 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 53
indapamide 1.25 mg, 2.5 mg methazolamide 25 mg, 50 mg methyclothiazide 5 mg metolazone 10 mg, 2.5 mg, 5 mg spironolactone-hctz 25-25 mg torsemide * 50 mg/5ml torsemide 10 mg, 100 mg, 20 mg, 5 mg triamterene-hctz 37.5-25 mg triamterene-hctz 37.5-25 mg, 75-50 mg clonidine hcl 0.1 mg, 0.2 mg, 0.3 mg clonidine hcl 0.1 mg 24 0.2 mg 24 0.3 mg 24 DEMSER 250 MG hydralazine hcl 20 mg/ml hydralazine hcl 10 mg, 100 mg, 25 mg, 50 mg midodrine hcl 10 mg, 2.5 mg, 5 mg minoxidil 10 mg, 2.5 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 54
RANEXA 12 * 1000 MG, 500 MG isosorbide dinitrate er * 40 mg isosorbide dinitrate 10 mg, 20 mg, 30 mg, 5 mg isosorbide mononitrate er 24 * 120 mg, 30 mg, 60 mg isosorbide mononitrate 10 mg, 20 mg minitran 24 0.1 mg0.2 mg 0.4 mg0.6 mg nitro-bid 2 % NITRO-DUR 24 0.3 MG0.8 MG nitroglycerin 24 0.1 mg0.2 mg 0.4 mg0.6 mg NITROSTAT SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG ADEMPAS 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG PA; LA ; QL 30 90 LETAIRIS 10 MG, 5 MG PA; LA ; QL 30 30 OPSUMIT 10 MG PA; LA ; QL 30 30 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 55
REMODULIN 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML B/D; LA REVATIO 10 MG/ML PA; QL 30 224 ML sildenafil citrate 20 mg PA; QL 30 90 TRACLEER 125 MG PA; LA ; QL 30 60 TRACLEER 62.5 MG PA; LA ; QL 30 120 alprazolam 0.25 mg QL 30 480 alprazolam 0.5 mg QL 30 240 alprazolam 1 mg QL 30 120 alprazolam 2 mg QL 30 150 buspirone hcl 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg fluvoxamine maleate 100 mg fluvoxamine maleate 25 mg, 50 mg QL 30 45 lorazepam 2 mg/ml, 4 mg/ml lorazepam intensol 2 mg/ml QL 30 150 ML lorazepam 0.5 mg, 1 mg, 2 mg QL 30 150 APTIOM 200 MG QL 30 180 APTIOM 400 MG QL 30 90 APTIOM 600 MG QL 30 60 APTIOM 800 MG QL 30 30 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 56
BANZEL 40 MG/ML PA BANZEL 200 MG, 400 MG PA carbamazepine er 12 100 mg, 200 mg, 300 mg carbamazepine er 12 * 200 mg, 400 mg carbamazepine 100 mg/5ml carbamazepine 200 mg carbamazepine 100 mg CELONTIN 300 MG clonazepam 0.5 mg QL 30 240 clonazepam 1 mg QL 30 120 clonazepam 2 mg QL 30 300 clonazepam 0.125 mg QL 30 960 clonazepam 0.25 mg QL 30 480 clonazepam 0.5 mg QL 30 240 clonazepam 1 mg QL 30 120 clonazepam 2 mg QL 30 300 clorazepate dipotassium 15 mg PA; QL 30 180 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 57
clorazepate dipotassium 3.75 mg, 7.5 mg PA; QL 30 120 diazepam 10 mg, 2.5 mg, 20 mg diazepam 5 mg/ml diazepam intensol 5 mg/ml PA; QL 30 240 ML diazepam 1 mg/ml PA; QL 30 1200 ML diazepam 10 mg, 2 mg, 5 mg PA; QL 30 120 dilantin infatabs 50 mg dilantin 100 mg, 30 mg DILANTIN 125 MG/5ML divalproex sodium er 24 * 250 mg, 500 mg divalproex sodium 125 mg divalproex sodium 125 mg, 250 mg, 500 mg epitol 200 mg ethosuximide 250 mg ethosuximide 250 mg/5ml felbamate 600 mg/5ml felbamate 400 mg felbamate 600 mg FYCOMPA 10 MG, 12 MG, 8 MG PA; QL 30 30 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 58
FYCOMPA 2 MG PA; QL 30 180 FYCOMPA 4 MG PA; QL 30 90 FYCOMPA 6 MG PA; QL 30 60 gabapentin 100 mg QL 30 1080 gabapentin 300 mg QL 30 360 gabapentin 400 mg QL 30 270 gabapentin 250 mg/5ml QL 30 2160 ML gabapentin 600 mg QL 30 180 gabapentin 800 mg QL 30 120 GABITRIL 12 MG, 16 MG lamotrigine er 24 * 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine 100 mg, 150 mg, 200 mg, 25 mg lamotrigine 25 mg, 5 mg levetiracetam er 24 * 500 mg, 750 mg LEVETIRACETAM IN NACL * 1000 MG/100ML, 1500 MG/100ML, 500 MG/100ML levetiracetam * 500 mg/5ml levetiracetam 100 mg/ml levetiracetam 1000 mg, 250 mg, 500 mg, 750 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 59
LYRICA 100 MG, 150 MG, 25 MG, 50 MG, 75 MG QL 30 120 LYRICA 200 MG QL 30 90 LYRICA 225 MG, 300 MG QL 30 60 LYRICA 20 MG/ML QL 30 946 ML ONFI 2.5 MG/ML PA ONFI 10 MG, 20 MG PA oxcarbazepine 300 mg/5ml oxcarbazepine 150 mg, 300 mg, 600 mg PEGANONE 250 MG phenobarbital 20 mg/5ml PA phenobarbital 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, PA 60 mg, 64.8 mg, 97.2 mg phenobarbital sodium 130 mg/ml PA PHENOBARBITAL SODIUM 65 MG/ML PA phenytek 200 mg, 300 mg phenytoin 125 mg/5ml phenytoin 50 mg phenytoin sodium extended 100 mg, 200 mg, 300 mg phenytoin sodium 50 mg/ml POTIGA 200 MG QL 30 180 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 60
POTIGA 300 MG, 400 MG QL 30 90 POTIGA 50 MG primidone 250 mg, 50 mg SABRIL 500 MG PA; LA ; QL 30 180 SABRIL 500 MG PA; LA ; QL 30 180 TEGRETOL 100 MG/5ML TEGRETOL 200 MG TEGRETOL-XR 12 * 100 MG, 200 MG, 400 MG tiagabine hcl 2 mg, 4 mg topiramate 15 mg, 25 mg topiramate 100 mg, 200 mg, 25 mg, 50 mg valproate sodium * 500 mg/5ml valproic acid 250 mg valproic acid 250 mg/5ml VIMPAT * 200 MG/20ML VIMPAT 10 MG/ML QL 30 1200 ML VIMPAT 100 MG, 150 MG, 200 MG QL 30 60 VIMPAT 50 MG QL 30 180 zonisamide 100 mg, 25 mg, 50 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 61
donepezil hcl 10 mg, 23 mg donepezil hcl 5 mg QL 30 30 donepezil hcl 10 mg donepezil hcl 5 mg QL 30 30 EXELON 24 13.3 MG 24 4.6 MG 24 QL 30 30 9.5 MG 24 galantamine hydrobromide er 24 16 mg, QL 30 30 8 mg galantamine hydrobromide er 24 24 mg galantamine hydrobromide 4 mg/ml galantamine hydrobromide 12 mg galantamine hydrobromide 4 mg QL 30 180 galantamine hydrobromide 8 mg QL 30 90 NAMENDA 10 MG/5ML PA NAMENDA 10 MG, 5 MG PA NAMENDA XR 24 14 MG, 21 MG, 28 MG, 7 MG PA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 62
NAMENDA XR 24 7 & 14 & 21 PA rivastigmine tartrate 1.5 mg, 3 mg, 4.5 mg, 6 mg amitriptyline hcl 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, PA 75 mg amoxapine 100 mg, 150 mg, 25 mg, 50 mg BRINTELLIX 10 MG QL 30 60 BRINTELLIX 20 MG QL 30 30 BRINTELLIX 5 MG QL 30 120 bupropion hcl er (sr) 12 * 100 mg, 150 mg, 200 mg bupropion hcl er (xl) 24 * 150 mg QL 30 90 bupropion hcl er (xl) 24 * 300 mg QL 30 30 bupropion hcl 100 mg, 75 mg citalopram hydrobromide 10 mg/5ml citalopram hydrobromide 10 mg, 20 mg QL 30 45 citalopram hydrobromide 40 mg QL 30 30 clomipramine hcl 25 mg, 50 mg, 75 mg PA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 63
desipramine hcl 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, PA 75 mg doxepin hcl 10 mg/ml PA duloxetine hcl 20 mg, 30 mg, 60 mg QL 30 60 EMSAM 24 12 MG 24 6 MG 24 PA; QL 30 30 9 MG 24 escitalopram oxalate 5 mg/5ml QL 30 600 ML escitalopram oxalate 10 mg, 5 mg QL 30 45 escitalopram oxalate 20 mg QL 30 60 FETZIMA 24 120 MG, 80 MG QL 30 30 FETZIMA 24 20 MG QL 30 180 FETZIMA 24 40 MG QL 30 90 FETZIMA TITRATION ORAL 20 & 40 MG fluoxetine hcl 10 mg QL 30 30 fluoxetine hcl 20 mg QL 30 120 fluoxetine hcl 40 mg fluoxetine hcl 20 mg/5ml 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 64
fluoxetine hcl 10 mg QL 30 45 fluoxetine hcl 20 mg imipramine hcl 10 mg, 25 mg, 50 mg PA maprotiline hcl 25 mg, 50 mg, 75 mg MARPLAN 10 MG QL 30 180 mirtazapine 15 mg, 7.5 mg QL 30 45 mirtazapine 30 mg, 45 mg mirtazapine 15 mg QL 30 30 mirtazapine 30 mg, 45 mg nefazodone hcl 100 mg, 150 mg, 200 mg, 250 mg, 50 mg nortriptyline hcl 10 mg, 25 mg, 50 mg, 75 mg nortriptyline hcl 10 mg/5ml paroxetine hcl 10 mg, 20 mg, 40 mg QL 30 45 paroxetine hcl 30 mg QL 30 60 PAXIL 10 MG/5ML QL 30 900 ML phenelzine sulfate 15 mg PRISTIQ 24 * 100 MG, 25 MG, 50 MG QL 30 30 protriptyline hcl 10 mg, 5 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 65
sertraline hcl 20 mg/ml sertraline hcl 100 mg sertraline hcl 25 mg, 50 mg QL 30 45 SURMONTIL 100 MG PA; QL 30 60 SURMONTIL 25 MG PA; QL 30 240 SURMONTIL 50 MG PA; QL 30 120 tranylcypromine sulfate 10 mg trazodone hcl 100 mg, 150 mg, 50 mg venlafaxine hcl er 24 150 mg QL 30 60 venlafaxine hcl er 24 37.5 mg, 75 mg QL 30 30 venlafaxine hcl 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg VIIBRYD 10 & 20 & 40 MG VIIBRYD 10 MG, 20 MG, 40 MG QL 30 30 amantadine hcl 100 mg amantadine hcl 50 mg/5ml amantadine hcl 100 mg APOKYN * 10 MG/ML PA; LA AZILECT 0.5 MG, 1 MG 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 66
benztrnpine mesylate 1 mg/ml benztrnpine mesylate 0.5 mg, 1 mg, 2 mg PA bromocriptine mesylate 5 mg bromocriptine mesylate 2.5 mg carbidopa-levodopa er * 25-100 mg, 50-200 mg carbidopa-levodopa 10-100 mg, 25-100 mg, 25-250 mg carbidopa-levodopa 10-100 mg, 25-100 mg, 25-250 mg carbidopa-levodopa-entacapone 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg entacapone 200 mg NEUPRO 24 1 MG 24 2 MG 24 3 MG 24 4 MG 24 6 MG 24 8 MG 24 pramipexole dihydrochloride 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg ropinirole hcl 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg selegiline hcl 5 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 67
selegiline hcl 5 mg trihexyphenidyl hcl 0.4 mg/ml PA trihexyphenidyl hcl 2 mg, 5 mg PA ABILIFY DISCMELT 10 MG QL 30 60 ABILIFY MAINTENA * 300 MG, 400 MG QL 28 1 aripiprazole 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg QL 30 30 chlorpromazine hcl 25 mg/ml chlorpromazine hcl 10 mg, 100 mg, 200 mg, 25 mg, 50 mg clozapine 100 mg QL 30 270 clozapine 200 mg QL 30 135 clozapine 25 mg, 50 mg clozapine 100 mg PA; QL 30 270 clozapine 12.5 mg, 25 mg PA CLOZAPINE 150 MG PA; QL 30 180 CLOZAPINE 200 MG PA; QL 30 135 FANAPT 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG ST; QL 30 60 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 68
FANAPT 1 & 2 & 4 & 6 MG ST FAZACLO 150 MG PA; QL 30 180 FAZACLO 200 MG PA; QL 30 135 fluphenazine decanoate 25 mg/ml fluphenazine hcl 2.5 mg/ml fluphenazine hcl 5 mg/ml fluphenazine hcl 2.5 mg/5ml fluphenazine hcl 1 mg, 10 mg, 2.5 mg, 5 mg GEODON * 20 MG QL 3 6 haloperidol decanoate * 100 mg/ml, 50 mg/ml haloperidol lactate 5 mg/ml haloperidol lactate 2 mg/ml haloperidol 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg INVEGA 24 * 1.5 MG, 3 MG, 9 MG QL 30 30 INVEGA 24 * 6 MG QL 30 60 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 69
INVEGA SUSTENNA * 117 MG/0.75ML QL 28 0.75 ML INVEGA SUSTENNA * 156 MG/ML QL 28 1 ML INVEGA SUSTENNA * 234 MG/1.5ML QL 28 1.5 ML INVEGA SUSTENNA * 39 MG/0.25ML QL 28 0.25 ML INVEGA SUSTENNA * 78 MG/0.5ML QL 28 0.5 ML LATUDA 120 MG, 40 MG QL 30 30 LATUDA 20 MG QL 30 240 LATUDA 60 MG, 80 MG QL 30 60 loxapine succinate 10 mg, 25 mg, 5 mg, 50 mg olanzapine * 10 mg QL 1 3 olanzapine 10 mg, 15 mg, 20 mg QL 30 60 olanzapine 2.5 mg, 5 mg, 7.5 mg QL 30 30 olanzapine 10 mg, 15 mg, 20 mg QL 30 60 olanzapine 5 mg QL 30 30 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 70
ORAP 1 MG, 2 MG perphenazine 16 mg, 2 mg, 4 mg, 8 mg quetiapine fumarate 100 mg, 200 mg, 25 mg, 300 mg, QL 30 90 400 mg, 50 mg RISPERDAL CONSTA * 12.5 MG, 25 MG, QL 28 2 37.5 MG, 50 MG risperidone 1 mg/ml QL 30 240 ML risperidone 0.25 mg, 0.5 mg QL 30 90 risperidone 1 mg, 2 mg, 3 mg QL 30 60 risperidone 4 mg QL 30 120 risperidone 0.25 mg, 0.5 mg QL 30 90 risperidone 1 mg, 2 mg, 3 mg QL 30 60 risperidone 4 mg QL 30 120 SAPHRIS SUBLINGUAL 10 MG QL 30 60 SAPHRIS SUBLINGUAL 2.5 MG QL 30 240 SAPHRIS SUBLINGUAL 5 MG QL 30 120 SEROQUEL XR 24 * 150 MG, 200 MG QL 30 30 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 71
SEROQUEL XR 24 * 300 MG, 400 MG SEROQUEL XR 24 * 50 MG thioridazine hcl 10 mg, 100 mg, 25 mg, 50 mg thiothixene 1 mg, 10 mg, 2 mg, 5 mg trifluoperazine hcl 1 mg, 10 mg, 2 mg, 5 mg VERSACLOZ 50 MG/ML ziprasidone hcl 20 mg, 40 mg ziprasidone hcl 60 mg, 80 mg ZYPREXA RELPREVV * 210 MG, 300 MG ZYPREXA RELPREVV * 405 MG amphetamine-dextroamphet er 24 10 mg, 5 mg amphetamine-dextroamphet er 24 15 mg, 20 mg, 25 mg, 30 mg QL 30 60 QL 30 120 PA PA; QL 30 600 ML QL 30 60 QL 30 90 PA; QL 28 2 PA; QL 28 1 QL 30 90 QL 30 30 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 72
amphetamine-dextroamphetamine 10 mg amphetamine-dextroamphetamine 12.5 mg amphetamine-dextroamphetamine 15 mg amphetamine-dextroamphetamine 20 mg amphetamine-dextroamphetamine 30 mg amphetamine-dextroamphetamine 5 mg amphetamine-dextroamphetamine 7.5 mg guanfacine hcl er 24 * 1 mg, 2 mg, 3 mg, 4 mg metadate er * 20 mg methylphenidate hcl er * 10 mg, 20 mg methylphenidate hcl 10 mg/5ml methylphenidate hcl 5 mg/5ml methylphenidate hcl 10 mg, 5 mg methylphenidate hcl 20 mg STRATTERA 10 MG, 18 MG, 25 MG QL 30 180 QL 30 144 QL 30 120 QL 30 90 QL 30 60 QL 30 360 QL 30 240 PA QL 30 90 QL 30 90 QL 30 900 ML QL 30 1800 ML QL 30 180 QL 30 90 QL 30 120 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 73
STRATTERA 100 MG, 60 MG, 80 MG QL 30 30 STRATTERA 40 MG QL 30 60 HETLIOZ 20 MG PA; LA ROZEREM 8 MG QL 30 30 SILENOR 3 MG QL 30 60 SILENOR 6 MG QL 30 30 temazepam 15 mg PA; QL 30 60 temazepam 7.5 mg PA; QL 30 30 zolpidem tartrate 10 mg, 5 mg PA; QL 30 30 dihydroergotamine mesylate 1 mg/ml naratriptan hcl 1 mg, 2.5 mg QL 30 9 RELPAX 20 MG, 40 MG QL 30 12 rizatriptan benzoate 10 mg, 5 mg QL 30 18 rizatriptan benzoate 10 mg, 5 mg QL 30 18 sumatriptan 20 mg/act QL 30 12 sumatriptan 5 mg/act QL 30 24 sumatriptan succinate 100 mg, 25 mg, 50 mg QL 30 9 sumatriptan succinate refill * 4 mg/0.5ml, 6 mg/0.5ml QL 30 6 ML 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 74
