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Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical conditionbefore we will cover another drug for that condition. For example, if Drug A and Drug B both treat yourmedical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you,our plan will then cover Drug B.You can find out if your drug has any additional requirements or limits by looking in the formulary that begins onpage 1. You can also get more information about the restrictions applied to specific covered drugs by visiting ourWeb site. We have posted on line documents that explain our prior authorization and step therapy restrictions.You may also ask us to send you a copy. Our contact information, along with the date we last updated theformulary, appears on the front and back cover pages.You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs thatmay treat your health condition. See the section, “How do I request an exception to the WellCare Value Script(PDP), WellCare Wellness Rx(PDP) formulary?” on page III for information about how to request an exception.What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service andask if your drug is covered.If you learn that our plan does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by our plan. When you receive thelist, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask our plan to make an exception and cover your drug. See below for information about how torequest an exception.How do I request an exception to the WellCare Value Script (PDP), WellCare WellnessRx (PDP) Formulary?You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that youcan ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered ata pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lowercost sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. Ifapproved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our planlimits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive thelimit and cover a greater amount.Generally, our plan will only approve your request for an exception if the alternative drugs included on the plan’sformulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treatingyour condition and/or would cause you to have adverse medical effects.You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restrictionexception. When you request a formulary, tiering or utilization restriction exception you should submit astatement from your prescriber or physician supporting your request. Generally, we must make our decisionwithin 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception ifyou or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. Ifyour request to expedite is granted, we must give you a decision no later than 24 hours after we get a supportingstatement from your doctor or other prescriber.12/01/2021III

What do I do before I can talk to my doctor about changing my drugs or requestingan exception?As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, youmay be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need aprior authorization from us before you can fill your prescription. You should talk to your doctor to decide if youshould switch to an appropriate drug that we cover or request a formulary exception so that we will cover thedrug you take. While you talk to your doctor to determine the right course of action for you, we may cover yourdrug in certain cases during the first 90 days you are a member of our plan.For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will covera temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to amaximum 30 day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if youhave been a member of the plan less than 90 days.If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your abilityto get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-dayemergency supply of that drug while you pursue a formulary exception.If you experience a level of care change (such as being discharged or admitted to a long-term care facility), yourphysician or pharmacy can call our Provider Service Center and request a one-time override. This one-timeoverride will be up to a 31-day supply (unless you have a prescription written for fewer days).For more informationFor more detailed information about your plan prescription drug coverage, please review your Evidence of Coverageand other plan materials.If you have questions about our plan, please contact us. Our contact information, along with the date we lastupdated the formulary, appears on the front and back cover pages.If you have general questions about Medicare prescription drug coverage, please call Medicare at1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048.Or, visit http://www.medicare.gov.12/01/2021IV

Our Plan's FormularyThe comprehensive formulary below provides coverage information about the drugs covered by our plan. If youhave trouble finding your drug in the list, turn to the Index that begins on page INDEX-1.The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., COUMADIN) andgeneric drugs are listed in lower-case italics (e.g., simvastatin).The information in the Requirements/Limits column tells you if our plan has any special requirements forcoverage of your drug. NM means the drug is not available via your monthly mail service benefit. This is noted in the Requirements/Limits column of your formulary. You may be able to receive more than one month’s supply of most of thedrugs on your formulary via mail service at a reduced cost share. Please see Chapter 3 of your Evidence ofCoverage for more information.** SSM stands for Senior Savings Model: If you are not receiving Extra Help to pay for your prescriptions, theamount you pay when you fill a prescription for select insulins will be a reduced, fixed amount during thedeductible, initial coverage, and coverage gap phases of the Part D benefit. Please refer to your Evidence ofCoverage for more information about this coverage. PA stands for Prior Authorization: Please see page II for details. PA-NS stands for Prior Authorization for New Starts: This means that if this drug is new to you, you will needto get approval from us before you fill your prescription. If you are taking this drug at the time of enrollment,you will not be required to meet criteria for approval. B/D stands for Covered under Medicare B or D: This drug may be eligible for payment under Medicare Part Bor Part D. You (or your physician) are required to get prior authorization from us to determine that this drug iscovered under Medicare Part D before you fill your prescription for this drug. Without prior approval, we maynot cover this drug. QL stands for Quantity Limits: Please see page II for details. LA stands for Limited Access medication. This prescription may be available only at certain pharmacies. Formore information consult your Pharmacy Directory or call Customer Service at the telephone number listedon the inside front and back covers of this formulary. ST stands for Step Therapy: Please see page III for details. Drug may be available for up to a 30-day supply only.**You have the choice to sign up for automated mail service delivery. You can get prescription drugs shipped toyour home through our network mail service delivery program. You should expect to receive your prescriptiondrugs within 10–14 calendar days from the time that the mail service pharmacy receives the order. If you donot receive your prescription drugs within this time, please contact us at 1-866-808-7471 (TTY 711), 24 hours aday, seven days a week, or visit mailrx.wellcare.com.12/01/2021V

