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