sumatriptan succinate * 4 mg/0.5ml QL 30 6 ML sumatriptan succinate * 6 mg/0.5ml QL 30 6 ML sumatriptan succinate * 6 mg/0.5ml QL 30 6 ML zolmitriptan 2.5 mg, 5 mg QL 30 12 zolmitriptan 2.5 mg, 5 mg QL 30 12 lithium carbonate er * 300 mg, 450 mg lithium carbonate 150 mg, 300 mg, 600 mg lithium carbonate 300 mg LITHIUM 8 MEQ/5ML NUEDEXTA 20-10 MG PA pyridostigmine bromide 60 mg riluzole 50 mg XENAZINE 12.5 MG PA; LA ; QL 30 240 XENAZINE 25 MG PA; LA ; QL 30 120 AMPYRA 12 * 10 MG PA; LA BETASERON * 0.3 MG PA; QL 28 14 COPAXONE * 40 MG/ML PA; QL 28 12 ML 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 75
GILENYA 0.5 MG PA; QL 28 28 glatopa * 20 mg/ml PA; QL 30 30 ML TYSABRI * 300 MG/15ML PA; LA baclofen 10 mg, 20 mg dantrolene sodium 100 mg, 25 mg, 50 mg tizanidine hcl 2 mg, 4 mg NUVIGIL 150 MG PA; QL 30 60 NUVIGIL 200 MG, 250 MG PA; QL 30 30 NUVIGIL 50 MG PA; QL 30 150 XYREM 500 MG/ML PA; LA ; QL 30 540 ML - acamprosate calcium 333 mg buprenorphine hcl sublingual 2 mg, 8 mg PA buprenorphine hcl-naloxone hcl sublingual 2-0.5 mg, PA; QL 30 120 8-2 mg buproban 12 * 150 mg CHANTIX 1 MG PA CHANTIX 0.5 MG, 1 MG PA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 76
CHANTIX 0.5 MG X 11 & 1 MG X 42 PA disulfiram 250 mg, 500 mg naloxone hcl 0.4 mg/ml, 1 mg/ml naltrexone hcl 50 mg NICOTROL INHALATION 10 MG NICOTROL NS 10 MG/ML SUBOXONE 12-3 MG PA; QL 30 60 SUBOXONE 2-0.5 MG, 4-1 MG, 8-2 MG PA; QL 30 120 ANDRODERM 24 2 MG 24 4 MG 24 PA; QL 30 30 AXIRON 30 MG/ACT PA; QL 30 440 ML oxandrolone 10 mg PA oxandrolone 2.5 mg PA testosterone cypionate * 100 mg/ml, 200 mg/ml PA testosterone enanthate * 200 mg/ml PA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 77
ASSURE ID 29G X 1/2 1 ML BYDUREON * 2 MG QL 28 4 BYDUREON * 2 MG QL 28 4 BYETTA 10 MCG * 10 MCG/0.04ML QL 30 2.4 ML BYETTA 5 MCG * 5 MCG/0.02ML QL 30 1.2 ML EXCEL COMFORT 29G X 12MM GLOBAL 70 % HUMULIN R U-500 * 500 ML B/D 29G X 1/2 0.3 ML, 29G X 1/2 1 ML LANTUS SOLOSTAR * 100 ML LANTUS * 100 ML LEVEMIR FLEXTOUCH * 100 ML LEVEMIR * 100 ML NOVOLIN 70/30 * (70-30) 100 ML NOVOLIN N * 100 ML 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 78
NOVOLIN R 100 ML NOVOLOG FLEX * 100 ML NOVOLOG MIX 70/30 FLEX * (70-30) 100 ML NOVOLOG MIX 70/30 * (70-30) 100 ML NOVOLOG PENFILL * 100 ML NOVOLOG * 100 ML PREFERRED PLUS 28G X 1/2 0.5 ML RA 2 X2 SYMLINPEN 120 * 2700 MCG/2.7ML PA; QL 30 10.8 ML SYMLINPEN 60 * 1500 MCG/1.5ML PA; QL 30 12 ML VICTOZA * 18 MG/3ML QL 30 9 ML acarbose 100 mg, 25 mg, 50 mg FARXIGA 10 MG QL 30 30 FARXIGA 5 MG QL 30 60 glimepiride 1 mg QL 30 240 glimepiride 2 mg QL 30 120 glimepiride 4 mg QL 30 60 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 79
glipizide er 24 * 10 mg QL 30 60 glipizide er 24 * 2.5 mg QL 30 240 glipizide er 24 * 5 mg QL 30 120 glipizide 10 mg QL 30 120 glipizide 5 mg QL 30 240 glipizide-metformin hcl 2.5-250 mg QL 30 240 glipizide-metformin hcl 2.5-500 mg, 5-500 mg QL 30 120 INVOKAMET 150-1000 MG, 150-500 MG, QL 30 60 50-1000 MG INVOKAMET 50-500 MG QL 30 120 INVOKANA 100 MG QL 30 90 INVOKANA 300 MG QL 30 30 JANUMET 50-1000 MG, 50-500 MG QL 30 60 JANUMET XR 24 * 100-1000 MG QL 30 30 JANUMET XR 24 * 50-1000 MG, QL 30 60 50-500 MG JANUVIA 100 MG, 25 MG, 50 MG QL 30 30 JENTADUETO 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG QL 30 60 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 80
metformin hcl er 24 * 500 mg QL 30 120 metformin hcl er 24 * 750 mg QL 30 60 metformin hcl 1000 mg QL 30 75 metformin hcl 500 mg QL 30 150 metformin hcl 850 mg QL 30 90 nateglinide 120 mg, 60 mg QL 30 90 pioglitazone hcl 15 mg, 30 mg, 45 mg QL 30 30 repaglinide 0.5 mg, 1 mg QL 30 120 repaglinide 2 mg QL 30 240 TRADJENTA 5 MG QL 30 30 ONETOUCH ULTRA 2 ONETOUCH ULTRA BLUE ONETOUCH ULTRA MINI ONETOUCH ULTRA SYSTEM ONETOUCH ULTRASMART Part B $0 Part B $0 Part B $0 Part B $0 Part B $0 NDC (53885044801); QL 365 1 NDC (53885024450, 53885024510, 53885099425); QL 25 100 NDC (53885042101, 53885042001,53885020801, 53885091101,53885091201, 53885041901); QL 365 1 NDC (53885024701); QL 365 1 NDC (53885052401); QL 365 1 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 81
ONETOUCH VERIO Part B $0 ONETOUCH VERIO IQ SYSTEM Part B $0 ONETOUCH VERIO Part B $0 ONETOUCH VERIO SYNC SYSTEM alendronate sodium 10 mg, 40 mg, 5 mg alendronate sodium 35 mg, 70 mg ibandronate sodium 150 mg pamidronate disodium * 30 mg/10ml, 6 mg/ml, 90 mg/10ml zoledronic acid * 4 mg/5ml zoledronic acid * 5 mg/100ml SENSIPAR 30 MG, 90 MG Part B $0 NDC (53885027210, 53885027150, 53885027025); QL 25 100 NDC (53885026701); QL 365 1 NDC (53885065701); QL 365 1 NDC (53885039601); QL 365 1 QL 28 4 B/D; QL 30 1 B/D B/D B/D QL 30 120 SENSIPAR 60 MG QL 30 60 CHEMET 100 MG DEPEN TITRATABS 250 MG 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 82
EXJADE 125 MG, 250 MG, 500 MG PA; LA FERRIPROX 500 MG PA; LA kionex kionex 15 gm/60ml sodium polystyrene sulfonate 15 gm/60ml sps 15 gm/60ml SYPRINE 250 MG altavera 0.15-30 mg-mcg apri 0.15-30 mg-mcg aranelle 0.5/1/0.5-35 mg-mcg aubra 0.1-20 mg-mcg aviane 0.1-20 mg-mcg balziva 0.4-35 mg-mcg briellyn 0.4-35 mg-mcg camila 0.35 mg cryselle-28 0.3-30 mg-mcg cyclafem 1/35 1-35 mg-mcg cyclafem 7/7/7 0.5/0.75/1-35 mg-mcg deblitane 0.35 mg delyla 0.1-20 mg-mcg desogestrel-ethinyl estradiol 0.15-0.02/0.01 mg (21/5) drospirenone-ethinyl estradiol 3-0.03 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 83
emoquette 0.15-30 mg-mcg enpresse-28 errin 0.35 mg falmina 0.1-20 mg-mcg gianvi 3-0.02 mg gildagia 0.4-35 mg-mcg gildess 1.5/30 1.5-30 mg-mcg heather 0.35 mg introvale 0.15-0.03 mg jolessa 0.15-0.03 mg jolivette 0.35 mg junel 1.5/30 1.5-30 mg-mcg junel 1/20 1-20 mg-mcg junel fe 1.5/30 1.5-30 mg-mcg junel fe 1/20 1-20 mg-mcg kariva 0.15-0.02/0.01 mg (21/5) kelnor 1/35 1-35 mg-mcg larin 1.5/30 1.5-30 mg-mcg larin 1/20 1-20 mg-mcg larin fe 1.5/30 1.5-30 mg-mcg larin fe 1/20 1-20 mg-mcg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 84
leena 0.5/1/0.5-35 mg-mcg lessina 0.1-20 mg-mcg levonest levonorgest-eth estrad 91 0.15-0.03 mg levonorgestrel 0.75 mg, 1.5 mg levonorgestrel-ethinyl estrad 0.1-20 mg-mcg levora 0.15/30 (28) 0.15-30 mg-mcg loryna 3-0.02 mg low-ogestrel 0.3-30 mg-mcg lutera 0.1-20 mg-mcg lyza 0.35 mg marlissa 0.15-30 mg-mcg medroxyprogesterone acetate * 150 mg/ml microgestin 1.5/30 1.5-30 mg-mcg microgestin 1/20 1-20 mg-mcg microgestin fe 1.5/30 1.5-30 mg-mcg microgestin fe 1/20 1-20 mg-mcg mononessa 0.25-35 mg-mcg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 85
myzilra necon 0.5/35 (28) 0.5-35 mg-mcg necon 1/35 (28) 1-35 mg-mcg necon 1/50 (28) 1-50 mg-mcg necon 10/11 (28) 35 mcg necon 7/7/7 0.5/0.75/1-35 mg-mcg next choice one dose 1.5 mg nikki 3-0.02 mg nora-be 0.35 mg norethindrone 0.35 mg norgestim-eth estrad triphasic 0.18/0.215/0.25 mg-35 mcg norlyroc 0.35 mg nortrel 0.5/35 (28) 0.5-35 mg-mcg nortrel 1/35 (21) 1-35 mg-mcg nortrel 1/35 (28) 1-35 mg-mcg nortrel 7/7/7 0.5/0.75/1-35 mg-mcg NUVARING 0.12-0.015 MG 24 ocella 3-0.03 mg orsythia 0.1-20 mg-mcg philith 0.4-35 mg-mcg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 86
pimtrea 0.15-0.02/0.01 mg (21/5) pirmella 1/35 1-35 mg-mcg portia-28 0.15-30 mg-mcg previfem 0.25-35 mg-mcg quasense 0.15-0.03 mg reclipsen 0.15-30 mg-mcg sharobel 0.35 mg solia 0.15-30 mg-mcg sprintec 28 0.25-35 mg-mcg sronyx 0.1-20 mg-mcg syeda 3-0.03 mg tarina fe 1/20 1-20 mg-mcg tri-legest fe 1-20/1-30/1-35 mg-mcg trinessa (28) 0.18/0.215/0.25 mg-35 mcg tri-previfem 0.18/0.215/0.25 mg-35 mcg tri-sprintec 0.18/0.215/0.25 mg-35 mcg trivora (28) velivet 0.1/0.125/0.15-0.025 mg vestura 3-0.02 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 87
viorele 0.15-0.02/0.01 mg (21/5) vyfemla 0.4-35 mg-mcg xulane 150-35 mcg 24 zarah 3-0.03 mg zenchent 0.4-35 mg-mcg zovia 1/35e (28) 1-35 mg-mcg zovia 1/50e (28) 1-50 mg-mcg danazol 100 mg, 200 mg, 50 mg SYNAREL 2 MG/ML ADAGEN * 250 ML PA; LA ALDURAZYME * 2.9 MG/5ML PA; LA CARBAGLU 200 MG PA; LA CERDELGA 84 MG PA CEREZYME * 200, 400 PA; LA CYSTADANE LA CYSTAGON 150 MG, 50 MG PA; LA FABRAZYME * 35 MG, 5 MG PA; LA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 88
KUVAN 100 MG, 500 MG PA; LA KUVAN 100 MG PA; LA levocarnitine * 200 mg/ml B/D levocarnitine 1 gm/10ml B/D levocarnitine 330 mg B/D LUMIZYME * 50 MG PA; LA MYOZYME * 50 MG PA; LA NAGLAZYME * 1 MG/ML PA; LA ORFADIN 10 MG, 2 MG, 5 MG PA; LA RAVICTI 1.1 GM/ML PA sodium phenylbutyrate 3 gm/tsp ZAVESCA 100 MG PA; LA DELESTROGEN * 10 MG/ML estrace 0.1 mg/gm estradiol 0.5 mg, 1 mg, 2 mg PA estradiol 0.025 mg 24 0.0375 mg 24 0.05 mg 24 0.06 mg 24 0.075 mg 24 0.1 mg 24 PA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 89
estradiol valerate * 20 mg/ml, 40 mg/ml jinteli 1-5 mg-mcg PA norethindrone-eth estradiol 1-5 mg-mcg PA VAGIFEM 10 MCG a-hydrocort 100 mg cortisone acetate 25 mg dexamethasone intensol 1 mg/ml dexamethasone 0.5 mg/5ml dexamethasone 0.5 mg/5ml dexamethasone 0.5 mg, 0.75mg, 1 mg, 1.5mg, 2 mg, 4 mg, 6 mg dexamethasone sod phosphate pf 10 mg/ml dexamethasone sodium phosphate 10 mg/ml, 100 mg/10ml, 120 mg/30ml, 20 mg/5ml fludrocortisone acetate 0.1 mg hydrocortisone 10 mg, 20 mg, 5 mg methylprednisolone (pak) 4 mg B/D methylprednisolone acetate 40 mg/ml, 80 mg/ml B/D 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 90
methylprednisolone 16 mg, 32 mg, 4 mg, 8 mg B/D methylprednisolone sodium succ 1 gm, 125 mg, B/D 40 mg prednisolone 15 mg/5ml B/D prednisolone sodium phosphate 15 mg/5ml, 25 mg/5ml, B/D 6.7 (5 base) mg/5ml prednisone (pak) 10 mg, 5 mg B/D prednisone intensol 5 mg/ml B/D prednisone 5 mg/5ml B/D prednisone 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg B/D SOLU-CORTEF 250 MG GLUCAGEN HYPOKIT 1 MG GLUCAGON 1 MG KORLYM 300 MG PA; LA PROGLYCEM 50 MG/ML NORDITROPIN FLEXPRO * 10 MG/1.5ML, 15 MG/1.5ML, 5 MG/1.5ML PA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 91
NORDITROPIN NORDIFLEX * 30 MG/3ML PA cabergoline 0.5 mg calcitonin (salmon) 200 act FORTICAL 200 ACT INCRELEX * 40 MG/4ML PA; LA methylergonovine maleate 0.2 mg MIACALCIN 200 ML B/D octreotide acetate 100 mcg/ml, 50 mcg/ml PA octreotide acetate 1000 mcg/ml, 200 mcg/ml, PA 500 mcg/ml PROLIA * 60 MG/ML QL 180 1 ML raloxifene hcl 60 mg SANDOSTATIN LAR DEPOT * 10 MG, 20 MG, 30 MG PA SIGNIFOR * 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML PA; LA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 92
SOMATULINE DEPOT * 120 MG/0.5ML, 60 MG/0.2ML, PA 90 MG/0.3ML SOMAVERT * 10 MG, 15 MG, 20 MG, 25 MG, 30 MG PA; LA XGEVA * 120 MG/1.7ML PA FORTEO * 600 MCG/2.4ML PA; QL 28 2.4 ML NATPARA * 100 MCG, 25 MCG, 50 MCG, 75 MCG PA calcium acetate 667 mg RENVELA 0.8 GM, 2.4 GM RENVELA 800 MG medroxyprogesterone acetate 10 mg, 2.5 mg, 5 mg norethindrone acetate 5 mg levothyroxine sodium 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 93
levoxyl 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine sodium 25 mcg, 5 mcg, 50 mcg methimazole 10 mg, 5 mg propylthiouracil 50 mg SYNTHROID 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 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg desmopressin ace 0.01 % desmopressin ace 0.01 % desmopressin acetate 4 mcg/ml desmopressin acetate 0.1 mg, 0.2 mg desmopressin acetate spray 0.01 % compro 25 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 94
dronabinol 10 mg B/D; QL 30 60 dronabinol 2.5 mg, 5 mg B/D; QL 30 60 EMEND 125 MG, 40 MG, 80 & 125 MG, 80 MG B/D granisetron hcl * 0.1 mg/ml, 1 mg/ml, 4 mg/4ml granisetron hcl 1 mg B/D meclizine hcl 12.5 mg, 25 mg metoclopramide hcl 5 mg/ml metoclopramide hcl 5 mg/5ml metoclopramide hcl 10 mg, 5 mg ondansetron hcl 4 mg/2ml, 40 mg/20ml ondansetron hcl 4 mg/5ml B/D ondansetron hcl 24 mg, 4 mg, 8 mg B/D ondansetron 4 mg, 8 mg B/D phenadoz 12.5 mg PA phenergan 12.5 mg, 25 mg, 50 mg PA prochlorperazine edisylate 5 mg/ml prochlorperazine maleate 10 mg, 5 mg prochlorperazine 25 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 95
promethazine hcl 25 mg/ml, 50 mg/ml PA promethazine hcl 6.25 mg/5ml PA promethazine hcl 12.5 mg, 25 mg, 50 mg PA promethazine hcl 12.5 mg, 25 mg, 50 mg PA promethegan 25 mg, 50 mg PA TRANSDERM-SCOP 72 1 MG/3 PA; QL 30 10 CUVPOSA 1 MG/5ML dicyclomine hcl 10 mg dicyclomine hcl 10 mg/5ml dicyclomine hcl 20 mg glycopyrrolate 4 mg/20ml glycopyrrolate 1 mg, 2 mg H2 famotidine * 20 mg/2ml, 200 mg/20ml, 40 mg/4ml famotidine 40 mg/5ml famotidine 20 mg, 40 mg famotidine premixed * 20-0.9 mg/50ml-% 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 96
ranitidine hcl 150 mg/6ml, 50 mg/2ml ranitidine hcl 15 mg/ml ranitidine hcl 150 mg, 300 mg APRISO 24 0.375 GM ASACOL HD 800 MG balsalazide disodium 750 mg budesonide er 24 3 mg CANASA 1000 MG colocort 100 mg/60ml DELZICOL 400 MG DIPENTUM 250 MG hydrocortisone 100 mg/60ml mesalamine 4 gm mesalamine 4 gm sulfasalazine 500 mg sulfazine ec 500 mg UCERIS 24 * 9 MG constulose 10 gm/15ml enulose 10 gm/15ml 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 97