Drug tier co-payment/coinsurance amountsPrescription drugs are grouped into one of five tiers. To find out which tier your drug is in, look in the Drug Tiercolumn of the formulary that begins on page 1. For more detailed information about your out-of-pocket costsfor prescriptions, including any deductible that may apply, please refer to your Evidence of Coverage and otherplan materials. Tier 1: Preferred Generic – Brand and generic drugs that are available at the lowest cost share for this plan.o Tier 1 Preferred copayment: 0o Tier 1 Standard copayment range: 5–8 Tier 2: Generic – Brand and generic drugs that Our Plan offers at a higher cost to you than preferred genericson tier 1.o Tier 2 Preferred copayment range: 3–10o Tier 2 Standard copayment range: 9–15 Tier 3: Preferred Brand – Brand and generic drugs that Our Plan offers at a lower cost to you than nonpreferred drugs on tier 4.o Tier 3 Preferred copayment range: 38–43o Tier 3 Standard copayment: 47o Tier 3 Preferred select insulins copayment: 35o Tier 3 Standard select insulins copayment: 35 Tier 4: Non-Preferred Drug – Brand and generic drugs that Our Plan offers at a higher cost to you thanpreferred brands on tier 3.o Tier 4 Preferred coinsurance range: 46–49%o Tier 4 Standard coinsurance: 50% Tier 5: Specialty Tier – Some injectables and other high-cost Brand and generic drugs. Indicates specialtydrugs are available for up to a 30-day supply only.o Tier 5 Preferred coinsurance range: 25–26%o Tier 5 Standard coinsurance range: 25–26%Consult your Evidence of Coverage or Summary of Benefits for your applicable co-pays/coinsurance and amounts.12/01/2021VI

Drug NameDrug Tier Requirements / LimitsANALGESICSGOUTallopurinol oral tablet 100 mg, 300 mg1colchicine oral tablet 0.6 mg4colchicine-probenecid oral tablet 0.5-500 mg3febuxostat oral tablet 40 mg, 80 mg4PAMITIGARE ORAL CAPSULE 0.6 MG3QL (60 EA per 30 days)probenecid oral tablet 500 mgNSAIDS3celecoxib oral capsule 100 mg3QL (120 EA per 30 days)celecoxib oral capsule 200 mg3QL (60 EA per 30 days)celecoxib oral capsule 400 mg3QL (30 EA per 30 days)celecoxib oral capsule 50 mg3QL (240 EA per 30 days)diclofenac potassium oral tablet 50 mg3QL (120 EA per 30 days)diclofenac sodium er oral tablet extended release 24 hour100 mg3diclofenac sodium oral tablet delayed release 25 mg, 50mg, 75 mg2diclofenac-misoprostol oral tablet delayed release 50-0.2mg, 75-0.2 mg4diflunisal oral tablet 500 mg3DUEXIS ORAL TABLET 800-26.6 MG5 ec-naproxen oral tablet delayed release 375 mg, 500 mg2etodolac er oral tablet extended release 24 hour 400 mg,500 mg, 600 mg2etodolac oral capsule 200 mg, 300 mg2etodolac oral tablet 400 mg, 500 mg2flurbiprofen oral tablet 100 mg3ibu oral tablet 600 mg, 800 mg1ibuprofen oral suspension 100 mg/5ml3ibuprofen oral tablet 400 mg, 600 mg, 800 mg1ibuprofen-famotidine oral tablet 800-26.6 mg4meloxicam oral tablet 15 mg, 7.5 mg1nabumetone oral tablet 500 mg, 750 mg2naproxen oral tablet 250 mg, 375 mg, 500 mg1naproxen oral tablet delayed release 375 mg, 500 mg2QL (120 EA per 30 days)PAPAYou can find information on what the symbols and abbreviations on this table mean by going to pagenumber V.12/01/20211

