CurrentFidelis CarePolicy N/A

2025 Alternative Covered Drugs

A formulary alternative drug list showing common brand drugs not covered by the plan and recommended covered alternatives, including formulary restrictions (PA, QL) and interchangeable generic indicators. Applies to the Wellcare/Fidelis Care 2025 formularies and affiliated Medicare brands.

Policy Summary

PayerFidelis Care

Policy2025 Alternative Covered Drugs

Policy CodePolicy N/A

Change TypeClarified (document date/coverage notes)

Effective Date

Next Review Date

Key ActionProviders must check the plan's current drug list (formulary) for comprehensive coverage details and any restrictions (prior authorization or quantity limits) before prescribing alternatives.

SourceLink

POLICY UPDATE CHANGES

Document notes alternatives and formulary restrictions as of May 8, 2025.

40,000+Drugs covered by Wellcare

MultipleAlternative mappings listed

SomeAlternatives with PA/QL

Coverage summary & alternative guidance

Coverage / Alternative Guidance

This section lists formulary alternative drugs for Wellcare/Fidelis Care 2025. Coverage stance: mixed — some non‑covered drugs have covered alternatives, but alternatives may be subject to plan restrictions. Alternatives marked with double asterisks (**) are interchangeable generics/authorized generics (same active ingredient). Note that listed alternatives may require prior authorization (PA), have quantity limits (QL), or be limited to MAPD plans only.

Policy Summary

PayerFidelis Care

Policy2025 Alternative Covered Drugs

Policy CodePolicy N/A

Change TypeClarified (document date/coverage notes)

Effective Date

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Required provider actions

Prior Authorization

Prior authorization required where indicated

Prior Authorization is required for alternatives marked "PA" and claims may be denied without the required prior authorization. Examples called out in the formulary include Victoza/Byetta alternatives, Repatha alternative Praluent, Forteo alternatives Teriparatide/Prolia, Procrit alternative Retacrit, and Xeljanz alternatives — all noted with PA where indicated.

Victoza/Byetta alternatives (listed with PA, QL)
Repatha alternative Praluent (PA)
Forteo alternatives Teriparatide / Prolia (PA, QL and QL respectively)
Procrit alternative Retacrit (PA)
Xeljanz alternatives (PA, QL)

Documentation Required

Check formulary for current coverage and restrictions

Verify the plan's current drug list (formulary) for comprehensive coverage details and any restrictions such as prior authorization (PA) or quantity limits (QL) before prescribing an alternative.

Check the plan’s online drug list / formulary for updates and plan‑specific coverage details

Billing Rule

Interchangeable alternatives accessible without new prescription

Generics and authorized generics marked with double asterisk (**) are interchangeable alternatives (same active ingredient) and may be dispensed without a new prescription if the member already has an active prescription for the non‑covered brand.

"**" = Interchangeable alternative (same active ingredient); may be accessed without a new prescription if member has an active prescription for the non‑covered drug.

Definitions & FAQs

** — Interchangeable alternative (same active ingredient); may be accessed without a new prescription if the member has an active prescription for the non-covered drug.

PA — Prior Authorization

QL — Quantity Limit

MAPD only — Medicare Advantage Prescription Drug plan specific coverage

Q: Is the alternative always covered without restriction? A: No. Alternatives may be subject to prior authorization (PA) or quantity limits (QL) as indicated; check the formulary for current restrictions.

Q: Can an interchangeable generic be dispensed without a new prescription? A: Yes — generics/authorized generics marked with ** may be accessed without needing a new prescription if the member has an active prescription for the non-covered drug.

OpenPayer

2025 Alternative Covered Drugs

Coverage summary & alternative guidance

Required provider actions

Applicable codes

Definitions & FAQs

Clinical evidence & notes

Revision history