gavilyte-c 240 gm gavilyte-g 236 gm gavilyte-h 5-210 mg-gm gavilyte-n 420 gm generlac 10 gm/15ml GOLYTELY 227.1 GM, 236 GM lactulose encephalopathy 10 gm/15ml lactulose 10 gm/15ml MOVIPREP 100 GM NULYTELY 420 GM peg 3350/electrolytes 240 gm peg 3350-kcl-na bicarb-nacl 420 gm peg-3350/electrolytes 236 gm polyethylene glycol 3350 polyethylene glycol 3350 RELISTOR * 12 MG/0.6ML, 8 MG/0.4ML PA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 98
SUPREP trilyte 420 gm alosetron hcl 0.5 mg, 1 mg PA AMITIZA 24 MCG, 8 MCG QL 30 60 cromolyn sodium 100 mg/5ml diphenoxylate-atropine 2.5-0.025 mg/5ml diphenoxylate-atropine 2.5-0.025 mg GATTEX * 5 MG PA; LA LINZESS 145 MCG QL 30 60 LINZESS 290 MCG QL 30 30 loperamide hcl 2 mg misoprostol 100 mcg, 200 mcg MOVANTIK 12.5 MG QL 30 60 MOVANTIK 25 MG QL 30 30 SUCRAID 8500 ML LA sucralfate 1 gm ursodiol 300 mg ursodiol 250 mg, 500 mg XIFAXAN 550 MG PA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 99
CREON 12000, 24000, 3000-9500, 36000, 6000 ZENPEP 10000, 15000, 20000, 25000, 3000-10000, 40000, 5000 DEXILANT 30 MG, 60 MG QL 30 30 esomeprazole sodium * 20 mg, 40 mg NEXIUM 20 MG, 40 MG QL 30 30 NEXIUM 10 MG, 20 MG, 40 MG QL 30 30 NEXIUM 2.5 MG, 5 MG omeprazole 10 mg, 40 mg QL 30 30 omeprazole 20 mg QL 30 60 pantoprazole sodium 20 mg, 40 mg QL 30 30 alfuzosin hcl er 24 * 10 mg QL 30 30 AVODART 0.5 MG QL 30 30 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 100
finasteride 5 mg JALYN 0.5-0.4 MG QL 30 30 tamsulosin hcl 0.4 mg bethanechol chloride 10 mg, 25 mg, 5 mg, 50 mg ELMIRON 100 MG potassium citrate er * 10 meq (1080 mg), 5 meq (540 mg) MYRBETRIQ 24 * 25 MG QL 30 60 MYRBETRIQ 24 * 50 MG QL 30 30 oxybutynin chloride er 24 * 10 mg, 15 mg QL 30 60 oxybutynin chloride er 24 * 5 mg QL 30 30 oxybutynin chloride 5 mg/5ml oxybutynin chloride 5 mg tolterodine tartrate er 24 2 mg, 4 mg QL 30 30 tolterodine tartrate 1 mg, 2 mg TOVIAZ 24 * 4 MG, 8 MG QL 30 30 trospium chloride 20 mg QL 30 60 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 101
VESICARE 10 MG, 5 MG QL 30 30 clindamycin phosphate 2 % metronidazole 0.75 % terconazole 0.4 %, 0.8 % terconazole 80 mg vandazole 0.75 % zazole 0.4 % zazole 0.8 % COUMADIN 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG ELIQUIS 2.5 MG, 5 MG enoxaparin sodium 300 mg/3ml enoxaparin sodium * 100 mg/ml, 120 mg/0.8ml, 150 mg/ml enoxaparin sodium * 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml fondaparinux sodium * 10 mg/0.8ml, 5 mg/0.4ml, 7.5 mg/0.6ml 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 102
fondaparinux sodium * 2.5 mg/0.5ml HEPARIN (PORCINE) D5W * 40-5 ML-%, 50-5 ML-% HEPARIN (PORCINE) NACL 100-0.45 ML-%, 50-0.45 ML-% HEPARIN SOD (PORCINE) D5W * 100 ML heparin sodium (porcine) 1000 ml, 10000 ml, B/D 20000 ml, 5000 ml HEPARIN SODIUM (PORCINE) 2500 ML B/D HEPARIN SODIUM (PORCINE) * 2000 ML B/D jantoven 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA 150 MG, 75 MG warfarin sodium 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO 10 MG, 15 MG, 20 MG XARELTO 15 & 20 MG 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 103
GRANIX * 300 MCG/0.5ML, 480 MCG/0.8ML PA LEUKINE * 250 MCG PA MOZOBIL * 24 MG/1.2ML PA NEUMEGA * 5 MG NEUPOGEN 300 MCG/0.5ML, 300 MCG/ML, PA 480 MCG/0.8ML, 480 MCG/1.6ML PROCRIT 10000 ML, 2000 ML, 20000 ML, PA 3000 ML, 4000 ML, 40000 ML anagrelide hcl 0.5 mg, 1 mg cilostazol 100 mg, 50 mg CINRYZE * 500 PA; LA FIRAZYR * 30 MG/3ML PA pentoxifylline er * 400 mg PROMACTA 12.5 MG PA; LA ; QL 30 360 PROMACTA 25 MG PA; LA ; QL 30 180 PROMACTA 50 MG PA; LA ; QL 30 90 PROMACTA 75 MG PA; LA ; QL 30 60 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 104
tranexamic acid * 100 mg/ml tranexamic acid 650 mg AGGRENOX 12 25-200 MG BRILINTA 90 MG clopidogrel bisulfate 75 mg EFFIENT 10 MG, 5 MG ZONTIVITY 2.08 MG (DMARDS) CIMZIA PREFILLED * 2 X 200 MG/ML PA CIMZIA STARTER KIT * 6 X 200 MG/ML PA CIMZIA * 2 X 200 MG PA HUMIRA * 40 MG/0.8ML PA HUMIRA PEN-CROHNS * 40 MG/0.8ML PA HUMIRA PEN-PSORIASIS * 40 MG/0.8ML PA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 105
HUMIRA * 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML PA hydroxychloroquine sulfate 200 mg leflunomide 10 mg, 20 mg methotrexate 2.5 mg REMICADE * 100 MG PA BIVIGAM * 10 GM/100ML, 5 GM/50ML PA CARIMUNE NF * 12 GM PA FLEBOGAMMA DIF * 0.5 GM/10ML, 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML, PA 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML FLEBOGAMMA * 0.5 GM/10ML PA GAMASTAN S/D * B/D GAMMAGARD 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, PA 30 GM/300ML, 5 GM/50ML GAMMAGARD S/D * 2.5 GM PA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 106
GAMMAGARD S/D LESS IGA * 10 GM, 5 GM PA GAMMAKED 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, PA 20 GM/200ML, 5 GM/50ML GAMMAPLEX * 10 GM/200ML, 5 GM/100ML PA GAMUNEX-C 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML, PA 5 GM/50ML OCTAGAM * 1 GM/20ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 25 GM/500ML, PA 5 GM/100ML PRIVIGEN * 10 GM/100ML, 20 GM/200ML, 40 GM/400ML, PA 5 GM/50ML ACTIMMUNE * 2000000 0.5ML PA; LA ARCALYST * 220 MG PA INTRON A 10000000 ML, B/D 6000000 ML INTRON A 10000000, 18000000, 50000000 B/D 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 107
REVLIMID 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, PA; LA 5 MG THALOMID 100 MG, 150 MG, 200 MG, 50 MG PA azathioprine 50 mg B/D BENLYSTA * 120 MG PA cyclosporine * 50 mg/ml B/D cyclosporine modified 100 mg, 25 mg, 50 mg B/D cyclosporine modified 100 mg/ml B/D cyclosporine 100 mg, 25 mg B/D gengraf 100 mg, 25 mg B/D gengraf 100 mg/ml B/D mycophenolate mofetil 250 mg B/D mycophenolate mofetil 200 mg/ml B/D mycophenolate mofetil 500 mg B/D mycophenolic acid 180 mg B/D mycophenolic acid 360 mg B/D NEORAL 100 MG, 25 MG B/D 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 108
NEORAL 100 MG/ML B/D NULOJIX * 250 MG B/D PROGRAF 0.5 MG, 1 MG, 5 MG B/D RAPAMUNE 1 MG/ML B/D SANDIMMUNE 100 MG/ML B/D sirolimus 0.5 mg, 1 mg B/D SIROLIMUS 2 MG B/D tacrolimus 0.5 mg, 1 mg B/D tacrolimus 5 mg B/D ZORTRESS 0.25 MG, 0.5 MG, 0.75 MG B/D ACTHIB * NM ADACEL * 5-2-15.5 LF-MCG/0.5 NM BCG VACCINE NM BEXSERO * NM BOOSTRIX * 5-2.5-18.5 NM CERVARIX * NM COMVAX * 7.5-5 MCG/0.5ML NM 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 109
DAPTACEL * 10-15-5 NM DIPHTHERIA-TETANUS TOXOIDS DT * 25-5 LFU/0.5ML B/D; NM ENGERIX-B 10 MCG/0.5ML, 20 MCG/ML B/D; NM GARDASIL 9 * NM GARDASIL 9 * NM GARDASIL * NM HAVRIX * 1440 EL U/ML, 720 EL U/0.5ML NM HIBERIX 10 MCG NM IMOVAX RABIES * 2.5 ML NM INFANRIX * 25-58-10 NM IPOL NM IXIARO * NM MENACTRA * NM MENOMUNE * NM MENVEO * NM M-M-R II * NM 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 110
PEDVAX HIB * 7.5 MCG/0.5ML NM PROQUAD * NM RABAVERT * NM RECOMBIVAX HB 10 MCG/ML, 40 MCG/ML, B/D; NM 5 MCG/0.5ML ROTARIX NM ROTATEQ NM SYNAGIS * 100 MG/ML, 50 MG/0.5ML NM TENIVAC * 5-2 LFU B/D; NM TETANUS-DIPHTHERIA TOXOIDS TD * 2-2 LF/0.5ML B/D; NM TRUMENBA * NM TWINRIX * 720-20 NM TYPHIM VI * 25 MCG/0.5ML NM VAQTA * 25 0.5ML, 50 ML NM VARIVAX * 1350 PFU/0.5ML NM YF-VAX * NM 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 111
ZOSTAVAX * 19400 UNT/0.65ML NM; QL 999 1 12 * 12 120 mg ABREVA 10 % ACEPHEN 120 MG, 325 MG, 650 MG ACEROLA C 500 500 MG acetaminophen 8 650 mg acetaminophen junior strength 160 mg acetaminophen 160 mg/5ml ACID GONE 95-358 MG/15ML ACID GONE 160-105 MG acid reducer 10 mg acidophilus/l-sporogenes 5 5 % 10 % advanced calcium formula 200 mg ADVIL 4-10-200 MG 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 112
ADVIL 2-30-200 MG ADVIL 30-200 MG ADVIL JUNIOR STRENGTH 100 MG AFRIN 0.25 % ALA-HIST IR 2 MG ALA-HIST PE 2-10 MG all day allergy-d 12 * 5-120 mg all day pain relief 220 mg ALLEGRA 30 MG aller-ease 60 mg 25 mg 10 mg, 25 mg aluminum hydroxide gel 320 mg/5ml ambi 12.5cpd/1dcpm/30pse 30-1-12.5 mg/5ml ambi 40pse/400gfn/20dm 40-400-20 mg antacid 400-400-40 mg/5ml anti-diarrheal 1 mg/5ml anti-diarrheal 2 mg antifungal 2 % antioxidant formula sg * 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 113
apap 500 500 mg/5ml ap-hist dm 7.5-4-15 mg/5ml AQUADEKS AQUA-E 30-2 MG/ML AQUANIL HC 1 % artificial tears 1.4 % ascorbic acid aspirin ec 325 mg aspirin 325 mg, 81 mg aspirin 300 mg, 600 mg athletes 1 % AXID AR 75 MG AYR SALINE 0.65 % AYR SALINE NASAL b complex b complex B-12 DOTS 500 MCG b-12 2000 mcg b-12 5000 mcg b-12 sublingual 2500 mcg bacitracin 500 gm 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 114
bacitracin zinc 500 gm b-complex/vitamin c bee zee benzonatate 100 mg, 200 mg benzoyl peroxide 6 % benzoyl peroxide 2.5 % benzoyl peroxide 5 % beta carotene 25000 biospec dmx 15-25 mg/5ml biotin 300 mcg B-NATAL 25 MG B-NATAL 25 MG BONE DENSITY 300-200 MG- bone meal BOUDREAUXS BUTT PASTE 16 % brohist d 4-10 mg c-500 500 mg cal/mag 200-100 mg CALCET CREAMY BITES 500-400 MG- 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 115
CALCET PETITES 200-250 MG- CALCI-MIX 1250 MG calcionate 1.8 gm/5ml cal-citrate plus vitamin d 250-100 mg- calcium + d 500-1000-40 mg-unt-mcg calcium + d3 600-200 mg- calcium 1000 + d 1000-800 mg- calcium 500 500-250-200 mg-mg- calcium 500/d 500-400 mg- calcium 500+d high potency 500-400 mg- calcium 600 600 mg calcium 600/vitamin d 600-400 mg- calcium 600+d plus minerals 600-400 mg- calcium 600+d plus minerals 600-400 mg- calcium antacid 750 mg calcium antacid 500 mg calcium antacid ultra 1000 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 116
calcium ascorbate 500 mg calcium carbonate 800 mg/2gm calcium carbonate 1250 mg/5ml calcium carbonate 1250 mg calcium carbonate 260 mg calcium carbonate-vitamin d 600-400 mg- calcium citrate + d 250-200 mg-, 315-200 mg- calcium citrate malate-vit d 250-100 mg- calcium citrate 760 mg/3.5gm calcium citrate 250 mg calcium citrate-vitamin d 200-125 mg- calcium for women 500-100-40 calcium gluconate 50 mg, 500 mg calcium gummies 250-100-500 mg- calcium lactate 100 mg, 648 mg, 650 mg calcium 500 mg calcium pantothenate 500 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 117
calcium soft chews 500-500-40 mg-unt-mcg calcium/c/d 500-10-250 mg-mg- calcium+d3 gradual release 24 * 600-40-500 mg-mg- calcium-magnesium 500-250 mg, 750-465 mg calcium-magnesium-vitamin d 400-166.7-133.3 mg-mg- calcium-magnesium-zinc 167-83-8 mg calcium-vitamin d3 500-400 mg-, 600-400 mg- calmag thins 200-50 mg CAL-QUICK 500-400 MG-UNT/5ML CALTRATE 600+D SOFT 600-800 MG- castellani paint modified 1.5 % CENTRUM KIDS COMPLETE 60 MG CENTRUM SILVER CEROVITE cetirizine hcl 5 mg cetirizine hcl 10 mg, 5 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 118
chelated calcium 200 mg chewable calcium 500-200-40 mg-unt-mcg chewable vite chewable vite/iron 15 mg childrens acetaminophen 80 mg childrens cold & allergy 1-2.5 mg/5ml childrens complete allergy 12.5 mg childrens non-aspirin 80 mg childrens plus & 12.5-2.5-160 mg/5ml childrens plus cold 1-2.5-160 mg/5ml chlo tuss ex 12.5-100 mg/5ml chlorpheniramine maleate er * 12 mg CITRACAL CALCIUM GUMMIES 250-115-250 MG-MG- CITRACAL PLUS HEART HEALTH 315-250-200 MG--MG citrus calcium +d 315-250 mg- 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 119
citrus calcium/vitamin d 200-250 mg- CLARITIN 5 MG CLARITIN REDITABS 5 MG classic prenatal 28-0.8 mg clotrimazole 3 2 % clotrimazole 1 % cod liver oil codituss dm 5-8.33-10 mg/5ml cold head congestion severe 5-10-200-325 mg 2.5-1-5 mg/5ml 5-10-200-325 mg/10ml complete 2-10-500 mg COMTREX 2-5-325 & 5-325 MG CONEX 1-30 MG/5ML CONEX 2-60 MG CONTAC 2-5-500 MG 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 120
coral calcium 133-66.7-133 mg-mg-, 185-50-100 mg-mg-, 250-125-100 mg- coral calcium plus 250-125-200 mg-mg- CORICIDIN HBP 10-200 MG CORTIZONE-10 1 % 4-30 mg 500-15 mg/15ml cough dm extendedrelease* 30 mg/5ml cromolyn sodium 5.2 mg/act cvs calcium citrate 200 mg cvs easy fiber/calcium cvs hydrocortisone acetate 0.5 % cvs 500 mg cvs 1 % cvs 0.5-0.9 % cvs nasal mist 0.9 % cvs 500 mg/15ml 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 121
cvs probiotic (lactobacillus) cvs senna-extra 17.2 mg cvs 50 mg cvs vitamin b-6 200 mg cvs vitamin c 1000 mg cyanocobalamin 1000 mcg/ml CYTO B2 343 MG/GM d 1000 1000 d 10000 10000 d 400 400 D3-50 50000 d-5000 5000 daily-vite/iron/beta-carotene day-time sinus 5-325 mg DELTUSS DP 1-30 MG/5ML DESENEX 2 % DESENEX 2 % DESITIN 13 % DIALYVITE 800 0.8 MG DIALYVITE 800-ZINC 15 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 122
DIALYVITE VITAMIN D3 MAX 50000 DIMETAPP 1-7.5 MG/5ML DIMETAPP 6.25-2.5 MG/5ML diphenhydramine hcl 50 mg docusate sodium 50 mg/5ml DOK 100 MG double antibiotic 500-10000 gm DRAMAMINE 25 MG dual action complete 10-800-165 mg DURAFLU 60-20-200-500 MG ecee plus ECOTRIN 500 MG ed bron gp 5-100 mg/5ml ED CHLORPED D 2-5 MG/ML ed chlorped jr 2 mg/5ml ED CHLORPED 2 MG/ML 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 123
ed-a-hist dm 10-4-15 mg/5ml ed-apap 160 mg/5ml ELDERTONIC enema 7-19 gm/118ml enema mineral oil ENEMEEZ MINI 283 MG ENEMEEZ PLUS 20-283 MG entre-cough 30-15-175 mg/5ml entre-hist pse 0.938-10 mg/ml ENUCLENE 0.25 % e-oil 100 unt/0.25ml epsom salt eq 12.5 mg eql 1 % eql calcium/vitamin d 600-100 mg- eql childrens calcium gummies 100-50-100 mg-mg- eql eql iron 200 (65 fe) mg eql lice solution 0.5-0.33-4 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 124