Drug NameDrug Tier Requirements / Limitsnaproxen sodium oral tablet 275 mg, 550 mg3oxaprozin oral tablet 600 mg4piroxicam oral capsule 10 mg, 20 mg3sulindac oral tablet 150 mg, 200 mg2VIMOVO ORAL TABLET DELAYED RELEASE375-20 MG, 500-20 MGOPIOID ANALGESICS, LONG-ACTING5 PAfentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr,25 mcg/hr, 50 mcg/hr, 75 mcg/hr4PA; QL (10 EA per 30 days)HYSINGLA ER ORAL TABLET ER 24 HOURABUSE-DETERRENT 100 MG, 120 MG, 20 MG, 30MG, 40 MG, 60 MG, 80 MG3PA; QL (30 EA per 30 days)methadone hcl intensol oral concentrate 10 mg/ml3PA; QL (90 ML per 30 days)methadone hcl oral solution 10 mg/5ml, 5 mg/5ml3PA; QL (450 ML per 30 days)methadone hcl oral tablet 10 mg, 5 mg3PA; QL (90 EA per 30 days)morphine sulfate er oral tablet extended release 100 mg, 15mg, 200 mg, 30 mg, 60 mg3PA; QL (90 EA per 30 days)4PA; QL (60 EA per 30 days)acetaminophen-codeine #3 oral tablet 300-30 mg3QL (360 EA per 30 days)acetaminophen-codeine oral solution 120-12 mg/5ml3QL (2700 ML per 30 days)acetaminophen-codeine oral tablet 300-15 mg3QL (400 EA per 30 days)acetaminophen-codeine oral tablet 300-60 mg3QL (180 EA per 30 days)butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml4endocet oral tablet 10-325 mg3QL (180 EA per 30 days)endocet oral tablet 2.5-325 mg, 5-325 mg3QL (360 EA per 30 days)endocet oral tablet 7.5-325 mg3QL (240 EA per 30 days)fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600mcg, 200 mcg, 600 mcg, 800 mcg5 PA; QL (120 EA per 30 days)fentanyl citrate buccal lozenge on a handle 400 mcg4PA; QL (120 EA per 30 days)hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml4QL (2700 ML per 30 days)hydrocodone-acetaminophen oral tablet 10-325 mg, 7.5325 mg3QL (180 EA per 30 days)hydrocodone-acetaminophen oral tablet 5-325 mg3QL (240 EA per 30 days)hydrocodone-ibuprofen oral tablet 7.5-200 mg3QL (150 EA per 30 days)OXYCONTIN ORAL TABLET ER 12 HOURABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30MG, 40 MG, 60 MG, 80 MGOPIOID ANALGESICS, SHORT-ACTINGYou can find information on what the symbols and abbreviations on this table mean by going to pagenumber V.12/01/20212

