Formulary alternative drugs and restrictions
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This document lists commonly used brand drugs that are not covered by the WellCare by Fidelis Care formulary and the covered alternative drugs, including any formulary restrictions (e.g., prior authorization, quantity limits). It is intended for providers and pharmacists and applies to the plan's pharmacy benefit.
No material clinical or coverage changes in this revision.
Formulary Alternative Drugs and Restrictions
Covered alternatives with restrictions
Listed brand drugs are not covered by the formulary; alternatives shown are covered with the stated restrictions.
See chunks 0-1 for insulin entries
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The alternative drugs listed in this guidance are suggestions only and may not be clinically appropriate for every patient or condition. Providers and pharmacists should check the plan drug list (formulary) for current coverage details before substituting or dispensing an alternative. The formulary and coverage rules can change during the year; the information here is current as of the effective date shown.
Actions, Prior Authorization, and Denials
Prior authorization required for indicated alternatives
Certain covered alternatives listed in the mapping table require prior authorization (PA) as indicated next to the alternative entry; providers must obtain PA when noted (for example: BYDUREON BCISE alternatives and many biologic alternatives list “RESTRICTIONS = PA”).
- Follow the PA requirement exactly as shown in the formulary mapping for the alternative drug.
- Examples in the source: mappings showing “RESTRICTIONS = PA” for biologics and other alternatives.
Utilization management indicators (QL / PA+QL)
Some formulary alternatives include utilization-management controls such as quantity limits (QL) or PA plus QL; when an alternative lists QL or PA, coverage is subject to those limits and/or PA requirements.
- Examples: many inhaled corticosteroid/LABA and GLP‑1 alternatives show “FORMULARY RESTRICTIONS = QL.”
- Some alternatives (notably multiple biologics and migraine/GLP‑1 entries) show “RESTRICTIONS = PA, QL.”
Documentation for continuity when member on a non‑covered drug
If a member is currently taking a drug that is not covered, providers or pharmacists should check the plan’s formulary (drug list) to identify covered alternatives and may request the existing prescription be listed with the therapeutically equivalent code (marked **) without submitting a new prescription.
- Generics, authorized generics, and biosimilars are marked with **; discuss listing the active prescription with ** to maintain continuity.
- The formulary and drug list should be checked because coverage and alternatives can change during the year.
Denial triggers for non‑covered drugs
Prescriptions written for drugs listed as not covered may be denied unless the prescriber uses a listed formulary alternative or obtains prior authorization when PA is indicated.
- Denial risk applies when the non‑covered brand is prescribed and no covered alternative or required PA is provided.
- Check the mapping table and obtain PA or switch to the listed alternative to avoid claim denial.
Policy Background
This document identifies commonly used brand drugs that are not covered by the WellCare by Fidelis Care formulary and shows the formulary-covered alternatives for each. Where applicable, alternatives include therapeutically equivalent generics or biosimilars (marked **) and any formulary restrictions such as Prior Authorization (PA) or Quantity Limits (QL). Examples include insulin mappings (e.g., BASAGLAR KWIKPEN mapped to SEMGLEE or LANTUS), inhaled corticosteroid/LABA alternatives for ADVAIR DISKUS, GLP-1 alternatives for discontinued BYDUREON BCISE (with PA/QL as noted), and multiple biologic mappings (e.g., HUMIRA to biosimilars like CYLTEZO with PA/QL). For epoetin alfa products, RETACRIT is listed as the formulary-covered alternative to EPOGEN/PROCRIT. Review the drug list for the complete mapping and current restriction details.
Key Terms and Abbreviations
Required Trials and Prior Authorization
| Non‑covered brand | Formulary alternative(s) | Restrictions / Provider action |
|---|---|---|
| BYDUREON BCISE [DISCONTINUED] | MOUNJARO; OZEMPIC; RYBELSUS; TRULICITY | Prior authorization (PA) and quantity limit (QL) required for listed alternatives |
| SEMGLEE (insulin glargine-yfgn) / LANTUS (insulin glargine) | SEMGLEE; LANTUS; INSULIN GLARGINE U-300; TOUJEO U-300; INSULIN GLARGINE-YFGN | No restrictions noted for listed insulin alternatives (check formulary for continuity guidance) |
| fluticasone-salmeterol (e.g., ADVAIR DISKUS / ADVAIR HFA) | ADVAIR HFA; breyna HFA; fluticasone-salmeterol diskus; BREO ELLIPTA; DULERA (for budesonide-formoterol entries) | Quantity limit (QL) applies to inhaled corticosteroid/LABA alternatives |
Quantity Limits and Related Restrictions
Biosimilar and Erythropoiesis-Stimulating Agent Guidance
EPOGEN / PROCRIT require prior authorization; RETACRIT is formulary alternative
RETACRIT (epoetin alfa‑epbx) is listed as the formulary‑covered alternative to EPOGEN/PROCRIT; EPOGEN and PROCRIT entries show “FORMULARY RESTRICTIONS = PA,” so prior authorization is required for the non‑formulary reference products.
- Chunk 10: “PROCRIT (epoetin alfa), DRUG(S) COVERED ON THE FORMULARY = RETACRIT (epoetin alfa‑epbx).”
- Chunk 10: “EPOGEN (epoetin alfa) PROCRIT (epoetin alfa), FORMULARY RESTRICTIONS = PA.”
CYLTEZO is formulary alternative to HUMIRA but requires PA and has QL
CYLTEZO (adalimumab‑adbm)** is listed as a formulary alternative to HUMIRA (adalimumab)** but is subject to utilization management: the mapping shows “FORMULARY RESTRICTIONS = PA, QL.”
- Chunk 8: “HUMIRA (adalimumab)** … DRUG(S) COVERED ON THE FORMULARY = CYLTEZO (adalimumab‑adbm)**.”
- Chunk 8: “HUMIRA (adalimumab)** … FORMULARY RESTRICTIONS = PA, QL.”
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