eql oyster shell calcium/d 500-200 mg- EQUALACTIN 625 MG exefen-ir 60-400 mg EX-LAX ULTRA 5 MG eye drops 0.05-0.25 % eye drops 0.05 % eye wash EZFE 200 434.8 (200 FE) MG ezfe forte 155-1 mg FEBROL 325 MG/5ML fer-iron 75 (15 fe) mg/ml ferretts ips 40 mg/15ml ferretts 325 (106 fe) mg FERRIMIN 150 150 MG ferrous fumarate 29 mg, 90 mg ferrous gluconate 225 (27 fe) mg, 240 (27 fe) mg, 324 (38 fe) mg ferrous sulfate er * 140 (45 fe) mg ferrous sulfate 220 (44 fe) mg/5ml 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 125
ferrous sulfate 220 (44 fe) mg/5ml ferrous sulfate 300 (60 fe) mg/5ml ferrous sulfate 324 (65 fe) mg, 325 (65 fe) mg FEVERALL 80 MG fexofenadine hcl childrens 30 mg/5ml fexofenadine hcl 180 mg fiber fiber fiber laxative 625 mg fiber FLEET BISACODYL 10 MG/30ML FLORANEX FLORASTOR KIDS 250 MG FOLGARD folic acid 5 mg/ml folic acid 20 mg folic acid 1 mg, 400 mcg, 800 mcg FOLITAB 500 * 525-500-0.8 MG FOLTABS 800 800-10-115 MCG-MG-MCG 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 126
FRESHKOTE 2.7-2 % FUNGICURE INTENSIVE/NAILGUARD 1 % FUNGOID TINCTURE 2 % FUNGOID TINCTURE 2 % GAVISCON EXTRA RELIEF FORMULA 508-475 MG/10ML GAVISCON 80-14.2 MG gentian violet 1 %, 2 % gentle laxative 10 mg geravim gnp antacid & anti-gas 1000-60 mg gnp artificial tears 5-6 mg/ml gnp calcium 1200 1200-1000 mg- gnp childrens chewables/ex c gnp childrens 2.5-1-5-160 mg/5ml gnp 5-2-10-325 mg gnp 5-2-10-325 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 127
gnp foaming antacid 80-20 mg gnp iron * 142 (45 fe) mg gnp 5-6.25-10-325 mg/15ml gnp 60 mg/15ml GONIOTAIRE 2.5 % goodsense all day allergy 10 mg goodsense pain relief pm 500-25 mg guaifenesin dm 400-20 mg guaifenesin-codeine 100-10 mg/5ml GUMMI BEAR MULTIVITAMIN/MIN headache pm 25-500 mg hm 12.5 mg/5ml hm famotidine 20 mg hm rapid melts junior 160 mg HONEY BEARS HONEY BEARS W/IRON-ZINC 30-200-3 HYDROCIL 95 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 128
hydrocortisone 0.5 % hydrocortisone 0.5 % hydrocortisone-aloe 0.5 %, 1 % hydroxocobalamin * 1000 mcg/ml HYPOTEARS 1-1 % ibuprofen junior strength 100 mg ibuprofen 200 mg ibuprofen pm 200-38 mg ICAPS LUTEIN-ZEAXANTHIN * ICAPS MV ICAPS infants ibuprofen 50 mg/1.25ml infants pain relief 80 mg/0.8ml INTEGRA 62.5-62.5-40-3 MG intense 25-10-650 mg intense 20-300 mg/5ml IROMIN-G iron (ferrous gluconate) 256 (28 fe) mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 129
iron 100 plus 100-250-0.025-1 mg iron 100/c 100-250 mg iron chews pediatric 15 mg iron 90 (18 fe) mg IRON UP 15 MG/0.5ML ISOPTO TEARS 0.5 % J-MAX 5-200 MG/5ML J-TAN D PD 1-7.5 MG/ML J-TAN PD 1 MG/ML k 100 100 mcg KAOPECTATE 262 MG/15ML kidkare 15-1-5 mg/5ml kls acid reducer 150 mg KONSYL 520 MG KONSYL 100 %, 28.3 % KONSYL 28.3 %, 30.9 %, 60.3 %, 71.67 % KONSYL-D 52.3 % kp b complex-c kp benzoyl peroxide 10 %, 5 % kp calcium 600+d 600-500 mg- 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 130
kp calcium 600+d 600-400 mg- kp calcium-magnesium-zinc 333-133-5 mg kp ferrous gluconate 324 (37.5 fe) mg kp ferrous sulfate 325 (65 fe) mg kp hydrocortisone 1 % kp ketotifen fumarate 0.025 % kp pseudoephedrine hcl 60 mg kp terbinafine hydrochloride 1 % kp vitamin d 1000 kp vitamin e 100 kpn prenatal 0.1 mg LAMISIL ADVANCED 1 % LAMISIL AF DEFENSE 1 % laxative pills 25 mg lice killing 0.33-4 % lice killing 0.33-4 % lice treatment 1 % liquid calcium with d3 600-1000 mg- liquid calcium/vitamin d 600-200 mg- 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 131
liquituss gg 200 mg/5ml localnesium 166.67-83.33 mg localnesium-c 400-116.7-166.7 mg LODRANE D 4-60 MG LOHIST-D 2-30 MG/5ML lohist-dm 5-2-10 mg/5ml lohist-peb 4-10 mg/5ml loperamide hcl 1 mg/7.5ml loratadine 10 mg loratadine-pseudoephedrine er 24 * 10-240 mg LOTRIMIN ULTRA 1 % lubricating plus 0.5 % LUMITENE 30 MG MAALOX 400 MG MAALOX 200-200-20 MG/5ML mag-al 200-200 mg/5ml mag-delay * 535 (64 mg) mg MAGINEX 615 MG 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 132
MAGNEBIND 300 250-300 MG magnesium citrate 1.745 gm/30ml magnesium citrate 100 mg magnesium 300 mg, 400 mg magnesium 200 mg, 30 mg magnesium oxide 400 mg magnesium oxide 250 mg, 400 (240 mg) mg, 400 mg, 420 mg, 500 mg MAG-TAB SR * 84 MG (7MEQ) MAPAP COLD FORMULA MULTI-SYMPT 10-5-325 MG m-end dmx 20-0.667-10 mg/5ml MEPHYTON 5 MG MERIBIN 5 MG METAMUCIL MULTIHEALTH FIBER 63 % METAMUCIL METAMUCIL 28 % MEXSANA 10.8 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 133
MI-ACID 700-300 MG miconazole 1 1200-2 mg-% miconazole 3 combo pack 200-2 mg-% (9gm) miconazole 3 4 % miconazole 3 miconazole 7 2 % miconazole 7 100 mg milk of magnesia concentrate 2400 mg/10ml milk of magnesia 1200 mg/15ml mineral oil MINTOX PLUS 200-200-25 MG MISSION PRENATAL HP MISSION PRENATAL motion 25 mg MOTRIN IB 200 MG mucaphed 10-400 mg MUCINEX 5-100 MG MUCINEX D 12 * 120-1200 MG, 60-600 MG MUCINEX FAST-MAX 5-325-200 MG 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 134
MUCINEX 100 MG MUCINEX 12 * 1200 MG mucus 10-650-400 mg/20ml mucus 5-100 mg/5ml mucus relief er 12 * 600 mg mucus relief 400 mg mucus-dm max 12 * 60-1200 mg mucus-dm 12 * 30-600 mg multi-delyn multi-delyn/iron multi-symptom 5-10-200 mg/10ml MURO 128 2 % my way 1.5 mg MYKIDZ IRON 10 15 MG/1.5ML MYKIDZ IRON 10 MG/2ML naproxen sodium 220 mg nasal decongestant 30 mg/5ml 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 135
nasal decongestant 30 mg/5ml nasal decongestant pe 10 mg 0.05 % NASCOBAL 500 MCG/0.1ML NASOPEN PE 50-10 MG/15ML natural fiber laxative 68 % natural fiber therapy 48.57 % natures tears 0.4 % neotuss 30-200 mg/5ml NEPHRONEX NEXAFED 30 MG NEXAFED SINUS PRESSURE + PAIN 30-325 MG niacin er * 250 mg, 500 mg niacin er * 1000 mg, 500 mg, 750 mg niacin 100 mg, 50 mg, 500 mg niacinamide 100 mg, 500 mg nicotine polacrilex 2 mg, 4 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 136
nicotine polacrilex 2 mg, 4 mg nicotine 21-14-7 mg 24 nicotine 24 14 mg 24 21 mg 24 7 mg 24 night-time sinus 6.25-5-325 mg nohist-lq 4-10 mg/5ml NOREL AD 4-10-325 MG NOVAFERRUM 125 125-100 MG-UNT/5ML NOVAFERRUM 15 MG/ML NU-IRON 150 MG NUTRISOURCE FIBER NUTRISOURCE FIBER omeprazole 20 mg organ-i nr 200 mg OS-CAL EXTRA D3 500-600 MG- OSTEO-PORETICAL 600-1000 MG- OYSCO 500 500 MG oyster shell calcium 250+d 250-125 mg- oyster shell calcium/d 500-400 mg- pain relief 8 * 650 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 137
160 mg/5ml 500 mg pain reliever 325 mg PANOXYL 10 % PANOXYL 10 % PANOXYL-4 CREAMY 4 % parva-cal 500-200 mg- PEDIACARE 7.5 MG/5ML PEDIA-LAX 50 MG/15ML PEPCID AC 10 MG peptic 262 mg PERDIEM 15 MG permethrin 1 % PERRY PRENATAL 13.5-0.4 MG PHENAGIL 3.5-10 MG phos-nak 280-160-250 mg polyvitamin 35 mg/ml polyvitamin/iron 10 mg/ml prenatal 27-0.8 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 138
PRETZ PRILOSEC OTC 20 MG pro-chlo 5-12.5-12.5 mg/5ml PROFE 391.3 (180 FE) MG PRONUTRIENTS CALCIUM+D3 600-800 MG- pseudoeph-bromphen-dm 30-2-10 mg/5ml psyldex 30 % PURE & GENTLE LUBRICANT 0.3 % pyrethins-piperonyl butoxide 0.2-2 % pyridoxine hcl 100 mg/ml pyrilamine-phenylephrine 5-16 mg/5ml pyrilamine-phenylephrine 25-10 mg qc 3 day 4 % qc natural vegetable 95 % q-pap infants 80 mg/0.8ml Q-TAPP DM 15-1-5 MG/5ML ra anti-itch 1 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 139
ra b-complex/vitamin c cr * ra beta carotene 15 mg ra calamine 6.971-6.971 % ra calcium 600/vit d/minerals 600-200 mg- ra calcium-boron 500-1.5 mg ra central-vite performance ra col-rite 50 mg ra coral calcium 200-100-100 mg- ra high potency iron 27 mg ra hydrocortisone plus 0.5 % ra ibuprofen 100 mg/5ml ra lubricant eye 0.4-0.3 % ra magnesium 500 mg ra 5-2-10-325 mg ra omeprazole-sodium bicarb 20-1100 mg ra ophthalmic 5 % ra oyster shell calcium/d 250-125 mg-, 500-200 mg- ra probiotic complex 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 140
ra severe cold/sinus relief pe 12.5-5-325 mg ra slow release iron * 45 mg, 47.5 mg ra soluble fiber 500 mg ra vitamin c drops 60 mg ra vitamin c/rose hips cr * 1000 mg ranitidine hcl 75 mg REFRESH CELLUVISC 1 % REFRESH OPTIVE ADVANCED 0.5-1-0.5 % REFRESH P.M. REGULOID 48.57 %, 58.6 % REHYDRALYTE RESCON DM 30-2-10 MG/5ML RESCON 2-60 MG RESPAIRE-30 30-150 MG RETAINE MGD 0.5-0.5 % RHINARIS 0.2 % RHINARIS 0.2 % RID ESSENTIAL 0.33-4 % RISA-BID PROBIOTIC 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 141
RISAMINE 0.44-20.625 % robafen cf 5-10-100 mg/5ml robafen 15 mg ROBITUSSIN CF 2.5-5-50 MG/5ML ROBITUSSIN LA 1-7.5 MG/5ML ROBITUSSIN LA 7.5 MG/5ML ROBITUSSIN 10-5-325 MG ROBITUSSIN LINGERING LA 15 MG/5ML ROBITUSSIN 100 MG/5ML ROBITUSSIN MAX 5-10-200 MG/5ML ROBITUSSIN PEAK COLD 6.25-2.5-160 MG/5ML rymed 2-10 mg rynex dm 2.5-1-5 mg/5ml rynex pse 1-15 mg/5ml saline 0.9-2.4 gm/5ml sb fib lax orange 33 % sb lice treatment 0.3-3 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 142
sb natural fiber laxative 49 % SCOOBY-DOO ONE A DAY SCOT-TUSSIN DM 2-15 MG/5ML SCOT-TUSSIN SENIOR 15-200 MG/5ML SECURA EXTRA PROTECTIVE 30.6 % SECURA PROTECTIVE 10 % selenium er * 200 mcg selenium 100 mcg senna laxative 8.6 mg senna 8.6 mg senna 176 mg/5ml, 8.8 mg/5ml SENNA PROMPT 9-500 MG senna s 8.6-50 mg SENSI-CARE PROTECTIVE BARRIER 49-15 % sleep aid 25 mg SLO-NIACIN * 250 MG slow magnesium/calcium 64-106 mg slow release iron * 140 (45 fe) mg, 50 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 143
SLOW-MAG 71.5-119 MG sm adult nasal decongestant 15 mg/5ml sm calcium/vitamin d3 600-800 mg- sm calcium-magnesium-zinc 333-133-8.3 mg SM CORAL CALCIUM 1000 (390 CA) MG sm iron slow release * 160 (50 fe) mg sm lansoprazole 15 mg sm magnesium oxide 250 mg sm motion 50 mg sm redness relief 0.012-0.2 % sm slow release iron * 143 (45 fe) mg sm vitamin b12 tr * 2000 mcg sm vitamin c cr * 500 mg sm vitamin d3 4000 sodium bicarbonate sodium chloride 5 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 144
SOLUBLE FIBER THERAPY SOOTHE 0.6-0.6 % SOOTHE 262 MG sorbulax 100 % stahist ad 25-60 mg/5ml stahist ad 25-60 mg STERILE 0.7 % stomach relief 525 mg/15ml laxative dc 240 mg 100 mg SUMMERS EVE DISP MEDICATED 0.3 % SYSTANE BALANCE 0.6 % SYSTANE SYSTANE 0.3 % TEARS AGAIN 2-0.1 % tg 10peh/380gfn 10-380 mg tg 10peh/380gfn/15dm 10-380-15 mg tgt cough formula dm max adult 10-200 mg/5ml 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 145
tgt 0.027-0.315 % tgt 25-10-650 mg tgt 1-0.3 % tgt pain reliever pm 25-500 mg th calcium-magnesium-zinc 334-134-5 mg th eye drop tears 0.2-0.2-1 % THERA/BETA-CAROTENE THERA-D 4000 4000 THERANATAL CORE NUTRITION 27-1 MG THERATEARS 0.25 % thiamine hcl 100 mg/ml tioconazole-1 6.5 % TITRALAC 420 MG tolnaftate 1 % tolnaftate 1 % tolnaftate 1 % total b/c triacting 2.5-5 mg/5ml 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 146
TRIAMINIC 12.5 MG TRIAMINIC 160 MG/5ML TRIAMINIC 6.25-2.5 MG/5ML tri-buffered aspirin 325 mg triple antibiotic 3.5-400-5000 triple paste af 2 % TRIPLE PASTE 12.8 % TRI-VI-SOL 750-400-35 -MG/ML TRI-VITA 1500-400-35 -MG/ML tri-vitamin 1500-400-35 TUSNEL 30-15-200 MG/5ML TUSNEL 15-5-50 MG/5ML, 7.5-50 MG/ML TUSNEL-DM PEDIATRIC 7.5-2.5-25 MG/ML tussin cf 5-10-100 mg/5ml tussin dm 100-10 mg/5ml tussi-pres b 10-4-20 mg/5ml 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 147
UPCAL D 500-500 MG- UPCAL D 500-500 MG-UNT/5GM VAGISTAT-3 200-2 MG-% (9GM) VICKS DAYQUIL MUCUS CONTROL DM 10-200 MG/15ML VICKS NYQUIL D 60-12.5-30-1000 MG/30ML VICKS VAPORUB 4.73-1.2-2.6 % VISINE-LR 0.025 % VITALETS 40 MG VITAMELTS ENERGY VITAMIN B-12 1500 MCG vitamin a & d 5000-400 vitamin a palmitate 15000 vitamin b-1 100 mg, 50 mg vitamin b-12 1000 mcg/15ml vitamin b-12 250 mcg, 500 mcg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 148
vitamin b-12 sublingual 1000 mcg vitamin b12-folic acid 500-400 mcg vitamin b-2 25 mg, 50 mg vitamin b-6 er * 200 mg vitamin b-6 100 mg, 25 mg, 50 mg vitamin c (calcium ascorbate) vitamin c 500 mg/5ml vitamin c 100 mg, 250 mg, 500 mg vitamin c 100 mg, 250 mg vitamin d (ergocalciferol) 50000 vitamin d 1000, 2000 vitamin d2 2000, 400 vitamin d3 2000, 400, 5000 vitamin d3 1200 15ml, 400 ml, 5000 ml vitamin d3 3000, 400 vitamin e 1000, 200 vitamin e 15 0.3ml 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 149
vitamin e 100 vitamin e-selenium 400-50 -mcg vitamin k (phytonadione) 100 mcg vitamin k1 1 mg/0.5ml, 10 mg/ml vitatrum WAL-ACT 2.5-60 MG WAL-DRYL 25-5-325 MG WAL-DRYL-D 25-10 MG WAL-FEX D 12 * 60-120 MG WAL-FLU 10-650 MG WAL-ITIN D 12 * 5-120 MG WAL-ITIN 5 MG/5ML WAL-PHED PE 4-10 MG WAL-PHED 4-60 MG wal-som 50 mg wee care 15 mg/1.25ml 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 150
zinc oxide 20 %, 40 % zinc oxide 25 % ZONATUSS 150 MG zoo friends complete 30 mg klor-con 10 * 10 meq klor-con m15 * 15 meq klor-con m20 * 20 meq klor-con 20 meq klor-con * 8 meq MAGNESIUM SULFATE D5W * 10-5 MG/ML-%, 20-5 MG/ML-% MAGNESIUM SULFATE 40 MG/ML, 80 MG/ML magnesium sulfate 50 % potassium chloride crys er * 10 meq, 20 meq potassium chloride er * 10 meq, 8 meq potassium chloride er * 10 meq, 20 meq 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 151