Drug NameDrug Tier Requirements / Limitshydromorphone hcl oral liquid 1 mg/ml4QL (600 ML per 30 days)hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg3QL (180 EA per 30 days)morphine sulfate (concentrate) oral solution 100 mg/5ml3QL (180 ML per 30 days)MORPHINE SULFATE (PF) INJECTIONSOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ML, 5MG/ML, 8 MG/ML4B/Dmorphine sulfate (pf) intravenous solution 10 mg/ml4B/DMORPHINE SULFATE (PF) INTRAVENOUSSOLUTION 2 MG/ML, 4 MG/ML, 8 MG/ML4B/DMORPHINE SULFATE (PF) SOLUTION 10 MG/MLINTRAVENOUS 10 MG/ML4B/Dmorphine sulfate intravenous solution 1 mg/ml, 4 mg/ml, 8mg/ml4B/Dmorphine sulfate oral solution 10 mg/5ml, 20 mg/5ml3QL (900 ML per 30 days)morphine sulfate oral tablet 15 mg, 30 mg3QL (180 EA per 30 days)nalbuphine hcl injection solution 10 mg/ml, 20 mg/ml4oxycodone hcl oral capsule 5 mg4QL (180 EA per 30 days)oxycodone hcl oral concentrate 100 mg/5ml4QL (180 ML per 30 days)oxycodone hcl oral solution 5 mg/5ml4QL (900 ML per 30 days)oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5mg3QL (180 EA per 30 days)oxycodone-acetaminophen oral tablet 10-325 mg3QL (180 EA per 30 days)oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325mg3QL (360 EA per 30 days)oxycodone-acetaminophen oral tablet 7.5-325 mg3QL (240 EA per 30 days)tramadol hcl oral tablet 50 mg2QL (240 EA per 30 days)tramadol-acetaminophen oral tablet 37.5-325 mgANESTHETICS3QL (240 EA per 30 days)lidocaine hcl (pf) injection solution 0.5 %, 1 %, 1.5 %3B/Dlidocaine hcl injection solution 0.5 %, 1 %, 2 %ANTI-INFECTIVES3B/DABELCET INTRAVENOUS SUSPENSION 5 MG/ML4B/DAMBISOME INTRAVENOUS SUSPENSIONRECONSTITUTED 50 MG5 B/Damphotericin b intravenous solution reconstituted 50 mg4B/DLOCAL ANESTHETICSANTIFUNGALSYou can find information on what the symbols and abbreviations on this table mean by going to pagenumber V.12/01/20213

Drug NameDrug Tier Requirements / Limitscaspofungin acetate intravenous solution reconstituted 50mg, 70 mg5 fluconazole in sodium chloride intravenous solution 200-0.9mg/100ml-%, 400-0.9 mg/200ml-%3fluconazole oral suspension reconstituted 10 mg/ml, 40mg/ml3fluconazole oral tablet 100 mg, 200 mg, 50 mg3fluconazole oral tablet 150 mg2flucytosine oral capsule 250 mg, 500 mg5 griseofulvin microsize oral suspension 125 mg/5ml4griseofulvin microsize oral tablet 500 mg4griseofulvin ultramicrosize oral tablet 125 mg, 250 mg4itraconazole oral capsule 100 mg4PAketoconazole oral tablet 200 mg3PAmicafungin sodium intravenous solution reconstituted 100mg, 50 mg5 NOXAFIL ORAL SUSPENSION 40 MG/ML5 nystatin oral tablet 500000 unit3posaconazole oral tablet delayed release 100 mg5 QL (93 EA per 30 days)terbinafine hcl oral tablet 250 mg1QL (90 EA per 365 days)voriconazole intravenous solution reconstituted 200 mg5 PAvoriconazole oral suspension reconstituted 40 mg/ml5 PAvoriconazole oral tablet 200 mg4PA; QL (120 EA per 30 days)voriconazole oral tablet 50 mgANTI-INFECTIVES - MISCELLANEOUS4PA; QL (480 EA per 30 days)albendazole oral tablet 200 mg5 amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml4atovaquone oral suspension 750 mg/5ml5 aztreonam injection solution reconstituted 1 gm, 2 gm4CAYSTON INHALATION SOLUTIONRECONSTITUTED 75 MG5 clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg2clindamycin palmitate hcl oral solution reconstituted 75mg/5ml4clindamycin phosphate in d5w intravenous solution 300mg/50ml, 600 mg/50ml, 900 mg/50ml4QL (630 ML per 30 days)PA; LAYou can find information on what the symbols and abbreviations on this table mean by going to pagenumber V.12/01/20214