potassium chloride er * 8 meq potassium chloride 20 meq/15ml (10%), 40 meq/15ml (20%) sodium chloride 2.5 meq/ml sodium fluoride 2.2 (1 f) mg TPN ELECTROLYTES * B/D AMINOSYN II * 10 %, 7 %, 8.5 % B/D AMINOSYN II/ELECTROLYTES * 8.5 % B/D AMINOSYN * 10 %, 8.5 % B/D AMINOSYN M * 3.5 % B/D AMINOSYN/ELECTROLYTES * 7 %, 8.5% B/D AMINOSYN-HBC * 7 % B/D AMINOSYN-PF * 10 %, 7 % B/D AMINOSYN-RF * 5.2 % B/D CLINIMIX/DEXTROSE (2.75/5) * 2.75 % B/D 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 152
CLINIMIX/DEXTROSE (4.25/10) * 4.25 % B/D CLINIMIX/DEXTROSE (4.25/20) * 4.25 % B/D CLINIMIX/DEXTROSE (4.25/25) * 4.25 % B/D CLINIMIX/DEXTROSE (4.25/5) * 4.25 % B/D CLINIMIX/DEXTROSE (5/15) * 5 % B/D CLINIMIX/DEXTROSE (5/20) * 5 % B/D CLINIMIX/DEXTROSE (5/25) * 5 % B/D FREAMINE HBC * 6.9 % B/D FREAMINE III * 10 % B/D HEPATAMINE * 8 % B/D INTRALIPID * 20 %, 30 % B/D NEPHRAMINE * 5.4 % B/D NUTRILIPID * 20 % B/D premasol * 10 % B/D premasol * 6 % B/D PROCALAMINE * 3 % B/D 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 153
PROSOL * 20 % B/D TRAVASOL * 10 % B/D TROPHAMINE * 10 % B/D DEXTROSE 5%/ELECTROLYTE #48 * dextrose lactated ringers * 5 % dextrose * 10 %, 5 %, 50 %, 70 % DEXTROSE-NACL * 10-0.2 % dextrose-nacl * 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 D5W * IONOSOL-MB D5W * ISOLYTE-P D5W * ISOLYTE-S * 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 154
kcl dextmse-nacl * 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 DEXTROSE-NACL * 20-5-0.225 MEQ/L-%-% lactated ringers * normosol-m d5w * NORMOSOL-R D5W * NORMOSOL-R PH 7.4 * PLASMA-LYTE 148 * PLASMA-LYTE A * PLASMA-LYTE-56 D5W * potassium chloride dextrose * 20-5 meq/l-%, 40-5 meq/l-% potassium chloride nacl * 20-0.45 meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l-% 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 155
potassium chloride * 0.4 meq/ml, 10 meq/100ml, 10 meq/50ml, 20 meq/100ml, 40 meq/100ml potassium chloride * 2 meq/ml ringers * sodium chloride * 0.45 %, 0.9 %, 3 %, 5 % calcitriol * 1 mcg/ml B/D calcitriol 0.25 mcg, 0.5 mcg B/D calcitriol 1 mcg/ml B/D paricalcitol 1 mcg, 2 mcg, 4 mcg B/D prenatal 27-1 mg azelastine hcl 0.05 % BEPREVE 1.5 % cromolyn sodium 4 % LASTACAFT 0.25 % PATADAY 0.2% PAZEO 0.7% 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 156
ALPHAGAN P 0.1 % AZOPT 1% betaxolol hcl 0.5 % BETOPTIC-S 0.25 % brimonidine tartrate 0.15 % brimonidine tartrate 0.2 % carteolol hcl 1 % COMBIGAN 0.2-0.5 % dorzolamide hcl 2 % dorzolamide hcl-timolol mal 22.3-6.8 mg/ml ISTALOL 0.5 % latanoprost 0.005 % levobunolol hcl 0.25 % levobunolol hcl 0.5 % LUMIGAN 0.01 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 157
metipranolol 0.3% PHOSPHOLINE IODIDE 0.125 % pilocarpine hcl 1 %, 2 %, 4 % SIMBRINZA 1-0.2 % timolol maleate 0.25 %, 0.5 % timolol maleate 0.25 %, 0.5 % TRAVATAN Z 0.004 % bacitra-neomycin-polymyxin-hc 1 % blephamide s.o.p. 10-0.2 % neomycin-polymyxin-dexameth 3.5-10000-0.1 neomycin-polymyxin-dexameth 3.5-10000-0.1 neomycin-polymyxin-hc 3.5-10000-1 sulfacetamide-prednisolone 10-0.23 % TOBRADEX 0.3-0.1 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 158
TOBRADEX ST 0.3-0.05 % tobramycin-dexamethasone 0.3-0.1 % ZYLET 0.5-0.3 % bacitracin 500 gm bacitracin-polymyxin b 500-10000 gm BESIVANCE 0.6 % CILOXAN 0.3 % ciprofloxacin hcl 0.3 % erythromycin 5 mg/gm gatifloxacin 0.5 % gentak 0.3 % gentamicin sulfate 0.3 % gentamicin sulfate 0.3 % ilotycin 5 mg/gm MOXEZA 0.5 % NATACYN 5 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 159
neomycin-bacitracin zn-polymyx 5-400-10000 neomycin-polymyxin-gramicidin 1.75-10000-0.25 ofloxacin 0.3 % polymyxin b-trimethoprim 10000-0.1 ml-% sulfacetamide sodium 10 % sulfacetamide sodium 10 % tobramycin 0.3 % TOBREX 0.3 % trifluridine 1 % VIGAMOX 0.5 % ZIRGAN OPHTHALMIC 0.15 % ALREX 0.2 % bromfenac sodium 0.09 % bromfenac sodium 0.09 % dexamethasone sodium phosphate 0.1 % diclofenac sodium 0.1 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 160
DUREZOL 0.05 % fluorometholone 0.1 % flurbiprofen sodium 0.03 % ILEVRO 0.3 % ketorolac tromethamine 0.4 %, 0.5 % LOTEMAX 0.5 % LOTEMAX 0.5 % LOTEMAX 0.5 % MAXIDEX 0.1 % prednisolone acetate 1 % prednisolone sodium phosphate 1 % naphazoline hcl 0.1 % PROLENSA 0.07 % proparacaine hcl 0.5 % RESTASIS 0.05 % QL 30 64 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 161
ANORO ELLIPTA 62.5-25 MCG/INH QL 30 60 COMBIVENT RESPIMAT 20-100 MCG/ACT QL 30 8 GM ipratropium-albuterol 0.5-2.5 (3) mg/3ml B/D ANTICHOLINERGICS ATROVENT HFA 17 MCG/ACT QL 30 25.8 GM INCRUSE ELLIPTA 62.5 MCG/INH QL 30 30 ipratropium bromide 0.02 % B/D ipratropium bromide 0.03 %, 0.06 % ASTEPRO 0.15 % azelastine hcl 0.1 %, 0.15 % cetirizine hcl 1 mg/ml diphenhydramine hcl 50 mg/ml hydroxyzine hcl * 25 mg/ml, 50 mg/ml PA hydroxyzine hcl 10 mg/5ml PA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 162
hydroxyzine hcl 10 mg, 25 mg, 50 mg PA hydroxyzine pamoate 100 mg, 25 mg, 50 mg PA levocetirizine dihydrochloride 2.5 mg/5ml levocetirizine dihydrochloride 5 mg olopatadine hcl 0.6 % - albuterol sulfate er 12 * 4 mg, 8 mg albuterol sulfate (2.5 mg/3ml) 0.083%, (5 mg/ml) B/D 0.5%, 0.63 mg/3ml, 1.25 mg/3ml albuterol sulfate 2 mg/5ml albuterol sulfate 2 mg, 4 mg levalbuterol hcl 1.25 mg/0.5ml B/D PERFOROMIST 20 MCG/2ML B/D SEREVENT DISKUS 50 MCG/DOSE QL 30 60 terbutaline sulfate 1 mg/ml terbutaline sulfate 2.5 mg, 5 mg 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 163
VENTOLIN HFA 108 (90 BASE) MCG/ACT QL 30 36 GM XOPENEX HFA 45 MCG/ACT QL 30 30 GM montelukast sodium 4 mg montelukast sodium 10 mg montelukast sodium 4 mg, 5 mg zafirlukast 10 mg, 20 mg cromolyn sodium 20 mg/2ml B/D acetylcysteine 10 %, 20 % B/D ARALAST NP * 1000 MG, 400 MG, 500 MG, PA; LA 800 MG AUVI-Q 0.15 MG/0.15ML, 0.3 MG/0.3ML DALIRESP 500 MCG EPIPEN 2-PAK 0.3 MG/0.3ML EPIPEN JR 2-PAK 0.15 MG/0.3ML ESBRIET 267 MG PA 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 164
KALYDECO 50 MG, 75 MG PA KALYDECO 150 MG PA OFEV 100 MG, 150 MG PA PROLASTIN-C * 1000 MG PA; LA PULMOZYME 1 MG/ML B/D XOLAIR * 150 MG PA; LA ZEMAIRA * 1000 MG PA; LA flunisolide 25 mcg/act (0.025%) fluticasone propionate 50 mcg/act ARNUITY ELLIPTA 100 MCG/ACT, 200 MCG/ACT budesonide 0.25 mg/2ml, 0.5 mg/2ml FLOVENT DISKUS 100 MCG/BLIST, 50 MCG/BLIST QL 30 50 ML QL 30 16 GM QL 30 30 B/D QL 30 120 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 165
FLOVENT DISKUS 250 MCG/BLIST QL 30 240 FLOVENT HFA 110 MCG/ACT, 220 MCG/ACT QL 30 24 GM FLOVENT HFA 44 MCG/ACT QL 30 21.2 GM PULMICORT FLEXHALER 180 MCG/ACT, QL 30 2 90 MCG/ACT - ADVAIR DISKUS 100-50 MCG/DOSE, 250-50 MCG/DOSE, QL 30 60 500-50 MCG/DOSE ADVAIR HFA 115-21 MCG/ACT, QL 30 12 GM 230-21 MCG/ACT, 45-21 MCG/ACT BREO ELLIPTA 100-25 MCG/INH, QL 30 60 200-25 MCG/INH SYMBICORT 160-4.5 MCG/ACT, 80-4.5 MCG/ACT QL 30 10.2 GM aminophylline * 25 mg/ml elixophyllin 80 mg/15ml 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 166
theo-24 24 100 mg, 200 mg, 300 mg, 400 mg theophylline er 12 * 100 mg, 200 mg, 300 mg, 450 mg theophylline er 24 * 400 mg, 600 mg theophylline 80 mg/15ml adapalene 0.1 % adapalene 0.1 % amnesteem 10 mg, 20 mg, 40 mg avita 0.025 % avita 0.025 % benzoyl peroxide-erythromycin 5-3 % claravis 10 mg, 20 mg, 30 mg, 40 mg clindamax 1 % clindamycin phosphate 1 % clindamycin phosphate 1 % clindamycin phosphate 1 % clindamycin phosphate 1 % ery 2 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 167
erythromycin 2 % erythromycin 2 % myorisan 10 mg, 20 mg, 40 mg sulfacetamide sodium 10 % tretinoin 0.01 %, 0.025 % tretinoin 0.025 %, 0.05 %, 0.1 % zenatane 10 mg, 20 mg, 30 mg, 40 mg gentamicin sulfate 0.1 % gentamicin sulfate 0.1 % mupirocin 2 % silver sulfadiazine 1 % ssd 1 % SULFAMYLON 85 MG/GM SULFAMYLON 5% ciclopirox 0.77 % ciclopirox 1 % ciclopirox olamine 0.77 % ciclopirox olamine 0.77 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 168
clotrimazole 1 % clotrimazole 1 % econazole nitrate 1 % ketoconazole 2 % nyamyc 100000 gm nystatin 100000 gm nystatin 100000 gm nystatin 100000 gm nystop 100000 gm procto-pak 1 % proctosol hc 2.5 % proctozone-hc 2.5 % prudoxin 5 % 8-MOP 10 MG acitretin 10 mg, 17.5 mg, 25 mg PA calcipotriene 0.005 % calcipotriene 0.005 % calcipotriene 0.005 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 169
calcitrene 0.005 % TAZORAC 0.05 %, 0.1 % PA ketoconazole 2 % selenium sulfide 2.5% ala cort 1 % alclometasone dipropionate 0.05 % alclometasone dipropionate 0.05 % apexicon 0.05 % betamethasone dipropionate aug 0.05 % betamethasone dipropionate aug 0.05 % betamethasone dipropionate aug 0.05 % betamethasone dipropionate aug 0.05 % betamethasone dipropionate 0.05 % betamethasone dipropionate 0.05 % betamethasone dipropionate 0.05 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 170
betamethasone valerate 0.1 % betamethasone valerate 0.1 % betamethasone valerate 0.1 % clobetasol propionate e 0.05 % clobetasol propionate 0.05 % clobetasol propionate 0.05 % clobetasol propionate 0.05 % clobetasol propionate 0.05 % cormax scalp application 0.05 % desonide 0.05 % desonide 0.05 % desonide 0.05 % desoximetasone 0.05 % desoximetasone 0.05 %, 0.25 % desoximetasone 0.05 % desoximetasone 0.25 % diflorasone diacetate 0.05 % diflorasone diacetate 0.05 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 171
fluocinolone acetonide body 0.01 % fluocinolone acetonide 0.01 %, 0.025 % fluocinolone acetonide 0.025 % fluocinolone acetonide 0.01 % fluocinolone acetonide 0.01 % fluocinonide 0.05 % fluocinonide 0.05 % fluocinonide 0.05 % fluocinonide 0.05 % fluocinonide-e 0.05 % fluticasone propionate 0.05 % fluticasone propionate 0.005 % halobetasol propionate 0.05 % halobetasol propionate 0.05 % hydrocortisone butyrate 0.1 % hydrocortisone butyrate 0.1 % hydrocortisone butyrate 0.1 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 172
hydrocortisone 1 %, 2.5 % hydrocortisone 2.5 % hydrocortisone 1 %, 2.5 % hydrocortisone valerate 0.2 % hydrocortisone valerate 0.2 % lokara 0.05 % mometasone furoate 0.1 % mometasone furoate 0.1 % mometasone furoate 0.1 % texacort 2.5 % triamcinolone acetonide 0.025 %, 0.1 %, 0.5 % triamcinolone acetonide 0.025 %, 0.1 % triamcinolone acetonide 0.025 %, 0.1 %, 0.5 % triderm 0.1 % lidocaine 5 % lidocaine 5 % PA; QL 1 3 lidocaine hcl 2 % lidocaine hcl 4 % lidocaine-prilocaine 2.5-2.5 % B/D 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 173
acyclovir 5 % ammonium lactate 12 % ammonium lactate 12 % ELIDEL 1 % PA fluorouracil 5 % fluorouracil 2 %, 5 % imiquimod 5 % laclotion 12 % metronidazole 0.75 % metronidazole 0.75 % metronidazole 0.75 % PANRETIN 0.1 % podofilox 0.5 % rosadan 0.75 % tacrolimus 0.03 %, 0.1 % PA TARGRETIN 1 % PA VALCHLOR 0.016 % PA; LA VOLTAREN 1 % EURAX 10 % EURAX 10 % malathion 0.5 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 174
permethrin 5 % acetic acid 0.25 % REGRANEX 0.01 % PA SANTYL 250 GM sodium chloride 0.9 % cevimeline hcl 30 mg chlorhexidine gluconate 0.12 % clotrimazole 10 mg lidocaine viscous 2 % nystatin 100000 ml periogard 0.12 % pilocarpine hcl 5 mg pilocarpine hcl 7.5 mg triamcinolone acetonide 0.1 % acetic acid 2 % acetic acid-aluminum acetate 2 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 175
CIPRODEX 0.3-0.1 % fluocinolone acetonide 0.01 % neomycin-polymyxin-hc 1 % neomycin-polymyxin-hc 3.5-10000-1 ofloxacin 0.3 % 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 176
12...112 8-MOP...169 abacavir sulfate...19 abacavir-lamivudine-zidovudine...22 ABELCET...15 ABILIFY DISCMELT...68 ABILIFY MAINTENA...68 ABRAXANE...35 ABREVA...112 acamprosate calcium...76 acarbose...79 acebutolol hcl...49 ACEPHEN...112 ACEROLA C 500...112 acetaminophen...112 acetaminophen 8...112 acetaminophen junior strength...112 acetaminophen-codeine...13 acetaminophen-codeine #2...13 acetaminophen-codeine #3...13 acetaminophen-codeine #4...13 acetazolamide...53 acetazolamide er...53 acetic acid...175 acetic acid-aluminum acetate...175 acetylcysteine...164 ACID GONE...112 acid reducer...112 acidophilus/l-sporogenes...112 acitretin...169...112 5...112 ACTHIB...109 ACTIMMUNE...107 acyclovir...23, 174 acyclovir sodium...23 ADACEL...109 ADAGEN...88 adapalene...167 adefovir dipivoxil...23 ADEMPAS...55 adriamycin...34 adrucil...34 ADVAIR DISKUS...166 ADVAIR HFA...166 advanced calcium formula...112 ADVIL...112 ADVIL...113 ADVIL LIQUI-GELS...113 ADVIL JUNIOR STRENGTH...113 afeditab cr...50 AFINITOR...38 AFINITOR DISPERZ...38 AFRIN...113 AGGRENOX...105 a-hydrocort...90 ala cort...170 ALA-HIST IR...113 ALA-HIST PE...113 ALBENZA...16 albuterol sulfate...163 albuterol sulfate er...163 alclometasone dipropionate...170 ALDURAZYME...88 alendronate sodium...82 alfuzosin hcl er...100 ALIMTA...34 ALINIA...16 all day allergy-d...113 all day pain relief...113 ALLEGRA...113 aller-ease...113...113 allopurinol...9 alosetron hcl...99 ALPHAGAN P...157 alprazolam...56 ALREX...160 altavera...83 aluminum hydroxide gel...113 amantadine hcl...66 ambi 12.5cpd/1dcpm/30pse...113 ambi 40pse/400gfn/20dm...113 AMBISOME...15 amifostine...41 amikacin sulfate...14 amiloride hcl...53 amiloride-hydrochlorothiazide...53 aminophylline...166 AMINOSYN...152 AMINOSYN II...152 AMINOSYN II/ELECTROLYTES...152 AMINOSYN M...152 AMINOSYN/ELECTROLYTES...152 AMINOSYN-HBC...152 AMINOSYN-PF...152 AMINOSYN-RF...152 amiodarone hcl...45, 46 AMITIZA...99 amitriptyline hcl...63 amlodipine besy-benazepril hcl...42 amlodipine besylate...50 amlodipine besylate-valsartan...44 amlodipine-valsartan-hctz...44 ammonium lactate...174 amnesteem...167 amoxapine...63 amoxicillin...29, 30 amoxicillin-pot clavulanate...30 amoxicillin-pot clavulanate er...30 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 177
amphetamine-dextroamphet er...72 amphetamine-dextroamphetami ne...73 amphotericin b...15 ampicillin...30 ampicillin sodium...30 ampicillin-sulbactam sodium...31 AMPYRA...75 anagrelide hcl...104 anastrozole...37 ANDRODERM...77 ANORO ELLIPTA...162 antacid...113 anti-diarrheal...113 antifungal...113 antioxidant formula sg...113 apap 500...114 apexicon...170 ap-hist dm...114 APOKYN...66 apri...83 APRISO...97 APTIOM...56 APTIVUS...19 AQUADEKS...114 AQUA-E...114 AQUANIL HC...114 ARALAST NP...164 aranelle...83 ARCALYST...107 aripiprazole...68 ARNUITY ELLIPTA...165 artificial tears...114 ASACOL HD...97 ascorbic acid...114 aspirin...114 aspirin ec...114 ASSURE ID...78 ASTEPRO...162 atenolol...49 atenolol-chlorthalidone...48 athletes...114 atorvastatin calcium...47 atovaquone...16 atovaquone-proguanil hcl...19 ATRIPLA...22 ATROVENT HFA...162 aubra...83 AUVI-Q...164 AVASTIN...36 aviane...83 avita...167 AVODART...100 AXID AR...114 AXIRON...77 AYR SALINE...114 AYR SALINE...114 azacitidine...34 AZACTAM DEXTROSE...16 azathioprine...108 azelastine hcl...156, 162 AZILECT...66 azithromycin...28 AZOPT...157 AZOR...44 aztreonam...16 b complex...114 b-12...114 B-12 DOTS...114 bacitracin...114, 159 bacitracin zinc...115 bacitracin-polymyxin b...159 bacitra-neomycin-polymyxin-hc...158 baclofen...76 balsalazide disodium...97 balziva...83 BANZEL...57 BARACLUDE...24 BCG VACCINE...109 b-complex/vitamin c...115 bee zee...115 BELEODAQ...36 benazepril hcl...43 benazepril-hydrochlorothiazide...42 BENICAR...45 BENICAR HCT...45 BENLYSTA...108 benzonatate...115 benzoyl peroxide...115 benzoyl peroxide...115 benzoyl peroxide...115 benzoyl peroxide-erythromycin...167 benztropine mesylate...67 BEPREVE...156 BESIVANCE...159 beta carotene...115 betamethasone dipropionate...170 betamethasone dipropionate aug...170 betamethasone valerate...171 BETASERON...75 betaxolol hcl...157 bethanechol chloride...101 BETOPTIC-S...157 BEXSERO...109 bicalutamide...37 BICILLIN L-A...31 BICNU...32 BILTRICIDE...16 biospec dmx...115 biotin...115 bisoprolol fumarate...49 bisoprolol-hydrochlorothiazide...48 BIVIGAM...106 bleomycin sulfate...34 blephamide s.o.p...158 B-NATAL...115 BONE DENSITY...115 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 178
bone meal...115 BOOSTRIX...109 BOSULIF...38 BOUDREAUXS BUTT PASTE...115 BREO ELLIPTA...166 briellyn...83 BRILINTA...105 brimonidine tartrate...157 BRINTELLIX...63 brohist d...115 bromfenac sodium...160 bromfenac sodium...160 bromocriptine mesylate...67 budesonide...165 budesonide er...97 bumetanide...53 buprenorphine hcl...76 buprenorphine hcl-naloxone hcl...76 buproban...76 bupropion hcl...63 bupropion hcl er (sr)...63 bupropion hcl er (xl)...63 buspirone hcl...56 BUSULFEX...33 butorphanol tartrate...13 BYDUREON...78 BYETTA 10 MCG...78 BYETTA 5 MCG...78 BYSTOLIC...49 c-500...115 cabergoline...92 cal/mag...115 CALCET CREAMY BITES...115 CALCET PETITES...116 CALCI-MIX...116 calcionate...116 calcipotriene...169 calcitonin (salmon)...92 cal-citrate plus vitamin d...116 calcitrene...170 calcitriol...156 calcium...117 calcium + d...116 calcium + d3...116 calcium 1000 + d...116 calcium 500...116 calcium 500/d...116 calcium 500+d high potency...116 calcium 600...116 calcium 600/vitamin d...116 calcium 600+d plus minerals...116 calcium acetate...93 calcium antacid...116 calcium antacid...116 calcium antacid...116 calcium ascorbate...117 calcium carbonate...117 calcium carbonate-vitamin d...117 calcium citrate...117 calcium citrate + d...117 calcium citrate malate-vit d...117 calcium citrate-vitamin d...117 calcium for women...117 calcium gluconate...117 calcium gummies...117 calcium lactate...117 calcium pantothenate...117 calcium soft chews...118 calcium/c/d...118 calcium+d3 gradual release...118 calcium-magnesium...118 calcium-magnesium-vitamin d...118 calcium-magnesium-zinc...118 calcium-vitamin d3...118 calmag thins...118 CAL-QUICK...118 CALTRATE 600+D SOFT...118 camila...83 CANASA...97 CANCIDAS...15 CAPASTAT SULFATE...22 CAPRELSA...39 captopril...43 captopril-hydrochlorothiazide...42 CARBAGLU...88 carbamazepine...57 carbamazepine er...57 carbidopa-levodopa...67 carbidopa-levodopa er...67 carbidopa-levodopa-entacapone...67 carboplatin...41 CARIMUNE NF...106 carteolol hcl...157 cartia xt...50 carvedilol...49 castellani paint modified...118 CAYSTON...16 cefaclor...25 cefaclor er...25 cefadroxil...26 cefazolin sodium...26 cefdinir...26 cefepime hcl...26 cefixime...26 cefotaxime sodium...26 cefoxitin sodium...26 cefpodoxime proxetil...26 cefprozil...27 ceftazidime...27 CEFTAZIDIME AND DEXTROSE...27 ceftriaxone sodium...27 cefuroxime axetil...27 cefuroxime sodium...27 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 179
celecoxib...9 CELONTIN...57 CENTRUM KIDS COMPLETE...118 CENTRUM SILVER...118 cephalexin...27 CERDELGA...88 CEREZYME...88 CEROVITE...118 CERVARIX...109 cetirizine hcl...118, 162 cevimeline hcl...175 CHANTIX...76 CHANTIX...76 CHANTIX...77 chelated calcium...119 CHEMET...82 chewable calcium...119 chewable vite...119 chewable vite/iron...119 childrens acetaminophen...119 childrens...119 childrens...119 childrens non-aspirin...119 childrens plus...119 childrens plus...119 chlo tuss ex...119 chlorhexidine gluconate...175 chloroquine phosphate...19 chlorothiazide...53 chlorpheniramine maleate er...119 chlorpromazine hcl...68 chlorthalidone...53 cholestyramine...47 cholestyramine light...47 ciclopirox...168 ciclopirox olamine...168 cilostazol...104 CILOXAN...159 CIMZIA...105 CIMZIA PREFILLED...105 CIMZIA STARTER KIT...105 CINRYZE...104 CIPRODEX...176 ciprofloxacin...29 ciprofloxacin hcl...29, 159 ciprofloxacin d5w...29 ciprofloxacin-ciproflox hcl er...29 cisplatin...41 citalopram hydrobromide...63 CITRACAL CALCIUM GUMMIES...119 CITRACAL PLUS HEART HEALTH...119 citrus calcium +d...119 citrus calcium/vitamin d...120 cladribine...34 claravis...167 clarithromycin...28 clarithromycin er...28 CLARITIN...120 CLARITIN REDITABS...120 classic prenatal...120 clindamax...167 clindamycin hcl...17 clindamycin palmitate hcl...17 clindamycin phosphate...17, 102, 167 clindamycin phosphate d5w...17 CLINIMIX/DEXTROSE (2.75/5)...152 CLINIMIX/DEXTROSE (4.25/10)...153 CLINIMIX/DEXTROSE (4.25/20)...153 CLINIMIX/DEXTROSE (4.25/25)...153 CLINIMIX/DEXTROSE (4.25/5)...153 CLINIMIX/DEXTROSE (5/15)...153 CLINIMIX/DEXTROSE (5/20)...153 CLINIMIX/DEXTROSE (5/25)...153 clobetasol propionate...171 clobetasol propionate e...171 clomipramine hcl...63 clonazepam...57 clonidine hcl...54 clopidogrel bisulfate...105 clorazepate dipotassium...57, 58 clotrimazole...120, 169, 175 clotrimazole 3...120 clozapine...68 CLOZAPINE...68 COARTEM...19 cod liver oil...120 codituss dm...120 colchicine-probenecid...9 COLCRYS...9 cold head congestion severe...120...120...120 colestipol hcl...47 colistimethate sodium...17 colocort...97 COMBIGAN...157 COMBIVENT RESPIMAT...162 COMETRIQ 100 MG...39 COMETRIQ 140 MG...39 COMETRIQ 60 MG...39 COMPLERA...22 complete...120 compro...94 COMTREX...120 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 180
COMVAX...109 CONEX...120 constulose...97 CONTAC...120 COPAXONE...75 coral calcium...121 coral calcium plus...121 CORICIDIN HBP...121 cormax scalp application...171 cortisone acetate...90 CORTIZONE-10...121...121...121 cough dm...121 COUMADIN...102 CREON...100 CRESTOR...47 CRIXIVAN...19 cromolyn sodium...99, 121, 156, 164 cryselle-28...83 CUBICIN...17 CUVPOSA...96 cvs calcium citrate...121 cvs easy fiber/calcium...121 cvs hydrocortisone acetate...121 cvs...121 cvs...121 cvs...121 cvs...121 cvs...121 cvs probiotic (lactobacillus)...122 cvs senna-extra...122 cvs...122 cvs vitamin b-6...122 cvs vitamin c...122 cyanocobalamin...122 cyclafem 1/35...83 cyclafem 7/7/7...83 cyclophosphamide...33 CYCLOPHOSPHAMIDE...33 cycloserine...22 cyclosporine...108 cyclosporine modified...108 CYSTADANE...88 CYSTAGON...88 cytarabine...35 CYTO B2...122 d 1000...122 d 10000...122 d 400...122 D3-50...122 d-5000...122 dacarbazine...33 daily-vite/iron/beta-carotene...122 DALIRESP...164 danazol...88 dantrolene sodium...76 dapsone...17 DAPTACEL...110 DARAPRIM...17 daunorubicin hcl...34 day-time sinus...122 deblitane...83 DELESTROGEN...89 DELTUSS DP...122 delyla...83 DELZICOL...97 DEMSER...54 DEPEN TITRATABS...82 DEPO-PROVERA...37 DESENEX...122 DESENEX...122 desipramine hcl...64 DESITIN...122 desmopressin ace...94 desmopressin ace...94 desmopressin acetate...94 desmopressin acetate spray...94 desogestrel-ethinyl estradiol...83 desonide...171 desoximetasone...171 dexamethasone...90 dexamethasone intensol...90 dexamethasone sod phosphate pf...90 dexamethasone sodium phosphate...90, 160 DEXILANT...100 dexrazoxane...41 dextrose...154 DEXTROSE 5%/ELECTROLYTE #48...154 dextrose lactated ringers...154 DEXTROSE-NACL...154 dextrose-nacl...154 DIALYVITE 800...122 DIALYVITE 800-ZINC 15...122 DIALYVITE VITAMIN D3 MAX...123 diazepam...58 diazepam intensol...58 diclofenac potassium...9 diclofenac sodium...9, 160 diclofenac sodium er...9 dicloxacillin sodium...31 dicyclomine hcl...96 didanosine...19 DIFICID...28 diflorasone diacetate...171 diflunisal...9 digitek...52 digoxin...52 dihydroergotamine mesylate...74 dilantin...58 DILANTIN...58 dilantin infatabs...58 diltiazem hcl...51 diltiazem hcl er...50 diltiazem hcl er...50 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 181
diltiazem hcl er...50 dilt-xr...51 diltzac...51 DIMETAPP...123 DIMETAPP...123 DIPENTUM...97 diphenhydramine hcl...123, 162 diphenoxylate-atropine...99 DIPHTHERIA-TETANUS TOXOIDS DT...110 disopyramide phosphate...46 disulfiram...77 divalproex sodium...58 divalproex sodium er...58 docetaxel...36 DOCETAXEL...36 docusate sodium...123 DOK...123 donepezil hcl...62 dorzolamide hcl...157 dorzolamide hcl-timolol mal...157 double antibiotic...123 doxazosin mesylate...44 doxepin hcl...64 doxorubicin hcl...34 doxorubicin hcl liposomal...34 doxy 100...32 doxycycline hyclate...32 doxycycline monohydrate...32 DRAMAMINE...123 dronabinol...95 drospirenone-ethinyl estradiol...83 DROXIA...40 dual action complete...123 duloxetine hcl...64 DURAFLU...123 duramorph...10 DUREZOL...161 e.e.s. 400...28 ecee plus...123 econazole nitrate...169 ECOTRIN MAXIMUM STRENGTH...123 ed bron gp...123 ED CHLORPED...123 ED CHLORPED D...123 ed chlorped jr...123 ed-a-hist dm...124 ed-apap...124 EDURANT...19 EFFIENT...105 ELDERTONIC...124 ELIDEL...174 ELIQUIS...102 ELITEK...41 elixophyllin...166 ELMIRON...101 EMCYT...33 EMEND...95 emoquette...84 EMSAM...64 EMTRIVA...20 enalapril maleate...43 enalapril-hydrochlorothiazide...42 endocet...11 enema...124 enema mineral oil...124 ENEMEEZ MINI...124 ENEMEEZ PLUS...124 ENGERIX-B...110 enoxaparin sodium...102 enpresse-28...84 entacapone...67 entecavir...24 entre-cough...124 entre-hist pse...124 ENUCLENE...124 enulose...97 e-oil...124 EPIPEN 2-PAK...164 EPIPEN JR 2-PAK...164 epirubicin hcl...34 epitol...58 EPIVIR HBV...24 eplerenone...44 epsom salt...124 EPZICOM...22 eq...124 eql...124 eql calcium/vitamin d...124 eql childrens calcium gummies...124 eql...124 eql iron...124 eql lice solution...124 eql oyster shell calcium/d...125 EQUALACTIN...125 ERIVEDGE...36 errin...84 ery...167 ery-tab...28 erythrocin lactobionate...28 erythrocin stearate...28 erythromycin...159, 168 erythromycin base...29 erythromycin ethylsuccinate...29 ESBRIET...164 escitalopram oxalate...64 esomeprazole sodium...100 estrace...89 estradiol...89 estradiol valerate...90 ethambutol hcl...23 ethosuximide...58 etodolac...10 etodolac er...9 etoposide...42 EURAX...174 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 182