Drug NameDrug Tier Requirements / LimitsCLINDAMYCIN PHOSPHATE IN NACLINTRAVENOUS SOLUTION 300-0.9 MG/50ML-%,600-0.9 MG/50ML-%, 900-0.9 MG/50ML-%4clindamycin phosphate injection solution 300 mg/2ml, 600mg/4ml, 9 gm/60ml, 900 mg/6ml, 9000 mg/60ml3colistimethate sodium (cba) injection solutionreconstituted 150 mg4dapsone oral tablet 100 mg, 25 mg3daptomycin intravenous solution reconstituted 350 mg, 500mg5 DAPTOMYCIN SOLUTION RECONSTITUTED 350MG INTRAVENOUS 350 MG5 EMVERM ORAL TABLET CHEWABLE 100 MG5 ertapenem sodium injection solution reconstituted 1 gm4gentamicin in saline intravenous solution 0.8-0.9 mg/ml-%,1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%, 2-0.9mg/ml-%3gentamicin sulfate injection solution 10 mg/ml, 40 mg/ml3imipenem-cilastatin intravenous solution reconstituted 250mg, 500 mg4ivermectin oral tablet 3 mg3linezolid in sodium chloride intravenous solution 600-0.9mg/300ml-%4linezolid intravenous solution 600 mg/300ml4linezolid oral suspension reconstituted 100 mg/5ml5 QL (1800 ML per 30 days)linezolid oral tablet 600 mg4QL (60 EA per 30 days)meropenem intravenous solution reconstituted 1 gm, 500mg4methenamine hippurate oral tablet 1 gm3metronidazole in nacl intravenous solution 5-0.79 mg/ml-%3metronidazole oral tablet 250 mg, 500 mg2neomycin sulfate oral tablet 500 mg2nitazoxanide oral tablet 500 mg5 nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg3nitrofurantoin monohyd macro oral capsule 100 mg3paromomycin sulfate oral capsule 250 mg4pentamidine isethionate inhalation solution reconstituted300 mg4QL (12 EA per 365 days)PA-NSQL (6 EA per 30 days)B/DYou can find information on what the symbols and abbreviations on this table mean by going to pagenumber V.12/01/20215

Drug NameDrug Tier Requirements / Limitspentamidine isethionate injection solution reconstituted 300mg4praziquantel oral tablet 600 mg4SIVEXTRO INTRAVENOUS SOLUTIONRECONSTITUTED 200 MG5 SIVEXTRO ORAL TABLET 200 MG5 streptomycin sulfate intramuscular solution reconstituted 1gm5 SULFADIAZINE ORAL TABLET 500 MG4sulfamethoxazole-trimethoprim intravenous solution 40080 mg/5ml4sulfamethoxazole-trimethoprim oral suspension 200-40mg/5ml3sulfamethoxazole-trimethoprim oral tablet 400-80 mg,800-160 mg1SYNERCID INTRAVENOUS SOLUTIONRECONSTITUTED 150-350 MG5 tobramycin inhalation nebulization solution 300 mg/5ml5 tobramycin sulfate injection solution 1.2 gm/30ml, 10mg/ml, 2 gm/50ml, 80 mg/2ml3trimethoprim oral tablet 100 mg2VANCOMYCIN HCL IN NACL INTRAVENOUSSOLUTION 1-0.9 GM/200ML-%, 500-0.9 MG/100ML%, 750-0.9 MG/150ML-%4vancomycin hcl intravenous solution reconstituted 1 gm, 10gm, 5 gm, 500 mg, 750 mg4vancomycin hcl oral capsule 125 mg4QL (80 EA per 180 days)vancomycin hcl oral capsule 250 mgANTIMALARIALS4QL (160 EA per 180 days)atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25mg4chloroquine phosphate oral tablet 250 mg, 500 mg3COARTEM ORAL TABLET 20-120 MG4mefloquine hcl oral tablet 250 mg3PRIMAQUINE PHOSPHATE ORAL TABLET 26.3(15 BASE) MG3primaquine phosphate tablet 26.3 (15 base) mg oral 26.3(15 base) mg3PAYou can find information on what the symbols and abbreviations on this table mean by going to pagenumber V.12/01/20216

Drug NameDrug Tier Requirements / Limitsquinine sulfate oral capsule 324 mgANTIRETROVIRAL AGENTS4abacavir sulfate oral soluti

A formulary is a list of covered drugs select ed by our plan in consultation with a team of health ca re p rovider s, which represents the prescription therapi es believed to be a nece ssary part o f a qualit y treatment program. Our plan will generally cover the drugs listed in our formulary