EVOTAZ...22 EXCEL COMFORT NEEDLE...78 exefen-ir...125 EXELON...62 exemestane...37 EXJADE...83 EX-LAX ULTRA...125 eye drops...125 eye drops...125 eye wash...125 EZFE 200...125 ezfe forte...125 FABRAZYME...88 falmina...84 famciclovir...24 famotidine...96 famotidine premixed...96 FANAPT...68 FANAPT...69 FARESTON...37 FARXIGA...79 FARYDAK...36 FASLODEX...37 FAZACLO...69 FEBROL...125 felbamate...58 felodipine er...51 fenofibrate...47 fenofibrate micronized...47 fenofibric acid...47 fentanyl...11 fentanyl citrate...11 FENTORA...11 fer-iron...125 ferretts...125 ferretts ips...125 FERRIMIN 150...125 FERRIPROX...83 ferrous fumarate...125 ferrous gluconate...125 ferrous sulfate...125, 126 ferrous sulfate er...125 FETZIMA...64 FETZIMA...64 FEVERALL...126 fexofenadine hcl...126 fexofenadine hcl childrens...126 fiber...126 fiber...126 fiber...126 fiber laxative...126 finasteride...101 FIRAZYR...104 FLEBOGAMMA...106 FLEBOGAMMA DIF...106 flecainide acetate...46 FLEET BISACODYL...126 FLORANEX...126 FLORASTOR KIDS...126 FLOVENT DISKUS...165, 166 FLOVENT HFA...166 fluconazole...15 fluconazole dextrose...15 fluconazole sodium chloride...15 flucytosine...15 fludarabine phosphate...35 fludrocortisone acetate...90 flunisolide...165 fluocinolone acetonide...172, 176 fluocinolone acetonide body...172 fluocinolone acetonide...172 fluocinonide...172 fluocinonide-e...172 fluorometholone...161 fluorouracil...35, 174 fluoxetine hcl...64, 65 fluphenazine decanoate...69 fluphenazine hcl...69 flurbiprofen...10 flurbiprofen sodium...161 flutamide...37 fluticasone propionate...165, 172 fluvoxamine maleate...56 FOLGARD...126 folic acid...126 FOLITAB 500...126 FOLTABS 800...126 fondaparinux sodium...102, 103 FORTEO...93 FORTICAL...92 foscarnet sodium...24 fosinopril sodium...43 fosinopril sodium-hctz...42 FREAMINE HBC...153 FREAMINE III...153 FRESHKOTE...127 FUNGICURE INTENSIVE/NAILGUARD...127 FUNGOID TINCTURE...127 furosemide...53 FUSILEV...41 FUZEON...20 FYCOMPA...58, 59 gabapentin...59 GABITRIL...59 galantamine hydrobromide...62 galantamine hydrobromide er...62 GAMASTAN S/D...106 GAMMAGARD...106 GAMMAGARD S/D...106 GAMMAGARD S/D LESS IGA...107 GAMMAKED...107 GAMMAPLEX...107 GAMUNEX-C...107 ganciclovir sodium...24 GARDASIL...110 GARDASIL 9...110 gatifloxacin...159 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 183
GATTEX...99 gavilyte-c...98 gavilyte-g...98 gavilyte-h...98 gavilyte-n...98 GAVISCON...127 GAVISCON EXTRA RELIEF FORMULA...127 GEMCITABINE HCL...35 gemcitabine hcl...35 gemfibrozil...47 generlac...98 gengraf...108 gentak...159 gentamicin saline...14 gentamicin sulfate...14, 159, 168 gentian violet...127 gentle laxative...127 GEODON...69 geravim...127 gianvi...84 gildagia...84 gildess 1.5/30...84 GILENYA...76 GILOTRIF...39 glatopa...76 GLEEVEC...39 glimepiride...79 glipizide...80 glipizide er...80 glipizide-metformin hcl...80 GLOBAL...78 GLUCAGEN HYPOKIT...91 GLUCAGON...91 glycopyrrolate...96 gnp antacid & anti-gas...127 gnp artificial tears...127 gnp calcium 1200...127 gnp childrens chewables/ex c...127 gnp childrens...127 gnp...127 gnp...127 gnp foaming antacid...128 gnp iron...128 gnp...128 gnp...128 GOLYTELY...98 GONIOTAIRE...128 goodsense all day allergy...128 goodsense pain relief pm...128 granisetron hcl...95 GRANIX...104 griseofulvin microsize...15 griseofulvin ultramicrosize...15 guaifenesin dm...128 guaifenesin-codeine...128 guanfacine hcl er...73 GUMMI BEAR MULTIVITAMIN/MIN...128 halobetasol propionate...172 haloperidol...69 haloperidol decanoate...69 haloperidol lactate...69 HARVONI...24 HAVRIX...110 headache pm...128 heather...84 HEPARIN (PORCINE) D5W...103 HEPARIN (PORCINE) NACL...103 HEPARIN SOD (PORCINE) D5W...103 heparin sodium (porcine)...103 HEPARIN SODIUM (PORCINE)...103 HEPATAMINE...153 HERCEPTIN...36 HETLIOZ...74 HEXALEN...33 HIBERIX...110 hm...128 hm famotidine...128 hm rapid melts junior...128 HONEY BEARS...128 HONEY BEARS W/IRON-ZINC...128 HUMIRA...106 HUMIRA...105 HUMIRA PEN-CROHNS...105 HUMIRA PEN-PSORIASIS...105 HUMULIN R U-500...78 hydralazine hcl...54 hydrochlorothiazide...53 HYDROCIL...128 hydrocodone-acetaminophen...11 hydrocodone-ibuprofen...11 hydrocortisone...90, 97, 129, 173 hydrocortisone butyrate...172 hydrocortisone valerate...173 hydrocortisone-aloe...129 hydromorphone hcl...11 hydromorphone hcl pf...11 hydroxocobalamin...129 hydroxychloroquine sulfate...106 hydroxyurea...40 hydroxyzine hcl...162, 163 hydroxyzine pamoate...163 HYPOTEARS...129 ibandronate sodium...82 IBRANCE...36 ibuprofen...10, 129 ibuprofen junior strength...129 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 184
ibuprofen pm...129 ICAPS...129 ICAPS LUTEIN-ZEAXANTHIN...129 ICAPS MV...129 ICLUSIG...39 idarubicin hcl...34 IFEX...33 ifosfamide...33 IFOSFAMIDE...33 ILEVRO...161 ilotycin...159 IMBRUVICA...39 imipenem-cilastatin...17 imipramine hcl...65 imiquimod...174 IMOVAX RABIES...110 INCRELEX...92 INCRUSE ELLIPTA...162 indapamide...54 INFANRIX...110 infants ibuprofen...129 infants pain relief...129 INLYTA...39...78 INTEGRA...129 INTELENCE...20 intense...129 intense...129 INTRALIPID...153 INTRON A...107 introvale...84 INVANZ...17 INVEGA...69 INVEGA SUSTENNA...70 INVIRASE...20 INVOKAMET...80 INVOKANA...80 IONOSOL-B D5W...154 IONOSOL-MB D5W...154 IPOL...110 ipratropium bromide...162 ipratropium-albuterol...162 irbesartan...45 irbesartan-hydrochlorothiazide...45 irinotecan hcl...42 IROMIN-G...129 iron...130 iron (ferrous gluconate)...129 iron 100 plus...130 iron 100/c...130 iron chews pediatric...130 IRON UP...130 ISENTRESS...20 ISOLYTE-P D5W...154 ISOLYTE-S...154 isoniazid...23 ISOPTO TEARS...130 isosorbide dinitrate...55 isosorbide dinitrate er...55 isosorbide mononitrate...55 isosorbide mononitrate er...55 isradipine...51 ISTALOL...157 ISTODAX...37 itraconazole...15 ivermectin...17 IXIARO...110 JAKAFI...39 JALYN...101 jantoven...103 JANUMET...80 JANUMET XR...80 JANUVIA...80 JENTADUETO...80 jinteli...90 J-MAX...130 jolessa...84 jolivette...84 J-TAN D PD...130 J-TAN PD...130 junel 1.5/30...84 junel 1/20...84 junel fe 1.5/30...84 junel fe 1/20...84 JUXTAPID...48 k 100...130 KADCYLA...37 KALETRA...22 KALYDECO...165 KAOPECTATE...130 kariva...84 kcl dextrose-nacl...155 KCL DEXTROSE-NACL...155 kelnor 1/35...84 ketoconazole...15, 169, 170 ketoprofen...10 ketorolac tromethamine...161 KEYTRUDA...37 kidkare...130 kionex...83 klor-con...151 klor-con 10...151 klor-con m15...151 klor-con m20...151 kls acid reducer...130 KONSYL...130 KONSYL-D...130 KORLYM...91 kp b complex-c...130 kp benzoyl peroxide...130 kp calcium 600+d...130, 131 kp calcium-magnesium-zinc...131 kp ferrous gluconate...131 kp ferrous sulfate...131 kp hydrocortisone...131 kp ketotifen fumarate...131 kp pseudoephedrine hcl...131 kp terbinafine hydrochloride...131 kp vitamin d...131 kp vitamin e...131 kpn prenatal...131 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 185
KUVAN...89 KYNAMRO...48 labetalol hcl...49 laclotion...174 lactated ringers...155 lactulose...98 lactulose encephalopathy...98 LAMISIL ADVANCED...131 LAMISIL AF DEFENSE...131 lamivudine...20, 24 lamivudine-zidovudine...22 lamotrigine...59 lamotrigine er...59 LANTUS...78 LANTUS SOLOSTAR...78 larin 1.5/30...84 larin 1/20...84 larin fe 1.5/30...84 larin fe 1/20...84 LASTACAFT...156 latanoprost...157 LATUDA...70 laxative pills...131 leena...85 leflunomide...106 LENVIMA 10 MG...39 LENVIMA 14 MG...39 LENVIMA 20 MG...39 LENVIMA 24 MG...39 lessina...85 LETAIRIS...55 letrozole...37 leucovorin calcium...41 LEUKERAN...33 LEUKINE...104 leuprolide acetate...37 levalbuterol hcl...163 LEVEMIR...78 LEVEMIR FLEXTOUCH...78 levetiracetam...59 levetiracetam er...59 LEVETIRACETAM NACL...59 levobunolol hcl...157 levocarnitine...89 levocetirizine dihydrochloride...163 levofloxacin...29 levofloxacin d5w...29 levoleucovorin calcium...41 levonest...85 levonorgest-eth estrad 91...85 levonorgestrel...85 levonorgestrel-ethinyl estrad...85 levora 0.15/30 (28)...85 levothyroxine sodium...93 levoxyl...94 LEXIVA...20 lice killing...131 lice treatment...131 lidocaine...173 lidocaine hcl...13, 173 lidocaine hcl (pf)...13 lidocaine viscous...175 lidocaine-prilocaine...173 linezolid...17 LINEZOLID...17 LINZESS...99 liothyronine sodium...94 liquid calcium with d3...131 liquid calcium/vitamin d...131 liquituss gg...132 lisinopril...43 lisinopril-hydrochlorothiazide...43 LITHIUM...75 lithium carbonate...75 lithium carbonate er...75 localnesium...132 localnesium-c...132 LODRANE D...132 LOHIST-D...132 lohist-dm...132 lohist-peb...132 lokara...173 lomustine...33 loperamide hcl...99, 132 loratadine...132 loratadine-pseudoephedrine er...132 lorazepam...56 lorazepam intensol...56 lorcet...11 lorcet hd...11 lorcet plus...11 lortab...11 loryna...85 losartan potassium...45 losartan potassium-hctz...45 LOTEMAX...161 LOTRIMIN ULTRA...132 lovastatin...47 low-ogestrel...85 loxapine succinate...70 lubricating plus...132 LUMIGAN...157 LUMITENE...132 LUMIZYME...89 LUPRON DEPOT...38 LUPRON DEPOT-PED...38 lutera...85 LYNPARZA...37 LYRICA...60 LYSODREN...38 lyza...85 MAALOX...132 MAALOX...132 mag-al...132 mag-delay...132 MAGINEX...132 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 186
MAGNEBIND 300...133 magnesium...133 magnesium citrate...133 magnesium oxide...133 MAGNESIUM SULFATE...151 magnesium sulfate...151 MAGNESIUM SULFATE D5W...151 MAG-TAB SR...133 malathion...174 MAPAP COLD FORMULA MULTI-SYMPT...133 maprotiline hcl...65 marlissa...85 MARPLAN...65 MATULANE...40 MAXIDEX...161 meclizine hcl...95 medroxyprogesterone acetate...85, 93 mefloquine hcl...19 MEGACE ES...38 megestrol acetate...38 MEKINIST...39 meloxicam...10 melphalan hcl...33 MENACTRA...110 m-end dmx...133 MENOMUNE...110 MENVEO...110 MEPHYTON...133 mercaptopurine...35 MERIBIN...133 meropenem...18 mesalamine...97 mesalamine-...97 mesna...42 MESNEX...42 metadate er...73 METAMUCIL...133 METAMUCIL MULTIHEALTH FIBER...133 METAMUCIL...133 metformin hcl...81 metformin hcl er...81 methadone hcl...12 methadone hcl intensol...11 methazolamide...54 methenamine hippurate...18 methimazole...94 methotrexate...106 methotrexate sodium...35 methotrexate sodium (pf)...35 methyclothiazide...54 methylergonovine maleate...92 methylphenidate hcl...73 methylphenidate hcl er...73 methylprednisolone...91 methylprednisolone (pak)...90 methylprednisolone acetate...90 methylprednisolone sodium succ...91 metipranolol...158 metoclopramide hcl...95 metolazone...54 metoprolol succinate er...49 metoprolol tartrate...49 metoprolol-hydrochlorothiazide...48 metronidazole...18, 102, 174 metronidazole nacl...18 mexiletine hcl...46 MEXSANA...133 MIACALCIN...92 MI-ACID...134 miconazole 1...134 miconazole 3...134 miconazole 3 combo pack...134 miconazole 7...134 microgestin 1.5/30...85 microgestin 1/20...85 microgestin fe 1.5/30...85 microgestin fe 1/20...85 midodrine hcl...54 milk of magnesia...134 milk of magnesia concentrate...134 mineral oil...134 minitran...55 minocycline hcl...32 minoxidil...54 MINTOX PLUS...134 mirtazapine...65 misoprostol...99 MISSION PRENATAL...134 MISSION PRENATAL HP...134 mitomycin...34 mitoxantrone hcl...40 M-M-R II...110 moderiba...24 MODERIBA 1200...24 moderiba 800...24 moexipril hcl...43 moexipril-hydrochlorothiazide...43 mometasone furoate...173 mononessa...85 montelukast sodium...164 morphine sulfate...12 morphine sulfate...12 morphine sulfate (pf)...12 morphine sulfate er...12 morphine sulfate er...12 motion...134 MOTRIN IB...134 MOVANTIK...99 MOVIPREP...98 MOXEZA...159 MOZOBIL...104 mucaphed...134 MUCINEX...134 MUCINEX D...134 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 187
MUCINEX FAST-MAX...134 MUCINEX...135 MUCINEX...135 mucus...135 mucus...135 mucus...135 mucus relief er...135 mucus-dm...135 mucus-dm max...135 MULTAQ...46 multi-delyn...135 multi-delyn/iron...135 multi-symptom...135 mupirocin...168 MURO 128...135 MUSTARGEN...33 my way...135 MYCAMINE...16 mycophenolate mofetil...108 mycophenolic acid...108 MYKIDZ IRON...135 MYKIDZ IRON 10...135 myorisan...168 MYOZYME...89 MYRBETRIQ...101 myzilra...86 nabumetone...10 nadolol...49 nafcillin sodium...31 NAGLAZYME...89 nalbuphine hcl...13 naloxone hcl...77 naltrexone hcl...77 NAMENDA...62 NAMENDA XR...62 NAMENDA XR...63 naphazoline hcl...161 naproxen...10 naproxen dr...10 naproxen sodium...10, 135 naratriptan hcl...74 nasal decongestant...135, 136 nasal decongestant pe...136...136 NASCOBAL...136 NASOPEN PE...136 NATACYN...159 nateglinide...81 NATPARA...93 natural fiber laxative...136 natural fiber therapy...136 natures tears...136 NEBUPENT...18 necon 0.5/35 (28)...86 necon 1/35 (28)...86 necon 1/50 (28)...86 necon 10/11 (28)...86 necon 7/7/7...86 nefazodone hcl...65 neomycin sulfate...14 neomycin-bacitracin zn-polymyx...160 neomycin-polymyxin-dexameth...158 neomycin-polymyxin-gramicidin...160 neomycin-polymyxin-hc...158, 176 NEORAL...108, 109 neotuss...136 NEPHRAMINE...153 NEPHRONEX...136 NEUMEGA...104 NEUPOGEN...104 NEUPRO...67 nevirapine...20 nevirapine er...20 NEXAFED...136 NEXAFED SINUS PRESSURE + PAIN...136 NEXAVAR...39 NEXIUM...100 next choice one dose...86 niacin...136 niacin er...136 niacin er...48 niacinamide...136 niacor...48 nicardipine hcl...51 nicotine...137 nicotine polacrilex...136, 137 NICOTROL...77 NICOTROL NS...77 nifedical xl...51 nifedipine er...51 nifedipine er osmotic...51 night-time sinus...137 nikki...86 NILANDRON...38 nimodipine...52 NIPENT...35 nitro-bid...55 NITRO-DUR...55 nitrofurantoin macrocrystal...18 nitrofurantoin monohyd macro...18 nitroglycerin...55 NITROSTAT...55 nohist-lq...137 nora-be...86 NORDITROPIN FLEXPRO...91 NORDITROPIN NORDIFLEX...92 NOREL AD...137 norethindrone...86 norethindrone acetate...93 norethindrone-eth estradiol...90 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 188
norgestim-eth estrad triphasic...86 norlyroc...86 normosol-m d5w...155 NORMOSOL-R D5W...155 NORMOSOL-R PH 7.4...155 NORPACE CR...46 nortrel 0.5/35 (28)...86 nortrel 1/35 (21)...86 nortrel 1/35 (28)...86 nortrel 7/7/7...86 nortriptyline hcl...65 NORVIR...20 NOVAFERRUM 125...137 NOVAFERRUM...137 NOVOLIN 70/30...78 NOVOLIN N...78 NOVOLIN R...79 NOVOLOG...79 NOVOLOG FLEX...79 NOVOLOG MIX 70/30...79 NOVOLOG MIX 70/30 FLEX...79 NOVOLOG PENFILL...79 NOXAFIL...16 NUEDEXTA...75 NU-IRON...137 NULOJIX...109 NULYTELY...98 NUTRILIPID...153 NUTRISOURCE FIBER...137 NUVARING...86 NUVIGIL...76 nyamyc...169 NYMALIZE...52 nystatin...16, 169, 175 nystop...169 ocella...86 OCTAGAM...107 octreotide acetate...92 OFEV...165 ofloxacin...160, 176 olanzapine...70 olopatadine hcl...163 omega-3-acid ethyl esters...48 omeprazole...100, 137 ondansetron...95 ondansetron hcl...95 ONETOUCH ULTRA 2...81 ONETOUCH ULTRA BLUE...81 ONETOUCH ULTRA MINI...81 ONETOUCH ULTRA SYSTEM...81 ONETOUCH ULTRASMART...81 ONETOUCH VERIO...82 ONETOUCH VERIO IQ SYSTEM...82 ONETOUCH VERIO SYNC SYSTEM...82 ONFI...60 OPSUMIT...55 ORAP...71 ORFADIN...89 organ-i nr...137 orsythia...86 OS-CAL EXTRA D3...137 OSTEO-PORETICAL...137 oxacillin sodium...31 oxaliplatin...41 oxandrolone...77 oxcarbazepine...60 oxybutynin chloride...101 oxybutynin chloride er...101 oxycodone hcl...12, 13 oxycodone-acetaminophen...13 OYSCO 500...137 oyster shell calcium 250+d...137 oyster shell calcium/d...137 pacerone...46 paclitaxel...36 pain relief 8...137...138...138 pain reliever...138 pamidronate disodium...82 PANOXYL...138 PANOXYL...138 PANOXYL-4 CREAMY...138 PANRETIN...174 pantoprazole sodium...100 paricalcitol...156 paromomycin sulfate...14 paroxetine hcl...65 parva-cal...138 paser...23 PATADAY...156 PAXIL...65 PAZEO...156 PEDIACARE...138 PEDIA-LAX...138 PEDVAX HIB...111 peg 3350/electrolytes...98 peg 3350-kcl-na bicarb-nacl...98 peg-3350/electrolytes...98 PEGANONE...60 PEGINTRON...24 PEG-INTRON...24 PEG-INTRON REDIPEN...24 PENICILLIN G POT DEXTROSE...31 penicillin g potassium...31 penicillin g procaine...32 penicillin g sodium...32 penicillin v potassium...32 PENTAM...18 pentoxifylline er...104 PEPCID AC...138 peptic...138 PERDIEM...138 PERFOROMIST...163 perindopril erbumine...43 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 189
periogard...175 permethrin...138, 175 perphenazine...71 PERRY PRENATAL...138 phenadoz...95 PHENAGIL...138 phenelzine sulfate...65 phenergan...95 phenobarbital...60 phenobarbital sodium...60 PHENOBARBITAL SODIUM...60 phenytek...60 phenytoin...60 phenytoin sodium...60 phenytoin sodium extended...60 philith...86 phos-nak...138 PHOSPHOLINE IODIDE...158 pilocarpine hcl...158, 175 pimtrea...87 pindolol...49 pioglitazone hcl...81 piperacillin sod-tazobactam so...32 pirmella 1/35...87 piroxicam...10 PLASMA-LYTE 148...155 PLASMA-LYTE A...155 PLASMA-LYTE-56 D5W...155 podofilox...174 polyethylene glycol 3350...98 polymyxin b-trimethoprim...160 polyvitamin...138 polyvitamin/iron...138 POMALYST...40 portia-28...87 potassium chloride...152, 156 potassium chloride crys er...151 potassium chloride er...151,152 potassium chloride dextrose...155 potassium chloride nacl...155 potassium citrate er...101 POTIGA...60, 61 PRADAXA...103 pramipexole dihydrochloride...67 pravastatin sodium...47 prazosin hcl...44 prednisolone...91 prednisolone acetate...161 prednisolone sodium phosphate...91,161 prednisone...91 prednisone (pak)...91 prednisone intensol...91 PREFERRED PLUS...79 premasol...153 prenatal...138, 156 PRETZ...139 prevalite...48 previfem...87 PREZCOBIX...22 PREZISTA...20 PRIFTIN...23 PRILOSEC OTC...139 PRIMAQUINE PHOSPHATE...19 primidone...61 PRISTIQ...65 PRIVIGEN...107 probenecid...9 PROCALAMINE...153 pro-chlo...139 prochlorperazine...95 prochlorperazine edisylate...95 prochlorperazine maleate...95 PROCRIT...104 procto-pak...169 proctosol hc...169 proctozone-hc...169 PROFE...139 PROGLYCEM...91 PROGRAF...109 PROLASTIN-C...165 PROLENSA...161 PROLEUKIN...37 PROLIA...92 PROMACTA...104 promethazine hcl...96 promethegan...96 PRONUTRIENTS CALCIUM+D3...139 propafenone hcl...46 propafenone hcl er...46 proparacaine hcl...161 propranolol hcl...49, 50 propranolol hcl er...49 propranolol-hctz...48 propylthiouracil...94 PROQUAD...111 PROSOL...154 protriptyline hcl...65 prudoxin...169 pseudoeph-bromphen-dm...139 psyldex...139 PULMICORT FLEXHALER...166 PULMOZYME...165 PURE & GENTLE LUBRICANT...139 PURIXAN...35 pyrazinamide...23 pyrethins-piperonyl butoxide...139 pyridostigmine bromide...75 pyridoxine hcl...139 pyrilamine-phenylephrine...139 qc 3 day...139 qc natural vegetable...139 q-pap infants...139 Q-TAPP DM...139 quasense...87 quetiapine fumarate...71 quinapril hcl...43 quinapril-hydrochlorothiazide...43 quinidine gluconate er...46 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 190
quinidine sulfate...46 quinine sulfate...19 ra anti-itch...139 ra b-complex/vitamin c cr...140 ra beta carotene...140 ra calamine...140 ra calcium 600/vit d/minerals...140 ra calcium-boron...140 ra central-vite performance...140 ra col-rite...140 ra coral calcium...140 ra high potency iron...140 ra hydrocortisone plus...140 ra ibuprofen...140 ra lubricant eye...140 ra magnesium...140 ra...140 ra omeprazole-sodium bicarb...140 ra ophthalmic...140 ra oyster shell calcium/d...140 ra probiotic complex...140 ra severe cold/sinus relief pe...141 ra slow release iron...141 ra soluble fiber...141 RA STERILE...79 ra vitamin c drops...141 ra vitamin c/rose hips cr...141 RABAVERT...111 raloxifene hcl...92 ramipril...43 RANEXA...55 ranitidine hcl...97, 141 RAPAMUNE...109 RAVICTI...89 REBETOL...24 reclipsen...87 RECOMBIVAX HB...111 REFRESH CELLUVISC...141 REFRESH OPTIVE ADVANCED...141 REFRESH P.M...141 REGRANEX...175 REGULOID...141 REHYDRALYTE...141 RELENZA DISKHALER...25 RELISTOR...98 RELPAX...74 REMICADE...106 REMODULIN...56 RENVELA...93 repaglinide...81 RESCON...141 RESCON DM...141 RESCRIPTOR...21 RESPAIRE-30...141 RESTASIS...161 RETAINE MGD...141 RETROVIR...21 REVATIO...56 REVLIMID...108 REYATAZ...21 RHINARIS...141 ribasphere...25 ribasphere ribapak...25 ribavirin...25 RID ESSENTIAL...141 rifabutin...23 rifampin...23 RIFATER...23 riluzole...75 rimantadine hcl...25 ringers...156 RISA-BID PROBIOTIC...141 RISAMINE...142 RISPERDAL CONSTA...71 risperidone...71 RITUXAN...37 rivastigmine tartrate...63 rizatriptan benzoate...74 robafen cf...142 robafen...142 ROBITUSSIN CF...142 ROBITUSSIN LA...142 ROBITUSSIN LA...142 ROBITUSSIN...142 ROBITUSSIN LINGERING LA...142 ROBITUSSIN...142 ROBITUSSIN MAX...142 ROBITUSSIN PEAK COLD...142 ropinirole hcl...67 rosadan...174 ROTARIX...111 ROTATEQ...111 roxicet...13 ROZEREM...74 rymed...142 rynex dm...142 rynex pse...142 SABRIL...61 saline laxative...142 SANDIMMUNE...109 SANDOSTATIN LAR DEPOT...92 SANTYL...175 SAPHRIS...71 sb fib lax orange...142 sb lice treatment...142 sb natural fiber laxative...143 SCOOBY-DOO ONE A DAY...143 SCOT-TUSSIN DM...143 SCOT-TUSSIN SENIOR...143 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 191
SECURA EXTRA PROTECTIVE...143 SECURA PROTECTIVE...143 selegiline hcl...67, 68 selenium...143 selenium er...143 selenium sulfide...170 SELZENTRY...21 senna...143 senna laxative...143 SENNA PROMPT...143 senna s...143 SENSI-CARE PROTECTIVE BARRIER...143 SENSIPAR...82 SEREVENT DISKUS...163 SEROQUEL XR...71,72 sertraline hcl...66 sharobel...87 SIGNIFOR...92 sildenafil citrate...56 SILENOR...74 silver sulfadiazine...168 SIMBRINZA...158 simvastatin...47 sirolimus...109 SIROLIMUS...109 SIRTURO...23 SIVEXTRO...18 sleep aid...143 SLO-NIACIN...143 slow magnesium/calcium...143 slow release iron...143 SLOW-MAG...144 sm adult nasal decongestant...144 sm calcium/vitamin d3...144 sm calcium-magnesium-zinc...144 SM CORAL CALCIUM...144 sm iron slow release...144 sm lansoprazole...144 sm magnesium oxide...144 sm motion...144 sm redness relief...144 sm slow release iron...144 sm vitamin b12 tr...144 sm vitamin c cr...144 sm vitamin d3...144 sodium bicarbonate...144 sodium chloride...152, 156, 175 sodium chloride...144 sodium fluoride...152 sodium phenylbutyrate...89 sodium polystyrene sulfonate...83 solia...87 SOLTAMOX...38 SOLUBLE FIBER THERAPY...145 SOLU-CORTEF...91 SOMATULINE DEPOT...93 SOMAVERT...93 SOOTHE...145 sorbulax...145 sorine...46 sotalol hcl...46 sotalol hcl (af)...46 SOVALDI...25 spironolactone...44 spironolactone-hctz...54 sprintec 28...87 SPRYCEL...39 sps...83 sronyx...87 ssd...168 stahist ad...145 stavudine...21...145...175 STIVARGA...40 stomach relief...145 stool softener...145 stool softener laxative dc...145 STRATTERA...73, 74 streptomycin sulfate...14 STRIBILD...22 SUBOXONE...77 SUCRAID...99 sucralfate...99 sulfacetamide sodium...160, 168 sulfacetamide-prednisolone...158 sulfadiazine...14 sulfamethoxazole-tmp ds...18 sulfamethoxazole-trimethoprim...18 SULFAMYLON...168 sulfasalazine...97 sulfazine ec...97 sulindac...10 sumatriptan...74 sumatriptan succinate...74, 75 sumatriptan succinate refill...74 SUMMERS EVE DISP MEDICATED...145 SUPRAX...27 suprax...28 SUPREP...99 SURMONTIL...66 SUSTIVA...21 SUTENT...40 syeda...87 SYLATRON...40 SYMBICORT...166 SYMLINPEN 120...79 SYMLINPEN 60...79 SYNAGIS...111 SYNAREL...88 SYNERCID...18 SYNRIBO...40 SYNTHROID...94 SYPRINE...83 SYSTANE BALANCE...145 SYSTANE...145 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 192
SYSTANE...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...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...146 tgt...146 tgt...146 tgt pain reliever pm...146 th calcium-magnesium-zinc...146 th eye drop tears...146 THALOMID...108 theo-24...167 theophylline...167 theophylline er...167 THERA/BETA-CAROTENE...146 THERA-D 4000...146 THERANATAL CORE NUTRITION...146 THERATEARS...146 thiamine hcl...146 thioridazine hcl...72 thiothixene...72 tiagabine hcl...61 TIKOSYN...46 timolol maleate...50, 158 tioconazole-1...146 TITRALAC...146 TIVICAY...21 tizanidine hcl...76 TOBRADEX...158 TOBRADEX ST...159 tobramycin...14, 160 tobramycin sulfate...14 tobramycin sulfate saline...14 tobramycin-dexamethasone...159 TOBREX...160 tolnaftate...146 tolterodine tartrate...101 tolterodine tartrate er...101 topiramate...61 toposar...42 topotecan hcl...42 torsemide...54 total b/c...146 TOVIAZ...101 TPN ELECTROLYTES...152 TRACLEER...56 TRADJENTA...81 tramadol hcl...13 tramadol-acetaminophen...13 trandolapril...43 tranexamic acid...105 TRANSDERM-SCOP...96 tranylcypromine sulfate...66 TRAVASOL...154 TRAVATAN Z...158 trazodone hcl...66 TREANDA...33 TRECATOR...23 TRELSTAR MIXJECT...38 tretinoin...41,168 triacting...146 triamcinolone acetonide...173, 175 TRIAMINIC...147 TRIAMINIC...147 TRIAMINIC...147 triamterene-hctz...54 TRIBENZOR...45 tri-buffered aspirin...147 triderm...173 trifluoperazine hcl...72 trifluridine...160 trihexyphenidyl hcl...68 tri-legest fe...87 trilyte...99 trimethoprim...18 trinessa (28)...87 triple antibiotic...147 TRIPLE PASTE...147 triple paste af...147 tri-previfem...87 TRISENOX...41 tri-sprintec...87 TRIUMEQ...22 TRI-VI-SOL...147 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 193
TRI-VITA...147 tri-vitamin...147 trivora (28)...87 TROPHAMINE...154 trospium chloride...101 TRUMENBA...111 TRUVADA...22 TUSNEL...147 TUSNEL...147 TUSNEL-DM...147 tussin cf...147 tussin dm...147 tussi-pres b...147 TWINRIX...111 TYBOST...21 TYGACIL...19 TYKERB...40 TYPHIM VI...111 TYSABRI...76 TYZEKA...25 UCERIS...97 ULORIC...9 unithroid...94 UPCAL D...148 ursodiol...99 VAGIFEM...90 VAGISTAT-3...148 valacyclovir hcl...25 VALCHLOR...174 VALCYTE...25 valganciclovir hcl...25 valproate sodium...61 valproic acid...61 valsartan...45 valsartan-hydrochlorothiazide...45 vancomycin hcl...19 vandazole...102 VAQTA...111 VARIVAX...111 VASCEPA...48 VELCADE...37 velivet...87 venlafaxine hcl...66 venlafaxine hcl er...66 VENTOLIN HFA...164 verapamil hcl...52 verapamil hcl er...52 VERSACLOZ...72 VESICARE...102 vestura...87 VICKS DAYQUIL MUCUS CONTROL DM...148 VICKS NYQUIL D...148 VICKS VAPORUB...148 VICTOZA...79 VIDEX...21 VIGAMOX...160 VIIBRYD...66 VIMPAT...61 vinblastine sulfate...36 vincasar pfs...36 vincristine sulfate...36 vinorelbine tartrate...36 viorele...88 VIRACEPT...21 VIRAMUNE XR...21 VIREAD...21 VISINE-LR...148 VITALETS...148 VITAMELTS ENERGY VITAMIN B-12...148 vitamin a & d...148 vitamin a palmitate...148 vitamin b-1...148 vitamin b-12...148, 149 vitamin b12-folic acid...149 vitamin b-2...149 vitamin b-6...149 vitamin b-6 er...149 vitamin c...149 vitamin c (calcium ascorbate)...149 vitamin d...149 vitamin d (ergocalciferol)...149 vitamin d2...149 vitamin d3...149 vitamin e...149, 150 vitamin e-selenium...150 vitamin k (phytonadione)...150 vitamin k1...150 vitatrum...150 VITEKTA...21 VOLTAREN...174 voriconazole...16 VOTRIENT...40 vyfemla...88 WAL-ACT...150 WAL-DRYL...150 WAL-DRYL-D...150 WAL-FEX D...150 WAL-FLU SEVERE COLD DAYTIME...150 WAL-ITIN...150 WAL-ITIN D...150 WAL-PHED PE...150 WAL-PHED...150 wal-som...150 warfarin sodium...103 wee care...150 WELCHOL...48 XALKORI...40 XARELTO...103 XARELTO...103 XENAZINE...75 XGEVA...93 XIFAXAN...99 XOLAIR...165 XOPENEX HFA...164 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 194
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 7 8 1-855-595-2063 WellCare Advocate Complete FIDA (TTY: 1-877-247-6272) 8 8 https://fida.wellcareny.com/ 195
09/01/2015 1-855-595-2063 (TTY: 1-877-247-6272) WellCare Advocate Complete FIDA 8 8 http://www.fida.wellcareny.com 68443